人民医院总体发展战略咨询1 1 医疗概况德国全国居民中 50
人民医院总体发展战略咨询继往开来 开拓进取 与时俱进
继往开来开拓进取与时俱进——中山市人民医院52华诞致词王得坤2002年3月16日是中山市人民医院成立52周年的纪念日，在这特别而重要的日子里，我谨代表中山市人民医院全体工作人员，向多年来一直关心和支持我院发展的各级领导、杨氏家族、社会各界朋友、海外同胞们表示衷心感谢！我院始建于1950年3月16日。
始创初期是一所设备十分简陋的小医院，仅有病床14张，产床20张，医务人员18人。
历经52年沧桑，几易其址，几度分合，以1982年杨颖滨大楼的建成作为向现代化医院迈进的转折点。
医院面貌和住院条件发生了根本性转变，中山市人民医院进入了一个新的发展时期。
1999年杨志云大楼的落成，使我院科室布局更为合理，其中的全净化手术间达到国际先进水平，洁静舒适的病房设施、宁静素雅的就医环境，提升了服务档次，从而促进了我院医疗业务发展的再次飞跃。
经过数代人的艰辛努力，励精图治，发展至今，中山市人民医院已成为我市最大型的集医疗、教学、科研和预防保健为一体的综合医院。
先后被授予国家“三级甲等医院”、“爱婴医院”、“广东省高等医学院校教学医院”、广东省“百家文明医院”等称号。
2000年，在上级部门的鼎力支持下，中山医科大学临床医学博士后流动站和研究生教学基地在我院成立。
我院有5位高级职称人员成为中山医科大学兼职硕士研究生导师。
同年，急救中心和康怡特诊中心的奠基以及烟墩、莲峰、东区等医院的归并使我们中山市人民医院向规模化、集团化发展迈开了坚实的步子。
2000年11月，我院举行了建院50周年大型庆典系列活动，以《中山市人民医院之歌》、院徽、院庆晚会、庆典纪念版VCD等，对内营造良好的庆典气氛的同时，开创了医院文化的新篇章，培养了积极向上、无私奉献、团结奋进的医院精神，大大增强了职工的主人翁责任感、归属感，大大提高了医院凝聚力。
对外则让全社会和海内外人士充分了解了我院的综合实力和精神风貌，充分体现了我院在“两个文明”建设中的良好形象。
人民医院总体发展战略咨询各国医院状况
美国：☐每千人4.1张床位，我国每千人2.1（未确实）☐大致分为三类医院：第一类是综合性的大医院，一般是医学院的附属医院，承担医、药、研的任务；第二类是较之稍小的有专业特色的医院，以医疗为主，另外协助综合性的大医院承担一些教学任务；第三类是以社区服务为主的医院，大量的工作是社区服务，也承担一部分临床工作☐所有医院，经常组成医疗健康系统，由一家大的医院为首，联合不同等级的医院所构成。
医院与医院之间有很强的互补性，因为它们的床位、规模和专业特色都不一样，可以自行发展自己特有的专业☐在美国，营利性的医院是为主的，占70%。
医学教学的经费是由州政府拨款；科研经费可以由医院申请专项基金得到☐基本上是董事会管理，董事会主要负责医院的发展方向和财政计划及医务人员情况的整体把关。
董事会要聘任医院院长，院长是首席执行官☐在美国，医疗保险制度已经成为一个常规的而且人人都接受的一项制度，由单位和个人共同负担☐美国的医学生有一个很隆重的仪式，叫做"穿白大衣"的仪式，目的是让医生具有一种职业的神圣感☐我们在美国的医院里随处可见供病人阅读的各种各样的小册子，其中一些小册子着重强调了病人在医院里所能享受到的权利☐医疗保险制度、医疗付费制度、社区医疗的问题、医疗系统的问题、药品的问题、行为规范等先进于其它国家日本：☐日本的社区卫生服务是由预防、医疗、保健、康复组成的全面医学(Comprehensive medicine)，发展非常均衡☐日本康复医学概念明确，已经把康复渗透到整个医疗过程，包括预防、早期识别、门诊、住院和出院后的医疗计划中去，无论医院门诊、病房、社区中的医疗福利设施都设有功能和设备比较完整的、配有专门康复医师的康复医学科。
康复医学和临床医学是并列的，它不是临床医学的重复，只是各阶段采取的手段有所差异，临床医学重在促进病理上的痊愈，康复将这一个目的延伸到使患者“提高功能、全面康复、重返社会”，达到生理上痊愈。
人民医院总体发展战略咨询医疗改革
职工医疗保障制度的改革试点工作已由镇江、九江两市扩大到全国范围内50多个城市。
医院如何适应医疗保障制度改革的需要，加强经济管理，保证医疗服务的高质量和高效益，并谋求自身的发展，是一个亟待研究的课题。
一、医院面临的形势1 .医疗成本加大:随着社会主义市场经济的发展，各种卫生材料和能源的价格不断调整和上涨，医院支出增加，医疗成本加大。
2 .“以药补医”受到限制:随着结算定额的控制和《药品目录》的执行，销售药品成为医院创收的主要手段已随着医疗保障制度的改革而被卡死。
3.财政补偿严重不足:据统计，卫生总费用中政府预算支出所占比重逐年下降，财政对医疗机构补助的增长速度低于同期财政收入的增长速度。
4.医疗价格不合理:主要表现在价格结构的不合理，挂号、注射、住院费、手术费等技术劳务性的医疗服务价格明显偏低。
5.医院面临新的竞争:病人及单位可以选择医院就医，医院的规模、技术、质量、服务以及费用等，已成为吸引病人，保证经济来源的重要因素，个人帐户的保险机制也促使病人对医院的要求不断提高，不仅要治好病，还要少花钱。
二、我院采取的主要措施1 .重组和优化配置医疗资源:根据社会需求和疾病谱的改变，较大幅度地调整科室床位设置，把相对过剩的科室的医护人员、床位、设备调整到急需的科室和病房，大大缓解了病人需求的矛盾。
2 .提高工作效率:工作效率越高，单位成本就越低，经济效益就越好。
我们以医院的规模、技术、质量、服务以及相等费用的优势吸引病人，取得比较好的效果。
3.调整服务内容:即在保证基本医疗不受影响的前提下，开发多层次全方位的服务。
开设了美容、性保健、康复体疗等特色服务项目。
这类服务均为病人自费，不受医疗保险结算定额的控制。
4.调整业务收入结构:要求科室严格执行药品目录，能用国产药的不用进口药；能用价格低的不用价格高的，尽可能少花钱看好病，减少药品收入在业务总收入中的比例，加大劳务技术的含量。
5.实行科室成本核算：方法有：1.以量定耗：如门诊办公用品费用按门诊人次定；病区医疗印刷品费用，以床位数及床日定。
九略—中山市人民医院总体发展战略咨询—人民医院发展战略框架 27页PPT文档
美国的密执安建立的疗养院是一个健康生活方式中心，是一个医学革命的典 范。在那里，以改变生活方式来促进健康取得了很大的成功。许多伟人、名 人和富翁到那里去求医。其中包括汽车大王福特，煤油大王洛克菲勒，发明 家爱迪生等。
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李嘉诚先生对医疗事业的关注：
• 李嘉诚先生积极支持内地的医疗事业，曾与1980年 成立李嘉诚基金会，历年来，捐款累积达港币47亿元。 李先生捐资20余亿港元的汕头大学设有医学院及五所 附属医院，现有学生九千人，并已有二万多名毕业生。
• 长江生命科技集团有限公司本着“还自清新本色， 给人类优质生活”的使命，业已研发出108种产品。 其中包括医药、保健、护肤、环境治理及生态农业。 长江生命科技于2019年在香港联合交易所的创业板上 市。
美国的健康中心还有：黑山健康教育中心；哈特兰得健康中心；生命泉修养 所；泊兰泉研究所；维德武得生活方式中心医院等。两年前在俄克拉荷马又 新建了一个占地面积很大、设备先进、建筑现代化的“美国生活方式中心”
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据不完全统计，目前美国国民在辅助医疗上的消 费已高达140亿美元，还仅仅是出于预防保健的目 的，还不包括购买草药、书籍及有关器械、装置 的款项，而美国人每年看西医自付的那部分钞票， 才128亿美元。 足见美国人肯“生命投资”，舍得 花钱买健康。
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国内最强最大
• 强，是指竞争能力
经营管理：
构建专业医院管理 公司，引入专业化管 理。
• 服务水平：
在理念/行为规范/客 户心理感受/环境/配 套设施等方面提供全 国范围内一流的服务。
人民医院总体发展战略咨询资料整理
1.1 医院的发展必须主动适应宏观经济体制的变革《中共中央、国务院关于卫生改革与发展的决定》指出：“我国卫生事业是政府实行一定福利的社会公益事业”。
公益性的本质是公众共同受益，政府的福利主要用于健康教育、预防、重点学科建设、特殊病人的治疗与救护等，国家对医院的投入将会逐渐减少以至“断奶”。
在市场经济条件下，医疗服务领域在没有投入的情况下，又不以盈利为目的，不能完全按经济领域的等价交换原则，医疗价格与价值背离的现象仍然会长期存在。
医院运行中一方面要按照一定的“福利价格”向社会提供医疗服务，另一方面要按照市场价格支付各项开支，而补偿机制又不完善，使医院的发展步履艰难。
1.2 医院的发展必须主动适应医疗保险制度的改革国家为了建立与市场经济适应的社会保障体系，将在城市实行职工社会统筹医疗基金与个人医疗账户相结合的职工医疗保险制度。
这对城市医院的经营管理和服务体系提出新的挑战。
新的医疗保险制度实施后，医院将面临许多问题，主要表现在：（1）医院之间竞争进一步加剧。
医保部门与参保职工对医院的选择性增强，“优质、适价、高效”成为病人选择就医诊所的基本标准。
选择性定点医疗一方面增强了参保人员对医疗服务的选择性，造成病人在医院之间的重新分布。
另一方面，把竞争机制引进了医院，医疗市场开始由卖方市场转入买方市场，医院组成行业，病人组成市场，病人选择医院，医院展开竞争。
（2）医院业务收入受到限制。
医疗保险基金筹资率与职工工资总额挂钩，实行“以收定支”的原则，使医院从参保对象所得的业务收入总额受到限定，加上医疗保险基金对医疗服务的付费结算方式改革，项目付费方式将由多种定额付费方式取代，使医院就诊人次、住院日、标准病例等单元服务收入受到限定。
（3）医院的管理力度增加。
医疗保险制度改革必然带来法律、法规的健全和完善，医疗保险制度改革必然带来法律、法规的健全和完善，医疗纠纷或事故将通过手段来解决，这就要求医院管理者不仅要懂得管理，更要依法治院，规范行医。
九略—中山市人民医院总体发展战略咨询—业务发展战略20021221
1 主业的总体定位 1-1 未来医院的主业是什么？ 1-2 对现有主业的战略性重新定位 2 主营业务的发展战略建议 2-1 对主营业务竞争力状况的总体分析和评价 2-2 对主营业务市场发展契机的分析 2-3 对主营业务经营模式的战略性建议 2-3 对主营业务发展的战略步骤建议
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•想做什么要名确、分四块，重点发展型（王院长：多学科联合 治疗、以120急救为基础的绿色通道体系、微创伤外科)、一般发 展型业务、培养开发业务（以健康为主的业务）、维持型业务。
穷尽、标准、原则 •看这个业务的性质（赢利性还是公益性） •如果赢利看赢利的能力 •技术看，处在什么样的技术阶段。也就是进一步发展的潜力有 多大。人民医院此技术在全国处在什么样的位置。 •医疗
其它业务发展战略规划
1 对其它业务经营总体状况的分析和评价 1-1 对社会效益、经营效益总体评价 1-2 对占用资源状况及资源使用效益的评价 2 对其它业务的发展战略建议 2-1 重组和优化建议 2-2 重组后各业务发展潜力分析 2-3 各业务发展的战略步骤建议
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•如何定主、其它，多张坐标图、最后加权 •还要考虑外部竞争 •所有背景资料、静心创新、推敲、包装 •背景资料文档（资料清单、关键要点、思路、证据及逻辑体系） •精心的提炼和创新（不要局限名词）反复论证 •分主营业务与非主营在医院上分不太好。 •对每个业务的论据、风险、业务导向，技术导向、规模、赢利 情况、特殊性、纬度。
人民医院发展战略框架2cavy
• 中山故理吸 引全球华人 资源
• 中山医疗救 国理念
社会需求 • 全面进入小康 • 全面健康 • 全民健康
为什么要定
位于健康医 疗集团？
经济基础 • 珠江三角洲地
区消费能力和 理念 • 中山医院自身 发展基础
地理环境 • 国家健康科技
产业基地 • 联合国人居奖
城市 • 国家十大卫生
城市之一 • 毗邻港澳
不大不足以久强
规模一流：在健康服务 板块（康复、保健、疗 养、健康度假、健康教 育）方面，在业内具有 一流规模。医疗规模将 在全国具有比较大的水 平。
服务项目最全：健康服 务项目在业内是最全面 的。医疗技术是完整的。
经营绩效：在同类经营 内容（以健康服务板块 为主）上税前收入最大。 集团总收入在医疗行业 名列前茅。
缺少竞争特色；难以持久发展；
对经营、资本运作要求较高 对消费者研究和满足消费需求有 有水平
经营管理难度增大 缺失竞争力内核 多元化风险增大
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打造
• 创新：服务内容、经营机制、发展规模上敢为 天下先
• 跳越发展：利用资本杠杆，有效整合现在人民 医院内外部资源，甚至国内外资源，在借鉴国 内外发展经验基础上后来居上，快速发展。
•创建健康中心(与李嘉诚) •建设康仪特诊中心 •成立医院管理公司 •控股投资小榄医院有限责任公司
2003 二、三季度
2003 一季度
以人民医院为投 资主体，吸引李 嘉诚投资，建设 健康服务中心
愿景实现的路径
公司结构 治理
股票上市 健康中心 香港上市
以人们医院为技 术主体，整合一 批医院，构建医 疗网络
• 管理机制：集团管理、 各事业部、各业务单元 有高效的运作机制、人 才激励机制。在全国具 有一流水平。
德国医疗行业的发展历程
德国医疗行业的发展历程德国是世界公认的医疗领域强国，其医疗制度在全球范围内备受关注。
医疗行业的发展历程可以追溯到19世纪初期，经过多次改革和创新，德国的医疗行业已经实现了高度发展和卓越成就。
19世纪初期，德国的医疗体系比较分散和落后，由私人医生和药店为主，国家几乎没有医疗保障机制。
19世纪末期，德国开始进行医疗改革，首先将医疗的责任从私人医生转移到国家医疗机构手中，成立了医院等医疗设施，但是总体来说，医疗质量和可及性仍有待提高。
20世纪初，德国仍然缺乏统一的医疗制度。
为了解决医疗保障问题，1911年颁布了全国性的社会保险法，确立了德国现代医疗保障体系的基础，使得医疗保障逐渐覆盖了更广泛的人群。
此后，德国医疗保险不断发展，1945年德国社会保障法颁布，规定将所有医疗机构纳入国家管理，推行社会化医疗。
1980年代，德国医疗行业出现了资金短缺和医患矛盾等问题，政府加强了对医疗机构的管理和监督。
在保证医疗质量的同时，政府建立了更加透明、公平、高效的医疗体系，使得民众能够更加方便地获得医疗服务。
如今，德国的医疗保障体系日益完善，医疗技术也得到了全面提升。
德国医生的培养方式也与其他国家大不相同，他们需要进行6年左右的医学院校学习，接受专业的医学培训和严格的考核，性价比极高。
德国医生有强烈的专业意识，能够深入了解病人的病情，从而更好地为病人提供治疗和护理。
德国医疗行业的成功发展有很多原因，其中最重要的是政府的积极支持和大力投入。
政府不断加强对医疗机构的管理和监督，完善医疗保障制度，同时也鼓励医生和医学专业人员的培养和发展。
此外，德国的医疗技术水平也处于世界前沿，不断创新和更新医疗器材和技术，为病人提供更加高效和安全的医疗服务。
总之，德国医疗行业经历了漫长的发展历程，取得了巨大的成就和进步。
德国的医疗保障体系、医生培养和医疗技术等方面都有独特的经验和优势。
对其他国家来说，可以借鉴德国医疗行业的发展模式和经验，进一步提升自己的医疗行业水平和质量。
九略—中山市人民医院总体发展战略咨询—企业行动纲领
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坚持实施首尾相接的业务流程，为客户创造一切价值 确保每个员工了解业务流程，清楚自己在其中肩负的 责任 任命业务流程负责人，由他负责考核、协调和改进业 务流程 围绕业务流程将硬件设施、奖励制度、组织结构进行 整合，创建对业务流程持欢迎态度的企业 建立业务流程委员会，防止用业务流程所具有的流动 性取代职能部门的结构性 从业务流程的角度对所做的工作进行管理，使公司更 加出色 使业务流程成为企业存在的一种方式
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通过公司之间业务流程的再造，根除额外的管理 费用、成本及存货的剩余源 使自己公司的业务流程与客户、供应商的相应业 务流程之间的联系流畅化、整体化 重新定位公司之间的工作，以便于每项工作都能 由最擅长的公司来完成 通过数据信息在公司之间的公开共享来进行业务 协调 探求与共同客户及共同供应商合作的机会 勇敢地面对公司之间的合作和信息共享所带来的 文化大挑战
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将测定工作与统计分开，使之成为每位经理工作 的一部分 抛弃从过去继承下来的测定数据 开发出能将全部目标与可控制的特定事物相关联 的业务模型 在该模型中安排好关键内容的测量值和目标 设计具有目标性、及时性、易于计算和理解的测 量值 将不断进行的绩效改善工作整合为规范的、基于 测量的过程， 通过这一过程使改善绩效成为无法回避的工作 让事实和测定结果胜过直觉和雄辩
九略—中山市人民医院总体发展战略咨询—nationalhospitalpharmaceuticalstratey
National Hospital PharmaceuticalStrategyFinal VersionPharmaceutical Management Agency1 February 2002Table of ContentsPAGE Executive Summary 51.0 Introduction 92.0 Current Market Overview 112.1 Current purchasing arrangements 112.2 Range of pharmaceuticals purchased 112.3 Data collection and analysis 112.4 Management of access to pharmaceuticals 122.5 The primary/ secondary care interface132.6 Distribution systems 133.0 Features and Objectives of a Strategy for Nationwide HospitalPharmaceutical Purchasing 144.0 Strategy Scope 184.1 Range of product-types included 184.2 Range of initiatives to be applied 184.2.1 Price management 184.2.2 Assessment of new pharmaceuticals 194.2.3 Promotion of quality in the use of medicines 214.2.4 Logistics management 225.0 Proposed Pricing Strategy Initiatives235.1 Application of reference pricing 235.2 Initial Request for Proposals 235.3 Alternative Commercial Proposals245.4 Sole supply arrangements 246.0 Implementation of a Nationwide Pharmaceutical Pricing Policy 256.1 Consultation with hospital managers and clinicians 256.2 Communication of national prices 266.3 Transitional arrangements 276.4 Assessment criteria 287.0 Monitoring and Measuring the Impact of the Strategy 317.1 Monitoring and analysis 317.2 Setting of expenditure targets 327.3 The impact of national contracts on costs of pharmaceuticals 327.4 NZ prices compared with overseas prices 338.0 Roles and Responsibilities 348.1 PHARMAC and PHARMAC’s Board of Directors 348.2 Hospital Pharmaceuticals Advisory Committee (HPAC) 348.3 DHBNZ 348.4 District Health Board’s 348.5 Hospital Managers 358.6 Ministry of Health 358.7 Hospital Clinicians 358.8 PTAC/Hospital Clinical sub-committees359.0 Proposed Timelines and Milestones 3610.0 Summary of proposed strategy for specific issues 3711. Other considerations 3911.1 Long-term impact on pharmaceutical market 3911.2 Effect on pharmaceutical research 3911.3 Effect on opportunities for clinical education 3911.4 National data systems 4011.5 “Orphan “ Section 29 medicines 4011.6 Potential mutual benefits for the primary and hospitals sectors 4012.0 Risks, Benefits and Costs of the Strategy 4112.1 Risks 4112.2 Benefits and Costs41 Glossary of terms and abbreviations 43 Appendix 1 Authorisation to PHARMAC from the Minister of Health 45 Appendix 2 Summarised consultation responses47PHARMAC’s overall objective, as outlined in Section 47 of the New Zealand Public Health and Disability Act 2000, is to secure for eligible people in need of pharmaceuticals, the best health outcomes that are reasonably achievable from pharmaceutical treatment and from within the amount of funding provided.Executive SummaryIn response to authorisation to perform a new funct ion given by the Minister of Health in September 2001, PHARMAC, in conjunction with representatives of the District Health Boards (DHBs), developed a strategy for nationwide purchasing of hospital pharmaceuticals (the “Strategy”), and undertook consultation with DHBs (CEOs, relevant managers, and provider units), clinical groups, pharmaceutical suppliers, and those other interested parties with whom PHARMAC usually consults. A summary of those responses and PHARMAC’s response to them is attached as Appendix 2. This second and final version of the Strategy will be presented to the Minister of Health in February 2002 with recommendations reflecting the views of PHARMAC and DHB CEOs.Changes to the scope of the draft Strategy, in terms of the way it is proposed PHARMAC would be involved in assessment of New Pharmaceuticals, revisions to the proposed structure and function of Section H of the Pharmaceutical Schedule, and policy details pertaining to national sole and/or preferred supplier arrangements, should be noted. It is also proposed that the Strategy be reviewed in 2 years time.The key objectives of the Strategy are to:(a) obtain the best possible value for money spent by DHBs on Pharmaceuticalsused in hospitals;(b) improve national consistency of access to Pharmaceuticals used in hospitals;and(c) establish a co-operative purchasing framework by collaboration between theDHBs.Consultation has highlighted that many stakeholders believe improved health outcomes should also be an objective of the Strategy. While this fits well with PHARMAC’s current legislative objective, it is likely to be difficult to monitor and measure in the hospital sector without extensive research and monitoring. However, the welfare of patients will be a key consideration in any decision criteria PHARMAC adopts under this Strategy. The fiscally oriented objectives of the Strategy will need to be balanced against the needs of the DHBs’ patients and clinicians, with consideration of any adverse impact on clinical outcomes. Consultation has highlighted some of the areas where PHARMAC’s ability to achieve this balance has been noted as a concern. Those areas are addressed in this version of the Strategy.It is acknowledged that initiatives to reduce price, and manage the costs/utilisation of Pharmaceuticals used in hospitals, are already in place in most DHBs. This Strategy aims to build on these initiatives, through a process of co-operation and collaboration between PHARMAC and the DHBs, in order to improve patient outcomes, and ensure maximum value for money from current and future investment in pharmaceutical technology used in hospitals. A constructive relationship between pharmaceutical suppliers and PHARMAC will also be helpful to the success of the Strategy.Key features of the proposed Strategy, once fully functional, would include:• Management of hospital and community expenditure on Pharmaceuticals according to a joint national target (a notional figure set with reference to monies held byDHBs/hospitals). It is not intended that PHARMAC would actually purchase the Pharmaceuticals.• Nationally consistent pricing policies covering 90% of DHB's spending on Pharmaceuticals used in hospitals (with provision for choice within the limits defined in contractual “Discretionary Variance” clauses for any patients whose health needs fall outside any contractually derived policy boundaries PHARMAC might set).• The establishment of a new section of the existing Pharmaceutical Schedule (“Section H”), containing the list of Pharmaceuticals used in hospitals for which PHARMAC has negotiated national contracts on behalf of the DHBs. Section H may also list those pharmaceuticals affected by national arrangements (such as products within a therapeutic sub-group affected by preferred supplier arrangements and alternative brands of chemicals under sole supply arrangements which could only be used within DV provisions). It is likely that Section H would be published separately from, but would legally form part of, the existing Pharmaceutical Schedule.• Full compliance with any national pricing contracts (where such compliance would permit DHBs to purchase other Pharmaceuticals within the contractually agreed Discretionary Variance limits), once existing supply contracts held by DHBs have expired or been terminated. DHBs could still choose to purchase outside the DV limits but would be exposed to losing financial incentives or incurring financial penalties. No DHB would be able to enter into any contract which would compromisea national pricing co ntract.• A centralised assessment process run by PHARMAC to appraise the clinical benefits and cost-effectiveness of New Pharmaceuticals. This process would assist DHBs to ensure that access to New Pharmaceuticals in their hospitals was consistent, where appropriate, with access in other DHBs. It is proposed that, over the first two years, this national process would run in parallel with, and augment, assessment processes that would [continue to] be undertaken by each individual DHB.• Information systems that mesh full national hospital utilisation and clinical data, where possible, in a format that is consistent with similar data collected in the primary care setting.• A national programme aimed at improving quality in the use of medicines by promoting best practice in the use of Pharmaceuticals within hospitals, and at the hospital/primary care interface.The Strategy was originally developed to focus initially on the purchase of:(a) Pharmaceuticals;(b) X-ray contrast media; and(c) IV fluids.However, it is now proposed that inclusion of X-ray contrast media and IV fluids within the scope of the Strategy should wait until the proposed mechanisms for national contracting have been established for Pharmaceuticals.PHARMAC proposes that the Strategy should initially include the following elements as a minimum:(a) price management; and(b) assessment of New Pharmaceuticals; and(c) promotion of quality in the use of medicines (QUM).It is also proposed that logistics management be further investigated for possible inclusion within the scope of the Strategy.It is acknowledged that inclusion of assessment of New Pharmaceuticals and QUM brings a wider focus to the Strategy than indicated by its current title. For this reason, it is proposed that the Strategy should more correctly be referred to as the “National Hospital Pharmaceutical Strategy.”Some of the initiatives proposed by PHARMAC to manage DHB expenditure on Pharmaceuticals used in hospitals are likely to be similar to those used in the community setting, but there are some notable differences. The application of reference pricing is not proposed, procedures for managing proposals would more closely involve representatives of the DHBs (including hospital based clinicians), and implementation of sole supply arrangements would be more flexible (refer to section 5.0). An initial request for proposals process, commencing in mid-2002 is proposed. However, subject to specific caveats, PHARMAC and the DHBs would consider proposals submitted by suppliers outside of that process at any time.Key features of the Strategy would be process transparancy and consideration of clinical concerns. Clinical issues would be discussed by PHARMAC, the clinical advisory committee(s), and HPAC before changes are implemented. Choice in the range of pharmaceuticals available within therapeutic groups would be maintained although the number of brands of particular chemicals, where generic competition exists, could be limited via contractual arrangements. Discretionary Variance provisions would provide flexibility to meet the needs of small numbers of patients who may fall outside the provisions of national contractual arrangements.The Strategy provides for national co-ordination and collaborative extension of many of the current systems already in place within individual DHBs. These include systems for assessing, and contracting for the supply of pharmaceuticals, processes for assessing new Pharmaceuticals and initiatives aimed at promoting best clinical practice where Pharmaceuticals are utilised in the care of patients.Implementation of the Strategy would require consideration of existing and/or new supply contracts entered into by DHBs individually and prompt resolution of current data issues that have to date, prevented PHARMAC from compiling or accessing a national dataset of pharmaceutical utilisation and expenditure for the hospital sector. The approach to these issues we have recommended is likely to require the input of resources, as well as co-operation, from DHBs (refer to sections 6.3 and 7.1).Based on specific feedback invited on what assessment criteria should be applied to the assessment of New Pharmaceuticals and of commercial proposals arising from the strategy, PHARMAC proposes to adopt its current criteria with the addition on a hospital-specific criterion (refer to section 6.4).The anticipated benefits of the Strategy are:• gradually improved consistency of prices for and access to Pharmaceuticals throughout New Zealand;• increased dialogue and co-operation on pharmaceutical issues facing all DHBs’ provider arms;• a more co-ordinated approach to Pharmaceutical use across primary and secondary care;• greater impetus to establish a national dataset for Pharmaceuticals used in hospitals;• a modest reduction in the prices paid for Pharmaceuticals used in hospitals (which would not necessarily result in an overall fall in total Pharmaceutical expenditure);• greater co-ordination of efforts to promote cost-effective utilisation of Pharmaceuticals; and• better utilisation of DHBs’ pharmacy and/or pharmaceutical procurement resources.1.0 IntroductionIn July 2001, the Minister of Health, the Honourable Annette King, announced her intention to authorise PHARMAC to lead a strategy for nationwide hospital pharmaceuticals purchasing (the “Strategy”). The new function issued by the Minister, which was published in the New Zealand Gazette in September 2001 (copy attached asAppendix 1), fits within the context of PHARMAC’s overall objective - to secure for eligible people in need of pharmaceuticals, the best health outcomes that are reasonablyachievable from pharmaceutical treatment and from within the amount of funding provided.The specific, key objectives of the Strategy are to:(a) obtain the best possible value for money spent by DHBs on Pharmaceuticalsused in hospitals;(b) improve national consistency of access to pharmaceuticals used in hospitals;and(c) establish a co-operative purchasing framework by collaboration between theDHBs.Implicit in these objectives is the presumption that the overall health status of New Zealanders should not be compromised as a consequence of this Strategy and, where possible, should be improved. It is acknowledged that the fiscally oriented objectives of the Strategy and constraints on VoteHealth will need to be balanced against the needsof the DHBs’ patients and clinicians, in terms of clinical outcomes.PHARMAC has developed, in consultation with advisors from the DHBs via the HospitalPharmaceuticals Advisory Committee (HPAC), a Strategy document and has conducted extensive consultation with DHBs, hospital clinicians and the pharmaceutical industry.Revisions have been made following consultation and this final Strategy document will be presented to the Minister of Health with a recommendation from PHARMAC staff inFebruary 2002.In developing the Strategy, HPAC concluded that, in order to ensure continued gains from the Strategy in the longer term, consideration would need to be given to the manner in which Pharmaceuticals are utilised within hospitals, in addition to their price and availability. It acknowledged that, as a consequence of the inclusion of these concepts, the scope of the Strategy is wider than indicated by its current title. For this reason, it is proposed that the Strategy should more correctly be referred to as the “National Hospital Pharmaceutical Strategy.”The Strategy document sets out:• A detailed plan and objectives for the Strategy.• Proposed initiatives, milestones and a timeline for implementation of a two year programme beginning during the current financial year.• Details of any transitional arrangements necessary to enable PHARMAC to manage the purchasing of some Pharmaceuticals on behalf of DHBs.• A definition of roles for all parties to be involved in the implementation of the Strategy.• Assessment of the costs, risks and benefits of the Strategy.• Proposed key performance indicators.2.0 Current Market Overview2.1 Current purchasing arangementsAlthough some DHBs have already entered into joint arrangements, purchasing of pharmaceuticals for use in hospitals is in most cases currently managed by each individual DHB. Most DHBs purchase the bulk of their hospital-only pharmaceuticals via contracts with pharmaceutical suppliers. Many of these contracts are described as “bundled deals” where DHBs negotiate prices across a range of pharmaceuticals, obtaining lower prices on some products in exchange for acceptance of higher prices than they might otherwise achieve on others. Some hospitals (Auckland and Christchurch) have achieved savings by running competitive tender processes.Where the DHBs have no contracts with suppliers, pharmaceuticals are purchased at the suppliers’ hospital list prices. Where such products are available on the Pharmaceutical Schedule, the prices (ex manufacturer) paid by DHBs may be the same as the subsidy set by PHARMAC.2.2 Range of pharmaceuticals purchasedThe range of products purchased by DHBs within the existing “pharmaceutical” purchasing arrangements varies from hospital to hospital. In addition to what are conventionally considered to be pharmaceuticals, some hospitals include such things as X-ray contrast media, IV fluids, total parenteral nutrition or special foods within this function, whereas others manage some or all of these other purchases separately. A number of unapproved and/or “orphan” pharmaceuticals may also be included. This variation contributes to the difficulties associated with comparing pharmaceutical expenditure between DHBs.2.3 Data collection and analysisNo national price database exists to enable a comparison of prices paid across the sector. Hospitals currently use a variety of computer systems to record information about their pharmaceutical purchasing and utilisation. Issues of confidentiality, and a lack of consistency in the way each hospital records and/or codes data are both barriers to the compilation of a national dataset. However, work on this issue done by Counties-Manukau last year suggests that there are price disparities acr oss the DHBs, and that no individual DHB is consistently achieving the lowest prices across the entire range of commonly used pharmaceuticals. Some of this variation may be explained by differences in the timing of contract negotiations between hospitals and the complexities associated with prices negotiated for “bundles” of pharmaceuticals. However, the fact that some suppliers have insisted that the pricing information contained in their contracts be kept confidential, supports the notion that some hopsitals pay more for their pharmaceuticals than others.Hospitals are beginning to develop systems which enable them to track pharmaceutical utilisation at an individual patient level. Automated drug distribution systems in place in some areas are capable of tracking up to 95% of use to an individual patient level. However, most DHBs can still only track use at a patient level to a limited degree, and phamaceutical utilisation is not yet fully trackable within any hospital. From the limited data available, it seems likely that there is variability in the needs, and thereforedemand, for pharmaceuticals within each hospital. For example, those hospitals that provide specialists services are more likely to have a greater demand forpharmaceuticals related to that speciality. However, universally the key therapeutic groups contributing to pharmaceutical expenditure include:• antibiotics;• cardiovascular drugs;• psychiatric medicines;• anaesthetic agents; and• cancer treatments.2.4 Management of access to pharmaceuticalsSystems for determining which pharmaceuticals can be used in each hospital, and processes for assessing New Pharmaceuticals before they are made available inhospitals, are in place within all DHBs. Most hospitals also manage some type of formulary or preferred medicines list (PML). Although the degree to which adherence tothese lists is enforced varies, it is widely held that the input of local clinicians into such formularies is a factor in their acceptance and effectiveness. Where guidelines for use and/or restrictions on access to certain pharmaceuticals exist, it is acknowledged that clinician compliance with such rules is dependent on the breadth of range ofpharmaceuticals available within the hospital, and degree of clinician input into the selection of this range. Making changes to the range of agents listed on a PML orformulary can also be difficult when preferences for certain brands or products become established.Some DHBs impose restrictions on access to pharmaceuticals by exclusively stocking one product. In many cases, the continued availabilty of an alternative product relies onanother DHB contracting for its supply. There is currently little or no conscious co-ordination of this approach.Many hospitals undertake drug utilisation reviews to ensure “best clinical practice” in theuse of them and have demonstrated an ability to indirectly produce savings in pharmaceutical expenditure via this method. Most appear to endeavour to manageexpenditure on New Pharmaceuticals by subjecting them to a multi-disciplinary clinical assessment process involving clinicians, and pharmacists. Where clinical budget holding exists, service manager approval may be required before a product can be added to a PML or formulary. These processes appear to work quite well at a local level because they ensure clinicians have had input into the decisions made. However, the process can create tensions between speciality groups. Use of New Pharmaceuticals and/or existing pharmaceuticals for new indications sometimes preceeds formal assessment, and internal budgeting arrangements can be an incentive for the approval of new medicines.While hospital managers tend to consider access to subsidies for new agents in the community, the criteria against which they assess new treatments vary. The rigor of the analysis, and the degree to which cost-effectiveness is considered when determining whether pharmaceuticals should be used within each hospital also appears to be quite variable. Some cost analysis is undertaken by most hospitals prior to introduction of New Pharmaceuticals. However, cost-benefit analysis is currently rarely performed, duein part to the limited availability of reliable and meaningful costing data relevant to the sector.Differences in the assessment processes and criteria may partly account for the fact that New Pharmaceuticals (or existing pharmaceuticals for new indications) are sometimes funded within some hospitals but not in others or, where funded universally, are subject to different caveats. In these cases, problems can arise when patients transfer from one hospital or DHB to another. However, this may be more of an issue when patients transfer from tertiary or quarternary services to secondary care or where they transfer to the care of a clinician who does not normally practice in the same speciality.2.5 The primary/secondary care interfacePatients who require on-going pharmaceutical treatment after hospitalisation are often discharged with a prescription reflecting the pharmaceutical treatment administered during their stay or prescribed treatment in an out-patient setting. However, patients are rarely discharged from hospitals with supplies of the pharmaceuticals they require. Their discharge prescriptions, like prescriptions for out-patients, may not reflect the availability of pharmaceuticals in the primary care sector. In certain cases, hospitals explicitly fund pharmaceuticals because they are not available on the Pharmaceutical Schedule. The scope for improved patient care via better communication between the primary and secondary care sector, and consistency of access to pharmaceuticals in both areas is widely acknowledged.2.6 Distribution systemsThere is variation between DHBs in the way pharmaceuticals are distributed. Pharmaceuticals purchased directly from Health Support Services (HSL) in some areas, may account for 50% of the volume of pharmaceuticals nationally. HSL provides a range of services to DHBs including logistics, purchasing, and inventory management. Some DHBs utilise only the logistics services offered by HSL, while others rely on HSL to negotiate prices for some pharmaceuticals on their behalf, and purchase on consignment from HSL also. Other DHBs purchase their pharmaceuticals through other wholesalers or directly from pharmaceutical suppliers. Some have direct-to-ward delivery arrangements with such organisations.3.0 Features and Objectives of a Strategy for Nationwide HospitalPharmaceutical PurchasingThe broad objectives of the Strategy already outlined, are aimed at achieving the bestpossible value for money spent by DHBs on Pharmaceuticals used in hospitals, and to improve nationally consistency of access to Pharmaceuticals across all DHBs whereappropriate. It is acknowledged that the need for Pharmaceuticals in hospitals depends to some extent on the range of services provided by the hospital. However, there have been notable areas of common care where access to Pharmaceuticals has been inconsistent. The Strategy aims to focus on areas such as these.Opportunity exists within the broader scope of the Strategy, to maximise patient outcomes from DHBs’ investments in New Pharmaceuticals. The range of initiatives proposed in respect of price and access to Pharmaceuticals, may at times affect choice in order to create a commercial environment that is conducive to obtaining better value for money. Where this is likely, fiscal gains would be balanced against consideration of the effect on patient care. However, in acknowledgement of concerns about the long-term impact of such initiatives on health outcomes, continuation of the Strategy will be reviewed 2 years post-implementation.Since DHBs are responsible for all expenditure on pharmaceuticals, it is proposed that the success o f the Strategy would be measured, in conjunction with the impact of PHARMAC’s initiatives in the community setting, against a nominal expenditure target for both areas. No budget transferance is, however, proposed. There would be no change to the DHBs’ f unding payments to hospitals, which currently provide for their pharmaceutical use, and funding for pharmaceuticals used in primary care would remain with the DHBs.Given the range of Pharmaceuticals used in hospitals, including a larger number of unapproved and/or “orphan” pharmaceuticals than are used in the primary care setting, it is probably not possible to put national contracts in place for all Pharmaceuticals included within the scope of the Strategy. Therefore, PHARMAC’s aim would be to ultimately put in place national supply contracts for about 90% of the value of Pharmaceuticals used in hospitals. This would account for a much smaller proportion (about 10%) of the entire range of Pharmaceuticals used in hospitals. These contracts would ideally confer a net clinical and/or commercial advantage (including net savings) against the current arrangements, if not for every individual DHB, then at least across all DHBs. It is possible that some hospitals would pay more for some Pharmaceuticals but it is expected that the additional costs of those pharmaceuticals would be more than offset by savings made on others.A key objective of the Strategy would be to ensure the compliance of all DHBs with any national arrangements PHARMAC may put in place. I t is proposed that hospitals would be able (and ultimately obliged) to purchase those Pharmaceuticals that are the subject of a national contract, at a single, national price negotiated by PHARMAC. Where there were no national arrangements, hospitals would be able to secure their own purchase arrangements.Compliance with national arrangements is likely to be closely linked with the fiscal and clinical acceptability of national arrangements. Therefore, key features of the Strategy would be process transparency and consideration of clinical concerns. Clinical issues。
人民医院总体发展战略咨询迈向新里程(展览)
世纪兼程————中山市人民医院五十周年回顾中山，全国唯一以伟人名字命名的城市，珠江三角洲腹地一颗璀灿的明珠。
中山人为这块热土孕育了孙中山先生这样的世纪伟人而深感自豪，中山市人民医院的全体员工更为置身于改革开放伟大的时代，实现孙中山先生“医国医人”的远大志向而倍感骄傲。
中山市人民医院创建于1950年3月16日，其间几易其址、几度分合，历经一代代人的艰辛努力，励精图治，现已发展为中山市唯一的一所集医疗、预防保健、科研和教学为一体的国家级“三级甲等医院”。
1994年9月，被卫生部、联合国儿童基金会和世界卫生组织命名为“爱婴医院”；1997年5月，被省卫生厅和省高教厅评为“广东省高等医学院校教学医院”；1998年10月，被省卫生厅授予“广东省百家文明医院”；同年5月，与美国夏威夷皇后医院缔结为姐妹医院；2000年3月，与中山医科大学联合共建博士后流动工作站；同年9月，成为中山医科大学临床研究生教学基地。
中山市人民医院现位于孙文中路2号，占地3万多平方米，建筑面积6万2千多平方米。
设有24个临床专科，55个专科门诊和中山市急救中心、中山市肿瘤研究所、中山市临床医学研究所、中山市血液净化中心、保健中心、影像中心、白内障治疗中心、听力中心，是广东省临床医学继续教育基地。
拥有员工1000多人，其中高级职称的100多人，年门诊量90多万人次，年住院病人1.6万人次。
除院本部外，还拥有东区分院、竹苑门诊、烟墩门诊和莲峰门诊（郑亮均医院）。
图：淡色全景图为底色衬托上述文字说明。
图：院徽、院歌一、建院初期（1950-1959）1、建院前的中山医疗卫生概况中山原名香山，南宋绍兴22年（公元1153年）设县。
公元1408年编纂的《永乐大典》载：“香山为邑，海中一岛耳，其地最狭，其民最贫。
”虽然贫穷，香山人还是注意医疗保健。
明永乐元年（1403年），程胜禄在香山县治西（今孙文西路）创办医学训术班，由此可见，当时不仅有人行医，还有医疗教育。
九略—中山市人民医院总体发展战略咨询—年全院上半年工作总结
认清形势群策群力合理部署再创佳绩━━2002年上半年工作总结2002年是我国正式加入WTO的第一个年头，改变工作作风，增强自身的竞争力，提高服务质量，强化内部管理，是保证医院生存和发展的关键。
年初，我们结合当前形势及我院的实际情况，制定了“认清形势抓住机遇锐意进取再创辉煌”为主题的工作规划，经过半年的努力，全院同心协力，在各方面均取得了良好的成绩。
一、转变观念，统一思想，全面深化医疗体制改革今年，我们继续坚持狠抓思想政治工作不动摇，以“医院可持续发展”为主题，以“加入WTO的挑战和机遇”为切入点，进一步完善思想政治工作网络，使思想政治工作深入人心，全体职工都热情投入到医院的各项改革中。
年初制定的“从快速发展过渡到稳步发展，从业务量快速增长而获得经济效益逐步转变为通过加强及完善管理而实现经济的稳步增长”的构想已进入了实质性实施阶段。
二、行风建设长抓不懈行风建设是我院可持续稳定发展的必经阶段，医院领导层，将行风建设工作摆上今年工作中的重要议程，并得到各级部门和全体职工的认同和支持，在实际工作中，不断提高服务意识，不断增强工作责任心；全体工作人员的服务态度和质量得到了不断的提高。
1 / 13三、营造文化氛围，树立医院团结、奋进的品牌效应。
《医院通讯》在营造我院医疗文化氛围中，起到了相当重要的作用，并得到了全国各界人士的赞许，今年我们充分利用医院现有宣传阵地，将医院院徽和院歌深入到医院的每个角落。
如在杨志云大楼的音响网络上，每天均以播放我院院歌，作为启播点，很好地树立了我院团结、奋进的品牌效应。
院史教育室是我们充分了解医院历史，实现将过去所集聚的潜能充分发挥，大力推动医院发展的重要阵地，更是体现我院工作人员高尚情操和优厚的文化底蕴的重要阵地。
医院院史教育室在今年4月始实行了全天开放，收到了院内外人士的一致好评。
工会组织开展了丰富多彩的文体活动。
元旦期间，组织全院职工举行了拔河比赛、二人三足接力赛及合作技巧比赛。
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1 1医疗概况德国全国居民中50%以上病人在
医院内死亡, 9 0%以上小孩在医院内出生。
每万居
民拥有医生238名,护士461名,每万居民拥有医院病床111张,每万居民被医院收治人次为1886次。
,设立1～3名院长,即行政院长、医疗院长和护理
院长。
一般500张床以下的医院只设行政院长, 800 张床以上设3名院长。
行政院长主管行政、后勤、
财务及人事等工作,负责整个医院的营运过程,包括
医院新建、扩建工程、后勤及技术保障、医院的财务收支、人员编制和科室间的协调等工作。
行政院长
一般为经济管理或工商管理专业毕业,再经过医疗
卫生事业管理培训后担任。
二是医疗院长,分管全
面医疗工作,此院长多由科主任晋升而来,升任为医
疗院长后,负责整个医院的医疗工作,包括医疗计划
的组织、安排和实施,医护人员的培训及医疗服务质量的监管。
三是护理院长,由护士长或护理主任晋
升而来,主抓全院的护理业务工作。
三位院长一般
为专家型的人才,构成医院领导的决策层,各自既有
不同的分工,又相互合作;行政院长是医院的最高决
策人和领导人。
每位院长均有专职秘书,负责接待、文件处理和指令传达等日常工作。
院长下属的职能
部门包括:人事部、医疗部和财务部等,其人员编制
为3～5人。
1 3科主任的职责科主任负责科室的行政、医
疗、人事及经营管理工作。
科室是医院基础的经营
核算单位,科主任一旦就位,就可以做到责、权、利一体化,但又受到院方和科室工作人员的监督。
医院
为了稳定医护队伍,原则上只要经营好,不亏损,医
疗质量有保障,病人满意;医护人员尽职尽责,技术
稳定,一般不会解聘。
另外,每位科主任均配有专职
秘书,负责接待病人、处理信函、安排病人的检查、转科、出院、发出病危或死亡通知书和打印医疗文件等日常工作。
由于科室实行秘书制,使医生、护士减少了许多非技术性的工作负担,专心于医疗工作,保证
医疗、护理质量。