医院门诊就医流程改进.docx

1、医院门诊就医流程改进基于信息技术的医院门诊流程再造研究1 引言牛津英语大辞典（Oxford English Dictionary）对流程（Process）的定义是，“一个或一系列连续有规律的行动，这些行动以确定的方式发生或执行，导致特定结果的实现一个或一系列连续的操作（Operation）。”(Oxford University Press,1978)所谓的就医流程，就是病人就医开始到结束的一系列活动，它属于医院的内部行为，医院安排作用较强。医院的业务流程不同于一般企业，它是一个流程系统，由三大类流程作为支撑，分别为核心流程、支持流程和管理流程，其中核心流程又可以细分为门诊流程、急诊流程和住院

2、流程。考虑到无论服务的“面上”，还是“量上”，对病人影响最大的流程是门诊流程。因此在本次就医流程讨论的重心放在“门诊就医流程”。The definition of word “process” in Merriam-Websters Collegiate Dictionary is “a natural phenomenon marked by gradual changes that lead toward a particular result”. Hospital process is defined by patient activities from beginning to end

3、 of hospitalization. It is an internal behavior under the arrangement and control of hospital itself. The business process of hospitals is different from normal enterprises. It is a workflow system, supported by three categories of workflows, which are core workflow, supportive workflow and manageme

4、nt workflow. The core workflow comprises outpatient workflow, emergency workflow and inpatient workflow. Taking into account the volume of outpatients and current service quality, outpatient workflow is essential to the patient satisfaction. Therefore this paper focuses on “outpatient workflow”.有学者通

5、过问卷调查法随机抽取200名门诊患者，对当日门诊数据及门诊各部门相关工作情况进行分析，研究发现目前我国大部分医院人均挂号至就诊时间平均为157.2 分钟，诊室诊断时间为18.89 分钟，预约至检查时间平均为106.4 分钟，取药等待时间平均为12.84 分钟(何谦, 廖清书, 刘建萍, 2005)。以上数据直观说明了医院门诊流程再造的紧迫性，如何从患者的角度考虑安排就诊过程，简化门诊流程的各个环节，减少患者在门诊的停留时间，以达到科学管理，提高门诊整体服务水平。Some researchers interviewed 200 outpatients randomly by using ques

6、tionnaires and analyzed the daily data from outpatient departments (OPD). It showed that in most hospitals in China, in average the waiting time from visit registration to doctor consultation is 157.2 minutes, the time of consultation is 18.89 minutes, the waiting time from appointment to examinatio

7、n is 106.4 minutes, the waiting time for pharmacy dispensary is 12.84 minutes (何谦, 廖清书, 刘建萍, 2005). The above data explicitly illustrated the immediate urgency of hospital outpatient process reengineering. How we can re-arrange the process of outpatient visit and how we can simplify the steps to dec

8、rease waiting time are questions in order to improve OPD service by scientific management.由于“医院流程再造(Hospital process reengineering)是一种有关作业改善的哲学，它在对原有流程深刻理解和科学分析基础上，以病人为核心，通过对原有流程进行系统性重新整合或重组，增加流程中有价值的活动，减少无价值活动，以达到改善服务质量，提高对病人特殊需要的反应速度和降低工作成本的目的”(冯薇, 2005)，本研究主要从三部分来分析医院流程再造活动：一是对现有流程的科学分析以及存在的问题剖析；

9、二是找出现有问题原因并提出再造分析思路；三是提出改进方案，给出流程再造后的流程图。Hospital process reengineering is a philosophy to improve operations. It is based on the profound understanding and scientific analysis, to refactoring or regrouping previous workflow operations systematically from a patient centric point of view, to increase

10、 value added activities and decrease valueless activities, for the purpose of improving service quality, accelerating response to patient and reducing cost. (冯薇, 2005). This paper analyzes the process reengineering activities in three folds. Firstly we analyze existent workflow and problems. Then we

11、 explore the reasons to the problems and paradigm to process reengineering. Thirdly, we propose improvement plan and workflow diagram after process reengineering. 2 医院传统门诊流程现状及存在的问题OPD workflow and existent problems 2.1现状 Current situation一般看来，普通门诊大致可以区分为“挂号-诊断-检查-处方-取药-治疗”这几个过程，但在实际过程中，医院门诊流程并不是清晰的

12、呈现出以六个流程，而出现了“五多一短”的现象，即1）医院病人集中多，2）治疗环节多，3）人群杂、病种多，4）应急变化多，5）医生变换多，6）诊疗时间短。Theoretically, an outpatient visit can be divided into procedures of registration, diagnosis, examination, prescription, pharmacy dispensary and treatment. However, in practice, OPD workflow presents a more complicated proce

13、ss with a phenomenon of 1) large volume of patients, 2) complex medical tasks, 3) mixed groups of patients and miscellaneous diseases, 4) various emergency cases, 5) variation of caregivers services and 6) short time of consultation.图1：医院门诊流程现状2.2问题与挑战图2：门诊流程工序现状分析表1 就诊流程程序统计活动次数操作9移动8检验1等待9总计27由于病人

14、到医院就诊时间是一个随机事件（取决于病人生病的客观事实）且取决于病人的主观意向，因此，就诊时间往往比较集中，门诊高峰现象是门诊工作最显著的特点之一。深层次的研究可以发现，导致这一现象的直接原因是患者有效就诊时间很少（大约只占患者在医院时间的10%），而如果将病人有效就诊时间提高到30%，病人在医院的停留时间将会减少三分之二；若提高到50%，则减少了将近五分之四的停留时间(韩炜, 2004)。为了医院更好的实施门诊流程再造，研究首先对现有流程进行了梳理(如图1所示)，以更好的发现问题、解决问题，为下一步流程再造夯实基础。由图1不难发现，现有流程存在以下几个方面的问题。Time of patien

15、t visit is a random event depending on patient subjective intention. Patient visit time tends to be centralized. High peak phenomenon is one of the most significant characteristics in outpatient department. Another significant phenomenon is that effective time for seeing a doctor is very short, whic

16、h only comprise 10% of patient time in hospital. If we can increase the effective consultation/treatment time to 30%, patient waiting time will be reduced by two thirds. If we increase it to 50%, patient waiting time will be reduced by four thirds(韩炜, 2004). In order to better implement OPD process

17、reengineering, we first analyzed the existent workflow, as shown in figure 1, in order to analyze the problem and further solve the problem. (1) 自然过程长。完成一次看病过程，大致要排6次队(挂号、候诊、检查划价、付费、药品划价、取药)，付三次费（挂号费、药费、辅助检查费）1. Large number of steps: in order to complete a hospital visit, a patient need to wait in

18、lines for six times (registration, waiting for consultation, pricing for examination, payment, medication pricing, pharmacy dispensary), and pay three times (registration fee, medication fee and examination fee).(2) 门诊“三长一短”。挂号时间长、候诊时间长、检查取药时间长以及诊察时间短。2. OPD three longs and one short. Registration t

19、ime is long; waiting time for consultation is long; waiting time for medication/examination is long and consultation/treatment time is short. (3) 检查过程过于烦琐。部分检查预约，如CT、B超等；部分检查具有特殊要求，如空腹、肠道清理等；检查场所分散。3. Examination process is overly complicated. Some examination needs on-site schedule, e.g. CT, Type-B

20、 Ultrasonic. Some examinations have special requirements. e.g. limosis or intestinal requirement. Some examinations are remotely distributed. (4) 导医服务欠缺，服务标识不清。病人盲目流动4. Lack of guide service and clear signs. Patients walk around without clear roadmap. 这些现象导致病人在门诊无效、非诊治时间延长(如图2以及表1所示)，造成门诊的拥挤，病人的烦躁，医

21、院和病人成本（金钱、时间）增加，导致医患矛盾增加，病人就医满意度下降，医院服务受到社会多方指责。The phenomenon results in inefficient and long non-medical time, as shown in Figure 2 and Table 1, which further leads to OPD crowding, patient upset, hospital and patients cost increasing, medical disputes, patient satisfaction decreasing and hospital

22、 being criticized by public. 3. 医院门诊流程再造方案设计Hospital outpatient process reengineering plan3.1 流程再造的必要性Necessity of process reengineering 为了提高门诊服务的运行效率，为患者提供优质快捷的服务，流程再造以分析现有的门诊流程为切入点，以减少门诊流程的中间环节为突破口，提高病人的满意度。具体而言，门诊流程再造要把握三条原则：1）以病人为中心，优化面向病人的就医流程；2）以价值为导向，提高医院经济运行效率；3）以人为本，强调服务团队的整合。In order to im

23、prove the operation efficiency of outpatient service and provide fast and high quality service, process reengineering starts from analyzing existent outpatient workflow, breaks through by reducing intermediate steps of outpatient visit to improve patient satisfaction. In this regards, outpatient pro

24、cess reengineering is based on three principles. (1) Patient centric: optimize for patient hospitalization; (2) Value: guided by value to improve hospital economic efficiency; (3) People oriented: emphasize on integration of service team. 3.2分析Analysis(1) 首先明确流程中增值和非增值的环节1. Clarify value added and n

25、on value added steps.增值环节：就诊、检查、治疗Value added activities: consultation, examination, treatment非增值环节：挂号、候诊、交费、取药Non value added activities: registration, waiting, payment, pharmacy dispensary.(2) 把握病人的“排队问题”2. Seize patient waiting problem每周的高峰期在星期一Peak time during a week is on Monday.每天的高峰期在上午Peak t

26、ime during a day is in the morning. 上午的高峰期在9时至11时 Peak time during morning is from 9am to 11am. (3) 确定影响流程的瓶颈3. Find out the bottlenecks of process非增值环节耗费时间过长Non value added activities take too much time. 空间布局不够合理和人性化Spatial layout is not rational and humanized. 标识不够清晰Guiding signs are not clear eno

27、ugh. 门诊患者就诊流程中，非就诊消耗时间长，存在问题多，制定相应的策略以优化门诊流程，缩短患者就诊等待时间是非常必要的(何谦, 廖清书, 刘建萍, 2005)针对瓶颈，实行门诊就医流程再造或优化In the process of outpatient visit, a large part of the time is consumed by non medical activities besides other problems. Its essential to make a strategy to optimize outpatient process and decrease t

28、he waiting time of patient (何谦, 廖清书, 刘建萍, 2005)3.3 设计方法Methodology 清除：清除对医院服务增值无效的环节和步骤。Sweeping: clean the activities and steps not contributing to value of hospital service. 简化：在尽可能清除了非必要性任务之后，对于剩下的工作进行简化。Simplification: make remaining tasks simple after cleaning unnecessary steps.整合：经过简化的任务应该进行整合

29、，使其流畅、连贯，以满足患者需求。Integration: integrate the simplified tasked to make them ease and smooth to satisfy patient requirements. 自动化：也可称为数字化，由于人力资源的短缺和为了使运营更有效率。Automation: also known as digitization, automate as many steps as possible to solve problem of human resource deficiency and make operation more

30、 efficient. 4. 基于信息技术的医院门诊流程再造的措施Measures for hospital outpatient process reengineering 4.1 挂号系统的优化(1)增加咨询和导诊的服务台。(2)(1)Add service desk for consultation and guidance.(2)增加了两个环节“导诊”和“预检”。 导诊可以大大方便患者就诊，减少患者因挂错号造成的徒劳，同时由于导诊的疏导和指示，可以减少医生因患者挂错号而进行的解答，让医生把更多的精力投入到诊断中。经过指示的患者在医院的就诊更加顺畅，事实上减少了对医院资源的占用时间率。在

31、诊断之前加上一个“预检”环节，其作用是对每一个排队的患者进行初步问诊，让必须进行辅助检查的病人先去做检查，待检查结果出来之后再进行实质意义上的排队诊治。预检则是考虑到医生在询问完病情后，往往需要辅助检查手段才能下诊断结论，造成患者二次排队得到正确诊断，患者第一次排的队伍意义不大，患者花费很长时间的排队其结果只是被转移到另外一个地方，去另一次排队。实际过程中，国内诸多医院，医生见到患者后略加询问后就是开各种检验的单据。但这两个环节并非增加了患者的停留时间。从实际情况看，导诊前不存在排队环节，而预检前的排队要么与就诊前的排队属同一个队伍，要么由于其对这个队伍的疏导作用增加的时间将不会存在。把确定是

32、否需要检查的环节调整至预检环节，理论上讲这个环节的医护人员完全有能力判断是否需要进行辅助检查，在不能判断的情况下完全可以向医生进行咨询。这两个环节的增加，其作用是抵消了就诊前的排队（将人流疏散至数个辅助检查部门），减少了因挂错号造成的资源浪费。We add two steps “guidance” and “pre-exam”, which will not increase the patients waiting time. In practice, (3)网上或电话预约(4)在通讯及网络比较发达的地区与国家，还可以采取网络或电话预约看病，可以大大节省看病时间。以上变化带来的结果是，减轻了医院候诊空间人群聚集的压力，可以缓解改变医院公共空间混乱繁杂的环境，节省医院中的等候空间。(黄锡缪, 2003)具体实施方面，首先对公众和病人进行教育，让他们接受7 天内首诊或复诊预约观念。在办理预约手续交费后，