國立中山大學學位論文典藏.PDF

Size: px

Start display at page:

Download "國立中山大學學位論文典藏.PDF"

淦禄
5 years ago
Views:

1 Constructing Service Pathways Model of Hemodialysis Center

2 I

3 Abstract Introduction The number of the people who needs dialysis escalates rapidly year each. The rising cost of dialysis is relative. Because Bureau National Health Insurance endures the co-payment of hemodialysis, patients have freedom of choice. Two critical factors that influence patient s decision in medical care are access and quality. Facing pressure from competition, many hemodialysis service providers believe that high quality service will retain patients to return as well as maintain a healthy physician-patient relationship. Therefore, they apply many quality management tools, which also include service pathways. There are few investigations that discuss service pathways. Thus, this research constructs a model to analyze the effect of service pathways in hemodialysis service providers. Method From Nov. 1, 2003 to Dec. 31, 2004, the researcher interviewed hemodialysis nurses to develop flow chart, customer encounter, and check list for hemodialysis. We also collected the check list records of the hemodialysis patients to examine the effect. Conclusion First, the construction of total service pathways comprised three critical interlocking phases: flow chart, customer encounter, and check list. After that we II

4 shall evaluate and correct them continuously. Secondly, the researcher found that most patients are routine members, and come from long-term care center and respiratory care ward (RCW). Thirdly, the indicators influencing hemodialysis results and error incidents were steady. Finally, in the value-added services dimensions, the indicators of nurses performance on greeting and asking patients if they want to have a meal were significant, but the indicators of telephone and inpatient interview were unfavorable. Keyword: hemodialysis, service pathways, flow chart, customer encounter, check list III

5 IV...I ABSTRACT... II...VI...VII

6 A...54 B...70 C...74 D...76 V

7 2-1 (CCr) VI

8 VII

9 service pathways ,500 6,000 7,000 3,000 4,000 3,000 4, , , , , % ,532,313, , , ,969,410,

10 Lane & Lindquist, SISO O Malley O Malley,

11 3

12 4

13 1-1 5

14 % 3 CCr (CCr) 0.8~1.2 3~5 8 CCr 120~80 30~ % 2. 6

15 Ignatavicius & Bayne, 1991 BUN 100% intermittent peritoneal dialysis IPD continuous ambulatory peritoneal dialysiscapd 4. hemofiltration 5. continuus aterio-venous hemofiltration CAVH 7

16 6. continuus cyclic Peritoneal dialysis CCPD 7. high efficiency hemodialysis 8. high flux hemodialysis 9. hemodiafiltration 2005 Holland1994 dry weight vital sign 2-1 8

17 2-1 Holland, J. (1994). Scheduling patients in hemodialysis center. Production and Inventory Management Journal, 35(2),

18 Regan1963 Gronroos1984 Kotler Armstrong 1986/1992 Anderson Michael1986Parasuraman 1985 Gronroos1988 Jophiy1996 Dunn

19 pre service2. intra service3. post service 26%~33% 26%~33% 46% 18 50% 33%Hsiao, Braun, Kelly, & Becker, 1988 O Malley2001 () pre service () actual service () post service Dunn et al %~33% 26%~33% 46% Hsiao % 33% O Malley

20 clinical pathways 1950 rate-limiting steps critical pathway 1960 Horowitzs, 1967 critical path clinical protocols clinical guideline clinical benchmarking case management multidisciplinary pathway of care, MPC integrated care cathways, ICPs Corbett Androwich1994 Dewoody & Price, 1994Heacock & Brobst, Edick Whipple

21 O Malley2001 clinical pathways service pathways Sandra Sue2004 ICPs service pathways

22 2-3 O Malley 2001 Edick & Whipple 2001 Sandra & Sue health care

23 Patton Rober Merton 1941 Stewart Shamdasani

24 Kurt Lewin 1994 rational social management Hart & Bond, 1995Holter Schwartz-Barcott

25 3-1 17

26 O Malley2001 Edick & Whipple

28 intensity sampling information-rich cases Patton, 1990 heuristic study

29 3-2 A A A A A B B B B B B B B B B B B B

30 % % % (%) 0~ ~64 63 (55.8%) (44.2%) 3-5 (%) (%) 1(0.9%) 1(0.9%) 105 (92.9%) 6(5.3%) 1(0.9%) 1(0.9%) 54(47.8%) 22(19.5%) 11(9.7%) 10(8.8%) 2(1.8%) 2(1.8%) 2(1.8%) 1(0.9%) 1(0.9%) 1(0.9%) 1(0.9%) 1(0.9%) 1(0.9%) 1(0.9%) 1(0.9%) 113(100%) 113(100%) 22

31 1996 credibility transferability thick description dependability Miles Huberman

32 analytical generalization 1996 Lather Yin, Bateman, & Moore, 1983 ( ) ( ) )

33 A B 1 25

35 Holland1994 O Malley2001 pre service actual service post service 4-1 A 27

36 H H-0 H-1 a H-1-1 a 28

37 (H) (H-0) (H-1) (H-2) (H-3) (H-4) (H-5) (H-6) (H-7) (H-3-1) (H-3-2) (H-3-3) (H-6-1) (H-6-2) (H-6-3)

38 30

39 double lumen D-L A-VF A-VG 31

40 IC T t-line Hct EPO CPR 32

41 6% RO 6% TorayJMSFresenins Toray 10 Rinse 10' Rinse 20' JMS 15 Rinse 15' Rinse 20' 15 33

42 30 Rinse 30' Fresenius Disinfection FDM 34 F 4 D 10 M 20 Toray 10 Rinse 10'Renalin Rinse 30'2 JMS 10 Rinse10' Rinse20' 10 (Rinse10') Fresenius Hotrinse FHC34 F 4 H C 37 RO RO RO 1000cc RO RO RO RO RO RO Rinse 30 2 RO RO 34

43 RO 35

44 B hemodialysis h h-1-1-a h-1-a h-1-1-a 36

45 A artery V vein AK artificial kidney 4 cc u hematocrit Hct hu-rythropoietin EPO Amp ±1 T M D C 30mmHg 30mmHg 80mg/dl 37

46 1 1. HctEPO mmHg 30mmHg 80mg/dl 3. 38

47 D

49 % Hct 4-5 (EPO)

50 mmHg mmHg >30mmHg >30mmHg mg/dl

51 4-7 2 <80mg/dl

52 4-8 3 >±1 T M D

53 45

54 46

55 PDCA plan do check act

57 Kotler, P., & Armstrong, G

59 Anderson, D. H., & Michael, J. M. (1986). Visitor preferences for management actions U. S. A. foresr service. General Technical Report, INT-212, Corbett, C. F., & Androwich, I. M. (1994). Critical paths: implications for improving price. Home Healthcare Nurse, 12(6), Dewoody, S., & Price, J. (1994). A system approach to multidimensional critical paths. Nursing Management, 25(11), Dunn, D., Hsiao, W. C., Ketcham, T. R., & Braun, P. (1988). A method for estimating the preservice and postservice work of physicians' services. JAMA, 260(16), Edick, V. W., & Whipple, T. W. (2001). Managing patient care with clinical pathways: a practical application. Journal of Nursing Care Quality, 15 (3), Gronroos, C. (1984). A Service quality model and its marketing implications, European Journal of Marketing, 18(4), Gronroos, C. (1988). Service quality: the six criteria of good perceived service quality. Review of Business, 9(3), Hart, E., & Bond, M. (1995). Action health social care: a guide to practice. Buckingham: Open University Press. 51

60 Heacock, D., & Brobst, R. A. (1994). A multidisciplinary approach to critical path development: a valuable CQI tool. Journal of Nursing Care Quality, 8(4), Holland, J. (1994). Scheduling patients in hemodialysis center. Production and Inventory Management Journal, 35(2), Holter, I. M. & Schwartz-Barcott, D. (1993). Action research: what is it? how has it been used and how can it be used in nursing. Journal of Advanced Nursing, 18(2), Horowitzs, J. (1967). CPM and PERT: an overview. critical path scheduling. Columbia Broadcating system, Inc. Hsiao, W. C., Braun, P., Kelly, N. L., & Becker, E. R. (1988). Results, potential effects, and implementation issues of the Resource-Based Relative Value Scale. JAMA, 260(16), Ignatavicius, D. D., & Bayne, M. V. (1991). Medical-surgical nursing: a nursing approach. Philadelphia: W. B. Saunders. Jophiy, L. (1996). Services marketing (3 rd ed.)., U.S.A.:Don Hull. Lane, P. M., & Lindquist, J. D. (1988). Hospital choice: a summary of the key empirical and hypothetical findings of the 1980s. Journal of Health Care Marketing. 8(4), Miles, M. B., & Huberman, A. V. (1985). Qualitative data analysis, (3 rd ed.). Newbury Park, CA: Sage. 52

61 O Malley, J. F. (2001). Healthcare marketing, sales, and service: an executive companion. Chicago: Health Administration Press. Parasuraman, A., Zeithaml, V. A., & Leonard, L. B. (1985). A conceptual model of service quality and its implication for future research. Journal of Marketing, 49(3), Patton, M. Q. (1990). Qualitative evaluation and research methods. London: Sage Publications. Regan, W. J. (1963). The service revolution. Journal of Marketing, 27(3), Sandra, C., & Sue, H. (2004). From integrated care pathways to service pathways: a ground breaking multi-agency approach in Rotherham children's services. Journal of Integrated Care Pathways, 8(2), Stewart, D. W. & Shamdasani, P. N. (1990). Focus groups: theory and practice. Sage Publications, Inc. Yin, R. K., Bateman, P. G., & Moore, G. B. (1983). Case studies and organizational innovation: strengthening the connection. Washington, DC: COSMOS Corporation. 53

62 A 54

63 () H-0 H NO? H-1 YES H-1-1 H-2 H-3 1 (H-3-1) (H-3-2) (H-3-3) H-4 H-5 H-6 H-6-1) (H-6-2) (H-6-3) 1. H-7 55

64 H-0 1 ( ) 2 3? YES 4 NO

65 H-1 ( )? YES H-1-1 NO (a) (b) (c) 1 (d) (e) ( ) e-1. e-2. 57

66 H-1-1 (a) (b) (c) (d) NO YES?(e) H-1 (f) 58

67 H-2 (a)?(b) YES (c) NO (d)

68 H ( ) H (D-L) H (A-VF) (A-VG) 1. H-7 60

69 H YES?(a) (b) NO (c) 2 1. H-7 2. IC 61

70 H ( ) H (D-L) (A-VF) (A-VG) 1. H-7 62

71 H-4 ( ) YES?(a) (b) 1 NO H Hct ( )EPO 63

72 H-5 ( ) 1 (a) (b) (c) 2 (d) (e) (f) 1. b-1 b

73 H-6 ( ) H-6-1 H-6-2 (H-6-2-1) (H-6-2-2) (H-6-2-3) H-6-3 (H-6-3-1) (H-6-3-2) 65

74 H-6-1 ( ) 6% 6% RO 6%

75 H-6-2 ( ) H Toray (H ) 2. JMS (H ) 3. Fresenins (H ) H Toray (H ) 2. JMS (H ) 3. Fresenins (H ) H RO (H ) 67

76 H-6-3 ( ) H H

77 H-7 ( ) H H H RO

78 B k-1-1-a k-1-1-b? *** k-1-1-c *** AB HDF RO ( )UPS 9. k-1-1-d 1.? 2.? 3??? 4.? k-1-1-e? k-1-1-f k-1-a RCW *** *** / / (RCW ) ( vital sign? ) k-1-b k-1-c k-1-d *** *** / *** ( vital sign? ) *** *** / *** ( vital sign? ) ( ) *** / *** ***? 70

79 71 ( ) *** / ( HDR)*** / k-2-a *** / k-2-b *** / k-2-c *** / *** k-2-d / ** ( ) / k-1-e ( /HDR)! *** / *** ( ) *** *** / ***( ) 7: :00-5:00 5:00-10:00 *** **** ****** ** ** IC

80 k a ( ) / ** k b ( ) k k-3-2-b k-3-2-c k k / / ** ** / ** ** ***** **** / **** 1.****2.****3.**** : a. b. c. d. e. f. g. h. i. - a.ic / IC - b. / - c. ** ( ) - d. / *** ** ** ( ) / *** / * ** 72

81 73 k-4-a / ( ) k-4-b ** ( )? k-5-a RCW *** (HDRRCW) *** * * ** ***( ) k-5-b *** / (HDR ) *** / * * ** ***( ) k-5-c *** (HDR ) *** / * * ** ***( ) k-5-d *** / ( ) ** / k-5-1 *** *** ( )? ( )? *** ( ) ***? *** *** *** *** ( ) *** ( ) k-5-2 *** *** ( )? ( )? *** ( )? ***??????

82 C ( ) Total 1 (kg) AV (mmhg) >30mmHg >30mmHg <80mg/dl AK (+) (cc) 74

83 75 (u) Hct ( % ) EPO (Amp) (kg) (mmhg) >±1 (T/M/D) 2 3 1a b c d e e-1 e-2 2T M D 3a b b-1 b-2 c d e f

84 76 D

86 78

87 79

88 >30mmHg 80

89 81

90 82

91 83

92 84

93 85

94 86

95 87

南華大學數位論文

南華大學數位論文 Psychoanalysis Investigation of Kidney transplantation patients Psychoanalysis Investigation of Kidney transplantation patients Abstract The Psychoanalysis is conducted of kidney transplantation patients,