| With development of socio-economy and living of the people,health has attracted great attention.The goal of new health reform is “to establish a universal basic health-care system providing safe,effective,convenient,and low-cost health-care services by 2020.” "The Twelfth Five-year Plan" further underscored that reform of public hospitals is one of the important strategy of the new health care reform.Addressing of the problems in tertiary hospitals such as too many patients,and the challenges in county hospitals such as poor technical level and the loss of staffs,National Health and Family Planning Commission proposed that cities and provinces to establish “Regional Medical Alliance(RMA)” to integrate and allocate health resources,implement hierarchical medical system and improve capacity of primary healthcare.RMA” with varied model have been established across China.Sichuan province also issued document about establishment of RMA across this province.Neijiang health and family planning commission launched establishment of Regional Medical Alliance in February 2015.Since March 2015 Neijiang stared the first RMA to integrated one tertiary-level hospital with a local secondary hospital.Objectives.This study used a mixed research methods(combine qualitative and quantitative)to assessment the current situation of Neijiang RMA from health service providers(hospital and health workers)and the demander(patients),and assess needs to establish RMA in order to provide evidences to policy makers for improvement of RMA in Neijiang city.Methods1.We used a purposive sampling to selected study place in Neijiang: Neijiang people hospital as the tertiary-level hospital and Weiyuan county hospital as the secondary hospital were selected as study place.2.Quantitative Survey.(1)Patients survey All patients in outpatient department and inpatient departmentof Weiyuan county hospital were targeted for recruitment during the study period.The questionnaire survey aimed at understanding patient's knowledge,attitude to the RMA in Neijiang and their needs to establish RMA.(2)Health workers survey All health workers who met the following criteria were targeted for questionnaire survey: worked in the tertiary hospitals more than 10 years,and all the secondary county hospital medical workers.This survey was to learn the health workers' recognition and attitude to RMA,and their needs to establish RMA.Data were entered using Epi Data 3.1.The data were analyzed using the Statistical Package for Social Science(SPSS 17.0).Descriptive statistics were used to present study participants' characteristics,knowledge,attitude,and needs.The Chi-square test was used to compare knowledge,attitude and needs between different demographic characteristics and type of hospitals,significant factors based on the Chi-square test(p<0.05)were entered in logistic regression models which were used to examine related factors.3.Qualitative Survey.Purposive sampling method was used to selected participatns for in-depth interview.The director who is responsible for RMA establishment at Neijiang health and family planning commission,leaders and representative of health workers from those two hospitals were included in in-depth interview.To understand the current situation of RMA building,effectiveness,knowledge,attitude and construction requirements,the current problems existing in the construction of medical association,influencing factors and so on.We analyzed in-depth interviews using the framework approach of international.Results405 patients(Including 317 outpatients and 88 inpatients)and 588 health workers(465 from the tertiary-level hospital and 123 from the secondary hospital)completed the questionnaire survey.Totally,15 participants completed in-depth interviews.1.Current situation of RMA in Neijiang(1)The survey of the top three comprehensive hospital which was the first people's hospital of Neijiang,The secondary county hospital was the Weiyuan third people's hospital(Hereinafter referred to as Weiyuan hospital).Two hospitals were large difference in the high-level talent quantity,key subject,high-end equipment,annual outpatient quantity,surgical operation quantity,and Amount of hospitalization.The first people's hospital of Neijiang was the largest one in the top three hospitals,It's technical strength,subject construction,talent,internal management,equipment,instrument and so on was the top in the area of the Neijiang.Weiyuan hospital's predecessor was the industrial worker hospital,with the declined of enterprise benefit,In recent years,the hospital the brain drain was serious,the hospital facing difficult operation.After the first people's hospital of Neijiang combination with Weiyuan hospital,difficulties of Weiyuan hospital was eased and improved soon,got obvious effectiveness.(2)RM mode in Neijiang was half of close which between loose and close.Two hospitals joint mechanism was protocol type.The legal,administrative and financial aspects remained independent(Three independent).he content of construct mainly included: 1)Experts stationed 2)Cultivation of talents 3)The business operation 4)Management guidance 5)Resource sharing 6)two-way referral system.(3)As the secondary county hospital was associated with the tertiary hospital,business income had increased significantly.Establishing medical association between Weiyuan hospital and Neijiang first people's republic hospital ten years later,workload,further education and two-way referral which before and after establishing to contrast: business income growth above 10% of Surgery,internal medicine,gynecology and obstetrics,function section in Weiyuan hospital,the hospital outpatient visits,hospital visitors,Amount of operating which growth was 8.5%,17.5% and 8.5% respectively,referral rate in critical patients increased to 170%,the number of further education medical workers who Wenyuan hospital sented to Neijiang first people's republic hospital increased to 150%.(4)Positive attitude of the municipal public health administrative department in the establishing of medical association.Leaders and medical workers of the secondary county hospital urgently hoped to establish medical association with the class 3-A hospital,the leaders' willingness of establishing medical association with the secondary county hospital was higher than medical workers in the class 3-A hospital.Secondary hospital patients knew less about medical association,who hoped experts could down to the hospital to accept hierarchical diagnosis model.(5)Difficulties and influencing factors of medical association: 1)Hospital benefit allocation was difficulty,which affected quality of work with enthusiasm.2)No policy support of medical association in the medical insurance ratio.3)The lack of remote medical information platform,which affect the work efficiency.4)Different ideas and culture between hospital medical workers between each other,affected the consistency of thought,knowledge,behavior.5)Different referral standards affected referral quality.6)Medical care habits affected the implementation of the hierarchical diagnosis in medical association.2.Awareness and needs assessment of Neijing region medical association.? Patients awareness of Neijiang region medical association.71.8% knew about region medical association,49.9% knew that association could improve primary medical institutes treatment level,37.9% considered that convenient for people to go to a doctor,98.3% had approval of medical association,87.6% gone to the medical association of Neijiang first people's republic hospital as first choice,88.1% willing to transfer to the medical association.? Medical care habits and satisfaction of patients.Patient medical care habits associated with age,gender,education,residence,occupation,medical insurance,yearly family income.50.1% preferred county hospital,26.9% to the clinic/private hospital,only 3.0% preferred to the city hospital,1.5% chose community hospital and provincial hospital;36.9% acquired medical care consider convenient first,35.5% considered medical technology level,20.2% considered cost,only 3.0% cared hospital service attitude and reimbursement ratio;64.5% thought the Weiyuan hospital medical technology level had obviously improved and 82.9% were satisfaction with medical care service after established the medical association.? Awareness of medical association from medical workers.More than a half knew about basic information of medical association,though there were quite a part medical workers didn't know clearly about Concept,type,model,content,function,but the medical workers' awareness from the members of medical association were higher than the major hospital.In the construction of medical association attitude,willingness,participation,the degree of utilization,the Weiyuan hospital medical personnel was significantly higher than the Neijiang medical personnel.In recognition of medical association mode,mechanism,the hospital medical works were different.Medical workers' cognition and attitude of medical association were associated with age,gender,working years,professional title,education.(4)The needs of region medical association from medical workers.There were different between major hospital's and the members of hospital's medical workers.First,In medical association form,major hospital hoped specialist ward round mainly,the members of hospital hoped to stationary point support;Second,major hospital regarded as two-way referral,but the members of hospital regarded as technical guidance;In the aspect of medical association effected on the doctor's,major hospital thought multi-sited license and value promotion were important,the members of medical association thought improve professional technology primarily;The fourth,the impact of this hospital,major hospital to set up the brand and attract patients mainly,but the members of hospital to improve hospital medical technology level;The fifth,in a key factor of building success medical association,in addition to support attitude of administrative departments of public health and competent authorities,major hospital thought should have a scientific cooperation mechanism each other,but the members of hospital thought construction of information platform more important.ConclusionNeijiang tertiary hospital established the "half of close" RMA with county level hospital,achieved effect in the aspects such as medical technology improvement,personnel training,two-way referral,experts supply,resource sharing.However,RMA was still lack of experience such as how to improve the effectiveness,save medical expense,implement hierarchical healthcare,health insurance,and profit distribution,etc.Establishing RMA also face many difficulties:(1)Policy and attitude support from administrative departments of public health is not enough;(2)Medical association management mechanism is not complete,distribution of interests is important;(3)The lack of remote hospital information platform construction;(4)Health insurance policy of medical association without any preferential;(5)Acquire health care habits are hard to change;(6)Different opinion of medical knowledge,attitude,demand,right evaluation in hospitals respectively;(7)Propaganda of medical association is not enough.According to the current situation of medical association and the requirements of health services demanders and the providers,policy recommendations as follow:1.The government should make a road map for RMA establishment and coordinate multi-sectors to participate in solving the difficulties of the RMA construction,especially in health policy,financial subsidy and administrative ownership,and other issues.2.Health administrative sectors should participate in the construction,management and supervision of RMA,to make assessment of long-term mechanism.3.Through further research and exploration,constantly improve innovation model and mechanism;It is important to pay attention to the form and content of RMA's affect,and significantly improve the ability of integrated services in the secondary hospital;Through standard referral criteria and processes to improve properreferral;Establishing health information platform to improve the efficiency of medical association.4.Increasing the propaganda and popularization to enhance awareness and participation of members,guiding healthcare seeking behaviors of the public. |
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