People-oriented health service is to let patients, their families and the community participate in diagnosis and treatment services. They are both beneficiaries and participants of health services. They are full of trust in the service system, which can also provide services in a humanized and integrated way according to their needs and preferences. In the final analysis, PCIC will adjust the health service delivery system and establish a fully functional medical service network composed of interconnected suppliers at all levels to be responsible for the health of residents. In this report, the term "people-oriented integrated service (PCIC)" refers to this model.
In China, the central government has promulgated a series of policies and invested in the construction of a service delivery system based on PCIC. In particular, the General Office of the State Council recently issued the Guiding Opinions on Promoting the Construction of Graded Diagnosis and Treatment System (20 15 Guo Ban Fa No.70), which clarified the establishment of graded diagnosis and treatment system and the functional orientation and responsibilities of various medical institutions at all levels, laying a good foundation for various reform measures. These include: vigorously improving the basic medical and health service capacity, strengthening the construction of basic medical and health personnel, strengthening the two-way referral system, making special arrangements for the treatment and disease management of patients with chronic diseases, accelerating the construction of medical and health information, establishing a regional medical and health information platform, realizing the continuous recording of electronic health records and electronic medical records, realizing information sharing among different levels and types of medical institutions, and ensuring the smooth flow of referral information, and so on.
A prominent challenge facing China is how to improve the quality of health services to meet the growing expectations of the public for better health and better health services. The success of rebuilding health service system according to PCIC model depends on the ability of health system to provide quality services to the public.
The quality of health service includes at least two aspects: technology and humanization. Technical quality refers to the correctness of diagnosis, appropriate intervention measures based on the best evidence, and the ability of clinical teams to provide corresponding intervention services, thus increasing the possibility of improving health outcomes. Humanized quality refers to the degree to which medical services pay attention to patients' preferences: being able to see your favorite doctor, continuity of service, good communication, consideration for patients and respect for patients' privacy are all regarded as quality services. Quality standards can change over time, because new medical knowledge and technology often raise our expectations for quality services, and we need to constantly review and update quality standards. Ensuring the highest standard of service quality means that all patients can get the right medical service at the right time and place every time.
The quality of medical service is the decisive factor affecting health outcomes. Evidence from OECD countries shows that 10% ~ 30% of premature deaths in the past decade can be attributed to the improvement of health service quality. Improving quality is related to improving patient outcomes and patient experience, but decision makers cannot ignore the close relationship between quality and cost. Studies have continuously found that high-quality service does not necessarily mean high cost, but the result of inferior service is often more hospitalization, more monitoring treatment and drug treatment, longer hospitalization time and unnecessary re-hospitalization, which leads to waste of resources and bad health results. Since 2009, the National Health and Family Planning Commission has set up national and local "medical quality management committees", which are responsible for setting standards and ensuring the improvement of the service quality of corresponding medical specialties. The Medical Quality Management Committee is located in tertiary hospitals and teaching hospitals, and is the technical lead unit in the corresponding technical fields in this region. Since 20 10, the national health and family planning commission has issued a number of quality control guidance documents for the pilot reform of public hospitals, carried out activities to reduce the abuse of antibacterial drugs, and improved patients' medical experience by making appointments online and extending hospital service hours. Recently, two policy documents on the reform of urban public hospitals and county hospitals reiterated the necessity of strengthening and improving service quality. From 2065438 to March 2005, the National Health and Family Planning Commission took an important first step in establishing a mechanism to support quality improvement, and established the Medical Management Service Guidance Center of the National Health and Family Planning Commission. The center undertakes a series of responsibilities, mainly to provide technical support for quality improvement in various places. This is just the beginning, and there are some important quality improvement functions that are not undertaken by the guidance center, including formulating, verifying and authorizing the adoption of national standardized quality indicators, managing the quality monitoring and evaluation of medical institutions, and coordinating the quality improvement work of various stakeholders. In the past ten years, most OECD countries have realized that improving quality is the core purpose of health development and have carried out systematic reforms to improve the quality of health services. The government is increasingly assuming the role of public manager and health service payer, leading the medical and health reform aimed at improving the quality of health service.
2. Challenges in building a people-oriented health service system.
The rapid aging and the increasing burden of chronic diseases constitute the main challenges faced by the population and epidemiology in China. With the increase of chronic diseases, China needs to consider a two-pronged approach, which not only solves the causes of chronic diseases, but also carries out early detection and management of chronic diseases. At present, China has not effectively achieved vertical integration (between suppliers at all levels) and horizontal integration (between various services such as health promotion, prevention, treatment and hospice care). This shows that the health service system is fragmented, which affects the efficiency of the medical and health service system and increases the cost. The lack of integration is also reflected in the following aspects: at present, China's public health system (focusing on health promotion and prevention) and medical service system (focusing on primary services to tertiary services) are separated; Lack of effective health electronic information system to ensure service integration; Lack of economic incentives to promote the interconnection between suppliers.
The case study found that the implementation of PCIC-based service delivery system reform faced the following constraints. But importantly, China has carried out many innovative projects to meet these challenges.
1. Although the government requires grass-roots units to combine prevention and control, the close integration of these two types of services nationwide is not enough.
2. There is only a little difference between going to the hospital to see an outpatient clinic and going to the grassroots to see an outpatient clinic, which is not enough to stop going to the hospital for the first time.
3. China is also trying to establish an integrated network of health institutions, namely "medical association". However, these medical associations are often dominated by large hospitals and become the source of patients in higher medical institutions.
4. There are many innovations in medical electronic informatization in China health industry, but most of these activities are isolated and there is no interoperability between systems. Many innovative activities mainly support large hospitals, not primary medical institutions.
5. Whether at the local or national level, China needs to improve or establish a unified and standardized evaluation system to measure and improve the quality of primary medical services, chronic disease management and patient satisfaction. This assessment system should be organically combined with quality improvement.
After reviewing the data of health service quality in China, it is found that China faces the following challenges in the process of transforming into a people-oriented health service generation, financing and provision model:
1. Institutional problems. Although more and more regions in China have carried out quality improvement in recent years, compared with OECD countries, the system support of the whole system is still weak. First of all, there seems to be no national quality improvement strategy to identify and decide the priority areas of intervention and formulate acceptable quality standards. At present, the work is more about dealing with the problems of abusing antibiotics and violently attacking medical staff, rather than solving the problems through a more comprehensive and systematic way of thinking. Secondly, it is necessary to form a strong unified leadership on quality issues to influence all stakeholders (public and private), formulate a quality improvement agenda, provide needed resources, reach a consensus on quality standards and indicators, and share experiences and lessons of quality improvement.
2. Medical service quality information. The systematic information about quality problems in China is insufficient to provide guidance for formulating effective and targeted intervention measures. Most quality assessments are descriptive studies aimed at one or several tertiary hospitals. Lack of evidence about the quality of health services in secondary hospitals and primary medical institutions.
At present, people's concerns about service quality and medical institutions are not from the perspective of patients' interests, which affects their trust in the health service system. With the increase of income, rapid urbanization and increasing demand for health services, people in China have high hopes for medical reform, which will improve the performance of health service delivery system.
The challenge facing the government is how to design appropriate intervention measures and strategies to turn the ideas contained in some policies promulgated by the government into reality-how to strengthen the response of the health service system and the people-oriented service ability, so as to gain the trust of patients? International experience shows that the core of the solution is "patient authorization", that is, the medical service system should make "patients participate in providing health services" or make them "independent partners in disease treatment, prevention and management", and health service providers "promote patients and the public to actively participate in health and medical services and strengthen the influence of patients and the public on medical service decision-making."
3. Suggestions on building a people-oriented health service system.
In order to respond to the calls and requirements for improving the quality of health services, relevant reforms can learn from and take the following efforts to realize future expectations:
1. Improve the organizational structure, guide the collection of quality information, and formulate quality improvement strategies.
The leadership and guidance of the government is very important to improve the ability of health service quality. International experience points out three activities that the government can consider: expanding the responsibilities of existing institutions or forming a coordination mechanism to lead, supervise and implement quality improvement; Conduct a national assessment; Formulate a national quality improvement strategy.
The national coordination mechanism can supervise the systematic improvement of health service quality. The organization is responsible for coordinating the work of all parties in quality assurance and quality improvement, actively mobilizing the participation of all stakeholders, and promoting the implementation of quality assurance and quality improvement strategies. Its main functions include: formulating national quality objectives; Establish quality standards and formulate quality indicators; Continuously evaluate and report the progress of compliance process; Formulate national standardized medical education curriculum; Professional qualification certification of medical staff; Supervise the certification and evaluation of public and private medical institutions; According to the results of cost-benefit analysis and ethical considerations, the treatment and intervention methods that can be reimbursed by social medical insurance are defined; Evaluation and promotion of clinical guidelines.
2. Systematically evaluate health service quality data and continue to use it to support quality improvement.
In the past decade, a prominent feature of quality improvement in OECD countries is the extensive use of quantitative data on the process and results of health services. Due to the increasingly rich data and the progress of statistical methods, it is easier to obtain reliable quality indicators than before.
The changes in the quality of medical service process are also reflected in the changes in the results. The change of survival rate, health and functional recovery caused by providing health services is the core of outcome evaluation, and the evaluation results are the most important for the beneficiaries of any health system, so it is also the vital content of evaluating the performance of any patient-centered service model.
3. Strengthen public participation and improve scientific medical care and self-management ability.
Generally speaking, public participation includes two main aspects: the public (patients) authorizes and stimulates citizens (patients) to actively participate. The public can participate at individual, family and community levels. Interaction between service providers, patients and families is also included.
Patients and communities need to master the necessary knowledge and information to improve the ability of scientific medical treatment. Once you have the necessary information, you can "mobilize" patients to participate in various activities to manage self-health and medical services, deal with dangerous behaviors and protect the living environment. The health service system can empower the public in many ways, improve the public's participation ability and mobilize the enthusiasm of patients. Interventions to strengthen self-management not only increase patients' knowledge, improve their skills in coping with diseases and their confidence in managing chronic diseases, but also help to bring better health results and even reduce the hospitalization rate in some cases. Doctor-patient decision-making shows the potential of different countries to improve patients' satisfaction and medical service level, which is helpful to make patients tend to choose cheaper minimally invasive treatment rather than surgical treatment.
4. Doctor-patient decision-making is a process in which patients, as active partners, work together with medical staff to determine an acceptable treatment plan and plan and implement a mutually agreed action plan.
Doctor-patient decision-making is the basis of people-oriented medical service model. This working mechanism ensures that doctors can make a correct diagnosis and propose a treatment plan on the basis of being scientific and considering patients' preferences, so that patients can get the medical services they need. Decision-making between doctors and patients is a cooperative way of working. Doctors and patients find problems together, determine key points, set goals, formulate treatment plans and solve problems. In this respect, the decision-making between doctors and patients reflects citizens' affirmation of their ability to participate in self-health management to a certain extent.
5. Establish a strong accountability mechanism for public hospitals to improve performance.
A basic content of public hospital reform is how to establish a good accountability mechanism, standardize hospital behavior, improve hospital performance, follow the mission entrusted by society, and help public hospitals achieve the government's public policy goals.
Strengthening the accountability system requires the following strategic measures: clarifying rules, reporting requirements and other mechanisms, and establishing a strong government accountability system for public hospitals, including contracts, financial management and auditing; Patient safety procedures, performance requirements, etc. ; Establish institutional arrangements to promote the monitoring and supervision of hospitals; And decided to disclose the information to the public.
6. Establish an incentive mechanism and accountability system consistent with public goals.
The behavior of any hospital is influenced by the incentive mechanism, which may be financial or non-financial. Incentive factors are usually reflected in how to compensate hospitals and medical staff, but also include the incentive effect of health service institutions and broader health service system culture on behavior.