无锡市公立医院管理体制改革剖析

无锡市在公立医院管理体制改革中，通过建立与卫生行政部门平行的医院管理中心来承担政府办医的职能。这种模式力图在提高公立医院内部管理的自治化水平的同时，增强政府监管的力度与公平性，从而促进政府办医目标的全面实现。     

医疗成本压力之痛

据陕西省卫生厅发布的2003～2007年政府办医院运营状况分析显示，政府对公立医院的补偿已从2003年的10．97％下降到2007年的8．51％。而与此同时，该省政府办医院资产负债率则从2003年的27．72％上升到2007年的32．89％。在政府补助严重不足和通胀压力进一步加大的情况下，医院的经营处境如何，采取了哪些应对措施。记者日前采访了几位公立医院的院长。     

公立医院改革:可否走第三条路?

近期有机会接受政府委托对一家公立医院改革试点医院进行了评估,与国内众多公立医院改革试点不同,这家医院采用了"公私合作"的ROT(Restructure-Operate-Transfer;重构-运营-移交)模式,由一家民营医疗机构无息借款给政府举办的公立医院,用于医院设施和内外环境的改造,在不改变公立     

中美医疗机构分类管理的比较研究

在美国,根据医院经营方式和所有权不同,从广义上可分为营利性、非营利性和政府办的公立医院三大类型.营利性医院与非营利性医院的区分,并不在于是否盈利.所有医疗单位,包括公立医院都必须有盈利,否则必将倒闭.在私立医院中,并不是营利性医院占多数,而是非营利性医院占多数.     

公立医院改制，谨慎的选择

公立医院改革目标，就是改变公立医院当前“不伦不类”的状况，让其回到分类管理的框架之中。改革路径有三：一是改为名副其实的公立医院，基建、硬件投入和人员工资主要由政府支付，其他变动成本可以从市场或社会保障获得补偿。二是进行产权转换，成为非政府的非营利性医院，可以吸收社会资金，减轻政府社会管理负担，同样可以保证医院的社会公益性。三是私有化，也就是改制成为营利性医疗机构。置换的资产用于公益性卫生事业。如果坚持政府主导和“公益性”导向的原则，第一条路径应该是主流，但与改制无关；第二条路径是次优选择；第三条路径往往是成本最大而社会效益并不明显的，应该是最谨慎的选择。     

公立医院改制有多种方式

公立医院改制是一个渐进的过程，包括产权与管理经营权改革两个部分，有公立医院所有权与经营权分离、自主化医院、公司化医院、私立医院等形式。也就是说，公立医院改制可以有多种方式，比如可以改制为国有民营（托管）医院、混合所有制医院、合资合作医院、股份制医院、私有制医院等。     

警惕改革中避重就轻倾向

对于公立医院改革,新医改方案的基本精神就是要调整政府职能,加强政府对于公立医院的宏观监管职能,将政府作为公立医院所有者的职能与具体管理医院的微观管理职能分离开来;通过调整政府与公立医院的关系,使得医院能够集中进行微观管理、提高运营效率和服务质量。此外,还要增加民营医疗服务的力量,缩小公立医疗服务的份额。     

公立医院的资源配置与结构调整

公立医院的资源配置和调整首先要根据社会经济的变化进行修订和完善，并建立动态的调控机制。目前，公立医疗资源的存量不仅应该基本稳定，而且应该有所发展，才能体现其主体地位。政府办的二、三级医院是现有资源存量中的优质资源，要适度发展，以满足群众多层次多样化的健康需求。由于城乡二元社会经济结构所造成城乡公立医疗资源配置不合理的状况，通过整合提高资源利用效率，同时要切实加大对农村卫生的投入，加强城乡社区卫生机构建设。改革公立医院办医主体实现形式，鼓励社会和民间资本参与公立医院建设。公立医院要重视院内资源管理，实现人尽其才，物尽其用。     

医院经营者和员工对公立医院体制改革态度的调查分析

目的　了解公立医院中医院管理者、学科带头人和技术骨干对公立医院体制改革的态度 ,探讨公立医院体制改革的模式与方法。方法　设计调查问卷 ,现场无记名调查 ,并进行统计分析。结果对 5 5所二三级医院 190 4人调查认为 ,有 84 9%赞同所在单位体制改革 ,有 89 7%的人能积极参与 ,有86 8%的人认为体制改革应从大中型医院起步 ,有 96 6 %的人选择国有控股的股份制、国有民营、非公有制医院等模式 ,其中有 6 6 %的人选择国有控股的股份制改革模式。结论　大多数公立医院的医院管理者、学科带头人和技术骨干等都高度认同和积极支持公立医院体制改革。他们对公立医院体制改革的模式和方法等 ,与政府出台的指导性意见一致 ,适时推进公立医院体制改革已具备良好的思想基础。     

政府缺位与医患纠纷的治理

一、政府缺位对医患关系的深层影响及其表现 1．政府投入不足。加大了医院和病人的压力，激化医患矛盾。在目前的医疗系统中，90％以上是公立医院，民营资本和公益组织进入还有很多障碍，因此医疗行业还是政府垄断行业。但是在公立医院的具体运作过程中，政府又下放了经营权和药品定价权，医院、医生的收入与经营挂钩，导致很多医院、医生唯利是图。这样的医疗系统，既改变了原来由国家提供医疗服务的优势，又缺乏公平竞争，从而集中了两个体制的弊端。可以说这是医患纠纷加剧的根源。     

L.I.F.E. and D.E.A.T.H

In this short, rhetorical article, I offer a thought experiment that seeks to make an analogy between ‘life’ and ‘disease’. This article was written whilst under the influence of Nietzsche, and I hope that readers will not mistake the polemical style and the occasional nod towards humour for flippancy. This is a serious subject, and this article attempts to ask, inexplicitly, a serious question. If we do suspend our subjective value judgements about life, and strip away what might be considered the ‘dogma’ of value in life, what effect might this have on our feelings towards voluntary euthanasia, and what can our reaction to that thought experiment tell us?     

A.S.P.E.N. Clinical Guidelines

Background: Children with severe intestinal failure and prolonged dependence on parenteral nutrition are susceptible to the development of parenteral nutrition–associated liver disease (PNALD). The purpose of this clinical guideline is to develop recommendations for the care of children with PN‐dependent intestinal failure that have the potential to prevent PNALD or improve its treatment. Method: A systematic review of the best available evidence to answer a series of questions regarding clinical management of children with intestinal failure receiving parenteral or enteral nutrition was undertaken and evaluated using concepts adopted from the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) Working Group. A consensus process was used to develop the clinical guideline recommendations prior to external and internal review and approval by the American Society for Parenteral and Enteral Nutrition Board of Directors. Questions: (1) Is ethanol lock effective in preventing bloodstream infection and catheter removal in children at risk of PNALD? (2) What fat emulsion strategies can be used in pediatric patients with intestinal failure to reduce the risk of or treat PNALD? (3) Can enteral ursodeoxycholic acid improve the treatment of PNALD in pediatric patients with intestinal failure? (4) Are PNALD outcomes improved when patients are managed by a multidisciplinary intestinal rehabilitation team?     

A.S.P.E.N. Clinical Guidelines

Background: Due to the high prevalence of obesity in adults, nutrition support clinicians are encountering greater numbers of obese patients who require nutrition support during hospitalization. The purpose of this clinical guideline is to serve as a framework for the nutrition support care of adult patients with obesity. Method: A systematic review of the best available evidence to answer a series of questions regarding management of nutrition support in patients with obesity was undertaken and evaluated using concepts adopted from the Grading of Recommendations, Assessment, Development and Evaluation working group. A consensus process, that includes consideration of the strength of the evidence together with the risks and benefits to the patient, was used to develop the clinical guideline recommendations prior to multiple levels of external and internal review and approval by the A.S.P.E.N. Board of Directors. Questions: (1) Do clinical outcomes vary across levels of obesity in critically ill or hospitalized non?intensive care unit (ICU) patients? (2) How should energy requirements be determined in obese critically ill or hospitalized non‐ICU patients? (3) Are clinical outcomes improved with hypocaloric, high protein diets in hospitalized patients? (4) In obese patients who have had a malabsorptive or restrictive surgical procedure, what micronutrients should be evaluated?     

A.S.P.E.N. Clinical Guidelines

Background: Hyperglycemia is a frequent occurrence in adult hospitalized patients who receive nutrition support. Both hyperglycemia and hypoglycemia (resulting from attempts to correct hyperglycemia) are associated with adverse outcomes in diabetic as well as nondiabetic patients. This American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Clinical Guideline summarizes the most current evidence and provides guidelines for the desired blood glucose goal range in hospitalized patients receiving nutrition support, the definition of hypoglycemia, and the rationale for use of diabetes‐specific enteral formulas in hospitalized patients. Method: A systematic review of the best available evidence to answer a series of questions regarding glucose control in adults receiving parenteral or enteral nutrition was undertaken and evaluated using concepts adopted from the Grading of Recommendations, Assessment, Development and Evaluation working group. A consensus process was used to develop the clinical guideline recommendations prior to external and internal review and approval by the A.S.P.E.N. Board of Directors. Results/Conclusions: 1. What is the desired blood glucose goal range in adult hospitalized patients receiving nutrition support? We recommend a target blood glucose goal range of 140–180 mg/dL (7.8–10 mmol/L). (Strong) 2. How is hypoglycemia defined in adult hospitalized patients receiving nutrition support? We recommend that hypoglycemia be defined as a blood glucose concentration of <70 mg/dL (<3.9 mmol/L). (Strong) 3. Should diabetes‐specific enteral formulas be used for adult hospitalized patients with hyperglycemia? We cannot make a recommendation at this time.