| [Purpose]This study was under the background of DRG payment system reform in China,and to build a tertiary public hospital performance evaluation model and to develop a set of performance evaluation tools with strong application value on the attending physician.By systematically combing tertiary public hospital performance evaluation of the attending physician,influencing factors and analyze the influencing factors of hierarchy paths and core factors,it was expected to provide theory support on tertiary public hospital performance management research and practice in the process of DRG payment system reform in China,and to improve medical quality and ensure the safety of patients,and to provide the beneficial reference to further improve medical service efficiency and the level of fine management of tertiary public hospitals.[Methods]In the construction of performance evaluation model for attending physicians in tertiary public hospital under the DRG payment system,this study adopted the bibliometrics method to analyze the development context and hot spots of the research field of physician performance evaluation,and located high-quality and important literature.SWOT strategy analysis was adopted to analyze the development strategy of China's tertiary public hospitals under DRG payment system.The field investigation method was used to analyze and summarize the responsibilities of the attending physicianIn terms of the research and development of performance evaluation tools,this study conducted a descriptive and systematic evaluation on the literature related to the study of physician performance evaluation indicators,and analyzed the high-frequency indicators and common evaluation methods.Semi-structured interviews were conducted with pilot hospitals in pilot cities for DRG payment system reform to summarize the characteristics of DRG payment system reform on hospital management and physician performance evaluation.After the preliminary indicator system was selected,the final performance evaluation tool was formed through a series of analysis methods including Delphi method,factor analysis method and analytic hierarchy process.In the analysis of performance influencing factors,DEMATEL and ISM were combined to analyze influencing factors like key factors,important causes,results,factors that were easy to affect and affected by other factors,and to clarify the hierarchical relationship and action path.Next,the study collected performance data and influencing factor questionnaire data of the attending physicians in department of orthopedics and cardiology in 3 public hospitals in Beijing(93),2 in Shenyang(36)and 2 in Jinan(40),and adopted the method of decision tree to conduct an empirical study of influencing factors.[Results]1.Construction of theoretical model of performance evaluation of attending physicians in tertiary public hospitals under DRG payment system(1)Through the development strategy analysis of DRG system of China's tertiary public hospitals,the development strategy was drawn as: adhere to the government's public welfare,insist on taking patients as the center of the service concept,mainly to provide medical care and treatment to critical and incurable patients,play the leading role in medical science,technology,innovation and professional training,and gradually implement the three changes,namely from scale expansion to quality and benefit development;from extensive management to fine management;from investment in hospital development and construction to investment in expansion of allocation.(2)This study analyzed the key issues of performance evaluation of attending physicians in tertiary public hospitals,and concluded that it should be based on medical quality,fully combined with the post responsibilities and characteristics of attending physicians,and included in DRG-based performance evaluation indicators.(3)Guided by the research conclusions above,four dimensions of specific performance objectives were identified including finance,external business,internal customers and learning and growth.In the financial aspect,DRG payment system reform required hospitals to control medical costs,improve medical service efficiency,and adjust the overall medical cost structure.In terms of external customers,hospitals should adhere to the patient-centered service concept,improve service awareness and improve patient satisfaction.As for internal business,the hospital should had high level of specialized medical ability and technology,focus on the improvement of the diagnosis and treatment ability of critical and difficult diseases,and pay attention to the standardization of medical service behavior and the rationality of diagnosis and treatment program.In the aspect of learning and growth,doctors' medical technology ability should be improved,clinical research ability strengthened,and their management ability.cultivated and improved.2.Research and development of performance evaluation tools for attending physicians in tertiary public hospitals under DRG payment system(1)Semi-structured interviews were used to analyze the impact of DRG payment system reform on hospital management and physicians,and it was found that after DRG payment system reform,hospitals were generally affected to a certain extent.First,the hospital management: the quality requirements of doctors' medical records were generally improved;Hospitals pay more attention to the development and management of clinical pathways,and the standardized requirements of diagnosis and treatment have been improved.To some extent,it affected the application of new technology.The function positioning of tertiary public hospitals was more clear,and the difficulty level of patients was improved.Hospitals generally began to use DRG as a tool for evaluation and management.Second,doctors' medical behavior: doctors paid more attention to medical expenses in the process of diagnosis and treatment;There was a cheating behavior in the use of DRG payment code;Third,medical quality: medical efficiency has been improved;there might be possible medical insufficiency due to the compression of medical costs;The doctor-patient relationship has been affected to some extent after the reform.Fourth,working environment: the competition among doctors was more fierce;workload and the pressure on doctors increased.Based on the conclusions above,this study analyzed the characteristics of physician performance evaluation under DRG payment system.It was suggested that: first,medical quality supervision should be strengthened and the weight of indicators of unexpected death(mortality rate of low-risk group)should be increased.Second,in order to prevent the occurrence of no serious disease,DRG enrollment rate could be included in the evaluation index.Third,in order to prevent the decomposition of hospitalization and improve benefits,the index evaluation weight of unplanned 30-day readmission rate could be increased.Fourth,the accuracy rate of the first page of the key medical and the error rate of disease into the group were adopted into the performance evaluation indicators.Fifth,management level of clinical pathway was improved by increasing the weight of indicators such as entry rate,exit rate and variation rate.Sixth,the performance evaluation index based on DRG was included.Seventh,more attention was paid to the doctor-patient relationship.(2)Combined with the previous research conclusions,the performance evaluation index system of primary physicians in tertiary public hospitals was constructed.Indexes including 7 primary indicators--1.health care costs,2.satisfaction,3.medical quality,4.medical efficiency,5.professional ability,6.management ability,7.research and teaching;13 secondary indicators--1.cost consumption index,2.patients' satisfaction,3.low mortality risk group,4.30-day unplanned readmission rate,5.Class a medical record rate,6.The time consumption index,7.The CMI,8.Number of DRG group,9.The use of new technology and promote,10.The situation of the management of the attending group,11.Articles published,12.Application subject,13.teaching situation The overall Cronbach coefficient value of the index was 0.856,s-cv /Ave=0.96,and KMO test value was 0.687,indicating good reliability and validity.According to the functional positioning of tertiary public hospitals in the new era,which mainly focused on the diagnosis and treatment of difficult and complex diseases,this study improved the index weight of CMI.At the same time,for the possible impact of DRG payment system on physician behavior and performance,the indicator system included the unplanned 30-day readmission rate,class-A medical record rate and the use and promotion of new technologies.According to the job responsibilities and requirements of the attending physicians,the indicators included the management of the attending group,scientific research and teaching indicators.3.Analysis of factors on the performance of attending physicians in tertiary public hospitals(1)Based on the feedback model of performance influencing factors proposed by Mitchell(2005),this study extracted performance influencing factors from three aspects of medical education,environment and personal characteristics,and constructed a framework model of performance influencing factors for primary physicians in tertiary public hospitals.The study systematically sorted out and selected 26 factors affecting the performance of primary physicians in tertiary public hospitals from macro to micro,including: 1.academic education,2.post graduate education,3.continuing education,4.geographic location,5.regional economy,6.regional population 7.medical and health resources,8.medical insurance payment methods,9.hospital scale and structure,10.hospital strategy and culture,11.hospital income,-expenditure structure,12.hospital performance appraisal and salary system,13.department scale,14.department categories,15.main diagnosis group structure,16.setting mode of main diagnosis group,17.doctors' professional spirit,18.knowledge structure,19.gender,20.age,21.family support,22.income level,23.physical health,24.mental health,25.job satisfaction,26.work pressure.(2)DEMATEL-ISM combined method was adopted to model the influencing factors on the performance of the selected attending physicians,and the relationship between the factors and the influencing levels of the factors were further analyzed.Through the analysis,it was concluded that regional economy,geographical location and medical insurance payment system were the most important factors affecting the performance of primary physicians in China's tertiary public hospitals and the most important reasons for the changes of other factors.The factors that were most susceptible to other factors were job satisfaction,followed by work pressure and income level.These three factors were also the factors with the highest score of centrality,that was,the factors that were most closely related to other influencing factors,and were also the most important outcome factors among the influencing factors.We could think that these three factors were the most direct factors affecting the performance of the attending physician.The hierarchy of influencing factors was obtained through the ISM method.The first level was the structure,job satisfaction and work pressure of the main group.Level 2: the setting of the attending group mode,physical health,mental health,Level 3,record of formal schooling education,graduate education,continuing education,medical and health resources,after the hospital scale structure,strategy and culture,the hospital income and expenditure structure,performance and salary system,section office of hospital scale structure,physician professionalism,knowledge structure,family support,income level;Level 4: regional population,medical insurance payment system,department category,gender,age.Level 5:geographical location,regional economy.Combined with DEMATEL's analysis results and ISM's analytic hierarchy process,a hybrid model was built for influencing factors of performance evaluation of primary physicians in tertiary public hospitals.(3)Empirical study on influencing factors the questionnaire survey on influencing factors and performance evaluation results of 169 attending physicians in department of orthopedics and cardiology of 7 grade iii public hospitals in Beijing,Shenyang and Jinan were collected.Among them,there were 89 doctors in Beijing with an average performance of 84.76 points.The average performance of 40 doctors in Shenyang was 78.76 points.The average performance of 40 doctors in Jinan was 79.58 points.In terms of the income of doctors,the highest proportion of the income level of the sample doctors in the three regions was 12,000-17,000 yuan,and the income level of the sample doctors in Beijing was12,000-17,000 yuan(49.4%)and more than 17,000 yuan(21.3%),which was higher than that in Shenyang and Jinan.In terms of physical health,18.9% of the attending physicians had basic diseases.The health status of the sample physicians in Jinan was the best,with the lowest proportion of those with basic diseases(12.5%),while the proportion of those with basic diseases in Shenyang was the highest(32.5%).In terms of mental health,34.5%of the doctors in the sample scored 7-9,and 26% scored 10-12,indicating that the overall mental health of the doctors in the sample was not optimistic.In terms of job satisfaction,91.6% of the attending physicians in the three cities scored above grade 4,indicating that the sample physicians' job satisfaction was generally high.In terms of work pressure,65.6of the physicians scored 3 points for work pressure,15.9% scored 4 points and 5 points for stress,indicating that the overall work pressure of the attending physicians in tertiary public hospitals was relatively high.Next,the method of machine learning--decision tree model was introduced for analysis,and the accuracy of sample data fitting was 93.12%,with a good fitting effect.The most critical factors affecting the performance of attending physicians were regional economy,followed by the income level of physicians,followed by age,job satisfaction and job pressure.At the same time,the hospital's development strategy,the hospital's performance system,the management mode of the main treatment group,the staff structure of the main treatment group,etc.all had a certain degree of influence on the performance results of the doctors was used to model the influencing factors of the performance of the selected doctors.Through the analysis,it is concluded that regional economy,geographical location and medical insurance payment mode were the most important factors influencing the performance of doctors in three-level public hospitals in China,and also the most important reason for the changes of other factors.The top 3vulnerable factors were job satisfaction,work pressure and income level.These were also the factors with the highest score of centrality,that was,the most closely related factors with other influencing factors,and the most important outcome factors.We can say that these three factors were the most direct influencing factors on the performance of the attending physicians.Combined with DEMATEL method,the level of ISM modeling was Level 1: the structure,job satisfaction and work pressure of the main diagnosis group;Level 2: the setting mode,physical health and mental health of the main diagnosis group;Level 3: academic education: post graduate education,continuing education,medical and health resources,hospital scale structure,hospital strategy,culture,hospital income,expenditure structure and hospital performance,salary system,department scale and structure,physician professionalism,knowledge structure,family support,income level;Level 4: regional population,medical insurance payment method,department category,gender,age.Level 5: geographical location and regional economy.(3)In this study,169 physicians from orthopedics and cardiology departments of 7tertiary public hospitals in Beijing,Shenyang and Jinan were collected.Through the preliminary analysis of the data,18.9% of the attending physicians in this survey had basic diseases.In terms of mental health,40.2% of the doctors in the sample scored 7-9 points,28.9% scored 10-12 points,51.4% scored 4 points,11.2% scored 5 points,and most of the doctors scored higher,indicating that the overall mental health of the sample students was not optimistic.In the aspect of job satisfaction,91.6% of the attending physicians scored above the level of 4 points,which was generally high.However,56.2% of doctors' work stress scores were 3 points,15.9% were 4-5 points,indicating that the work stress of the attending physicians in the tertiary public hospitals was relatively high.In the empirical study of the influencing factors,the research introduced the method of machine learning decision tree model to analyze,and the accuracy rate of correctly fitting the performance score reaches 93.12%,and the fitting effect was good.It could be seen that the most critical factors affecting the performance of the attending physicians were the regional economy,followed by the income level,and then the age,job satisfaction and work pressure.At the same time,the development strategy of the hospital,the assessment system of the hospital,the management mode of the main diagnosis group,and the personnel structure of the main diagnosis group all had a certain impact on the performance of doctors.[Conclusions]1.It built the attending physician performance theory mode of tertiary public hospital under DRG payment system,the model to DRG payment system of China's tertiary public hospital development strategy as the guidance,the key problems of the performance evaluation,specific performance evaluation goals of four dimensions,and the principle,application and other related contents of performance evaluation of the whole process was analyzed,and for the subsequent development of evaluation tools and the analysis of the factors affecting had strong guidance,tertiary public hospital performance management of our country had a certain reference value.2.Through the systematic literature review and the analysis of the impact of DRG payment system reform on physician performance evaluation indicators,this study developed a performance evaluation tool which had better reliability and validity compared with the traditional physician performance evaluation tool.It was more suitable for the environment of DRG payment system reform in China,and the evaluation subject was more targeted.3.The key and important factors affecting the performance of attending physicians in tertiary public hospitals included regional economy,geographical location,physician income level,job satisfaction,job pressure and age.While the hospital's development strategy,the hospital's performance system,the management mode of the main treatment group,the staff structure of the main treatment group,etc.all had a certain degree of impact on the performance results of the doctors[Innovation and Deficiency]1.Innovation(1)This study constructed a performance evaluation model for attending physicians in tertiary public hospitals under the DRG payment system.The model took the DRG payment system reform as the background,the development strategy of tertiary public hospitals as the guidance,and the new requirements for primary physicians in tertiary public hospitals under the concept of big health as the basis.It followed the progress of medical reform and the development of the time,and was more in line with the actual situation of hospital management in China.It was prospective and innovative.(2)This study built a theoretical framework of influencing factors containing macro factors such as regional economy and micro factors like personal traits.It analyzed performance factors of the attending physician in tertiary public hospitals from different levels and angles.Compared with the domestic and foreign related research,it was more systematic,comprehensive and suitable to China's national conditions,and laid a theoretical basis for related research.(3)In this study,machine learning method was introduced into the empirical study.Compared with traditional statistical methods such as structural equation model,decision tree had fewer restrictions on the distribution of data and the sample size,and the analysis conclusion was more accurate and had stronger sense of depth.2.Deficiency(1)Most of the indicators in the system were outcome indicators,with less process indicators,and assessment of doctors' diagnosis and treatment behavior was relatively weak(2)In the empirical analysis of performance influencing factors based on decision tree,convenient sampling method was adopted in data extraction of Beijing,Shenyang and Jinan,cities all located in northern China,which may caused certain data bias. |
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