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-Webster’s 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 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 management 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 questionnaires 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 examination 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 decrease 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；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 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 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 process 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. 到达挂号候诊就诊是否需要检查

排队

划价是否需要开药排队划价治疗是否需要治疗离开排队交费排队取药排队是否是交费

否处方

否是 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 patient 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, which 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 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 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 time 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。