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題名:雙元代理醫病關係中專業自主與服務績效:系絡效果與醫師情感狀態之中介角色
作者:汪秀玲
作者(外文):Hsiu-Ling Wang
校院名稱:義守大學
系所名稱:管理研究所博士班
指導教授:黃俊英
學位類別:博士
出版日期:2009
主題關鍵詞:代理關係分隔優勢策略臨床同理心服務績效誘因控制專業自主系絡效果contextual effectsdominant strategyincentive controlservice performanceagencyprofessional autonomydetachmentclinical empathy
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本研究根據代理關係誘因控制、策略變革、醫療專業主義與疏離理論,探索台灣醫院總額健保制度下成果基礎誘因(outcome-based incentive,OBI)對醫師服務績效(生產力、品質表現)之系絡效果;並調查醫師認知專業自主受違犯,是否源自於優勢策略改變(主指醫院強調成本抑制或收入提增),並且透過情感狀態(對組織分隔、對病人同理心)的中介,影響服務績效,期能釐清削弱醫師服務績效之過程。
本研究採回溯性橫斷面設計,針對 84 家綜合醫院(含區域層級和醫學中心) 1,260 位受僱醫師為研究對象,以結構式問卷調查高階主管與醫師,次級資料取自中央健保局西醫醫院總額申報以及衛生署醫療機構檔案,回收配對獲得有效樣本計 51 家醫院 441 位醫師以及 51 位主管資料。進行結構方程模式(LISREL 8.7)驗證假說與理論模型之配適性,並以階層線性模型(HLM 6.0)驗證組織變項對個體依變項之系絡效果。
本研究的主要發現有七:(一)醫院 OBI 水準對組織和個體的服務績效之預測效果:(1)組織層次:OBI 水準並不影響整體的品質與生產力;評鑑層級、公私立別對服務績效有顯著影響,醫學中心住診生產力高於區域醫院,公立醫院門、住診生產力低於私立醫院;(2)個體層次:OBI 對醫師服務表現有正向的系絡效果,當醫院採取高 OBI,則醫師愈可能提供高品質照護,醫師住診生產力也較高。(二)醫師專業自主認知的前置因子:當醫院以成本抑制為優勢策略,對「管理監督」認知有正向的系絡效果,收入提增策略對「掌控處置工作」、「組織地位」也具正向系絡效果,亦即,醫院採取「成本抑制」、「收入提增」策略,分別會促發、減緩醫師專業自主受違犯的感受;「評鑑層級」(醫學中心、區域醫院)對「掌控處置工作」、「工作負荷」也具系絡效果。個體變項中,僅有「專科別」對「管理監督」的認知具有解釋力。(三)專業自主認知對情感狀態的直接效果:「管理監督」、「組織地位」對醫師分隔分別具正向、負向效果。「管理監督」對臨床同理心三因子(「自動自發」、「熱心照護」、「站在病人立場」)具正向效果,其他專業自主構面不會影響醫師同理心。綜言之,當醫師認知專業自主受違犯時,對組織分隔頻率提高,但不會損害對病人同理心。(四)專業自主認知對服務績效的直接效果:「管理監督」對醫師品質績效、門診生產力有正向影響,「組織地位」對品質績效、門診生產力分別有負向、正向影響。(五)分隔對服務績效之預測效果:醫師分隔頻率愈高,其品質表現愈差,而分隔對門、住診生產力無顯著影響。(六)臨床同理心對服務績效之預測效果:臨床同理心三因子(自動自發、熱心照護、站在病人立場)對品質表現有正向效果,同理心愈高,其品質表現愈佳。「熱心照護」對門、住診生產力也具正向效果。(七)績效損失的機制(情感狀態的中介效果):就醫師身為醫院代理人而言,「分隔」會部分中介「管理監督」、「組織地位」的認知與品質表現間關係;就醫師身為病人代理人而言,「臨床同理心」三因子(「自動自發」、「熱心照護」、「站在病人立場」)會部分中介「管理監督」認知與品質表現之關係,「熱心照護」會中介「管理監督」認知與生產力表現之關係。
本研究是少數同時考量組織變數與個體變數跨層次實證研究之一,詮釋制度環境衝擊微觀系絡中醫師人員運作,組織系絡會形塑醫師行為,但也不能忽視心理反應情境的個人差異。實證結果指出,成果基礎誘因對個體層次的醫師品質表現有正向的系絡直接效果,與預期方向相反。而「評鑑層級」或「權屬別」反映服務複雜度以及組織在網絡中角色,對醫院層次的服務績效有顯著差異。組織執行收入提增與成本抑制策略,分別會減緩或促發醫師專業自主受違犯的感受,因而產生服務績效的正面與負面後果。同時也支持「社會情緒機制」對醫師服務績效之重要性-專業自主受違犯為何會增加(或減少)服務績效,呈現醫師雙元代理人的情感狀態(分隔、臨床同理心),在前置因子與結果變項間扮演不同的中介角色,並闡述醫師分隔引發績效損失和臨床同理心產生的績效增益是兩條不同路徑。品質與生產力為兩個相關、但不同的服務績效構面,儘管醫師經歷對組織分隔,會展開因應資源來維護他們生產力水準。本研究也發現,專業自主受違犯並未導致臨床同理心降低,顯示醫師的醫德並未惡化。建議醫院機構管理者在執行誘因控制、策略改變活動時格外謹慎,同時運用不同管理重點、調和 OBI 與 BBI (behavior-based incentive) 準則,透過醫師認知、情感與行為,達成組織期望之績效改善。
Based on studies of incentive control of agency theory, strategy change, medical professionalism and alienation theory, we examined the contextual effects of outcome-based incentives (OBI) on physician and hospital service performance after the implementation of Hospital Global Budgeting (HGB) in Taiwan. This study identifies dual mediating processes, namely physician detachment and clinical empathy, that are activated by the infringing of professional autonomy during the implementation of hospital strategic changes that emphasize cost containment and revenue enhancement. This article will offer a theoretical and empirical approach for isolating the performance decrements that occur during changes.
This was a retrospective, cross-sectional study. We selected 1,260 physicians employed at 84 general hospitals in Taiwan. A structured questionnaire was mailed to chief executive officers and physicians of the study hospitals. Secondary data was provided by the Bureau of National Health Insurance (BNHI) and Department of Health (DOH), Executive Yuan. A total of 441 usable questionnaires from 51 hospitals were returned. Our model was tested with the use of structural equations modeling (SEM) using LISREL 8.7 software. To examine the contextual effects along with hierarchical linear modeling, HLM 6.0 software was applied.
We draw conclusions in the following areas. 1. Direct effect of service performance by OBI policy. (1) At the organizational level, the hospitals using OBI did not significantly effect productivity of the out-patient department (OPD) or the inpatient department (IPD). When comparing accreditation levels and ownership type of hospitals, the productivity of IPDs in medical centers was higher than in regional hospitals. Productivity of OPDs and IPDs in public hospitals was lower than in private ones. (2) At the individual level, at higher levels of OBI, physicians gained better service quality along with better performance in OPD and IPD. 2. Antecedents of physician''s perceptions on professional autonomy. Implementation of hospital strategic changes on cost containment positively impacted physicians'' recognition of "Administrative supervision". However, a strategy of revenue enhancement disclosed positive influence on perceptions of "Physician''s control over his/her work" and "Status in hospital". These findings suggest that an increasing emphasis on revenue generation reduces physicians'' perceptions of professional autonomy infringement, whereas increasing emphasis on cost containment enhances their beliefs in a breach of autonomy. Also, a hospital''s rank had an independent effect on "Physician''s control over his/her work" and "Work load". By medical specialization, surgeons experienced a greater sense of "Administrative supervision" when compared to internists. 3. Direct effects of professional autonomy on affective state. Our results showed the perceptions of "Administrative supervision" and "Status in hospital" separately have a positive and negative influence on detachment. In addition, the perceptions of "Administrative supervision" had a positive influence on three components of clinical empathy, namely "Perspective taking", "Compassionate care" and "Standing in patient’s shoes". In sum, physician detachment is associated with a breach of autonomy; however, physicians do not decrease their empathy for the patient. 4. Direct effects of professional autonomy on service performance. There is positive influence of "Administrative supervision" perceptions on quality and productivity. However, the "Status in hospital" perceptions were negatively related to quality performance as well as positively related to physician productivity. 5. Direct effects of detachment on service performance. Detachment had a negative influence on quality performance but did not effect productivity in OPD and IPD. 6. Direct effects of clinical empathy on service performance. The three dimensions of clinical empathy, namely "Perspective taking", "Compassionate care", and "Standing in patient''s shoes", all had a positive influence on quality performance; "Compassionate care" was also positively related to productivity in OPD and IPD. 7. Performance loss mechanism: the mediating effect of affective state. The perceptions of "Administrative supervision" and "Status in hospital" had a negative influence on detachment, and detachment had a negative influence on quality performance. The perceptions of "Administrative supervision" had a positive relationship with quality performance and the effect was mediated by three dimensions of empathy-"Perspective taking", "Compassionate care", and "Standing in patient''s shoes". The perceptions of "Administrative supervision" had a positive influence on productivity and the effect was mediated by "Compassionate care".
Our results show that the OBI system did not have a significant influence on the productivity and quality in hospitals, but did have a direct impact on physician''s service performance. Strategic changes of revenue enhancement and cost containment respectively promote or curb professional autonomy, which can subsequently produce positive or negative effects on the performance. Because productivity performance is more easily measured and monitored than quality performance, physicians will try to maintain their productivity to expected levels. Our study also confirms that "Affect-event theory (AET)" plays an important role in performance outcome; and separating out physicians as dual agents responsible towards hospitals and patients is important in gauging response to changing practices. The study''s findings provide evidence that different strategic emphases (cost containment vs. revenue enhancement) translate into qualitatively different (negative vs. positive) effects on physicians'' perceptions of professional autonomy and insights into mechanisms of performance loss that include positive pathways in hospitals. We posit that empathy can reduce loss in quality performance and physician''s detachment curbs the loss of quality performance due to a decrease in physicians'' professional autonomy. We further suggest that detachment produces overall negative effects on physicians'' performance while empathetic processes produce gains. Managerially, it is thus important to attend to the perceptions of physicians while altering incentive controls and strategic change processes in organizations.
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