中国公立医院院长委托代理绩效管理研究
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摘要
公立医院在促进我国经济发展,保障人民健康方面,发挥着重要作用。公立医院院长是医院经营者,其绩效水平对医院的绩效具有重要影响。研究建立我国公立医院院长的绩效管理体系,调动和发挥院长的积极性,对于保障广大患者利益,促进卫生事业的持续健康发展,具有十分重要的现实意义。
研究目的
通过分析,理清我国政府与公立医院院长的委托代理关系,设计符合我国国情的公立医院院长委托代理模式,制定院长绩效考评指标和相应的激励约束措施,建立健全我国公立医院院长绩效管理体系,促进院长行为目标与政府目标的统一,提高公立医院运行绩效。
研究内容及方法
首先,分析我国公立医院的委托代理特点,对委托代理风险及其表现形式进行归纳和总结,并剖析委托风险的原因,在探讨我国公立医院管理模式改革实践的基础上,设计符合我国国情的公立医院院长委托代理模式。
其次,根据政府的目标要求,结合代理风险的防范,设计、制定我国公立医院院长的绩效评价指标。通过运用文献法、专家咨询法、专题小组讨论法、层次分析法和灰数统计法,筛选评价指标,制定评价方法及标准;并选择三级医院、二级医院各4家进行调查,运用综合指数法、加权TOPSIS法、灰关联分析法、投影寻踪综合评价等4种方法对医院绩效评价指标进行验证,检验其科学性。
最后,综合运用文献法和理论研究,提出公立医院院长激励约束机制的设计原则和奖惩实施办法,认为实行年薪制和设立卫生管理职称系列,有利于建立责权利统一的激励约束机制。
研究结论
通过理论研究、专家访谈、现场调查等实证研究,作者认为:
我国公立医院院长的委任是一种“行政性委托代理”,其委托代理关系的特点是:委托方式的行政化;代理人身份的行政性;委托代理目标的多重性;委托人与代理人之间的信息控制不对称。这种委托代理关系下存在的代理问题主要表现有内部人控制、过分的在职消费、玩忽职守、寻租(rent-seeking)行为、“偷懒”行为等形式。这些问题存在的主要原因有:委托人与代理人各自的目标利益不一致;委托人与代理人责任风险的不对等;代理人责任与权利不对称;公立医院所有者缺位;信息不对称,监督力量薄弱;多元委托和多元化目标;激励约束机制不够完善等。
最近几年,对公立医院管理的改革探索主要有两种模式,一种是以江苏宿迁为代表的“产权私化”模式;另一种是以上海和无锡为代表的“管办分家”模式。“产权私化”模式简单地把属于国有资产的医疗机构关、停、并、转,使代表人民利益的政府彻底丧失对公立医院所有权,必然难以实现公立医院改革的目标。“管办分家”模式,增加了管理机构,使代理层次增多,管理成本增加,管理效率将难以提高,而且并未在委托院长代理的关键环节上,有效地解决委托人和代理人的问题。
通过分析,笔者认为,当前公立医院改革的问题不在于产权改革,而在于管理权分离的创新,更在于委托人和代理人之间契约的设计和履行。主要研究结果如下:
1.设计新的公立医院院长委托代理模式
保障人民健康,人人享有基本医疗是我国政府的职责,是公立医院的责任。因此,公立医院应该“政府办、政府管,职业院长管”。对于公立医院院长的任命,政府应通过职业化院长市场,进行公开竞聘,选择管理能力强的职业院长。公立医院院长的委托代理模式应为“一处委托、多方监管,责权明确、利益相关”。
2.建立比较完整、操作性强的院长绩效评价指标体系
本指标体系与既往的绩效评价体系的不同之处在于:其一,充分反映了委托人即政府的目标,明确了院长的职责。既往的评价体系大多是事后控制,从医院管理过程中抽出一些指标来考评院长的绩效,新的评价体系,按照委托人利益和意图进行设计,做到了事前控制,可引导并规范公立医院院长的行为更加符合委托人的利益。其二,在指标体系设计上将医院绩效和院长个人行为、能力有机的结合起来;将医疗保险工作、绿色医院和可持续发展能力等列入考评指标;也把一些重要事项,如计生工作、维稳工作、安全生产等作为直接问责指标,实行“一票否决”,充分体现了委托人的利益和目标。再者,除由卫生行政部门、病人、医院员工三方评价外,提出引入第四方,即卫生行政部门以外的其它政府职能部门来评价院长绩效,使委托方能更全面评价院长绩效。此外,指标体系设计了环境影响因素模型,通过剔除环境因素对不同医院绩效的影响,使医院院长绩效的考评更加真实、客观,更具有可比性,和实用性。
3.制定适合我国公立医院院长的激励约束办法。
针对我国公立医院的特点,提出了公立医院院长激励约束机制的设计原则和奖惩实施办法,结合人事制度年度考评办法,将院长绩效考评结果分为优秀、称职、基本称职和不称职四档,并提出了年薪制的实施方案。
创新之处
1.设立了新的公立医院院长委托代理模式。
2.建立了比较完整、操作性强的院长绩效评价体系。
继续本研究的思路
1.在新的公立医院院长委托代理模式下,政府各行政职能部门及院长能否履行各自职能,促进委托和代理双方利益的高度统一,有待深入研究;
2.须作更大范围的实证研究,检验医院绩效及院长个人行为、能力指标的科学性和可操作性,不断对指标体系进行完善;
3.进一步完善并验证环境影响因素模型的作用。
In china, the public hospital is playing a critical role to protect the people’s health and increase the economic development of the country. The head of a hospital is a major influence to the performance of the hospital.. Therefore, it will significantly to excogitate an efficient performance management system for a head of public hospital to motive the enthusiasm that safeguard the patient benefit, promote the public health development.
Aims: This thesis is to identify the relationship between heads of public hospital and the government based on the principal-agent theory that further sets up principal-agent model and a performance appraisal system to motive heads of public hospital in order to link the purpose of two parties and promot public hospital’s performance.
Content and methods: This thesis would analyze the principal-agent characteristic of public hospital and summary the principal-agent hazard and reasons of it. In addition, this thesis would investigate the risks of the principal-agent and discusses practice on the public hospital management pattern reform in order to design a suitable principal-agent pattern of the public hospital for the national condition.
Secondly, to adaption government's goal and void risk of the principle-agent, enhance the performance of heads of hospital and create a performance appraisal system, this thesis applied literature review, Delphi method, focus group and multiple regression analysis etc. to pick up the criteria. Moreover, this thesis is submitted by probability sampling techniques to decide samples (4 hospitals in level 3, 4 hospitals in level 2) in Shenzhen and Wuhan city. Furthermore, using the synthesis exponential method, the connection analytic method, Topsis method and the projection seek out the traces the quality synthetic evaluation and so on, 4 methods to carry on the confirmation to the hospital achievements, the criteria of performance management in scientific nature.
Finally, applied literature review and theory study, proposal design former and measure of inspirit and restrict. Meanwhile, the thesis also presented the implementation plan of yearly salary system and set up rank of health management.
Conclusion: through the evidence-based study, such as: theory study, the expert visiting and investigation, the author develop a performance appraisal system of a head of public hospital and identify the principle-agent relationship, which is considered the principal-agent to relate“the administrative principal-agent”. However, this concept is unable to fulfill the management operation, including the trustee is inconsistent with the agent respective, the trustee and the agent responsibility risk is not coordinated, the agent responsibility and the right are asymmetrical, owner vacancy, asymmetrical information and surveillance strength is weak, multi-principle and multi-goal, agent's drive restraint mechanism insufficient consummation. These problems leaded to the proxy question as: the employee management, the excessive in office expense, negligence, rent-seeking, shirking and so on behavior.
Recently several years, many State-Owned enterprises reform it procedure that has carried on the positive exploration to the medical reform. Mainly may divide into two kind of patterns, one kind is“the property right privatization”model as Jiangshu Suqian representative; Another kind is“the manage separates from the ownership”as Shanghai and Wuxi representative. In general,“the property right privatization”is based on closing, stopping, and extension of public hospital property that is difficulty achieve the goal of the reforming public hospital. Moreover, the second model will make the agent level to increase, manage the cost to increase, manage the efficiency with difficulty to enhance, and the problems between trustee and agent.
This thesis is to consider that the innovation of public hospital is conducted by the contract design between the trustee and the agent and innovation of management right separate from ownership, is not based on innovation of propert right. Therefore, this thesis would obtain the following achievement through the research.
1. Conformation the new principal-agent pattern for heads of public hospitals.
Government should found and management public hospital and select occupational supervisor. The recruitment of heads of public hospital is from job market in order to select a competent head. As a result, the health service in our country would keep in satisfaction level and people benefit from the service particularly in the public hospitals.
Moreover, the appropriate principal-agent pattern within our national condition is supposed to be followed criteria: 1) appoints a head of public hospitals by the administration of public health department as a government representative; 2) multi-department carry on supervising to the hospital; 3) needs further to be clear about the responsibility every sides; 4) requests every sides benefit and reward with his achievements.
2. Established a full completely and suitable performance appraisal index system to heads of public hospital.
The new system is based on the concept of forwards-control in that the principle-agent contract has been clearly addressed the responsibility and the objective of government. Specifically, the criteria of new system approach the national benefits to regard as medical insurance, the concept of green hospital and the sustainable development capabilities. In order to fair appraisal different heads’achievements, this appraisal system uses 360°method that examines by four parties: higher department responsible for the work, patient, hospital staff and people from other government administrative department. At the same time, this new system also considers the situational factors in order to get more comparability and usability.
3. Formulated a proper motivation and restriction measure to heads of public hospital within our national condition.
According to characteristic of public hospital in our country, proposed design principle to establish motivation, restriction mechanism, rewards and punishment measure. The judgment of performance could be divided into four levels, including excellent, good, normal and fail. The thesis also proposed scheme of the yearly salary system of heads of public hospital.
Innovations:
1.Proposed the new principal-agent pattern for heads of public hospitals.
2.Established a full completely and suitable performance appraisal index system to heads of public hospital.
Ideas of the follow research:
1. Continue this research on principal question in public hospitals and to promote the agent to fulfill the owner function very well in the new pattern and consolidate advantage of principal and agent;
2. Makes large-scale positive research on performance appraisal system and further completes it,examines operational and scientific of the system of personal behavior and ability index;
3. Further completes and validates the model of environmental effect of performance of the head of public hospital.
研究目的
通过分析,理清我国政府与公立医院院长的委托代理关系,设计符合我国国情的公立医院院长委托代理模式,制定院长绩效考评指标和相应的激励约束措施,建立健全我国公立医院院长绩效管理体系,促进院长行为目标与政府目标的统一,提高公立医院运行绩效。
研究内容及方法
首先,分析我国公立医院的委托代理特点,对委托代理风险及其表现形式进行归纳和总结,并剖析委托风险的原因,在探讨我国公立医院管理模式改革实践的基础上,设计符合我国国情的公立医院院长委托代理模式。
其次,根据政府的目标要求,结合代理风险的防范,设计、制定我国公立医院院长的绩效评价指标。通过运用文献法、专家咨询法、专题小组讨论法、层次分析法和灰数统计法,筛选评价指标,制定评价方法及标准;并选择三级医院、二级医院各4家进行调查,运用综合指数法、加权TOPSIS法、灰关联分析法、投影寻踪综合评价等4种方法对医院绩效评价指标进行验证,检验其科学性。
最后,综合运用文献法和理论研究,提出公立医院院长激励约束机制的设计原则和奖惩实施办法,认为实行年薪制和设立卫生管理职称系列,有利于建立责权利统一的激励约束机制。
研究结论
通过理论研究、专家访谈、现场调查等实证研究,作者认为:
我国公立医院院长的委任是一种“行政性委托代理”,其委托代理关系的特点是:委托方式的行政化;代理人身份的行政性;委托代理目标的多重性;委托人与代理人之间的信息控制不对称。这种委托代理关系下存在的代理问题主要表现有内部人控制、过分的在职消费、玩忽职守、寻租(rent-seeking)行为、“偷懒”行为等形式。这些问题存在的主要原因有:委托人与代理人各自的目标利益不一致;委托人与代理人责任风险的不对等;代理人责任与权利不对称;公立医院所有者缺位;信息不对称,监督力量薄弱;多元委托和多元化目标;激励约束机制不够完善等。
最近几年,对公立医院管理的改革探索主要有两种模式,一种是以江苏宿迁为代表的“产权私化”模式;另一种是以上海和无锡为代表的“管办分家”模式。“产权私化”模式简单地把属于国有资产的医疗机构关、停、并、转,使代表人民利益的政府彻底丧失对公立医院所有权,必然难以实现公立医院改革的目标。“管办分家”模式,增加了管理机构,使代理层次增多,管理成本增加,管理效率将难以提高,而且并未在委托院长代理的关键环节上,有效地解决委托人和代理人的问题。
通过分析,笔者认为,当前公立医院改革的问题不在于产权改革,而在于管理权分离的创新,更在于委托人和代理人之间契约的设计和履行。主要研究结果如下:
1.设计新的公立医院院长委托代理模式
保障人民健康,人人享有基本医疗是我国政府的职责,是公立医院的责任。因此,公立医院应该“政府办、政府管,职业院长管”。对于公立医院院长的任命,政府应通过职业化院长市场,进行公开竞聘,选择管理能力强的职业院长。公立医院院长的委托代理模式应为“一处委托、多方监管,责权明确、利益相关”。
2.建立比较完整、操作性强的院长绩效评价指标体系
本指标体系与既往的绩效评价体系的不同之处在于:其一,充分反映了委托人即政府的目标,明确了院长的职责。既往的评价体系大多是事后控制,从医院管理过程中抽出一些指标来考评院长的绩效,新的评价体系,按照委托人利益和意图进行设计,做到了事前控制,可引导并规范公立医院院长的行为更加符合委托人的利益。其二,在指标体系设计上将医院绩效和院长个人行为、能力有机的结合起来;将医疗保险工作、绿色医院和可持续发展能力等列入考评指标;也把一些重要事项,如计生工作、维稳工作、安全生产等作为直接问责指标,实行“一票否决”,充分体现了委托人的利益和目标。再者,除由卫生行政部门、病人、医院员工三方评价外,提出引入第四方,即卫生行政部门以外的其它政府职能部门来评价院长绩效,使委托方能更全面评价院长绩效。此外,指标体系设计了环境影响因素模型,通过剔除环境因素对不同医院绩效的影响,使医院院长绩效的考评更加真实、客观,更具有可比性,和实用性。
3.制定适合我国公立医院院长的激励约束办法。
针对我国公立医院的特点,提出了公立医院院长激励约束机制的设计原则和奖惩实施办法,结合人事制度年度考评办法,将院长绩效考评结果分为优秀、称职、基本称职和不称职四档,并提出了年薪制的实施方案。
创新之处
1.设立了新的公立医院院长委托代理模式。
2.建立了比较完整、操作性强的院长绩效评价体系。
继续本研究的思路
1.在新的公立医院院长委托代理模式下,政府各行政职能部门及院长能否履行各自职能,促进委托和代理双方利益的高度统一,有待深入研究;
2.须作更大范围的实证研究,检验医院绩效及院长个人行为、能力指标的科学性和可操作性,不断对指标体系进行完善;
3.进一步完善并验证环境影响因素模型的作用。
In china, the public hospital is playing a critical role to protect the people’s health and increase the economic development of the country. The head of a hospital is a major influence to the performance of the hospital.. Therefore, it will significantly to excogitate an efficient performance management system for a head of public hospital to motive the enthusiasm that safeguard the patient benefit, promote the public health development.
Aims: This thesis is to identify the relationship between heads of public hospital and the government based on the principal-agent theory that further sets up principal-agent model and a performance appraisal system to motive heads of public hospital in order to link the purpose of two parties and promot public hospital’s performance.
Content and methods: This thesis would analyze the principal-agent characteristic of public hospital and summary the principal-agent hazard and reasons of it. In addition, this thesis would investigate the risks of the principal-agent and discusses practice on the public hospital management pattern reform in order to design a suitable principal-agent pattern of the public hospital for the national condition.
Secondly, to adaption government's goal and void risk of the principle-agent, enhance the performance of heads of hospital and create a performance appraisal system, this thesis applied literature review, Delphi method, focus group and multiple regression analysis etc. to pick up the criteria. Moreover, this thesis is submitted by probability sampling techniques to decide samples (4 hospitals in level 3, 4 hospitals in level 2) in Shenzhen and Wuhan city. Furthermore, using the synthesis exponential method, the connection analytic method, Topsis method and the projection seek out the traces the quality synthetic evaluation and so on, 4 methods to carry on the confirmation to the hospital achievements, the criteria of performance management in scientific nature.
Finally, applied literature review and theory study, proposal design former and measure of inspirit and restrict. Meanwhile, the thesis also presented the implementation plan of yearly salary system and set up rank of health management.
Conclusion: through the evidence-based study, such as: theory study, the expert visiting and investigation, the author develop a performance appraisal system of a head of public hospital and identify the principle-agent relationship, which is considered the principal-agent to relate“the administrative principal-agent”. However, this concept is unable to fulfill the management operation, including the trustee is inconsistent with the agent respective, the trustee and the agent responsibility risk is not coordinated, the agent responsibility and the right are asymmetrical, owner vacancy, asymmetrical information and surveillance strength is weak, multi-principle and multi-goal, agent's drive restraint mechanism insufficient consummation. These problems leaded to the proxy question as: the employee management, the excessive in office expense, negligence, rent-seeking, shirking and so on behavior.
Recently several years, many State-Owned enterprises reform it procedure that has carried on the positive exploration to the medical reform. Mainly may divide into two kind of patterns, one kind is“the property right privatization”model as Jiangshu Suqian representative; Another kind is“the manage separates from the ownership”as Shanghai and Wuxi representative. In general,“the property right privatization”is based on closing, stopping, and extension of public hospital property that is difficulty achieve the goal of the reforming public hospital. Moreover, the second model will make the agent level to increase, manage the cost to increase, manage the efficiency with difficulty to enhance, and the problems between trustee and agent.
This thesis is to consider that the innovation of public hospital is conducted by the contract design between the trustee and the agent and innovation of management right separate from ownership, is not based on innovation of propert right. Therefore, this thesis would obtain the following achievement through the research.
1. Conformation the new principal-agent pattern for heads of public hospitals.
Government should found and management public hospital and select occupational supervisor. The recruitment of heads of public hospital is from job market in order to select a competent head. As a result, the health service in our country would keep in satisfaction level and people benefit from the service particularly in the public hospitals.
Moreover, the appropriate principal-agent pattern within our national condition is supposed to be followed criteria: 1) appoints a head of public hospitals by the administration of public health department as a government representative; 2) multi-department carry on supervising to the hospital; 3) needs further to be clear about the responsibility every sides; 4) requests every sides benefit and reward with his achievements.
2. Established a full completely and suitable performance appraisal index system to heads of public hospital.
The new system is based on the concept of forwards-control in that the principle-agent contract has been clearly addressed the responsibility and the objective of government. Specifically, the criteria of new system approach the national benefits to regard as medical insurance, the concept of green hospital and the sustainable development capabilities. In order to fair appraisal different heads’achievements, this appraisal system uses 360°method that examines by four parties: higher department responsible for the work, patient, hospital staff and people from other government administrative department. At the same time, this new system also considers the situational factors in order to get more comparability and usability.
3. Formulated a proper motivation and restriction measure to heads of public hospital within our national condition.
According to characteristic of public hospital in our country, proposed design principle to establish motivation, restriction mechanism, rewards and punishment measure. The judgment of performance could be divided into four levels, including excellent, good, normal and fail. The thesis also proposed scheme of the yearly salary system of heads of public hospital.
Innovations:
1.Proposed the new principal-agent pattern for heads of public hospitals.
2.Established a full completely and suitable performance appraisal index system to heads of public hospital.
Ideas of the follow research:
1. Continue this research on principal question in public hospitals and to promote the agent to fulfill the owner function very well in the new pattern and consolidate advantage of principal and agent;
2. Makes large-scale positive research on performance appraisal system and further completes it,examines operational and scientific of the system of personal behavior and ability index;
3. Further completes and validates the model of environmental effect of performance of the head of public hospital.
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