國立高雄第一科技大學

科技法律研究所

課程：醫療與法律

指導教授：周天 所長
報告人 ：碩專班二年級
9520706 王曉梅

P 19-35 ， Liability and quality issues in health case ， fifth edition

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 成大醫院 :18 屆國家品質獎 機關團體獎

策略目標 策略內容
教學：培育術德兼備之醫療團隊
研究：提升研發創新能力，成為國內外特定主題之研究重鎮。
服務：全人照護之優質醫療品質
目標一： 1.  建置跨單位之整合性醫療團隊
建構以病人為中心 2.   建置急重症醫學中心，整合相關資源與人員培訓。
的醫療環境 3.   推廣器官捐贈及提升器官移植技術
4.   強化個案管理制度及功能
5.   強化醫療品質，營造病人安全環境。
6.   簡化服務流程，強化行政品質。
7.   推動資訊系統再造工程
形象：提升社會及外界評價，強化成大品牌
目標一： 1.  塑造全面品質文化
強化全面品質管理 2.  活化品質改善手法
模式 3.  創造醫院品牌魅力
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營運：達收支平衡
經營理念

•以病人為中心
　
•追求卓越品質
　
•秉持醫學倫理
　

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 Quality vs. hospital market

Source: 王津勝區域醫院品質績效之探討公共衛生學研究所碩士在職專班高雄醫學大學　 2003 年 4

 Major approaches to quality
assessments

Structure Process Outcome

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 Assessment of the Quality of
care
 Model I :Avendis Donabedian [Vol.1 (1980)79-84]
: A set of activities that go on within and between
practitioners and patients.
By directing observation
(1).Process of care:
By review recorded
information

(2). Consequences: Individuals (health 、 welfare)

society

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 Process evaluation
 Advantages:
Specify criteria and stds. 、
Documentation in the medical record for
preventive&informative purposes 、
To permits attribution of responsibility for discrete
clinical decisions
 Drawbacks:
The weakness of the scientific basis for much of
accepted pratice.
High cost care.(technical interventions)
interpersonal process is slighted.
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 Outcome evaluation
 Advantages:
flexible 、 included of process of all health care.
 Problem:
duration 、 timing 、 extent 、 specifity 、 is often known too late to
to affect pratice
 Is useful for comparing hospitals?
mortality (DHHS) & morbidity .

Jesse Green,et al : the severity of the p’t illness

 Paul Ellwood: Outcomes management

consists of a common p’t-understand language of health outomes;
A national database containing

clinical (medical intervention) finance

health outcomes
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 Avendis Do. argued that-----
 Structure: personnel 、 equipment 、 internal
regulation 、 financial resource
(1). Disadvantages: blunt 、 least useful
(2). Advantages:easiest 、 relatively stable
 Outcomes: patient’s health status
Shall include improvement of : social 、
attitute
、 psychological function 、 health-related
knowledge behaviroral change,as well.

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 Possible indicators of good or bad
quality health care
 Mortality& morbidity rates
 Adverse evevts: nosocomial infection
 Formal disciplinary actions:state medical board
 Malpratice awards
 Process evaluation of physician’s
performance:H/Tscreening &management
 Physicial’s specialization
 Scope of hospital services,evaluated by
external guidelines(JCAHO)

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 Comparative performance
 The markert approach would allow the
consumers to select higher quality
provider.
 Who? patient ?insurer?employers
 How?

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 美國醫療機構評鑑聯合會
（ Joint Commission on Accreditation of Healthcare
Organizations ， JCAHO)
 於每年六月會公布下年度病人安全之目標，包含簡要且具實證或
專業為基礎之建議，且每年會針對前一年所列的目標及建議評值
醫院整體遵循程度。

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 Improving Quality
 Reorganization :
Health care corps:dominat the delivery of health care services.
Inforamtion processing: collect 、 process 、 analysis data.
Data describe: efficacy of diagnosis 、 treatment modalities 、
construct pratice guidelines
Analysis of Outcome data : comparing the outcomes of care provider by
practitioners or institutions with average or optimal pratice.
 Information processing:
1986-1992 : Federal Health Care Financing administration & States
(Pennisylvia 、 N.Y….. )
published the result of comparing outcomes data,
Lay managers to assess physician quality

 The new industry- originated practices:

Total quality management(TQM)
Continuous quality improvement(CQI)
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 quality management ，
TQM ）
 是用一種整體規畫，促成企業變革的理
論，是對人類、服務、產品、顧客有一
致的看法及理念。

 美國衛生行政學會 : 為 TQM 所下的定

義為「代表一種讓顧客滿意度持續增加
，同時也能降低成本的管理系統」。

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Timothy S.Jost: Oversight of the qulity of medical
care: regulation,management,or the markert?

 Deming et al.: Industrial setting:

continuous quality improvement (CQI)& total quality management( TQM)

 Philosophy:
(1).Quality is in term of meeting the needs “customers”
(2).Energy is better directed toward improving the system through which
care is delivered than toward looking for” bad apples”(quality assurance)
(3).Data are very important for driving & shape systems improvement.
(4).Management & staff must be invoved at all levels in the process
of improvement.(TQM)
(5).Quality improvement is never finished .( CQI)

 Challenge
 Benefits: bad apple (traditional regulatory programs)

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 Notes & Question
 Adopting managerial priniciples to
improve
quality
 CQI or TQM : personnel management
 Why physicians might object to the
application of these management
strategies to their professional services?

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 The problem of medical error

A.Medical Iatrogenesis:
(1).Definition: medical errors
(2).Bad medicine 、 apples
(3).is attributed to: systemic failure 、… ..
(ex Jonna K. Weinberg)
B.The extent of medical misadventures:
cost (recovery & lost productivity)
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 P’t s,Drs.,Lawyers:Medical injury
Malpratice litigation, and
p’t compensation in N.K

 The report of the Harvard Medical Pratice Study to the States of N.K(1990) :

 In 1984 ， 280 of 7,743 records were judged

to result from negligent care

(1). Physician confidence :

(2). The 57% of adverse events resulted in
minimal& transient disability;
(3). Negligent adverse events>>>non-negligent
events resulted in disability.

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 Risk Factor
 Age:65yrs (DRG)
 No significant differences:
 Significant differences:

(1). government hospitals

(2). upstate,non-MSA hosp
(3). Non-teaching hosp.

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 The nature of adverse events
 Errors in diagnosis & non-invasive Tx
 65 yrs p’ts
 Younger p’ts: due to surgical failures
 Site: o.r(the highest rate); e.r (70% from
negligence)
 Type: Performing a procedure
Diagnostioc error & prevention errors
 Severity: the more severe the degree of
negligence
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 Litigation data
 The true size of the gap
 The tort litigation system

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 Notes and Question


(1).David M.Studdert et al: “Measures of Medical Injury

Burden,Malpratice Litigation,a nd Alternative
Compensation Model from Utah and Colorado” (. 33 Ind
,L.Rev.1643,1662,2000)

A. Surgery
B.Drug
(2). A study of Insurance company:
80% substandard anesthetic care

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 Notes and Question
 Does the tort system’s value as a Q.C system in
detecting and deterring error? Or do they support the
need for reform?
 The tort litigation system cannot screen out claims
with no negligence
 Do liability doctrines adequately attack medical
error?
 The hospital& surgery both are risky factors.
 Errors in office-based surgery
 A sophisticated look at the pratice of medicine

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 Remedying Quality Problems
 Origins of clinical standards of pratice:
comments clinical policy standard pratice.
(the decentralized process)

(1).Advantages:
unwarranted burst of enthusiasm are dampened 、 best mind
、 flexibility
(2).Drawbacks:
oversimplification(side - effect 、 cost) 、 overuse 、
adocacy system may arise in proponents push 、 sampling

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 Remedying Quality Problems
(1).The diffusion of new tech.

(2).The variation of medical pratice: John E.Wenberg

(states,regions)
A. uncertainty
In Maine, 70yrs women 20% (one hospital market)
hysterectomy 70% (another markert)
B. medical consensus
C. aging-related condition

(3).The appropriateness of medical treatmant :

1/3-1/4 of medical service may be of no value to p’t

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Several approaches to improve quality
 Professional ethics and socialization
 Self-regulation of the medical profession and the
industry(accreditation 、 medical licensing action)
 The development of pratice parameter or protocol
(1). Problems:
overuse 、 scientific evidentce is imcomplete
、 reliance on expert judgement 、 slow 、
expensive

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 Medical Board of California
The mission of the Medical Board is to
protect healthcare consumers through the
proper licensing and regulation of
physicians and surgeons and certain
allied healthcare professions and through
the vigorous, objective enforcement of the
Medical Practice Act, and, to promote
access to quality medical care through the
Board's licensing and regulatory functions.

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