| Objective:The purpose of this study is to analyze the development of city public hospitals by literature review and policy research,and then analyze the effectiveness and shortcomings of the reform of city tertiary public general hospitals combined with empirical research,understand the advantages,disadvantages,opportunities and shortcomings based on analysis of the external environment,and explore the reform and development strategies of city public general hospitals from the perspective of different stakeholders.Method:1.Theoretical analysis: Reviewed the evaluation methods of public hospital performance at home and abroad through literature research and policy analysis,and selected and sorted out the stakeholder theory and the reform and development process of city public hospitals,so as to classify the stakeholders of city public hospitals,concept definition and analysis of interest claims.2.System dynamics analysis: System Dynamics(SD)was used to dividethe stakeholders of city public hospitals into several subsystems,and established a causal relationship network between each subsystem to analyze the impact of various stakeholders on the performance of city public hospitals,and to understand which stakeholders have contributed to the performance of city public hospitals.3.Case Study: Based on the perspective of stakeholders,analyzed the development of all tertiary public general hospitals in Liuzhou City,Guangxi,from 2012 to 2017,and understood the government policy measures,medical staff satisfaction,patient satisfaction,private hospital development status and media attention,etc.,so as to provide a theoretical and factual basis for comprehensive analysis of the reform of the tertiary public general hospitals in Guangxi pilot cities.4.Construction of indicator system: The reform data of the tertiary public general hospitals in Guangxi pilot cities were classified and summarized,with the overall performance of city public hospitals as the target layer,and the four dimensions of the Balanced Score Card(BSC)were the secondary indicators:the financial dimension,the customer dimension,the internal operation dimension,and the learning and growth dimension.The framework of performance evaluation index system was constructed.Furthermore,with the help of the retrieval and statistics of the performance evaluation literature of city public hospitals and the expert consultation and argumentation,the index system was screened to form a performance evaluation index system for city public hospitals containing 24 tertiary indicators.5.Comprehensive evaluation: Entropy Weight Method(EWM)is used to calculate the weight of the index system,and then score and calculate by using the scoring method and weighted TOPSIS respectively,and then theperformance of the tertiary public general hospitals in Guangxi pilot cities were ranked and evaluated.6.SWOT analysis: SWOT theory is used to analyze the strengths,weaknesses,opportunities and threats of urban public hospitals.SWOT-CLPV theory is used to analyze the leverage,control,vulnerability and problem of city public hospitals in the face of opportunities and threats.Results:1.Development of tertiary public general hospitals in pilot cities in Guangxi1.1 Reform practice in pilot areas: A series of reform measures are implemented during the reform of the public hospitals in Guangxi pilot cities,including: breaking the medicine to supplement the doctor,establishing a scientific compensation mechanism;establishing and perfecting the modern hospital management system;establishing a salary system that suits the characteristics of the medical industry;establishing a sound graded diagnosis and treatment system.Progress achieved: various supporting policies were successfully introduced;Liuzhou was eliminated with the drug-filling mechanism;standardizing the behavior of medical services;the medical association has made some progress.1.2 Pilot city tertiary public general hospital reform effectiveness:(1)In terms of service prices,the proportion of drug cost in medical expenses has decreased year by year,and the growth rate of drug revenues in 2015-2017 was4.7%,-7.7%,and 8.6%,respectively,growth rate are controlled within 10%,and drug cost control has achieved remarkable results.(2)In terms of service volume,hospitalized and surgical patients have increased year by year,after the reform,the growth rate of admissions in 2015-2017 was 6.8%,8.7%,and 13.5%,respectively,the growth rate increased year by year,and the growth rate of hospitalized patients reached 15% or more after the reform,hospitalization services have gradually become the leading business.(3)In terms of service efficiency,the bed utilization rate is above 96%,the bed use efficiency is high,the number of hospital bed turnovers in 2015-2017 was 36.7,36.9,and 38.1,respectively,increasing year by year,and the average hospitalization days for discharged patients decreased from 10.2 days in 2014 to 9.4 days in 2017,the hospital service efficiency continues to increase.(4)In terms of patient satisfaction,the coincidence rate of admission and discharge diagnosis is over99%,and the diagnostic coincidence rate before and after surgery is over 98%.At the same time,the coincidence rate of clinical and pathological diagnosis in2015-2017 after reform was 95.81%,96.20% and 97.81%,respectively,rising year by year,and the quality of diagnosis is higher;In terms of service quality,the rate of improvement has increased year by year,the mortality rate has decreased year by year,the success rate of inpatient rescue has gradually increased,and the overall service quality has been continuously improved.The satisfaction of outpatients and inpatients in 2018 was 98.0% and 99.0%,respectively,which were higher than 94.1% and 97.0% in 2014 before the reform,and patient satisfaction with medical care is increasing.1.3 Insufficient in reform of tertiary public hospitals in pilot cities:(1)In terms of service prices,the inspection fee and health materials fee increased year by year.After the reform,the hospital inspection income growth rate in2015-2017 was 8.5%,15.1% and 17.6%,respectively.The growth rate increased year by year and reached over 10%.Inspection fees and sanitary materials fees are still required to control.(2)In terms of financial status,in the first year of reform,the growth rate of financial subsidy income in 2015 reached 125.5%,and the growth rate reached the highest value.Then the growth rate in 2016 and2017 was-35.1% and-14.6% respectively.,showing negative growth and lacking a stable financial subsidy mechanism.(3)In terms of resource allocation,before the reform,the asset-liability ratios in 2012-2014 were 67.0%,65.0%,and 64.1%,respectively,which decreased year by year.However,the asset-liability ratio of hospitals in 2015-2017 after reform was 63.6%,67.5%,and 67.8%,respectively,increasing year by year,2016 exceeded the 2012 level,the hospital debt management is unreasonable.In terms of talent structure,in the first year after the reform,the number of doctors and nurses in 2015 was 582 and 1024,respectively,which were lower than 619 and 1039 in 2014,the number of doctors and nurses did not increase but decreased,and the proportion of physicians in 2015-2017 was 30.1%,29.8%,and 30.2%,the proportion of nurses was 53.0%,51.8%,and 50.3%,respectively,and the proportion of both decreased year by year.In addition,the bed resources continue to expand,the number of open beds increased from 1,515 in 2014 to 1,819 in 2017,but the number of doctors and nurses per bed dropped from 0.38 and 0.66 in 2014 to0.36 and 0.60 in 2017,respectively.There is talent outflow,and it is necessary to pay attention to the introduction and stability of talents.(4)In terms of medical staff satisfaction,job satisfaction decreased from 94.5% in 2014 to 94% in 2017,and satisfaction decreased.In terms of workload,36% of medical staff worked longer than 44 hours,and there was high-load work.2.Comprehensive evaluation of performance of tertiary public general hospitals in pilot citiesThe performance evaluation indicator system shows that the combined weights of finance,learning and growth,internal operations and customer dimensions are 0.2026,0.0695,0.2501 and 0.4778,respectively,of which thecustomer dimension has the highest weight,followed by the internal operation dimension.Through these two dimensions,the hospital’s public welfare and service efficiency can be reflected.This is also the key to the reform of public hospitals.Thirdly,it is the financial dimension,which is the necessary link to maintain the development of the hospital.Finally,it is the dimension of learning and growth,that is,the sustainable development of the hospital,including the rationality of resource allocation and the service capacity and load of medical staff.The comprehensive performance evaluation results show that the performance rankings of the three-level public general hospitals in the pilot cities have increased year by year after the reform in 2014.However,from all dimensions,they have not reached a high level.From 2016 to 2017,the asset operation efficiency rankings were ranked 5th and 4th respectively,and the personnel structure rankings were 4th and 6th respectively,and the patient cost burden was ranked 5th and 6th respectively.It is confirmed that there are still problems in the process of reform,such as abnormal operation of assets,unreasonable personnel structure,and high burden of patient expenses.3.Analysis of stakeholders in city public hospitalsBased on literature research and policy analysis,the relevant parties of city public hospitals are divided into two systems: the internal system of public hospital(internal operation of hospitals,medical staff,etc.)and the external system of public hospital(government,private hospitals,patients,suppliers,media,etc.).Through further analysis of the causal relationship of system dynamics,it is concluded that:(1)the hospital’s own operational development(service volume,service quality,service efficiency),staff situation(service attitude,workload,work enthusiasm,salary,training,talent introduction)and the level of equipment can affect the performance of public hospitals.(2)Thedevelopment of private hospitals,patient complaint supervision,media supervision,government reform policies and other external stakeholders’ demands can improve the performance of public hospitals.4.SWOT analysis of city public hospital reform and development4.1 Analysis of the external environment for the development of city public hospitals:(1)Under the background of the new medical reform,a series of new measures have been launched,for example: the continuous liberalization of restrictions on doctors’ multi-point practice;the establishment of third-party medical centers;implementation of "Internet + medical health";reform of DRGs;continue to promote modern hospital management system and promote graded diagnosis and treatment.(2)The number of private hospitals,the number of medical treatments,the number of beds and the number of physicians in China have been increasing year by year,and growth rates of the number of institutions,medical treatments and bed scale are more than 10% per year respectively;the growth rate of doctors also exceeds 5%;the indicators of private enterprises in Guangxi are also increasing year by year,and the proportion of their indicators in all hospitals in Guangxi is increasing year by year.It can be seen that private hospitals are in the whole country or Guangxi,all show a good development situation.(3)National policies encourage social supervision,support all sectors of society to participate in supervision,and mention improving the public opinion monitoring and disposal mechanism to play the role of media supervision.Judging from the media’s concerns,the topic of public hospitals and doctor-patient relationships has received media attention.The media plays the role of integrating the interests of both parties and balancing the relationship between them.It is the bridge,the link of communication,such as the same catalyst,a good direction is good for the people and has a positive impact;on thecontrary,it has many negative effects.4.2 Based on the analysis of the external environment of city public hospitals and case study,the advantages of the development of city tertiary public general hospitals are concluded as follows:(1)historical brand image is good,social recognition is high;(2)financial subsidies are exclusive,medical insurance coverage is wide;(3)regional medical centers,patient attraction Strong;(4)significant scale advantage,strong ability to resist risks;(5)health talents gathered,discipline construction ability.And the disadvantages are as follows: The disadvantages are as follows:(1)After the cancellation of the compilation,the supporting policies are backward and the salary distribution system is unreasonable;(2)The corporate governance is not fully promoted,and the market adaptability is weak;(3)The government’s input compensation is difficult to implement,and the cancellation of the drug addition cannot reduce the burden for patients.Opportunities are as follows:(1)The development of private hospitals has not yet taken shape,and the development of public hospitals still dominates;(2)the salary of medical staff in public hospitals has attracted attention and will gradually improve;(3)cooperating with private hospitals for mutual benefit;(4)to build a health management service system centered on the health of the whole people;(5)focusing on difficult and serious diseases,expand the advantages of specialties;(6)developing Internet hospitals with the help of “Internet + medical care”;(7)the growth of population of the old and the increase in service demand.The threats are as follows:(1)the threat of service level improvement in county-level public hospitals;(2)the threat of private hospitals attracting talents;(3)the influence of doctors practicing freely in a number of hospitals on public hospitals;(4)The qualification of medical insurance has increased the advantage of private hospitals to absorb patients;(5)new media challenges.Conclusion:Generally speaking,since the establishment of the second batch of reform pilot of city public hospitals in 2014,the tertiary public general hospitals in the pilot cities of Guangxi have carried out a good matching and implementation of government policies,and achieved phased results,but also exposed some problems.In 2017,the pilot reform of city public hospitals has spread out,and the new policies in 2018 have put forward more requirements for city public hospitals.In recent years,private hospitals have been developing continuously,the competition for public hospitals has intensified,the rapid rise of new Internet media has increasing impact on the image of public hospitals.In the future,city public hospitals will face greater challenges.Therefore,city public hospitals should constantly summarize the shortcomings in the reform,give full play to their advantages,seize the development opportunities,rationally coordinate the demands of various stakeholders,and achieve comprehensive and coordinated development.Policy proposal:1.Government:(1)supervise and control the serious debt of public hospitals;(2)promulgate corresponding policies to coordinate the implementation of drug zero margin rate;(3)strengthen the government’s supervision of public hospitals;(4)reform the proportion of medical insurance payment and the way of medical insurance payment;2.City public hospitals themselves:(1)focus on building and developing key specialties;(2)strengthen the cultural construction of public hospitals continuously;(3)give full play to the role of consortium in graded diagnosis and treatment;(4)explore and strengthen multi-party cooperation;3.Medical staff:(1)reduce workload;(2)rationalize salary of medical staffs;(3)and formulate career development plan;4.Patient:(1)improve service quality;(2)reduce cost burden;(3)improve service attitude;(4)unobstruct complaint feedback channels;5.Private hospitals:(1)learn from the development experience of private hospitals;(2)strengthen cooperation between public hospitals and private hospitals;6.Media:(1)contact with the media more,pay attention to the training of spokespersons;(2)seek truth from facts,while doing a good job of confidentiality. |
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