anesthesia management
DESCRIPTION
This is my presentation in Chinese as to manage the department of Anesthesiology in Taiwan, the most efficient practice in the world.TRANSCRIPT
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麻醉科在綜合醫院最佳的經營策略
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Needs help?
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Needs help?
Help what?
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! David Armano http://darmano.typepad.com
台大 麻醉科 孫維仁教授
從成本分析......到價值定位
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From Babel Tower to Ether Dome
白色巨塔
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Ether Dome (乙醚塔)
現代醫學的聖殿
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Ether Dome (乙醚塔)
現代醫學的聖殿
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Ether Dome (乙醚塔)
現代醫學的聖殿
1846
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沒有麻醉就沒有外科手術
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麻醉科經營的特色
高風險!
勞力密集!
高專業度!
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資訊科技
資料(data)
有用的訊息
(information)
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2004全國健保支出
(億元)
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2004全國健保支出
(億元)
1%
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掠奪資源本是生物的天性
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價值鏈
麻醉 外科 成功手術
無經濟附加價值
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價值鏈
成本結構
麻醉 外科 成功手術
無經濟附加價值
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2004.Feb
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2004.Aug
-唇亡齒寒
2004.Feb
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Cost down?or, Quality/Safety down?
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成本 (Cost)為得到預期的結果所投入的資源
成本 ﹦資源
結果/成本 ﹦投資報酬率
成本 ≠ 浪費 成本 ≠ 費用
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利潤﹦收入 - 支出
利潤﹦收入 - (費用+成本)
利潤﹦收入 - (費用+直接成本+間接成本)
利潤中心?成本中心?
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最大利潤的迷思
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最大化利潤 ﹦增加營收+壓低成本+管控費用
最大利潤的迷思
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最大化利潤 ﹦增加營收+壓低成本+管控費用
∆利潤 =0∆利潤 =∆收入 - (∆費用+∆成本) =0∆收入﹦∆費用+∆成本
最大利潤的迷思
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最大化利潤 ﹦增加營收+壓低成本+管控費用
∆利潤 =0∆利潤 =∆收入 - (∆費用+∆成本) =0∆收入﹦∆費用+∆成本增加營收一定會增加成本,因為有邊際成本的效應(marginal cost)
最大利潤的迷思
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Methods
Cost analysis of anesthetic practice
Conventional method
National Health Insurance database
Activity-based costing
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階段目標
麻醉
誘導 氣管插管
維持麻醉深度穩定生理狀態
恢復 甦醒、力量
術後 無痛、舒適
民航
起飛 平穩上升
飛行維持高度穩定飛行
降落 準時安全著陸
地勤 行李無損
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An Activity-based Analysis of Anesthetic Cost in a
Medical Center
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術前 術中 術後
工時*台數 台數台數成本動因
作業活動
手術房內 手術房外 止痛作業分項
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術前 術中 術後
工時*台數 台數台數成本動因
作業活動
手術房內 手術房外 止痛作業分項
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術前 術中 術後
工時*台數 台數台數成本動因
作業活動
手術房內 手術房外 止痛作業分項
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全院健保總收入
(百萬元)2006-April
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全院健保總收入
(百萬元)
2%
2006-April
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全院總收入全院總盈餘
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24%
全院總收入全院總盈餘
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24%
全院總收入全院總盈餘
24%
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麻醉與外科系
(百萬元)
2006-April
總盈餘
(百萬元)
總收入
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麻醉與外科系
(百萬元)
2006-April
總盈餘11%
(百萬元)
總收入
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麻醉與外科系
(百萬元)
2006-April
總盈餘11% 4%
(百萬元)
總收入
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Where are they?攤提不足
教育費用
閒置設備
研究費用
間接費用
攤提錯誤?
觀念錯誤?
人為修正?(百萬元)
不完全揭露?還是成本扭曲?
21% off!
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健保局估計麻醉成本
๏ 平均每台麻醉120分
๏ 0.25位主治醫師0.5位住院醫師1位麻醉護士
๏ 材料費佔技術費50%
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醫院估計麻醉成本
๏ 以實際手術時間為計算基準
๏ 管理費依直接成本16%
๏ 材料費內含於總額
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ABC估計麻醉成本
๏ 以實際工時間為計算基準๏ 以(工時*台數)為成本動因
๏ 依照不同成本目標,解構麻醉作業為三大過程
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工時估計健保局和醫院對於麻醉工時估算﹦手術工時
準備和善後維修時間估算不足
實際麻醉工時﹦手術前工時+手術工時+手術後工時
0
50
100
150
200
主治醫師 住院醫師 護理人員
191
51
38
120
60
30
120
60
30
健保局 醫院 ABC
ABC成本分析
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健保局不承認間接人工實際麻醉工時﹦手術前工時+手術工時+手術後工時
實際麻醉工時﹦直接人工+間接人工
健保局估算工時﹦直接人工
0
50
100
150
200
健保局 醫院 ABC
71
120120120
直接成本﹦手術工時間接成本﹦手術前工時+ 手術後工時
ABC成本分析
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外科系不願認列間接工時實際麻醉成本﹦直接人工+間接人工
實際外科系成本﹦直接人工
0
50
100
150
200
外科成本結構 麻醉科成本結構
71
120120
直接成本﹦手術工時間接成本﹦手術前工時+ 手術後工時
ABC成本分析
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2006-April
外科系吃飯, 麻醉科埋單!
ABC成本分析
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ABC成本分析
間接工時是浪費嗎?是誰造成的?
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作業時間分配不足是麻醉成本扭曲的主因
孫維仁
李書行教授 指導
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ABC成本分析
間接人工時是浪費嗎?可以節省嗎?是誰造成的?
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降低成本的迷思
一個地勤罷工的航空公司,
機長若願意飛,你敢搭乘嗎?
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降低成本的迷思
一個地勤罷工的航空公司,
機長若願意飛,你敢搭乘嗎?
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我們有8個飛機場…..
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我們有8個飛機場…..功能 地點 房間 使用率
1 主開刀房 東址四樓 24 135%2 產科開刀房 東址五樓 3 60%3 健檢中心 東址六樓 3 100%4 導管室/血管室 東址一樓 2 ±50%5 內視鏡室 東址一樓 2 ±50%6 門診中心 西址三樓 6 60%7 美容中心 西址二樓 2 ±50%8 乳房中心 公館院區 4 30%
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盈餘估計(%)健檢靜脈麻醉盈最高
半身麻醉完全不敷成本
全身麻醉見解各異
-300
-225
-150
-75
0
75
開刀房內靜脈麻醉 健檢靜脈麻醉 全身麻醉 半身麻醉
-255
-21
37
-15-29
-13
43
-102
-131
22
44
-31
健保局 醫院 ABC
ABC成本分析
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收入比例全身麻醉收入佔據全部收入的78%
ABC成本分析
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0
1,500
3,000
4,500
6,000
全身麻醉 半身麻醉 自費止痛
5,000
2,500
5,700
成本只佔34%
術後自費止痛成本分析
0
1,250
2,500
3,750
5,000
全身麻醉 半身麻醉 自費止痛
120
240
480
500
500
1,150
250
1,600
3,200
直接人工 直接費用 行政費用
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截長補短的套裝包裹(Package)每台手術如果接包裹自費止痛,所有麻醉項目皆呈現22%以上的盈餘。
目前自費止痛比例10%。
估計全身麻醉單項自費止痛比例若能提升至32%,則損益兩平!
ABM策略 I
-300
-225
-150
-75
0
75
開刀房內靜脈麻醉 全身麻醉 半身麻醉
22
4345
-255
-21-15
Simple Package
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Supply Chain Services
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製作報表
Supply Chain Services
處置剩藥
緊急回應
定時巡房
調劑管理
解說 簽約
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製作報表
Supply Chain Services
處置剩藥
緊急回應
定時巡房
調劑管理
解說 簽約
Acute Pain Service
= 7000元的服務流程!
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生產線集中,縮減獨立開刀房現有獨立手術房共八處,分散全院三區。
預計2007將增加兒童醫院三區。
低效率區域(如公館院區),麻醉業務外包。
閒置生產線過多,週轉效率不彰,是導致成本居高不降的基本原因。
ABM策略 II
0
2.5
5.0
7.5
10.0
林口長庚 北榮 馬偕 台大
8
334
獨立手術區
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合理分攤至成本對象閒置時間和產能均分至外科系各部門。
減少虧本之麻醉作業(如半身麻醉)。
提升週轉效率,增加護理人員彈性工時之比例!
ABC策略:
麻醉 外科
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合理分攤至成本對象閒置時間和產能均分至外科系各部門。
減少虧本之麻醉作業(如半身麻醉)。
提升週轉效率,增加護理人員彈性工時之比例!
ABC策略:
成本結構
麻醉 外科
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全院營收狀態
(百萬元)
2006-April
真實
(百萬元)
帳面
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全院營收狀態
(百萬元)
2006-April
真實31%
(百萬元)
帳面
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全院營收狀態
(百萬元)
2006-April
真實31% 3%
(百萬元)
帳面
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Where have all the profit gone?
攤提不足
教育費用
閒置設備
研究費用
間接費用
攤提錯誤?
觀念錯誤?(百萬元)
21% off!
價值2.5億/月的間接成本
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麻醉機 生理監視器 藥物
閒置的產能間接成本的來源
無附加價值成本(Non-value added cost)
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作業基礎成本與管理
ABC
資源
ABM 成本動因 作業 管理
成本標的
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作業基礎成本與管理
ABC
資源
ABM 成本動因 作業 管理
成本標的
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作業基礎成本與管理
作業
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作業基礎成本與管理
標的
資源
ABC
成本分派構面
作業
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作業基礎成本與管理
標的
資源
ABC
成本分派構面
作業
成本
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作業基礎成本與管理
事業流程構面ABM
標的
資源
ABC
成本分派構面
作業
成本
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作業基礎成本與管理
事業流程構面ABM
標的
資源
ABC
成本分派構面
作業
成本
目標cost
driver
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COST
DOWN
成本= 為了創造價值所消耗的資源
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COST
DOWN
成本 ﹦資源
成本= 為了創造價值所消耗的資源
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COST
DOWN
成本 ﹦資源
報酬/成本 ﹦投資報酬率
成本= 為了創造價值所消耗的資源
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COST
DOWN
成本 ﹦資源
報酬/成本 ﹦投資報酬率
投入的成本有報酬產出 ≠ 浪費
成本= 為了創造價值所消耗的資源
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COST
DOWN
成本 ﹦資源
報酬/成本 ﹦投資報酬率
投入的成本有報酬產出 ≠ 浪費
投入的成本沒有達到預期的報酬產出 ﹦損失
成本= 為了創造價值所消耗的資源
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COST
DOWN
成本 ﹦資源
報酬/成本 ﹦投資報酬率
投入的成本有報酬產出 ≠ 浪費
投入的成本沒有達到預期的報酬產出 ﹦損失
投入的成本沒有報酬產出﹦浪費,費用
成本= 為了創造價值所消耗的資源
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價值鏈
成功手術麻醉 外科
無附加價值成本(Non-value added cost)
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價值鏈成本結構
成功手術麻醉 外科
無附加價值成本(Non-value added cost)
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-總體經濟衰退時,誰能倖免?
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-總體經濟衰退時,誰能倖免?
No one!
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! David Armano http://darmano.typepad.com
麻醉醫師在醫院內所扮演的角色
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! David Armano http://darmano.typepad.com
Synthesizer!
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新的挑戰,新的思維
風險管理(安全)為中心!
服務為目的!
知識+技術為核心!
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麻醉科在綜合醫院最佳的經營策略
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麻醉科在綜合醫院最佳的經營策略
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-覆巢之下無完卵