| For medical service for residents in the lack of medical resources and the contradiction between the need and the grading system in a new round of medical and health system reform in 2009 formally put forward,after years of exploration and practice,the hierarchical diagnosis system in China after a "-to explore-established" process,in September 2015 formally established the goal and implementation approach for the construction of the hierarchical diagnostic system.At present,most of the researches on graded diagnosis and treatment evaluation in China focus on local system and reform effect,but lack of overall systematic evaluation,especially the performance evaluation based on the theoretical framework of graded diagnosis and treatment system.From the perspective of practice,all the pilot areas of graded diagnosis and treatment system in China have carried out effect evaluation to different degrees.Due to the lack of the design and data support of the indicator system,only a small part of them have carried out quantitative evaluation.Due to the lack of systematic empirical evaluation based on certain theoretical basis,it cannot support the overall promotion of policies and their effect on the ground.The graded diagnosis and treatment system is a systematic project,and the path and method of pilot reform vary from place to place.Only by carrying out evaluation based on a certain theoretical system can we find common problems and dig out more suitable practices and experiences for promotion.Therefore,in order to fully evaluate the grading system of diagnosis and treatment effect in our country,combining with the "Healthy China 2030" plan for the spirit,this study starts with the development process and exploration practice of China’s hierarchical diagnosis system,and summarizes the connotation and hierarchical diagnostic related theory research,health oriented,guided by the classification system of diagnosis and treatment target,from macroscopic to microcosmic implementation steps of hierarchical diagnosis and treatment,on the basis of analyzing the classification diagnosis and stakeholder cooperation game built on "sharp slow partition","linkage" up and down,"the first option at the grass-roots level","two-way referral" theory of hierarchical diagnosis and treatment process model,and according to the theoretical model.A performance evaluation system and methods of graded diagnosis and treatment system in line with China’s national conditions were established to provide feasible paths and suggestions for the development of graded diagnosis and treatment system.The main contents of this study are as follows:First,by systematically summarizing the experience and practice of hierarchical medical system in the international medical service system,it is found that standardizing the medical order is an effective means to improve the service efficiency of the health system in various countries.To this end,all countries have taken effective measures to strengthen the rational division of medical services,and strengthen the cooperation among institutions to provide health-based full cycle health services for residents.Further carry out domestic and foreign literature research on hierarchical medical system,and make a detailed review on the implementation effect,implementation difficulties,influencing factors and countermeasures of the existing research on hierarchical diagnosis system,and then conclude that the hierarchical diagnosis system has the internal logic and interactive relationship of "clear" and "real" cooperation.Secondly,it systematically summarizes the research progress of hierarchical diagnosis and treatment,and extracts the main dimensions of hierarchical diagnosis and treatment.Based on the content process of hierarchical diagnosis and treatment and the interactive game of stakeholders,this paper explores and designs the overall framework of performance evaluation of hierarchical diagnosis and treatment,and forms a theoretical model in line with the practical characteristics of China’s hierarchical medical system,which lays a theoretical and operational foundation for clarifying the interactive process of hierarchical diagnosis and treatment and improving the performance evaluation system of hierarchical diagnosis and treatment.Based on theoretical level and grounded theory,four main categories and 10 sub category dimensions of performance evaluation of hierarchical diagnosis and treatment are gradually formed.On this basis,the connotation of each dimension was analyzed,the connotation and indicator framework of each dimension were proposed,and corresponding hypotheses were established,which laid a foundation for further exploration of the indicator system of graded diagnosis and treatment performance evaluation.Again,through the confirmatory factor analysis of the survey data of different levels of medical institutions in 16 districts of Tianjin by structural equation model,the cross interaction relationship among variables such as hierarchical governance,organizational collaboration,behavioral motivation and treatment choice is clarified,which verifies the rationality of the hierarchical diagnosis and treatment performance evaluation model proposed in this study,and finally forms the localization connotation in line with China Through machine learning training,a self-adaptive intelligent evaluation method of hierarchical diagnosis and treatment performance is formed.On this basis,the effect of hierarchical diagnosis and treatment in 16 districts and counties of Tianjin was evaluated by automatic intelligent classification with different dimensions and different structural modes,and the evaluation results were analyzed and summarized in depth.Finally,based on the results of the above evaluation study,some suggestions are put forward to improve the hierarchical medical system.At the level of hierarchical governance,we should constantly strengthen the leading role of the government and integrate the Healthy China policy into various policies.In order to promote the hierarchical medical system as a breakthrough,straighten out the medical order,explore the overall payment of medical insurance,improve the efficiency of the medical and health service system,and promote the equalization of basic public health services.At the level of organization and cooperation,priority should be given to strengthening the level of primary health services,improving the signing service system of family doctors,and laying the foundation for hierarchical diagnosis and treatment cooperation.At the same time,information technology should be used to strengthen the cooperation among medical institutions at all levels.At the level of behavioral motivation,innovative personnel sharing mechanism,supplemented by more flexible performance policies,strengthen personnel interaction among medical institutions at all levels,and improve the ability of primary health services.At the level of treatment selection,we should establish a two-way contract mechanism between residents and medical institutions in the hierarchical diagnosis and treatment system,improve the referral information platform,open two-way referral channels,and guide residents to seek medical treatment in an orderly manner. |
