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关注|变了味的床位周转率,让住院更难了……

2018-06-06 宗建平 医师报

作为一位急诊医师,每天遇到的最大问题是患者住院难,有许多危重患者收不进,这是一个非常突出的问题,几乎消耗了急诊医师人员的主要精力与资源,造成这种结果有许多因素造成的,但床位周转率的考核是一个重要的因素。

作为一位急诊医师,每天遇到的最大问题是患者住院难,有许多危重患者收不进,这是一个非常突出的问题,几乎消耗了急诊医师人员的主要精力与资源,造成这种结果有许多因素造成的,但床位周转率的考核是一个重要的因素。

床位周转率是指一定时间内平均每张床收治了多少患者,这是医院考核和医院等级评定的一个很重要指标,增加床位周转率,减少每床平均住院日是科室和医院的管理水平体现,在当今中国大陆大医院住院床位极其紧张的当下,增加床位周转率就能让更多的患者能够及时住院治疗,这个考核指标初衷是没有问题。

但结果没有达到预期的目的,还而造成住院更难,尤其是疑难复杂的患者。为什么床位周转率考虑会变了味呢?

作为在住院部工作的医护人员明显感到这个考核指标的压力,几乎所有医院与科室考核特别绩效挂钩,完不成这个指标直接影响到个人的收入多少,为了完成这位指标,慢慢开始变味了。

在医院存在人力资源、设备等要素配置不足的情况下,许多检查预约登记时间过长,疑难复杂的患者要完成检查等待时间更长,没有办法完成周转率考核指标,只得学会变通,为了完成转周率,不得不收住那些住院时间短和周转率快的患者,甚至本来可以不用住院的患者,例包皮手术、肠息肉摘除、轻型肺炎等成为大医院的抢手“货”。

另外一类考核指标门诊均次费用和住院均次费用也推波助澜,这类患者的住院既能降低门诊和住院均次费用,又能提高床位周转率。

这一变通结果反而使住院床位更加紧张,疑难危重患者要住院反而成了大问题,急诊科中疑难危重患者收不进,多收疑难危重患者科室反而倒霉;这种现象的背后带来更大的问题是将有限的医疗保费用资源被大量“合理”地消耗,这不是我们想看到的结果。

这种考核指标是一种典型的终端考核指标,绝大多数情况下终端考核指标是有其它合理的地方,最典型的是18世纪末英国政府把犯人发配到澳洲事件。

18世纪末期,英国政府决定把犯了罪的英国人统统发配到澳洲去。一些私人船主承包了英国往澳洲大规模地运送犯人的工作。英国政府实行的办法是以上船的犯人数支付给船主费用。一旦船只离开了岸,船主按人数拿到了政府的钱,对于这些人能否能远涉重洋活着到达澳洲就不管不问了。有些船主为了降低费用,甚至故意断水断食。英国政府费了大笔资金,却没能达到大批移民的目的。英国政府想了很多办法,例在派政府官员监督、派了医生及对船主进行教育培训,情况依然没有好转,死亡率一直居高不下。一位英国议员发现是制度的缺陷,问题是政府给予船主报酬是以上船人数来计算的,结果政府采用了以到澳洲上岸的人数为准计算报酬,问题迎刃而解。

这个案例告诉我们,绩效考核的导向作用很重要,绩效导向决定了员工的行为方式,如果认为绩效考核是惩罚员工的工具,通过处罚来完成目的,那么在实际情况下,员工没办法完成,一定会想办法去变通,避免犯“错”,结果一定会忽视创造性,一定会忽视医疗质量,降低医疗水平,目标就无法达成。

周转率考核是一种终端考核指标,那为什么还会出现问题呢?为了说明这个问题还是从管理学上另一个重要案例去说起。那就是《关上你的窗帘》的故事说起。据说美国华盛顿广场有名的杰弗逊纪念大厦,因年深日久,墙面出现裂纹。为能保护好这幢大厦,有关专家进行了专门研讨。最初大家认为损害建筑物表面的元凶是侵蚀的酸雨,专家们进一步研究,却发现对墙体侵蚀最直接的原因,是每天冲洗墙壁所含的清洁剂对建筑物有酸蚀作用。因为墙壁上每天都有大量的鸟粪,而每天需要用清洁剂冲洗才能达到保洁的目的。

进一步追究,因为墙上有很多蜘蛛,才引来很多的燕子。大厦四周有蜘蛛喜欢吃的飞虫,飞虫在这里繁殖特别快,背后的原因是这里的尘埃最适宜飞虫繁殖。因为开着的窗阳光充足,大量飞虫聚集在此,超常繁殖,由此发现解决的办法很简单,只要关上整幢大厦的窗帘。此前专家们设计的复杂而又详尽的维护方案也就成了一纸空文。

彼得圣吉在《第五项修炼》里提到,问题的解决方案既有“根本解”,也有“症状解”,“症状解”能迅速消除问题的症状,但只有暂时的作用,而且往往有拖延问题解决或加深问题的副作用,使问题更难得到根本解决。“根本解”是根本的解决方式,只有通过系统思考,看到问题的整体,才能发现“根本解”。

这种管理方法我把它名命为起点管理,医院也一样,为了更好地服务患者,特别三甲医院,首先要考核危重患者的收住率无可非疑,但必须要采用起点考核的办法,在这个基础上,再去考核周转率,换一句话说考核要从患者入院的第一天起考核各个环节,特别是要考核第一天检查的完成率,努力减少患者等待检查的时间,如果有了起端管理,医院的管理者们才会去考虑人力资源、设备配置等,真正从管理上去解决这些问题,周转率的问题就会水到渠成,就能达到更好为危重疑难患者服务,这才是我们的目标,不要让考核指标变了味。

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    2018-06-07 明月清辉

    谢谢分享.学习了

    0

  3. 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GetPortalCommentsPageByObjectIdResponse(id=322149, encodeId=4b6d322149ae, content=^_^^_^^_^, beContent=null, objectType=article, channel=null, level=null, likeNumber=77, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/vi_32/Swp2ehfHpiciczeTntUyQOlIGMzQ705ic67sdMTVMbwTv7KbmlUvxrGvRSvQZjPkz7ib5tEDfIaORgczPtmHDpwojg/0, createdBy=c54b2163125, createdName=wqkm, createdTime=Thu Jun 07 06:54:52 CST 2018, time=2018-06-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=322131, encodeId=bdb132213132, content=阅, beContent=null, objectType=article, channel=null, level=null, likeNumber=88, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/vi_32/fhZdOu27e88Voqh19n8eF8cLplo8L4nicKtH0WnE3KFELXns5XDu8rsiceK2HHDZc2SEStia5VV3Pia2QLMVqlWbHw/0, createdBy=6e012139475, createdName=神功盖世, createdTime=Thu Jun 07 06:41:14 CST 2018, time=2018-06-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=322112, encodeId=6d443221124a, content=一起学习学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=88, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/vi_32/TDiaAWyicHgedzX3wKo3qcxudVJib7AfibfvNeufHRF2jG3Bw8MmZyWjIhtBV1mpJI7Sy9n7RcBKK5t3CuOKuOFxkg/0, createdBy=dd702206933, createdName=wzb521zf, createdTime=Thu Jun 07 06:25:15 CST 2018, time=2018-06-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=322106, encodeId=6f01322106d9, content=学了, beContent=null, objectType=article, channel=null, level=null, likeNumber=63, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTKcmgibQ4oCrK7Z6f4CvMcs4k7QUGCkhopcGxvxaBfVciadECSIwaRVttllIOEKumpEaRrq5PoOUxow/0, createdBy=e3bb2081203, createdName=哈哈869, createdTime=Thu Jun 07 06:19:19 CST 2018, time=2018-06-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=322093, encodeId=58d532209302, content=好好好好好好好好, beContent=null, objectType=article, channel=null, level=null, likeNumber=77, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/08/29/bbc5cc0eed9b8d17623d2fd49dbdf19a.jpg, createdBy=79522135794, createdName=yjs木玉, createdTime=Thu Jun 07 05:11:40 CST 2018, time=2018-06-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=322090, encodeId=995f322090ed, content=学习学习学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=49, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfNLvzZhgPxRkia1DP5MpwEgtXo1XhXA11xD6MWKxunAZFXKSNic0fWHUQx83oNHPlRMxxIctM83QKeCLkJpMibibiaC/0, createdBy=7e581734408, createdName=深海的鱼, createdTime=Thu Jun 07 04:01:38 CST 2018, time=2018-06-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=322085, encodeId=bc5632208554, content=学习了很有用, beContent=null, objectType=article, channel=null, level=null, likeNumber=45, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib3IzoRn621JdKCFUI4XvNELcibocrAVU6aUzEVDSaf3rYH08PUYUiagGqxAEhj8g9WqqNvD1CupIpCrmnR2OrqHZh/0, createdBy=7f181365728, createdName=飛歌, createdTime=Thu Jun 07 00:40:50 CST 2018, time=2018-06-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=322083, encodeId=7d2832208364, content=学习了很有用, beContent=null, objectType=article, channel=null, level=null, likeNumber=65, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib3IzoRn621JdKCFUI4XvNELcibocrAVU6aUzEVDSaf3rYH08PUYUiagGqxAEhj8g9WqqNvD1CupIpCrmnR2OrqHZh/0, createdBy=7f181365728, createdName=飛歌, createdTime=Thu Jun 07 00:40:08 CST 2018, time=2018-06-07, status=1, ipAttribution=)]
    2018-06-07 wqkm

    ^_^^_^^_^

    0

  4. 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attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfNLvzZhgPxRkia1DP5MpwEgtXo1XhXA11xD6MWKxunAZFXKSNic0fWHUQx83oNHPlRMxxIctM83QKeCLkJpMibibiaC/0, createdBy=7e581734408, createdName=深海的鱼, createdTime=Thu Jun 07 04:01:38 CST 2018, time=2018-06-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=322085, encodeId=bc5632208554, content=学习了很有用, beContent=null, objectType=article, channel=null, level=null, likeNumber=45, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib3IzoRn621JdKCFUI4XvNELcibocrAVU6aUzEVDSaf3rYH08PUYUiagGqxAEhj8g9WqqNvD1CupIpCrmnR2OrqHZh/0, createdBy=7f181365728, createdName=飛歌, createdTime=Thu Jun 07 00:40:50 CST 2018, time=2018-06-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=322083, encodeId=7d2832208364, content=学习了很有用, beContent=null, objectType=article, channel=null, level=null, likeNumber=65, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib3IzoRn621JdKCFUI4XvNELcibocrAVU6aUzEVDSaf3rYH08PUYUiagGqxAEhj8g9WqqNvD1CupIpCrmnR2OrqHZh/0, createdBy=7f181365728, createdName=飛歌, createdTime=Thu Jun 07 00:40:08 CST 2018, time=2018-06-07, status=1, ipAttribution=)]
    2018-06-07 神功盖世

    0

  5. 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attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfNLvzZhgPxRkia1DP5MpwEgtXo1XhXA11xD6MWKxunAZFXKSNic0fWHUQx83oNHPlRMxxIctM83QKeCLkJpMibibiaC/0, createdBy=7e581734408, createdName=深海的鱼, createdTime=Thu Jun 07 04:01:38 CST 2018, time=2018-06-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=322085, encodeId=bc5632208554, content=学习了很有用, beContent=null, objectType=article, channel=null, level=null, likeNumber=45, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib3IzoRn621JdKCFUI4XvNELcibocrAVU6aUzEVDSaf3rYH08PUYUiagGqxAEhj8g9WqqNvD1CupIpCrmnR2OrqHZh/0, createdBy=7f181365728, createdName=飛歌, createdTime=Thu Jun 07 00:40:50 CST 2018, time=2018-06-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=322083, encodeId=7d2832208364, content=学习了很有用, beContent=null, objectType=article, channel=null, level=null, likeNumber=65, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib3IzoRn621JdKCFUI4XvNELcibocrAVU6aUzEVDSaf3rYH08PUYUiagGqxAEhj8g9WqqNvD1CupIpCrmnR2OrqHZh/0, createdBy=7f181365728, createdName=飛歌, createdTime=Thu Jun 07 00:40:08 CST 2018, time=2018-06-07, status=1, ipAttribution=)]
    2018-06-07 wzb521zf

    一起学习学习

    0

  6. 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attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfNLvzZhgPxRkia1DP5MpwEgtXo1XhXA11xD6MWKxunAZFXKSNic0fWHUQx83oNHPlRMxxIctM83QKeCLkJpMibibiaC/0, createdBy=7e581734408, createdName=深海的鱼, createdTime=Thu Jun 07 04:01:38 CST 2018, time=2018-06-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=322085, encodeId=bc5632208554, content=学习了很有用, beContent=null, objectType=article, channel=null, level=null, likeNumber=45, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib3IzoRn621JdKCFUI4XvNELcibocrAVU6aUzEVDSaf3rYH08PUYUiagGqxAEhj8g9WqqNvD1CupIpCrmnR2OrqHZh/0, createdBy=7f181365728, createdName=飛歌, createdTime=Thu Jun 07 00:40:50 CST 2018, time=2018-06-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=322083, encodeId=7d2832208364, content=学习了很有用, beContent=null, objectType=article, channel=null, level=null, likeNumber=65, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib3IzoRn621JdKCFUI4XvNELcibocrAVU6aUzEVDSaf3rYH08PUYUiagGqxAEhj8g9WqqNvD1CupIpCrmnR2OrqHZh/0, createdBy=7f181365728, createdName=飛歌, createdTime=Thu Jun 07 00:40:08 CST 2018, time=2018-06-07, status=1, ipAttribution=)]
    2018-06-07 哈哈869

    学了

    0

  7. 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attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfNLvzZhgPxRkia1DP5MpwEgtXo1XhXA11xD6MWKxunAZFXKSNic0fWHUQx83oNHPlRMxxIctM83QKeCLkJpMibibiaC/0, createdBy=7e581734408, createdName=深海的鱼, createdTime=Thu Jun 07 04:01:38 CST 2018, time=2018-06-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=322085, encodeId=bc5632208554, content=学习了很有用, beContent=null, objectType=article, channel=null, level=null, likeNumber=45, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib3IzoRn621JdKCFUI4XvNELcibocrAVU6aUzEVDSaf3rYH08PUYUiagGqxAEhj8g9WqqNvD1CupIpCrmnR2OrqHZh/0, createdBy=7f181365728, createdName=飛歌, createdTime=Thu Jun 07 00:40:50 CST 2018, time=2018-06-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=322083, encodeId=7d2832208364, content=学习了很有用, beContent=null, objectType=article, channel=null, level=null, likeNumber=65, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib3IzoRn621JdKCFUI4XvNELcibocrAVU6aUzEVDSaf3rYH08PUYUiagGqxAEhj8g9WqqNvD1CupIpCrmnR2OrqHZh/0, createdBy=7f181365728, createdName=飛歌, createdTime=Thu Jun 07 00:40:08 CST 2018, time=2018-06-07, status=1, ipAttribution=)]
    2018-06-07 yjs木玉

    好好好好好好好好

    0

  8. 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level=null, likeNumber=65, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib3IzoRn621JdKCFUI4XvNELcibocrAVU6aUzEVDSaf3rYH08PUYUiagGqxAEhj8g9WqqNvD1CupIpCrmnR2OrqHZh/0, createdBy=7f181365728, createdName=飛歌, createdTime=Thu Jun 07 00:40:08 CST 2018, time=2018-06-07, status=1, ipAttribution=)]
    2018-06-07 深海的鱼

    学习学习学习

    0

  9. 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attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfNLvzZhgPxRkia1DP5MpwEgtXo1XhXA11xD6MWKxunAZFXKSNic0fWHUQx83oNHPlRMxxIctM83QKeCLkJpMibibiaC/0, createdBy=7e581734408, createdName=深海的鱼, createdTime=Thu Jun 07 04:01:38 CST 2018, time=2018-06-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=322085, encodeId=bc5632208554, content=学习了很有用, beContent=null, objectType=article, channel=null, level=null, likeNumber=45, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib3IzoRn621JdKCFUI4XvNELcibocrAVU6aUzEVDSaf3rYH08PUYUiagGqxAEhj8g9WqqNvD1CupIpCrmnR2OrqHZh/0, createdBy=7f181365728, createdName=飛歌, createdTime=Thu Jun 07 00:40:50 CST 2018, time=2018-06-07, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=322083, encodeId=7d2832208364, content=学习了很有用, beContent=null, objectType=article, channel=null, level=null, likeNumber=65, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib3IzoRn621JdKCFUI4XvNELcibocrAVU6aUzEVDSaf3rYH08PUYUiagGqxAEhj8g9WqqNvD1CupIpCrmnR2OrqHZh/0, createdBy=7f181365728, createdName=飛歌, createdTime=Thu Jun 07 00:40:08 CST 2018, time=2018-06-07, status=1, ipAttribution=)]
    2018-06-07 飛歌

    学习了很有用

    0

  10. 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level=null, likeNumber=65, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib3IzoRn621JdKCFUI4XvNELcibocrAVU6aUzEVDSaf3rYH08PUYUiagGqxAEhj8g9WqqNvD1CupIpCrmnR2OrqHZh/0, createdBy=7f181365728, createdName=飛歌, createdTime=Thu Jun 07 00:40:08 CST 2018, time=2018-06-07, status=1, ipAttribution=)]
    2018-06-07 飛歌

    学习了很有用

    0

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