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The Vital Role of Executive Rounding in Promoting a Culture of Safety in Hospitals. 行政查房在促进医院安全文化中的重要作用。
IF 1.7 4区 医学 Q3 HEALTH POLICY & SERVICES Pub Date : 2024-07-01 Epub Date: 2024-07-04 DOI: 10.1097/JHM-D-24-00116
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引用次数: 0
Implementation of a High-Value, Evidence-Based Care Program: Impact and Opportunities for Learning Organizations. 实施高价值、循证护理计划:学习型组织的影响与机遇。
IF 1.7 4区 医学 Q3 HEALTH POLICY & SERVICES Pub Date : 2024-07-01 Epub Date: 2024-07-04 DOI: 10.1097/JHM-D-23-00099
Stephen B Williams, Peter McCaffrey, David Reynoso, Phillip Keiser, Rick Trevino, John Heymann, Gulshan Doulatram, Abe DeAnda, Timothy J Harlin, Gulshan Sharma

Goal: Value-based care is not simply a matter of cost, but also one of outcomes and harms per dollar spent. This definition encompasses three key components: healthcare delivery that is organized around patients' medical conditions, costs and outcomes that are actively and consistently measured, and information technology that enables the other two components. Our objective in this project was to implement and measure a systemwide high-value, evidence-based care initiative with five pillars of high-value practices.

Methods: We performed a quasi-experimental study from September 1, 2019, to August 31, 2022, of a new care program at the University of Texas Medical Branch. Drawing from the ABIM Foundation's Choosing Wisely Campaign, the program was based on five pillars-blood management and antimicrobial, laboratory, imaging, and opioid stewardship-with interdisciplinary teams led by institutional subject matter experts (i.e., administrative leaders) accompanied by nursing, information technology, pharmacy, and clinical and nonclinical personnel including faculty and trainees. Each pillar addressed two goals with targeted interventions to assess improvements during the first three fiscal years (FYs) of implementation. The targets were set at 10% improvement by the end of each FY. Monthly measurements were recorded for each FY.

Principal findings: We tracked performance toward 30 pillar goals and determined that the teams were successful in 50%, 50%, and 70% of their goals for FY 2020, 2021, and 2022, respectively. For example, in the antimicrobial stewardship FY 2021 pillar, one goal was to decrease meropenem days of therapy (DOT) by 10% (baseline was 45 DOT/1,000 patient days; the target was 40.5 DOT/1,000 patient days). We measured quarterly DOT/1,000 patient day rates of 32.02, 30.57, and 26.9, respectively, for a cumulative rate of 26.9. Critical interventions included engaging and empowering providers and service lines (including outliers whose performance was outside norms), educational conferences, and transparent data analyses.

Practical applications: We showed that a multidisciplinary approach to the implementation of an evidence-based, high-value care program through a partnership of engaged administrative leaders, providers, and trainees can result in sustainable and measurable high-value healthcare delivery. Specifically, structuring the program with pillars to address defined metrics resulted in progressive improvement in meeting value-based goals at the University of Texas Medical Branch. Also, challenges can be embraced as learning opportunities to inform value-based interventions that range from technological to educational tactics. The results at the University of Texas Medical Branch provide a benchmark for the implementation of a program that engages, empowers, and aligns innovative value-based care initiatives.

目标:以价值为基础的医疗不仅仅是成本问题,也是每花费一美元所产生的结果和危害问题。这一定义包含三个关键要素:围绕患者病情组织的医疗服务、积极且持续衡量的成本和结果,以及实现其他两个要素的信息技术。我们在这个项目中的目标是在全系统范围内实施并衡量一项高价值循证医疗计划,该计划有五大高价值实践支柱:我们在 2019 年 9 月 1 日至 2022 年 8 月 31 日期间对德克萨斯大学医学分院的一项新护理计划进行了准实验研究。该计划借鉴了 ABIM 基金会的 "明智选择 "运动,以五大支柱为基础--血液管理和抗菌药物、实验室、成像和阿片类药物管理--由机构主题专家(即行政领导)领导的跨学科团队,以及护理、信息技术、药学、临床和非临床人员(包括教师和受训人员)组成。每个支柱都涉及两个目标,并在实施的前三个财政年度(FYs)采取有针对性的干预措施,以评估改进情况。目标设定为在每个财政年度结束时提高 10%。每个财政年度都记录了每月的测量结果:我们跟踪了 30 个支柱目标的执行情况,并确定各团队在 2020、2021 和 2022 财政年度分别实现了 50%、50% 和 70% 的目标。例如,在 2021 财年抗菌药物管理支柱中,一个目标是将美罗培南治疗天数 (DOT) 减少 10%(基线为 45 DOT/1,000;目标为 40.5 DOT/1,000)。我们测得的季度 DOT/1,000 患者日比率分别为 32.02、30.57 和 26.9,累计比率为 26.9。关键的干预措施包括让医疗服务提供者和服务项目(包括表现超出标准的异常值)参与进来并增强其能力、召开教育会议以及进行透明的数据分析:实际应用:我们的研究表明,通过行政领导、医疗服务提供者和受训人员的合作,采用多学科方法实施循证、高价值护理计划,可以实现可持续、可衡量的高价值医疗服务。具体来说,德克萨斯大学医学分院以支柱来构建计划,以解决确定的指标问题,从而在实现以价值为基础的目标方面取得了逐步改善。此外,还可以将挑战视为学习机会,为基于价值的干预措施提供信息,包括技术和教育策略。德克萨斯大学医学分院的成果为实施一项计划提供了一个基准,该计划旨在吸引、授权和调整创新的价值导向型医疗措施。
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引用次数: 0
Leadership to Accelerate Healthcare's Digital Transformation: Evidence From 33 Health Systems. 加速医疗保健数字化转型的领导力:来自 33 个医疗系统的证据。
IF 1.7 4区 医学 Q3 HEALTH POLICY & SERVICES Pub Date : 2024-07-01 Epub Date: 2024-07-04 DOI: 10.1097/JHM-D-23-00210
Christy Harris Lemak, Dalton Pena, Douglas A Jones, Dae Hyun Kim, Janet Guptill

Goal: The COVID-19 pandemic, healthcare market disruptors, and new digital healthcare technologies have made a substantial impact on the delivery of healthcare services, highlighting the critical roles of leaders in hospitals and health systems. This study sought to understand the evolving roles of CEOs, CIOs, and other executive leaders in the postpandemic era and highlight the adaptability and strategic vision of executives in shaping the future of healthcare delivery.

Methods: Between October 2022 and May 2023, 51 interviews were conducted with CEOs, CIOs, and other executives responsible for delivering technology solutions for 33 nonprofit health systems in the United States. They were asked to describe their backgrounds; how information solutions and technologies were viewed within their organizations' strategy, operations, and governance; and the key characteristics of executive leaders.

Principal findings: The study has found that effective CEOs have an authentic belief in technology's role in achieving their organization's mission and that contemporary CIOs are strategic executive partners who align strategy with culture to improve care. This study examines how healthcare systems are creating digitally savvy executive leadership teams that operate in a new, integrated model that unites previously siloed functions.

Practical applications: Some healthcare CIOs are unprepared for current and future business challenges, and some CEOs are unsure how to leverage digital technologies and C-suite expertise to transform their organizations. This research provides insights into how the nation's health systems are building and sustaining leadership teams capable of adapting to the healthcare environment and accelerating organizational transformation.

目标:COVID-19 大流行、医疗保健市场颠覆者和新的数字医疗保健技术对医疗保健服务的提供产生了重大影响,凸显了医院和医疗保健系统中领导者的关键作用。本研究旨在了解首席执行官、首席信息官和其他行政领导在大流行后时代不断演变的角色,并强调行政人员在塑造未来医疗服务方面的适应能力和战略眼光:在 2022 年 10 月至 2023 年 5 月期间,我们对美国 33 家非营利医疗系统负责提供技术解决方案的首席执行官、首席信息官和其他高管进行了 51 次访谈。他们被要求描述自己的背景;在其组织的战略、运营和管理中如何看待信息解决方案和技术;以及行政领导的主要特征:研究发现,高效的首席执行官对技术在实现其组织使命中的作用有着真切的信念,当代首席信息官是战略执行伙伴,他们将战略与文化相结合,以改善医疗服务。本研究探讨了医疗保健系统如何创建精通数字技术的高管领导团队,以一种全新的整合模式将以前各自为政的职能部门联合起来:一些医疗保健系统的首席信息官对当前和未来的业务挑战毫无准备,而一些首席执行官则不知道如何利用数字技术和首席执行官的专业知识来实现组织转型。本研究深入探讨了美国医疗系统如何建立和维持能够适应医疗环境并加快组织转型的领导团队。
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引用次数: 0
Using Artificial Intelligence in Electronic Health Record Systems to Mitigate Physician Burnout: A Roadmap. 在电子健康记录系统中使用人工智能减轻医生的职业倦怠:路线图。
IF 1.7 4区 医学 Q3 HEALTH POLICY & SERVICES Pub Date : 2024-07-01 Epub Date: 2024-07-03 DOI: 10.1097/JHM-D-24-00094
Mariam Fawzy Eid

Summary: Physician burnout, a significant problem in modern healthcare, adversely affects healthcare professionals and their organizations. This essay explores the potential of artificial intelligence (AI) to positively address this issue through its integration into the electronic health record and the automation of administrative tasks. Recent initiatives and research highlight the positive impact of AI assistants in alleviating physician burnout and suggest solutions to enhance physician well-being. By examining the causes and consequences of burnout, the promise of AI in healthcare, and its integration into electronic health record systems, this essay explores how AI can not only reduce physician burnout but also improve the efficiency of healthcare organizations. A roadmap provides a visualization of how AI could be integrated into electronic health records during the previsit, visit, and postvisit stages of a clinical encounter.

摘要:医生职业倦怠是现代医疗保健领域的一个重要问题,对医疗保健专业人员及其组织造成了不利影响。本文探讨了人工智能(AI)通过集成到电子健康记录和行政任务自动化来积极解决这一问题的潜力。最近的倡议和研究强调了人工智能助手在缓解医生职业倦怠方面的积极影响,并提出了提高医生福利的解决方案。通过研究职业倦怠的原因和后果、人工智能在医疗保健领域的前景及其与电子健康记录系统的整合,本文探讨了人工智能如何不仅能减轻医生的职业倦怠,还能提高医疗保健机构的效率。本文提供了一个路线图,直观地说明了如何在临床诊疗的诊前、诊中和诊后阶段将人工智能整合到电子健康记录中。
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引用次数: 0
Control: The Foundation of Successful Safety Planning. 控制:成功安全规划的基础。
IF 1.7 4区 医学 Q3 HEALTH POLICY & SERVICES Pub Date : 2024-07-01 Epub Date: 2024-07-04 DOI: 10.1097/JHM-D-24-00114
Susan W Hendrickson
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引用次数: 0
RADM Anne M. Swap, FACHE, 2024 Recipient of the ACHE Gold Medal Award. 美国海军陆战队司令安妮-M-斯瓦普(Anne M. Swap),FACHE,2024 年 ACHE 金奖获得者。
IF 1.8 4区 医学 Q3 HEALTH POLICY & SERVICES Pub Date : 2024-05-01 Epub Date: 2024-05-10 DOI: 10.1097/JHM-D-24-00070
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引用次数: 0
You Cannot Function in "Overwhelm": Helping Primary Care Navigate the Slow End of the Pandemic. 你不能在 "不堪重负 "中工作:帮助基层医疗机构渡过大流行病的低谷。
IF 1.8 4区 医学 Q3 HEALTH POLICY & SERVICES Pub Date : 2024-05-01 Epub Date: 2024-05-10 DOI: 10.1097/JHM-D-23-00102
Erin E Sullivan, Rebecca S Etz, Martha M Gonzalez, Jordyn Deubel, Sarah R Reves, Kurt C Stange, Lauren S Hughes, Mark Linzer

Goal: This study was developed to explicate underlying organizational factors contributing to the deterioration of primary care clinicians' mental health during the COVID-19 pandemic.

Methods: Using data from the Larry A. Green Center for the Advancement of Primary Health Care for the Public Good's national survey of primary care clinicians from March 2020 to March 2022, a multidisciplinary team analyzed more than 11,150 open-ended comments. Phase 1 of the analysis happened in real-time as surveys were returned, using deductive and inductive coding. Phase 2 used grounded theory to identify emergent themes. Qualitative findings were triangulated with the survey's quantitative data.

Principal findings: The clinicians shifted from feelings of anxiety and uncertainty at the start of the pandemic to isolation, lack of fulfillment, moral injury, and plans to leave the profession. The frequency with which they spoke of depression, burnout, and moral injury was striking. The contributors to this distress included crushing workloads, worsening staff shortages, and insufficient reimbursement. Consequences, both felt and anticipated, included fatigue and demoralization from the inability to manage escalating workloads. Survey findings identified responses that could alleviate the mental health crisis, namely: (1) measuring and customizing workloads based on work capacity; (2) quantifying resources needed to return to sufficient staffing levels; (3) promoting state and federal support for sustainable practice infrastructures with less administrative burden; and (4) creating patient visits of different lengths to rebuild relationships and trust and facilitate more accurate diagnoses.

Practical applications: Attention to clinicians' mental health should be rapidly directed to on-demand, confidential mental health support so they can receive the care they need and not worry about any stigma or loss of license for accepting that help. Interventions that address work-life balance, workload, and resources can improve care, support retention of the critically important primary care workforce, and attract more trainees to primary care careers.

目标:本研究旨在解释在 COVID-19 大流行期间导致初级保健临床医生心理健康状况恶化的潜在组织因素:利用 Larry A. Green 初级医疗公益促进中心 2020 年 3 月至 2022 年 3 月对全国初级医疗临床医生的调查数据,一个多学科团队分析了超过 11,150 条开放式评论。第一阶段的分析是在收回调查问卷后实时进行的,采用了演绎和归纳编码法。第二阶段采用基础理论来确定新出现的主题。定性分析结果与调查的定量数据进行了三角验证:临床医生从大流行开始时的焦虑和不确定感转变为孤立无援、缺乏成就感、道德伤害以及计划离开这一行业。他们谈到抑郁、职业倦怠和精神伤害的频率非常高。造成这种痛苦的因素包括沉重的工作量、日益严重的人员短缺和报销不足。感受到和预期到的后果包括因无法处理不断增加的工作量而产生的疲劳和士气低落。调查结果指出了可以缓解心理健康危机的应对措施,即:(1)根据工作能力衡量和定制工作量;(2)量化所需资源,以恢复到足够的人员配备水平;(3)促进州和联邦对可持续的实践基础设施的支持,减轻行政负担;以及(4)创建不同长度的病人访问,以重建关系和信任,促进更准确的诊断:对临床医生心理健康的关注应迅速转向按需的、保密的心理健康支持,这样他们就能获得所需的护理,而不必担心因接受帮助而蒙受耻辱或失去执照。解决工作与生活的平衡、工作量和资源等问题的干预措施可以改善医疗服务,支持留住极其重要的基层医疗队伍,并吸引更多的受训者投身于基层医疗事业。
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引用次数: 0
Extremes of Emergency Department Boarding are Associated With Poorer Financial Performance Among Hospitals. 急诊科住院人数的极值与医院较差的财务业绩有关。
IF 1.8 4区 医学 Q3 HEALTH POLICY & SERVICES Pub Date : 2024-05-01 Epub Date: 2024-05-10 DOI: 10.1097/JHM-D-23-00150
Anthony M Napoli, Shihab Ali, Janette Baird, Dan Shanin, Nick Jouriles

Goal: Boarding emergency department (ED) patients is associated with reductions in quality of care, patient safety and experience, and ED operational efficiency. However, ED boarding is ultimately reflective of inefficiencies in hospital capacity management. The ability of a hospital to accommodate variability in patient flow presumably affects its financial performance, but this relationship is not well studied. We investigated the relationship between ED boarding and hospital financial performance measures. Our objective was to see if there was an association between key financial measures of business performance and limitations in patient progression efficiency, as evidenced by ED boarding.

Methods: Cross-sectional ED operational data were collected from the Emergency Department Benchmarking Alliance, a voluntarily self-reporting operational database that includes 54% of EDs in the United States. Freestanding EDs, pediatric EDs and EDs with missing boarding data were excluded. The key operational outcome variable was boarding time. We reviewed the financial information of these nonprofit institutions by accessing their Internal Revenue Service Form 990. We examined standard measures of financial performance, including return on equity, total margin, total asset turnover, and equity multiplier (EM). We studied these associations using quantile regressions of added ED volume, ED admission percentage, urban versus nonurban ED site location, trauma status, and percentage of the population receiving Medicare and Medicaid as covariates in the regression models.

Principal findings: Operational data were available for 892 EDs from 31 states. Of those, 127 reported a Form 990 in the year corresponding to the ED boarding measures. Median boarding time across EDs was 148 min (interquartile range [IQR]: 100-216). A significant relationship exists between boarding and the EM, along with a negative association with the hospital's total profit margin in the highest-performing hospitals (by profit margin percentage). After adjusting for the covariates in the regression model, we found that for every 10 min above 90 min of boarding, the mean EM for the top quartile increased from 245.8% to 249.5% (p < .001). In hospitals in the top 90th percentile of total margin, every 10 min beyond the median ED boarding interval led to a decrease in total margin of 0.24%.

Practical applications: Using the largest available national registry of ED operational data and concordant nonprofit financial reports, higher boarding among the highest-profitability hospitals (i.e., top 10%) is associated with a drag on profit margin, while hospitals with the highest boarding are associated with the highest leverage (i.e., indicated by the EM). These relationships suggest an association between a key ED indicator of hospital capacity management and overall institutional financial performance.

目标:急诊科(ED)病人住院与护理质量、病人安全和体验以及急诊科运行效率的下降有关。然而,急诊科病人滞留最终反映了医院容量管理的效率低下。医院适应病人流量变化的能力可能会影响其财务业绩,但这种关系并没有得到很好的研究。我们调查了急诊室住院人数与医院财务绩效指标之间的关系。我们的目标是了解业务绩效的主要财务指标与急诊室寄宿情况所反映的患者就诊效率限制之间是否存在关联:我们从急诊科标杆联盟(Emergency Department Benchmarking Alliance)收集了急诊科的横向运营数据,该联盟是一个自愿自我报告的运营数据库,包括美国 54% 的急诊科。独立的急诊室、儿科急诊室和登机数据缺失的急诊室被排除在外。关键的运行结果变量是登机时间。我们查阅了这些非营利机构的国内税收署 990 表,从而审查了其财务信息。我们研究了财务绩效的标准衡量指标,包括股本回报率、总利润率、总资产周转率和股本乘数(EM)。在回归模型中,我们将增加的急诊室数量、急诊室收治比例、城市与非城市急诊室地点、外伤状况以及接受医疗保险和医疗补助的人口比例作为协变量进行了量化回归,从而研究了这些关联:主要研究结果:我们获得了 31 个州 892 家急诊室的运营数据。其中,127 家急诊室在与急诊室登机时间测量相对应的年份提交了 990 表。各急诊室的中位登机时间为 148 分钟(四分位距 [IQR]:100-216)。在表现最好的医院(按利润率百分比计算)中,住院时间与急诊室之间存在明显的关系,同时与医院的总利润率呈负相关。在对回归模型中的协变量进行调整后,我们发现寄宿时间每超过 90 分钟 10 分钟,排名前四分位的医院的平均平均住院时间就会从 245.8% 增加到 249.5%(P 实际应用):利用现有最大的全国急诊室运营数据登记簿和一致的非营利性财务报告,盈利能力最高的医院(即前 10%)的寄宿率越高,利润率就越低,而寄宿率最高的医院的杠杆率也最高(即 EM 值)。这些关系表明,医院能力管理的一个关键性 ED 指标与整体机构财务绩效之间存在关联。
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引用次数: 0
Silver Linings: Building Sustainable Improvement Capacity. 银线:建设可持续的改进能力。
IF 1.8 4区 医学 Q3 HEALTH POLICY & SERVICES Pub Date : 2024-05-01 Epub Date: 2024-05-10 DOI: 10.1097/JHM-D-24-00061
Angela Vincent Michael
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引用次数: 0
Comparison of Full-Time Equivalent and Clinic Time Labor Input Measures in Productivity Metrics. 生产率指标中的全时当量与诊所时间劳动力投入量的比较。
IF 1.8 4区 医学 Q3 HEALTH POLICY & SERVICES Pub Date : 2024-05-01 Epub Date: 2024-05-10 DOI: 10.1097/JHM-D-23-00106
Iman Saeed, Kyle Barr, Sivagaminathan Palani, Paul Shafer, Steven Pizer

Goal: A lack of improvement in productivity in recent years may be the result of suboptimal measurement of productivity. Hospitals and clinics benefit from external benchmarks that allow assessment of clinical productivity. Work relative value units have long served as a common currency for this purpose. Productivity is determined by comparing work relative value units to full-time equivalents (FTEs), but FTEs do not have a universal or standardized definition, which could cause problems. We propose a new clinical labor input measure-"clinic time"-as a substitute for using the reported measure of FTEs.

Methods: In this observational validation study, we used data from a cluster randomized trial to compare FTE with clinic time. We compared these two productivity measures graphically. For validation, we estimated two separate ordinary least squares (OLS) regression models. To validate and simultaneously adjust for endogeneity, we used instrumental variables (IV) regression with the proportion of days in a pay period that were federal holidays as an instrument. We used productivity data collected between 2018 and 2020 from Veterans Health Administration (VA) cardiology and orthopedics providers as part of a 2-year cluster randomized trial of medical scribes mandated by the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act of 2018.

Principal findings: Our cohort included 654 unique providers. For both productivity variables, the values for patients per clinic day were consistently higher than those for patients per day per FTE. To validate these measures, we estimated separate OLS and IV regression models, predicting wait times from the two productivity measures. The slopes from the two productivity measures were positive and small in magnitude with OLS, but negative and large in magnitude with IV regression. The magnitude of the slope for patients per clinic day was much larger than the slope for patients per day per FTE. Current metrics that rely on FTE data may suffer from self-report bias and low reporting frequency. Using clinic time as an alternative is an effective way to mitigate these biases.

Practical applications: Measuring productivity accurately is essential because provider productivity plays an important role in facilitating clinic operations outcomes. Most importantly, tracking a more valid productivity metric is a concrete, cost-effective management tactic to improve the provision of care in the long term.

目标:近年来生产率没有提高,可能是由于对生产率的衡量不够理想。医院和诊所可借助外部基准来评估临床生产率。长期以来,工作相对值单位一直是实现这一目的的通用货币。生产率是通过将工作相对价值单位与全职当量(FTE)进行比较来确定的,但全职当量并没有一个通用或标准化的定义,这可能会造成问题。我们提出了一种新的临床劳动投入衡量标准--"门诊时间"--来替代已报告的全职当量衡量标准:在这项观察验证研究中,我们使用了一项分组随机试验的数据,对全职医生时间和门诊时间进行了比较。我们用图表对这两种生产率进行了比较。为了进行验证,我们分别估计了两个普通最小二乘法(OLS)回归模型。为了验证并同时调整内生性,我们使用了工具变量(IV)回归,并将工资期中联邦假日的天数比例作为工具。我们使用了 2018 年至 2020 年期间从退伍军人健康管理局(VA)心脏病学和骨科提供者处收集的生产率数据,这些数据是 2018 年《退伍军人健康管理局维护内部系统和加强外部综合网络(MISSION)法案》规定的医疗抄写员 2 年分组随机试验的一部分:我们的队列包括 654 名独特的医疗服务提供者。就两个生产率变量而言,每个门诊日的患者人数值始终高于每个全职员工每天的患者人数值。为了验证这些指标,我们分别估算了 OLS 和 IV 回归模型,通过这两个生产率指标预测等待时间。在 OLS 模型中,两个生产率指标的斜率均为正且幅度较小,但在 IV 回归模型中,两个生产率指标的斜率均为负且幅度较大。每门诊日病人数的斜率幅度远远大于每全职医生日病人数的斜率幅度。目前依赖全职医生数据的指标可能存在自我报告偏差和报告频率低的问题。使用门诊时间作为替代方法是减少这些偏差的有效途径:准确衡量生产率至关重要,因为医疗服务提供者的生产率在促进诊所运营成果方面发挥着重要作用。最重要的是,跟踪更有效的生产率指标是一种具体的、具有成本效益的管理策略,可长期改善医疗服务的提供。
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引用次数: 0
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