簡易檢索 / 詳目顯示

回結果列表
研究生： 倪壽民
Shou-min ni
論文名稱： 區域醫院導入實證醫學之策略性關鍵成功因素
The Strategic Critical Success Factors for Implementation of Evidence-based Medicine in Regional Hospital of Taiwan
指導教授： 欒斌
Pin Luarn
口試委員: 吳宗成
Tzong Chen Wu
陳正綱
Chen Kang Chen
學位類別： 碩士
Master
系所名稱： 管理學院 - 管理研究所
Graduate Institute of Management
論文出版年： 2010
畢業學年度： 98
語文別： 中文
論文頁數： 124
中文關鍵詞： 實證醫學 、區域醫院 、導入策略 、關鍵成功因素
外文關鍵詞： Evidence-based medicine, Clinical practice guideline, Health care organization, evidence-based health management, hospital management
相關次數： 點閱：246  下載：4 
分享至:
查詢本校圖書館目錄 查詢臺灣博碩士論文知識加值系統 勘誤回報

    • 實證醫學是一種有系統的資料搜尋、評估與使用，透過網際網路與電子資料庫的運用，醫師們可以快速的獲得大量的醫療資訊，並將其應用在日常診療工作中。
    本研究主要在探討所在實證醫學在台灣的區域級醫院導入狀況的研究，探討預期成效，接受度及導入策略之關鍵成功因素。由於各區域級醫院均為近8年內開始導入實證醫學，且各醫院實證醫學實施之普及度均不同，因此本研究之探討內容上，包括：區域醫院實證醫學責任單位之組織架構，各醫院實證醫學導入及推廣之現況，辨識針對各院實施實證醫學之障礙，提出未來實施實證醫學之策略。
    本研究以質化研究方式，深入訪談四家北部區域級教學醫院，主要研究目的在探討各不同性質區域醫院對於實證醫學之導入動機、導入過程及導入成效，藉此找出其關鍵成功因素，以供決策者制定導入及持續應用之策略。研究過程對為各區域級醫院實證醫學單位負責人進行深入訪談，驗證出之導入關鍵成功因素對實證醫學實施成功因素，經由分析後，歸納出下列研究結論：個案醫院認為導入實證醫學之關鍵成功要素為個人與組織對於實證醫學學習的動機。其他相關內外環境機制與此因素互動以持續產生動能運作實證臨床環境，達成最佳健康照護結果並兼顧品質與成本優勢。導入實證醫學的成效則在於醫療品質之提升顯著，而對於成本控制的效應較難評估。最後依研究結果歸納出本研究之發現及區域等級醫院導入實證醫學的成功模式。
    本研究並提出具體建議供各區域醫院持續改善實證醫學實行之參考。由於受限於研究時的受訪樣本數，此差異仍有賴於後續研究證明。

    The major issue of this study is the identification of critical success factors for implementation and the integration of evidence-based medicine to typical regional hospitals in TAIWAN. The idea of the Evidence Based Medicine (EBM) is changing the traditional clinical practice paradigm. Medical professionals improve their knowledge and skills by applying EBM to their researches and practices， which promote the clinical decision and the quality of health service。
    This research discusses the study of implementation of EBM to four midsized regional hospital in Taiwan. The clinicians in these four different hospitals awared of the importance of evidence-based medicine and related guidelines. However, the leaders in charge of EBM are frustrated by implementational processes that are enormously time comsuming, skill and resource intensive. Through qualitative research with extensive investigation and discussion to those team leaders; the most important critical success factors were identified. Among these factors, motivation of learner and learning groups stands the first place. According to above conclusion, developing strategy of EBM in regional hospitals of Taiwan was revealed.

    目錄 誌謝 1 摘要 2 Abstract 3 目錄 4 圖目錄 8 表目錄 9 第一章 緒論 10 第一節 研究背景 10 1.1.1實證醫學的發展 11 1.1.2實施實證醫學的目的 12 1.1.3推行實證醫學的成效 13 第二節 研究動機 14 第三節 研究目的 15 第四節 研究範圍與流程 16 第五節 論文架構 18 第二章 相關文獻探討 19 第一節 實證醫學導入概況 19 2.1.1實證醫學的定義 19 2.1.2臨床實施實證醫學 23 2.1.3實證醫學與管理 25 2.1.4實證醫學在台灣的發展 26 2.1.5區域醫院導入實證醫學現況 27 2.1.6實證醫學對醫療品質的影響 28 2.1.7臨床指引的概念 29 第二節 實證醫學之運作背景 31 2.2.1實證醫學的實施要素 31 2.2.2醫學的知識轉譯 36 2.2.3資訊科技的實證應用 38 2.2.4實證醫學的資源與運作機制 39 2.2.5實證競賽性與團隊學習 40 2.2.6實證醫學環境設置 41 2.2.7跨專業實證醫學運作機制 43 第三節 導入新知識科技之相關理論 43 2.3.1實證醫學與組織變革 44 2.3.2變革策略與實證醫學整合 45 2.3.3醫療成本的控制與經濟分析 48 2.3.4關鍵成功因素 48 2.3.5創新擴散 52 2.3.6文獻總結 54 第三章 研究架構與方法 55 第一節 研究架構 55 3.1.1研究範圍與變數說明 56 3.1.2研究架構圖說 57 第二節 研究命題 59 第三節 分析方法 60 3.3.1研究設計 61 3.3.2個案深度訪談法 63 3.3.3簡單敘述統計法 63 第四章 研究結果與分析 64 第一節 各醫院訪談分析 64 4.1.1個案醫院簡介 64 4.1.2個案醫院綜合分析 66 4.1.3個案醫院實證醫學傳遞過程分析 67 4.1.4依訪談內容分析各構面之命題 68 第二節 實證醫學實施之關鍵成功因素 76 4.2.1實證醫學導入的理想狀態 77 4.2.2實證醫學組織結構 78 4.2.3實證醫學資源投入程度 78 4.2.4實證醫學教學 79 4.2.5實證醫學導入之關鍵成功因素 81 第三節 實證醫學之導入策略 83 4.3.1醫療工作者的態度與文化 83 4.3.1組織結構調適策略 84 4.3.2資源配置策略分析 85 第五章 研究結論與建議 86 第一節 結論與建議 86 5.1.1研究分析與結論 86 5.1.2 管理意涵 87 5.1.3面對外在環境的實證醫學因應策略 88 5.1.4 區域醫院導入實證醫學的創新方式 89 5.1.5 區域等級醫院導入實證醫學的成功模式 89 第二節 研究貢獻 90 第三節 研究限制 91 第四節 後續研究建議 91 參考文獻 93 英文文獻 93 【附錄一】訪談問卷表 99 【附錄二】訪談內容 102 個案醫院A 102 個案醫院B 108 個案醫院C 114 個案醫院D 119

    英文文獻
    Atkins, D., Fink, K., & Slutsky, J. (2005). Better information for better health care: the Evidence-based Practice Center program and the Agency for Healthcare Research and Quality. Ann Intern Med, 142(12 Pt 2), 1035-1041.
    Berwick, D. M. (2008). The Triple Aim: Care,Health, and Cost. HEALTH AFFAIRS, 27(3), 10.
    Biller-Andorno, N., Lenk, C., & Leititis, J. (2004). Ethics, EBM, and hospital management. Journal Of Medical Ethics, 30(2), 136-140.
    Bor-Wen, C., Wen-Hong, C., Maw-Liann, S., & Chih-Ming, L. (2009). Implementation Methodology of Evidence-Based Medicine based on technological diffusion approach: a case of system establishment within the hospital industry. [Article]. International Journal of Technology Management, 47(1-3), 37-56.
    Boynton, A. C., & Zmud, R. W. (1984). An Assessment of Critical Success Factors. Sloan Management Review, 25(4), 17.
    Brewer, B. B., Brewer, M. A., & Schultz, A. A. (2009). A Collaborative Approach to Building the Capacity for Research and Evidence-Based Practice in Community Hospitals. [doi: DOI: 10.1016/j.cnur.2008.10.003]. Nursing Clinics of North America, 44(1), 11-25.
    Brooke, B. S., Meguid, R. A., Makary, M. A., Perler, B. A., Pronovost, P. J., & Pawlik, T. M. (2010). Improving surgical outcomes through adoption of evidence-based process measures: Intervention specific or associated with overall hospital quality? [doi: DOI: 10.1016/j.surg.2009.10.037]. Surgery, 147(4), 481-490.
    Bullen, C. V., & Rockart, J. F. (1981). A primer on critical success factors: Massachusetts Institute of Technology (MIT), Sloan School of Management.
    Cabana, M. D., Rand, C. S., Powe, N. R., Wu, A. W., Wilson, M. H., Abboud, P. A., et al. (1999). Why don't physicians follow clinical practice guidelines? A framework for improvement. JAMA, 282(15), 1458-1465.
    Carla, O. D., & C. Jackson Grayson, J. (1999). Knowledge tranfer: Discover your value proposition. Strategy & Leadership, 27(2), 10.
    Chaudhry, B. (2006). Systematic Review: Impact of Health Information Technology on Quality, Efficiency, and Costs of Medical Care. Annals of Internal Medicine, 144(10), 10.
    Committee on Quality Health Care in America, I. o. M. (Ed.). (2001). Crossing the quality chasm: a new health system for the 21st century: NATIONAL ACADEMY PRESS.
    Damanpour , F. (1992). Organizational Size and Innovation Organization Studies, 13(3), 375-402.
    Daniel, D. R. (1961). Management Information Crisis. Harvard Business Review, Sept-Oct.
    Dickersin, K., Straus, S. E., & Bero, L. A. (2007). Evidence based medicine: increasing, not dictating, choice. BMJ, 334 Suppl 1, s10.
    DORR, D. A. (2006). Implementing a Multidisease Chronic Care Model in Primary Care Using People and Technology. DISEASE MANAGEMENT, 9(1), 15.
    Drummond, M. F., & Jefferson, T. O. (1996). Guidelines for authors and peer reviewers of economic submissions to the BMJ. The BMJ Economic Evaluation Working Party. BMJ, 313(7052), 275-283.
    Easingwood, C. J., Storey, C. (1991). Success factors for new financial services. International Journal of Bank Marketing, 9, 3-10.
    Easingwood, C. J., Storey, C. (1993). Marketplace success factors for new financial services. Journal of Services Marketing, 7, 41-54.
    Ferguson, C. R., & Dickinson, R. (1982). Critical Success Factors for Directors in the Eighties. Business Horizons, 25(3), 14.
    Fitzpatrick, M. (2001). The tyranny of health : doctors and the regulation of lifestyle. London ; New York: Routledge.
    Fonarow, G. C., Gheorghiade, M., & Abraham, W. T. (2004). Importance of in-hospital initiation of evidence-based medical therapies for heart failure—a review. [Article]. American Journal of Cardiology, 94(9), 1155-1160.
    Glasziou, P. (2006). Managing the evidence flood. Surg Clin North Am, 86(1), 193-199, xi.
    Glasziou, P., & Haynes, B. (2005). The paths from research to improved health outcomes. Evidence Based Medicine, 10(1), 4-7.
    Graham, I., Mb, H., Se, S., J, T., W, C., & N, R. (2006). Lost in knowledge translation: time for a map? The Journal of continuing education in the health professions, 26(1) , p. 13-24.
    Gray, J. A. M. (2001). Evidence-based healthcare (2nd ed.). Edinburgh ; New York: Churchill Livingston.
    Grol, R. (2000). Between evidence-based practice and total quality management: the implementation of cost-effective care. Int J Qual Health Care, 12(4), 297-304.
    Guyatt, G., Cairns, J., & et al. (1992). Evidence-Based Medicine. JAMA, 268(17), 2420.
    Haynes, R. B. (2006). Of studies, syntheses, synopses, summaries, and systems: the “5S”
    evolution of information services for evidence-based health care decisions. ACP Journal Club, 145(3), 2.
    Higgins, J., Green, S., & Cochrane Collaboration. (2008). Cochrane handbook for systematic reviews of interventions. Chichester, West Sussex ; Hoboken NJ: John Wiley & Sons.
    Himmelstein, D. U., Woolhandler, S., Hellander, I., & Wolfe, S. M. (1999). Quality of care in investor-owned vs not-for-profit HMOs. JAMA, 282(2), 159-163.
    Horwitz, R. (1996). The dark side of evidence-based medicine. Cleve Clin J Med., 63, 320-323.
    Issenberg, S. B., McGaghie, W. C., Hart, I. R., Mayer, J. W., Felner, J. M., Petrusa, E. R., et al. (1999). Simulation technology for health care professional skills training and assessment. JAMA, 282(9), 861-866.
    Izakovic, M. (2007). New trends in the management of inpatients in U.S. hospitals--quality measurements and evidence-based medicine in practice. Bratisl Lek Listy, 108(3), 117-121.
    James, B. C. (Ed.). (1989). QUALITY MANAGEMENT FOR HEALTH CARE DELIVERY. Chicago: The Hospital Research and Educational Trust.
    Jones, R. J. E., & Santaguida, P. (2005). Evidence-based practice and health policy development: the link between knowledge and action. [doi: DOI: 10.1016/j.physio.2004.07.009]. Physiotherapy, 91(1), 14-21.
    Kanthan, R., & Mills, S. (2007). Cooperative learning in the first year of undergraduate medical education. World J Surg Oncol, 5, 136.
    Kotter, J. P. (1996). Leading change. Boston, Mass.: Harvard Business School Press.
    Kotter, J. P. (2010). Leading change : why transformation efforts fail. Boston, Mass.: Harvard Business Press.
    Kotter, J. P., & Cohen, D. S. (2002). The heart of change : real-life stories of how people change their organizations. Boston, Mass.: Harvard Business School Press.
    Larson, E. B. (1999). Evidence-based medicine: is translating evidence into practice a solution to the cost-quality challenges facing medicine? Jt Comm J Qual Improv, 25(9), 480-485.
    Leavitt, H. J. (1965). Managerial psychology Chicago: The University of Chicago Press, Ltd.
    Leavitt, H. J. (1976). Applied Organization Change in Industry. In J. G. March (Ed.), Handbook of Organization (pp. 144-176). Chicago: Rand McNally.
    Leon, S. A., Fontelo, P., Green, L., Ackerman, M., & Liu, F. (2007). Evidence-based medicine among internal medicine residents in a community hospital program using smart phones. [Article]. BMC Medical Informatics & Decision Making, 7, 5-11.
    Lewin, K. (1951). Field theory in social science. New York: Harper and Row.
    McGovern, D. P. B. (2001). Key topics in evidence-based medicine. Oxford
    New York: BIOS Scientific Publishers ;
    Distributed in the United States, its dependent territories by Springer-Verlag.
    MCKIBBON, A. (2008). 實證醫學原理與應用 (楊宗翰編譯, Trans.): 合記圖書出版社.
    McKinley, C., Fletcher, A., Biggins, A., McMurray, A., Birtwhistle, S., Gardiner, L., et al. (2007). Evidence-based Management Practice: Reducing Falls in Hospital. [doi: DOI: 10.1016/S1322-7696(08)60551-X]. Collegian: Journal of the Royal College of Nursing Australia, 14(2), 20-25.
    Mertins, K. (Ed.). (2001). Knowledge Management. Berlin: Springer-Verlag.
    Nordenström, J. (2007). Evidence-based medicine in Sherlock Holmes' footsteps. Malden, Mass.: Blackwell Pub.
    Panik, A., Bokovoy, J., Karoly, E., Badillo, K., Buckenmyer, C., Vose, C., et al. (2006). Research on the frontlines of healthcare: a cooperative learning approach. Nurs Res, 55(2 Suppl), S3-9.
    Pappaioanou, M., Malison, M., Wilkins, K., Otto, B., Goodman, R. A., Churchill, R. E., et al. (2003). Strengthening capacity in developing countries for evidence-based public health: the data for decision-making project. Soc Sci Med, 57(10), 1925-1937.
    The Patient Protection and Affordable Care Act., public law 111-148 C.F.R. (2010).
    Pfeffer, J., & Sutton, R. I. (2006). Evidence-based management. Harv Bus Rev, 84(1), 62-74, 133.
    Pinto, J. K., & Slevin, D. P. (1989). The Project Champion: Key to Implementation Success. Project Management Journal, 20(4), 15.
    Pratt, R. J., Pellowe, C. M., Wilson, J. A., Loveday, H. P., Harper, P. J., Jones, S. R. L. J., et al. (2007). epic2: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England. [doi: DOI: 10.1016/S0195-6701(07)60002-4]. Journal of Hospital Infection, 65(Supplement 1), S1-S59.
    Rockart, J. F. (1979). Chief executives define their own data needs. Harvard Business Review 2, 81-93.
    Rogers, E. M. (1995). Diffusion of innovations (4th ed.). New York: Free Press.
    Rogers, E. M. (2003). Diffusion of innovations (5th ed.). New York: Free Press.
    Rosswurm, M. A., & Larrabee, J. H. (1999). A model for change to evidence-based practice. Image J Nurs Sch, 31(4), 317-322.
    Sackett, D. L., Rosenberg, W. M., Gray, J. A., Haynes, R. B., & Richardson, W. S. (1996). Evidence based medicine: what it is and what it isn't. BMJ, 312(7023), 71-72.
    Sanders, J. M. (2004). Knowledge management:something old, something new! Work Based Learning in Primary Care, 2, 9-17.
    Sevdalis, N., Norris, B., Ranger, C., & Bothwell, S. (2009). Designing evidence-based patient safety interventions: the case of the UK's National Health Service hospital wristbands. [Article]. Journal of Evaluation in Clinical Practice, 15(2), 316-322.
    Silverman, E. M., Skinner, J. S., & Fisher, E. S. (1999). The association between for-profit hospital ownership and increased Medicare spending. N Engl J Med, 341(6), 420-426.
    Snyder, J. E., & Gauthier, C. C. (2008). Evidence-based medical ethics : cases for practice-based learning. Totowa, N.J.: Humana Press.
    Stetler, C. B., Ritchie, J., Rycroft-Malone, J., Schultz, A., & Charns, M. (2007). Improving quality of care through routine, successful implementation of evidence-based practice at the bedside: an organizational case study protocol using the Pettigrew and Whipp model of strategic change. Implement Sci, 2, 3.
    Straus, S. (Ed.). (2005). Evidence-Based Medicine. How to Practise and Teach EBM (3rd ed.). Edinburgh: Churchill Livingstone.
    Straus, S. E. (2005). Evidence-based medicine : how to practice and teach EBM (3rd ed.). Edinburgh ; New York: Elsevier/Churchill Livingstone.
    Straus, S. E., Ball, C., Balcombe, N., Sheldon, J., & McAlister, F. A. (2005). Teaching Evidence-based Medicine Skills Can Change Practice in a Community Hospital. [Article]. JGIM: Journal of General Internal Medicine, 20(4), 340-343.
    Straus, S. E., Tetroe, J. M., & Graham, I. D. (2009). Knowledge translation is the use of knowledge in health care decision making. [doi: DOI: 10.1016/j.jclinepi.2009.08.016]. Journal of Clinical Epidemiology, In Press, Corrected Proof.
    Turner, T. J. (2009). Developing evidence-based clinical practice guidelines in hospitals in Australia, Indonesia, Malaysia, the Philippines and Thailand: Values, requirements and barriers. BMC Health Services Research, 9.
    Wennberg, J. (2002). Geography and the debate over Medicare reform. [suppl Web exclusives]. Health Aff (Millwood). , 18.
    Woolhandler, S., & Himmelstein, D. U. (1999). When money is the mission--the high costs of investor-owned care. N Engl J Med, 341(6), 444-446.
    Wright, V. (2009). Evidence based management? J Perioper Pract, 19(1), 12-13.
    Zwarenstein, M., & Reeves, S. (2006). Knowledge translation and interprofessional collaboration: Where the rubber of evidence-based care hits the road of teamwork. J Contin Educ Health Prof, 26(1), 46-54.

    中文文獻
    王娜，姜寶法. (2006). 循證公共衛生決策的發展現狀及其前景. 中國公共衛生, 22(10), 2.
    吉建偉. (2004). 循證—醫院深化管理的新支點. 中國衛生事業管理, 189(3), 2.
    餘振興, 蘇., 陳聲平 (2009). 醫師對實證醫學推行之認知與電子資料庫使用情形初探－以某區域教學醫院爲例. 臺灣家庭醫學雜誌, 19(2), 71-80.
    吳定 (Ed.). (1996). 公務管理. 臺北: 華視.
    吳明順. (2007). 以團體觀摩競賽提昇實證醫學的教學成效. 台灣醫學, 11(4), 425-430.
    林誠. (2005). 醫療產業導入知識管理的績效評估-以個案區域教學醫院為例. 健康管理學刊, 3(1), 14.
    邱浩彰. (2007). 輔仁大學醫學系實證醫學的教學. 醫學教育, 11(3), 193-200.
    胡嘉智. (2007). 組織變革. from 國家圖書館專文:
    徐圭璋. (2008). 實證醫學(EBM)與醫療品質. 醫療品質雜誌, 第2卷(第1期), 16-20.
    徐金耀. (2008). 循證衛生管理的探討. 醫學與哲學, 29(2), 2.
    郭耿南, 陳. 王. (2007). 實證醫學:醫療照護決策 (1 ed.). 臺北市: 合記圖書.
    陳文欽. (2004). 從資源基礎理論探討醫療產業經營關鍵成功因素--策略矩陣分析法之應用. 遠東學報, 21(3), 501-510.
    陳孟侃. (2008). 實證醫學文獻查證應用類推廣組銀獎機構之經驗分享. 醫療品質雜誌, 2(3), 82-85.
    陳傑峰. (2004). 實證醫學於健康照護之應用. 醫療爭議審議報導, 9, 141-146.
    陳傑峰, 邱. (2008). 實證醫學之知識轉譯地圖. 台灣醫學, 12(4), 455-460.
    楊培銘. (2004a). 實證醫學與健保爭議審議. 醫療爭議審議報導, 7(11), 4.
    楊培銘. (2004b). 實證醫學與健康照護. 醫療爭議審議報導, 13, 196-198.
    詹中原. (2006). 組織變革之因應.
    賴鈺嘉. (2009). 小型醫院推動EBM之經驗分享. Paper presented at the 台灣實證醫學年會.
    羅恆廉. (2008). 2007 年實證醫學文獻查證應用競賽資料. Journal of Health Care Quality, 2(4), 89-93.
    羅恆廉. (2009). 實證醫學與考科藍系統性回顧之發展近況. [行政院衛生署 醫療爭議審議委員會]. 醫療爭議審議報導, 40(5), 8.
    許星瑩. (2009). 我國醫院醫療品質監督評價指標體系的循證評價. 現代預防醫學, 36(6), 1076-1095.
    趙寧志. (2007). 現代醫院品質管制模式的探討. 華北國防醫藥, 19(4), 3.
    鄭木明. (2005). 循證醫學 臨床醫學的新模式. 循證醫學, 5(5), 4.

    QR CODE