| Objectives:This study aims to provide suggestions and strategies to improve the performance of urban medical groups by establishing a theoretical framework and the specific index system for the performance evaluation of urban medical groups.Methods:1.Delphi method: With the previous literature review,on the basis of clarifying the theoretical framework of urban medical group performance evaluation,the evaluation index system was preliminarily designed and formulated from the perspective of integrated medical and health service system construction.Through two rounds of Delphi consultation with 16 experts,the evaluation indexes were screened,the expert opinions were gradually unified,and the reliability,validity and weight of the indexes were tested,so as to finally form the performance evaluation index system of urban medical group.2.Analytic hierarchy process: Based on the established performance index system,this study used the analytic hierarchy process to build a pairwise comparison judgment matrix,and scored the relative importance of each index according to the experts.Through calculation and consistency test,the weight coefficient of each index and combination weight ranking was finally determined.3.Field investigation method: An institution investigation questionnaire was designed based on the index system,and a comprehensive investigation on the performance status of urban medical groups led by 10 general hospitals in Guangxi wass carried out from five aspects: system integration,resource integration,service integration,integration effect and service evaluation.4.Expert interview method: On the basis of questionnaire survey,in-depth interviews were conducted with 30 persons who are in charge of health administrative personnel,internal management and performance management personnel of medical groups,and medical alliance research experts of 10 urban medical groups in the region,so as to comprehensively understand the development status and difficulties of urban medical groups,and seek their opinions and suggestions on the performance improvement of urban medical group.5.Comprehensive evaluation method: The field survey data were combined with TOPIS and RSR method to comprehensively evaluate the performance of Guangxi urban medical groups,and the performance of 10 urban medical groups was ranked,stratified and evaluated.6.Stakeholder analysis method: the Clarkson stakeholder classification method was used to obtain the main stakeholders of urban medical group,define the degree of interest relevance and right holding of the main stakeholders,determined the relationship and priority of stakeholders by establishing the right interest matrix,and then made the choice of strategic scheme.7.SWOT analysis: Based on SWOT theory,opportunities and challenges faced by major stakeholders of urban medical groups as well as their strengths and weaknesses were listed and analyzed by means of matrix.Starting with strategy pairing method,suggestions on SO,WO,ST and WT strategies for performance improvement of urban medical groups are proposed.Results:1.Urban medical group performance evaluation index systemThe urban medical group performance evaluation index system constructed by Delphi method has 5 first-level indexes,21 second-level indexes and 66third-level indexes.The authority coefficients of the two rounds of Delphi consultation were 0.87 and 0.88 respectively,indicating a high degree of expert authority.The coordination coefficients were 0.217 and 0.310 respectively,and both P values were less than 0.001.The second round was larger than the first round.The expert opinions tended to be consistent,and the convergence effect of expert advice was better.The analytic hierarchy process(AHP)was used to calculate the index weight and construct the judgment matrix,in which the consistency ratio CR value of single ranking and total ranking was less than 0.1,which obtained satisfactory consistency.Based on social network theory and structure-process-result model,this index system covers system integration,resource integration,service integration,integration effect and service impact from the perspective of integrated medical and health service system construction.2.Empirical research results of performance evaluation of Guangxi urban medical groupThe questionnaire designed according to the index system passed the test of reliability and validity after preliminary investigation,which proves that the index system can be used in empirical research.From the perspective of system integration effect,among the 10 sample urban medical groups surveyed,80%were established based on grid,70% established management committees or organizations,60% implemented financial investment,90% have formulated articles of association,which defines the responsibilities,rights and benefit sharing mechanism of the leading hospital and member hospitals,60%implemented financial investment,and the integration of external governance mechanism and internal management system of Guangxi urban medical groups are good;in terms of the effect of resource integration,70.45% of the institutions in the group achieved mutual recognition of examination and test results,54.77% of the medical institutions in the group have achieved continuous recording and sharing of electronic medical records with the leading hospital,60% have achieved unified financial management,70% have established unified personnel management and hierarchical diagnosis as well as treatment information platforms,and all medical groups have formed a telemedicine service network in the group.However,the proportion of grass-roots medical and health institutions participating in the construction of medical groups in the region was 27.60%,only 30% have established a compound payment method of paying by disease and head,and 80% have not obtained the overall planning of chronic disease outpatient service.From the point of view of service integration effect,clear function positioning and green channel service of patient referral are better,but 60% of them have not set up a public health management center to coordinate the public health services within the group.From the perspective of integration effect,the number of discharged patients in primary medical and health institutions within the Group had a large increase,medical cost control was good,chronic disease management and medical staff satisfaction was high,but the proportion of two-way referral and the proportion of grass-roots medical insurance fund were relatively low,and the asset liability ratio of grass-roots medical institutions was high.The structural dimension was significantly better than the process and outcome dimensions,and the values of the same index varied greatly among different urban medical groups.3.Comprehensive performance evaluation results of Guangxi urban medical groupThe overall operating performance of 10 urban medical groups in Guangxi was evaluated by TOPSIS and RSR.The average Ci of the 10 urban medical groups was 0.4593,and 40% of the urban medical groups’ v Ci values were higher than the average.The Ci values of different urban medical groups were obviously different.RSR method was used to classify the comprehensive evaluation results,and the performance of urban medical groups was divided into three grades:poor,medium and excellent.One of them was rated as poor grade,accounting for 10%;seven were rated as middle grade,accounting for 70%,and two were rated as excellent grade,accounting for 20%.Most indicators of the first ranked urban medical group were better than those of the last ranked urban medical group.The performance evaluation indicators of the last ranked urban medical group were bad.The two urban medical groups in the excellent grade put emphasis on the integration of systems,resources and services,as well as the strong planning guidance of the government.They were highly integrated management within the group,and paid attention to the integration,sinking and radiation of health resources to drive the improvement of grass-roots health service capacity and implemented a smooth two-way referral system,which has achieved good integration effect and service impact.4.Major stakeholders of Performance improvement of Guangxi Urban Medical GroupBased on the Clarkson stakeholder classification method,the stakeholders of urban medical group were divided into primary and secondary categories.Through the interactive relationship diagram,it was determined that the supplier,demander,manager,financier and social supervisor of medical and health services were the main stakeholders of the performance of urban medical group.The suppliers were mainly the leading hospitals and member units,as well as medical staff and various drug and equipment suppliers.The demand side was patients and residents;the management side was government departments at all levels including health administration departments,development and reform departments and human resources and social security departments;the financing side mainly involved finance and medical insurance departments;and the social supervision side mainly involved social media.Conclusions:1.The establishment of the performance evaluation index system based on the policy guidance of the integrated medical and health service system.It not only paid attention to the core elements of the operation efficiency of medical institutions,but also fully considerd the external influencing factors,paid attention to the output of health value,highlighted the important position of medical prevention integration,and comprehensively reflected the overall dimension of the performance reform objectives of urban medical groups at the present stage,It provided a more reliable measurement basis for further empirical research.2.Overall,the construction of Guangxi urban medical group has achieved certain results,and the momentum of reform is good.The construction of urban medical group is conducive to the improvement of health service level of medical institutions at all levels.Due to different geographical environment,economic level and health resource allocation,the development level of urban medical groups is different.Through comparison,it is found that the level of economic development is still an important factor restricting the allocation of medical and health resources in urban medical groups.Urban medical groups still have a large gap in the construction of a unified platform for medical resources,the interconnection of information,the reform of medical insurance payment methods and the establishment of a public health system of medical prevention integration,which needs to be strengthened.3.The overall performance of Guangxi urban medical group is at the “mid-range”level,which is still in the initial and exploratory stage.The development is unbalanced and uneven,and there is still room for improvement and improvement.The evaluation results are consistent with the actual development of urban medical group.4.The keys of performance improvement of urban medical group should mainly focus on the mechanism of connecting the resources of leading hospitals and grass-roots medical and health institutions,the promotion will of government departments,the institutional guarantee of health administrative departments,the coordination of medical insurance policies and the realization of fairness and accessibility of health services for patients and residents.Policy Proposals:1.Urban medical group is the product of the construction of integrated medical and health service system and the aggregation in social network.Its performance improvement involves many stakeholders.The performance improvement of urban medical group needs to grasp the internal advantages and external opportunities beneficial to the main stakeholders and overcome the disadvantages and challenges faced by the main stakeholders on the basis of clarifying the stakeholders and starting from the internal and external environmental factors,and to jointly establish a good ecological environment and coordination mechanism for the performance improvement of urban medical groups through the governance of the external system and the management of the internal mechanism.2.As the management party,the government department should vigorously develop the economy,fulfill the main responsibility of running hospitals,make the reasonable top-level design from a macro perspective,increase financial investment in health,integrate the forces of finance,medical insurance,development and reform,human resources and social security,and build a unified and efficient health governance system;the health administrative department should promote the balanced distribution of regional high-quality medical resources through rational planning and layout,and improve the management system and operation mechanism of urban medical groups;and improve supporting reform measures such as medical insurance,medicine and salary system to ensure the performance improvement of urban medical groups in many aspects;and strengthen the introduction of evaluation index system or monitoring indicators,and strictly supervise the implementation of policies through performance appraisal and relevant incentive and restraint mechanisms.3.As the supply side,leading hospitals should adhere to and strengthen the Party’s overall leadership over public hospitals in improving the performance of urban medical groups,so as to promote the high-quality development of urban medical groups.Many measures should be adopted: clarify the functional orientation of medical institutions at all levels of urban medical group,and carry out all-round division of labor and cooperation;speed up the construction of compact urban medical groups and establish a resource sharing mechanism;improve the system and standards of graded diagnosis and treatment,and promote the implementation of graded diagnosis and treatment;establish modern hospital management system based on information construction;pay attention to the integration of medical treatment and prevention,and strengthen the linkage between urban medical groups and public health institutions;establish incentive policy mechanism to fully mobilize the enthusiasm of medical staff;advocate the construction of core culture and condense the soft power of reform.Primary medical and health institutions should seize the opportunity to enhance service capacity and develop key and characteristic specialties while improving general practice,make efforts to promote health education and health management,improve residents’ health literacy,change the concept of medical treatment,and implement the first medical treatment at the grassroots level.4.As the fundraiser,the health care and finance should strengthen the reform of medical insurance payment mode and give full play to the leverage of medical insurance in the performance improvement of urban medical group,increase financial support for urban medical groups and improve financial incentive measures.As the demand side,patients should actively pay attention to the construction of urban medical groups,change our traditional concept of medical treatment,and actively improve health literacy.As the social supervision party,the public awareness should be enhanced through media publicity and positive guidance,while the third party socialization supervision should be carried out to jointly promote the improvement of the performance of urban medical groups. |
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