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为规范医疗行为、改进医疗质量、控制不合理医疗费用、探索农村医疗机构与宏观管理政策双向联动机制,依据PRECEDE-ROCEED模型和机制设计理论提供的分析框架,设计以临床路径管理、政府部门联动的补偿机制改革和信息化监管三方同步推进的干预模式,在卫XI项目地区开展综合干预试点研究,并采用逐步推进式方式,有计划逐步地将综合干预措施推广到卫XI项目和非项目地区,为公立医院改革的突破路径积累经验和借鉴。  相似文献
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ISSUES: Countries and international organizations have recently renewed their interest in how health systems perform. This has led to the development of performance indicators for monitoring, assessing, and managing health systems to achieve effectiveness, equity, efficiency, and quality. Although the indicators populate conceptual frameworks, it is often not very clear just what the underlying concepts might be or how effectiveness is conceptualized and measured. Furthermore, there is a gap in the knowledge of how the resultant performance data are used to stimulate improvement and to ensure health care quality. ADDRESSING THE ISSUES: This paper therefore explores, individually, the conceptual bases, effectiveness and its indicators, as well as the quality improvement dynamics of the performance frameworks of the UK, Canada, Australia, US, World Health Organization, and Organisation for Economic Co-operation and Development. RESULTS: We see that they all conceive health and health system performance in one or more supportive frameworks, but differ in concepts and operations. Effectiveness often implies, nationally, the achievement of high quality outcomes of care, or internationally, the efficient achievement of system objectives, or both. Its indicators are therefore mainly outcome and, less so, process measures. The frameworks are linked to a combination of tools and initiatives to stimulate and manage performance and quality improvement. CONCLUSIONS: These dynamics may ensure the proper environment for these conceptual frameworks where, alongside objectives such as equity and efficiency, effectiveness (therefore, quality) becomes the core of health systems performance.  相似文献
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构建卫生服务质量的概念框架   总被引:1,自引:0,他引:1  
卫生服务质量包括可及性和有效性两个根本维度,体现在卫生服务结构、过程和结果三个过程中。有效性包括临床服务和人际服务两个关键成分。当研究群体卫生服务质量的时候,应该引入公平性和效率的概念。作者强调政府和卫生服务提供者应该重视卫生服务质量,而不仅是医疗服务质量;重视临床和人际服务质量,而不仅是临床服务质量。按照本文提出的质量概念框架,作者对建立我国卫生服务质量评价指标体系进行讨论。  相似文献
4.
农村地区吸引和稳定卫生人员研究的理论框架   总被引:1,自引:0,他引:1       下载免费PDF全文
本文提出了一个研究吸引和稳定农村地区卫生人员的理论框架。该框架以卫生人员的工作意愿及其影响因素为核心,同时兼顾分析劳动力市场供需关系和强制性人力资源政策对卫生人员工作选择的影响。在我国深入开展卫生体制改革的历史潮流中,希望这一分析有助于政策制定者和研究人员加强对卫生人力资源,尤其是农村地区卫生人员吸引和稳定的重视和研究。  相似文献
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Abstract  Evidence-based practice (EBP) has become a critical concept for ethical, accountable professional nursing practice. However, critical analysis of the concept suggests that EBP overemphasizes the value of scientific evidence while underplaying the role of clinical judgement and individual nursing expertise. This paper explores the empiricist position that valid evidence is the basis for all knowledge claims. We argue against the positivist idea that science should be regarded as the only credible means for generating evidence on which to base knowledge claims. We propose that the process of critically reflecting on evidence is a fundamental feature of empirical epistemology. We suggest that critical reflection on evidence derived from science, arts and humanities and, in particular, nursing practice experience can provide a sound basis for knowledge claims. While we do not attempt to define what counts as evidence, it is argued that there is much to be gained by making the processes of critical reflection explicit, and that it can make a valid contribution to expert nursing practice, without recourse to irreducible concepts such as intuition.  相似文献
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Health care is consuming an ever larger share of national resources in the United States. Measures to contain costs and evidence of unexplained variation in patient outcomes have led to concern about inadequacy in the quality of health care. As a measure of quality, the evaluation of hospitals through analysis of their discharge databases has been suggested because of the scope and economy offered by this methodology. However, the value of the information obtained through these analyses has been questioned because of the inadequacy of the clinical data contained in administrative databases and the resultant inability to control accurately for patient variation. We suggest, however, that the major shortcoming of prior attempts to use large databases to perform across-facility evaluation has resulted from the lack of a conceptual framework to guide the analysis. We propose a framework which identifies component areas and clarifies the underlying assumptions of the analytic process. For each area, criteria are identified which will maximize the validity of the results. Hospitals identified as having unexpectedly high unfavorable outcomes when our framework is applied will be those where poor quality will most likely be found by primary review of the process of care. We outline the following criteria for the selection of disease-outcome pairs to be studied in large administrative database analysis: (1) disease entities or clinical states selected should be well defined and easily diagnosed; (2) if diagnostic classification systems are used, disease groups should be homogeneous as to the clinical states they contain; (3) the disease entities should be prevalent; (4) a plausible link should exist between the quality (process) of care and the frequency of the outcome; (5) types of care which conform to acceptable practice standards but still lead to variation in the outcome of interest should be excluded from the analysis; (6) the outcomes should be prevalent; (7) constraints of the ICD-9 coding system should be understood such that only those disease-outcome pairs least affected by these limitations are selected for analysis; (8) constraints of the structure of the database should be considered when the analysis is performed; and (9) disease-outcome pairs should be chosen where there is agreement on the processes of care that affect the outcome of interest, either favorably or unfavorably.  相似文献
8.
FOCUS: The paper focuses on public health practitioners who collectively represent one of three key workforce groups identified by England's Chief Medical Officer as critical to the successful delivery of national public health policy priorities. QUESTION: We report on two areas of work which attempt to address the following two-part question: in developing the public health practitioner workforce in England, what is needed, and how do we do it? APPROACH: First, we describe a five-component conceptual framework for developing the public health workforce which is grounded in data derived from a national Open Space event hosted by the University of the West of England in March 2005. The five components are (i) strategic support and oversight; (ii) national technical and professional support; (iii) national career building; (iv) local organisational development, and (v) sub-regional skills development. Key elements of each component are described in the paper. Second, we describe in some detail a new multidisciplinary skills development programme which illustrates one of the framework components (sub-regional skills development). The programme, established in January 2005, is aimed at three key groups of public health practitioners: health visitors (specialist community public health nurse), school nurses and environmental health officers. Its main features and some initial evaluation findings are presented. CONCLUSIONS: To be effective, activities aimed at supporting the development of the public health practitioner workforce should, where possible, aim to be congruent with core public health principles of self-determination and collective responsibility. We also conclude that leadership and vision at a national level, combined with local implementation of evidence-based training programme such as the one described could help to achieve much greater and more rapid progress in skilling up the existing public health practitioner workforce than has been possible up to now. But we note that this requires sustained investment, robust sector-wide delivery frameworks, and a group of committed local public health champions.  相似文献
9.
This paper reviews some major epidemics in the past 5,000 years in human history and derives 12 lessons in the context of epidemiologic surveillance. The corresponding 12 challenges proposed in this paper could be used to guide us in building a better and more comprehensive surveillance system in the 21st century. This will be achieved by: continuing the evolvement and improvement of surveillance; maintaining on an ongoing basis; being systematic; being population-based; including risk and intervention indicators in the data base; more efficient data analysis; stimulating etiologic research; improving forecasting capability; linking to development of intervention; evaluating the intervention; better ways of information dissemination; and dissemination without prejudice.  相似文献
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The term ``paradox' signifies acontradiction of some sort. Modern health careappears to be rich in contradictions, and it isclaimed to be paradoxical in a number of ways.In particular health care is held to be aparadox itself: it is supposed to do good, butis accused of doing harm. The objective of thisarticle is to investigate whether the conceptof paradox can serve as a framework foranalysing pressing problems in modern healthcare. To pursue this, three distinctive levelsof paradox are identified: resolvableparadoxes, antinomies and aporias. The analysisreveals that when facing the challenges ofmodern health care the focus of attentionshould be to resolve the resolvable paradoxes,to acknowledge the antinomies and to learn tolive with the aporias.  相似文献
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