二、创亚洲化精益医院——构建医院精益管理链

1.精细化管理与精益管理链

从社会发展进程看，精细化管理的发展与汽车工业是分不开的。福特汽车的规模化生产影响了整个20世纪的制造业，表明了流水线、标准化是科学管理的重要起步阶段；通用汽车的细分化生产激发了消费者的个性化需求，从而调整自身的生产与服务能力，形成了科学管理的中间发展阶段；因势而生的丰田汽车 “精益化管理”是在前两个阶段基础上的深化和细化，提升了众多企业和职业经理人的管理理念，是管理科学的最新发展阶段。

从理论发展角度，精细化管理具有三个理论来源，即泰勒的科学管理理论、戴明的质量管理理论和丰田的精益管理模式。

泰勒的科学管理理论强调用科学的研究方法建立规范标准化，并贯彻到生产中以获得更好的业绩。戴明质量管理理论对精细化管理理论的主要贡献在于：强调事先的流程和程序设计；强调体系原因和非体系原因；强调管理者应该不只是管，更重要的是帮；强调对员工的训练。丰田精益生产模式追求以越来越少的投入——较少的人力、较少的设备、较短的时间和较小的场地创造出尽可能多的价值，丰田精益生产模式的根本方法是：通过流程的标准化和自动化，调动员工的参与，实现流程的持续改进和精益求精，最终改进效率、减少浪费、提高速度。

丰田精益生产体系的精髓是丰田三角模型，其内涵是一个以人员和人员发展为核心的整体系统。围绕这一核心，技术工具、管理工具、哲学理念三大模块均衡发展，这四大部分有机组合在一起就形成了精益文化。

近年来，随着物流行业的兴起，在精益管理研究中，开始出现了一门新兴的管理研究领域——精益供应链理论。这一理论是精益生产与精益管理，通过物流的形式进行了连接，产生了综合效应，值得我们医院管理者学习与重视。

精益供应链（Lean Supply Chains）：来源于精益管理，将从产品设计到顾客得到产品这整个过程所必需的步骤和合作伙伴整合起来，快速响应顾客多变的需求。其核心是减少、消除企业中的浪费，用尽可能少的资源最大程度地满足客户需求。

精益供应链的出现，成为减少浪费、降低成本、缩短操作周期、提供强化的客户价值从而增强企业竞争优势的一种 “伟大的方法”。精益供应链理论从单纯的企业管理与物流管理中走出，形成了一门新兴的管理理论。

美国供应链管理专业协会对精益供应链理论的定义是指管理活动所涵盖的所有组织的计划与管理。这些活动包括资源的获取、服务的提供、转化及流程管理。精益供应链管理还有一个关键的部分，就是服务合作伙伴的协调。

链条的机制

一是链条一般是金属的链环或环形物所构成的紧密联系物，多用于重要的机械传动。二是链条主要包括有四大系列：①传动链，主要用于有效地传递动力。②输送链，主要用于有效地输送物料。③曳引链，主要用于有效地拉曳和起重。④特种链，主要设置在机械装置上的特殊功能链。三是链条是由链板、链销和轴套等精密配置而成，相互连接的紧密、有效能保持动能的长久、高效。是机械行业中最为有效的生产工具。

链条机制对系统功能的作用

一是行为导向作用。按机制所引导的方向有序运动，进而保持系统内部的整体有序性，不会受外在的或内部的其他因素影响。二是低耗高效。低输入高输出是链条系统功能的最重要特征，它是低成本高效率的转换器，可以减少系统内部的无序和内耗、矛盾与冲突。三是维系稳态。链条机制告诉我们，相互间的齿状连接是最稳固的，它可以防止系统内部的紊乱、动荡、骤变和间断等结构上的失衡，进而维系了系统内部的稳态。四是信息传递。信息是组织内部的普遍联系方式，与物流的畅通互为前提，当物流紊乱时，信息流必然受到影响，信息流也会出现阻塞和无序。而物流畅通时，则信息流也会变得灵敏、准确。

精益管理链（Lean Management Chains，LMC）是从精益供应链发展和派生出来的新概念。精益管理链是指在管理活动中，要以顾客满意为轴向，不断优化生产过程、服务过程、供应过程，减少浪费、降低成本、形成精益管理的有效过程。精益管理链借鉴了精益供应链的原理与链条概念的功能注解，形成了独特的管理理论。

精益管理链有两个轴向，分别是行为管理轴向和价值管理轴向。

2.管理协同理论及其应用

作为系统科学的重要分支，管理协同学，产生于二十世纪七十年代，创始人是德国物理学家哈肯教授。所谓协同，按照哈肯的观点，就是系统中各个子系统的相互协调、合作、同步的联合作用与集体行动。协同是系统整体性和相关性的内在表现形式，有组织系统的内部作用所产生的协同。协同作用会产生协同效应，而协同效应则是一种整体效果，它不同于个体之间的效应之和，也不是简单的有序排列。哈肯在协同学理论中提出了序参量与超序参量、快变量与慢变量，对称与对称破缺等重要原理与概念，为协同学的研究奠定了基础。

协同作用在客观世界中普遍存在，有些不被认识，但已被认同，如政治协同、军事协同、文化协同、科技协同等，虽然发生在不同领域表现为不同形式，但都有其内在的规律性。管理协同是诸多协同中重要的一种，它是从系统组织的角度来研究管理的效能。

管理协同——协同的经济学含义是由美国著名经济学家安索夫从战略角度定义的，即为什么企业整体的价值有可能大于各部分价值的总和，这是指：在一定的投资总额下，一个产品系列齐全的公司可以比那些只生产系列产品中的个别产品的公司在单一产品上实现较高的销售收入或较低的运行成本。这就是整体的协同价值大于各部分价值总和的原因之所在。

安索夫的协同概念包括互补效应和协同效应两部分，互补效应是指 “自组织”，即：通过整体的效益来节约成本、增加收益，而协同效应是指 “搭便车”。

“自组织”效应——自组织是管理协同组织的一个特点，它可以根据内部要素和外部环境的变化而自我调节、积蓄能量，因势利导地发挥作用，产生协同的正效应。自组织的产生是管理序参量的作用原理。

“搭便车”效应——安德鲁·坎贝尔等在 《战略协同》一书中说：　“通俗地讲，协同就是 ‘搭便车’。当从公司一个部分中积累的资源可以同时且无成本地应用于公司的其他部分的时候，协同效应就发生了”。

管理协同是用协同论的思想和方法研究管理规律和实施管理的一种理论体系，其目的是更加有效地实现组织的整体管理效能。

对医院管理来说，医院管理的协同就是用协同论的基本理论和方法来指导医院管理的实践活动，使医院管理的子系统更加协调，管理内部优化组合和配置，进而产生一个新的具有生命力的组织管理系统，实现医院管理协同效应的目的。

管理协同把医院管理作为一个价值链来进行研究，对内部的人、财、物、技术等各种资源进行优化配置和有效利用，可产生一种自组织的适应变化的能力。哈肯把序参量引入系统学中，是研究和认识的系统原理中的协调与改变所产生的系数。

管理协同与精细化的关联——通过研究可以发现，管理协同与精细化管理的思想内核、主要内容和运行手段都是紧密联系的。主要表现为：

一是目标取向的高度一致性。管理协同和精细化管理的思想，不管是在营利组织还是在非营利组织中的运用，都有利于最大限度地实现组织的目标，最大限度地提高组织的运行效率和降低成本。管理协同的实质是一种自组织协同，它是指没有外界因素的驱使下，系统内部开放式的合作所自动出现的功能有序化的新结构现象，可实现提高效率和提升效益的目标。而精细化管理的内涵最明显的是 “精、准、细、严”，这也是以提高效率、降低成本来实现组织目标的。

二是管理要素与内容的趋同性。管理协同强调的是组织内部的组成，要服从总体的目标，并通过供应链等形式的运作来进行系统整合，从而提高组织的运作效率，使组织内部紧密联系，具有竞争力。精细化管理的思想则也是通过流程和职能的量化，实行节约化的管理，强调以人为本，使 “认真严谨”成为一种工作习惯。

三是整合内部资源的关联性。无论是管理协同还是精细化管理都强调重视对组织内部职能的分析和合理利用，在职能分清和协调的问题解决后，进行资源整合，提高整体效能。精细化管理也是把有形资源、无形资源、知识资源进行精细化的细分和整合，以提高组织的运行效能。

四是工作平台的融合性。管理协同和精细化管理都强调了组织内部子系统的工作平台，以及信息网络化的平台，和服务流程的实践平台，以人为本的思想平台，这些都是管理作用的基础。

3.医院精益管理链的形成

当国内许多公立医院还在为规模化扩张而竭尽心力之时，一些世界发达国家的医院已经开始收获精益管理所带来的丰硕成果。美国著名医院管理大师所著的 《向世界最好的医院学管理》和 《精益医院》等书，无不向我们展示了医院精益管理的种种益处。

马克·格雷班在 《精益医院》一书的最后，描述了他们的最后思考——2001年美国的工业界发出了这样一种声音，我们希望看到一个世界医疗界的丰田。在那时，美国医疗界还没有一个明确的领导者能够拥有一个显著优于其他医院的工作流程或创新成果。即使到现在也依然没有一个精细化管理的榜样可供大家学习，不过已经有很多家医院谱写了“创精益医院”的故事。

今天我们也要发出这样一种声音，在中国也已经有了自己的 “创精益医院”的探索与原创理论的贡献。我们的研究从理论上讲，是将管理科学最新成果——精益供应链与协同理论，和中国医院管理相结合的产物。从实践上讲，是一个比较完整的、具有创新性的、还有普适性的医院管理创新应用成果。这表明，我们在这一方面的研究已经达到了一个新的高度。

医院精益管理链的研究是基于我们2013年获得中华医学科技奖卫生管理奖的项目——医院精细化管理创新的关键提升技术，并立足于理论联系实践的最新成果，是我院关于医院精细化管理实践的再创新。

2010年和2012年，中国协和医科大学出版社分别出版了我的两本专著 《医院精细化管理概论》和 《创精益医院》，在综合吸收前者的理论基础和后者的管理实践的基础上，根据我院近年来在医院精细化管理过程中新的创新探索，对理论与实践相结合的成果进行了进一步的提炼与升华。

在医院的管理体系中，我们寻找了自己认为最重要的环节，包括六个子系统：医疗质量系统、人才成长系统、绩效考核系统、服务流程系统、内部管理结构系统和医院文化体系。这六个子系统包含了医院主要的运行和管理能力，它们之间运转中所产生的相互影响、相互协调和相互作用，使得医院管理的各个子系统间不断产生协同作用。

选择这六个子系统的交汇点，进行齿状结构化的链条般链接，并对这些关键链接进行管理组合，形成医院精益管理链。这一链接构成了医院管理中动态性、循环性和持续性的医院精益管理体系。这种链接与协同的管理关键技术，促进与提高了医院的整体管理成效。

基于精益供应链和协同论的理论基础，应用于医院精细化管理的关键提升技术，我们的创新之处，就是构建医院精益管理链。医院精益管理链的形成，主要有以下四个步骤和特点。

第一，在医院精细化管理的过程中，充分运用精益供应链与管理协同的原理，对医院管理的资源、要素、流程、平台等实施有效的精益管理，以追求医院精细化管理和协同管理的最佳效益。

第二，医院精益管理链的构建要注意运用链条机制的原理，将医院管理作用的要素，实行齿状对接，以求无缝连接和最优效果。并注意运用协同管理的自组织原理，将医院的子系统最优化，并产生 “1+1＞2”的整体效应。

第三，构建医院精益管理链的三部曲：一是对于院长和医院决策者来说，要选对要素！各个不同医院和医院在不同时期，它的核心要素都是在动态变化之中，需要我们注意识别，并注意掌握。二是选对、选准要素后，要根据精细化管理的要求，按照PDCA循环的原理，进行重点管控，产生显著的变化与效果。三是注意利用协同原理，将要素之间的管理效果实行 “自组织”和 “搭便车”效应。这样就达到了医院构建精益管理链的目的。

第四，各医院的精益管理链可以各不相同，但都必须围绕医院的战略管理、医院的组织结构管理、医院的学科建设与人才管理、医院的文化管理、医院员工的管理、医院医疗质量管理、医院服务管理、医院流程管理、医院的绩效与薪酬管理等来进行和构建。这样才能抓住医院管理的 “牛鼻子”，达到医院精益管理链的效能目的！

医院管理中的牛鞭效应导致管理信息从一线到领导层的扭曲偏离。

4.医院精益管理链的六步注解

医疗质量是医院的生命线，也是患者求医的主要目的与动因。医院管理的优劣对于患者而言主要是看医疗质量的动态反应过程，患者需要优质的医疗服务，其中包含了医疗技术的精湛、准确、高超，也包含了医疗服务的优质、快捷与高效。根据马斯洛的需要层次的五个方面的理论，在医疗质量中，这五个层次都有包含。

世界卫生组织（WHO）从供方角度把医疗质量定义为：医疗质量是卫生服务部门及其机构利用一定的卫生资源向居民提供医疗卫生服务以满足居民明确和隐含需要的能力综合。国外推崇的是从需方定义的医疗质量观：医疗质量是指消费者实际获得的医疗卫生服务与期望值之间的差距。

在我国，一般来说，狭义的医疗质量包括医务人员的技术水平、防治疾病的效果等方面的质量。广义的医疗质量除了包括有效、安全、及时性以外，还强调患者的满意度、医疗工作效率、医疗技术经济效果以及医疗的连续性和系统性。

随着社会经济的发展，医院管理的现实难度越来越大，主要表现为医院与医生提供的医疗技术与服务能力与水平和患者与社会的要求中间具有一个相当大的落差。很多医学因素、风险因素、社会因素、心理因素、环境因素等构成了医疗服务的复杂性与医疗质量评判的复杂性。

医院是救死扶伤，实行人道主义的场所。医院医疗服务的对象是患者的生命与健康。与企业、农业的生产不同，不是普通的产品。产品不合格，可以再造，而医疗质量出问题，则患者生命则会丧失，不会重来。从这个意义上看，医疗质量是患者的生命，也是医院的生命。

医疗质量的特点包括五个方面：

第一，医疗质量具有极端重要性。人命关天。医生、护士等天天都与患者生命打交道，来不得半点马虎，半点疏忽。稍有不慎都会铸成大错，酿成大祸。给患者与家庭带来无尽的伤害。所以医院怎样重视医疗质量都不为过。医院医疗质量极端重要，是医院的生命，是医院管理永恒的主题。

第二，医疗质量具有反复性。医院不是昨天重视医疗质量了，开展过医疗安全教育了，就可以一劳永逸了。医院开着，医疗活动开展着，就随时都有可能出现医疗质量问题。任何一家医院都不敢说，没有医疗质量问题。任何一个医生、护士也不敢说，永远不会发生医疗质量问题。反复出现，随时发生是医院医疗质量问题的重要特点。

第三，医疗质量具有时效性。医院近阶段重视医疗质量就会收到效果。就会降低医疗纠纷，医疗差错的发生。反之，医院忽视医疗质量，就会出现医疗问题频发。医院医疗质量管理必须警钟长鸣。必须时时讲、天天讲、年年讲。必须院长讲、主任讲、医生讲、护士讲。

第四，医疗质量具有责任性。虽然医疗质量问题有责任性问题、技术性问题、服务性问题等多种类型，但贯穿其中的，都是医护人员的责任心问题。大凡搞错患者部位的、选择错误手术与治疗方式的、对患者滥用药物造成伤害的、对患者生命冷漠没有及时救治的等隐含着医护人员的责任心。责任是一种人生观，是一种态度，是一种能力，更是一种从医观。

第五，医疗质量具有创新性。医疗质量必须时时抓、年年抓。这里面，就有一个创新性问题。如果，一个医院一直沿用一种方法进行医疗质量教育与医疗质量管理，就会出现脱节，就会出现懈怠，就会出现漠视。我们医院管理者必须不断研究、学习、创新，运用新鲜方法、新鲜案例、新鲜途径开展医疗质量管理，这样才会不断收到好的效果。

医疗质量对于医生和医院来讲，其含义与意义是和患者与社会的理解不一致或有落差的。这就是我们中国现实的医院管理的难题与难度。很多院长都有这样的体会，在医院内部来说，第一头痛的事就是处理医疗纠纷，第一难抓的管理就是医疗质量，第一难让社会与患者满意的就是医疗技术与服务水平所构成的医疗服务水平。

因此，医疗质量管理需要形成回路。医疗质量管理存在客观难度。但凡担任过院长或从事过医政管理的人员都会有这样的一种共识，那就是医疗质量管理难！那么难在哪里呢？一方面难在患者的重视，甚至几乎苛求的现象也不鲜见，这是无法改变的一种客观需求。因为医疗质量关乎患者的生命，所以患者对此倍加关注、倍加珍惜、倍加苛求，都是可以理解的。

而医疗技术与医疗水平客观上尚未达到这样的一种高度，也就是说没有一家医院、没有一个医生，可以包治百病。可以说，不发生任何医疗质量问题，这显然是不可能的，也是不现实的。

从上述意义上来讲，医疗质量管理的主观难度是在医疗活动中，许多医院与医生都是重视技术，重视直观的、显见的、初步的医疗效果。而往往容易忽视医疗活动中出现的细节问题、环节问题，副作用、并发症，以及派生而出的患者心理上的变化与不适应。

这些医疗质量管理上的主观问题，一方面是医院医生在认识上的不足，另一方面就是没有把医院科室与个人的医疗质量管理形成一个有效的管理回路，没有形成PDCA循环，没有形成日、周、月、季、年周而复始的有效的医疗质量管理循环。

2004年，中国台湾医院管理专家邱文达博士创新地在医院医疗质量管理中开展了品管圈的新型活动形式。品管圈（Quality Control Circle，QCC）是由相同、相近或互补之工作场所的人员组成（又称QC小组，一般6人左右），全体合作、集思广益，按照一定的活动程序，对自己的业务水平、岗位职责不断地进行维持与改善的活动。品管圈的运转就是管理到改善到管理再到改善，如此循环往复，持续改进的过程，即PDCA的过程。

在众多的医疗质量管理工具中，“品管圈”是一个可在短期内见效、明显改善相应部门质量和提高效率的活动。它倡导以一线员工为中心，组成质量改善圈，共同学习和运用品管方法，讨论、发现、解决工作中存在的问题，形成自下而上、卓有成效的质量改善机制。从 “要我做”到 “我要做”，使 “质量改善”真正成为一种文化，一种习惯，成为一种团队工作的固有模式，并凭借它去寻找问题、发现问题、解决问题。

PDCA循环和品管圈的模式及方法，让我们在构建医院精益管理链的医疗质量管理中产生了联想，那就是能否借鉴品管圈的管理模式和PDCA循环的方法，将医院的质量管理纳入其中，构建医院医疗质量管理品管圈。

借鉴品管圈（QCC）的管理模式和PDCA循环的方法，结合医院医疗质量管理的实际情况，无锡市第二人民医院在构建医院精益管理链的医疗质量管理中创新开展了医疗质量管理品管圈的构建。

“五个不放过”是我从事医院管理近二十年所带来的一组思考，那就是医院的医疗质量关键在于医院的医疗效果和患者的满意度，而关乎医疗质量和患者满意度的最重要环节就是死亡患者的病例管理与讨论，这其中有不少是医疗纠纷病例，也有不少是危重患者的抢救病例，还有不少是我们医院开展医疗技术创新没有成功的病例。

从某种意义上讲，可以说，医院的死亡病例讨论是一部最具有活学活用价值的医院管理，那么 “五个不放过”就是我们在医院医政管理过程中往往存在的患者与家属不满意，而医院和医生又容易忽视和容易自以为是的一些问题。

“五个不放过”，即患者死亡了，其死亡原因不明不放过；手术失败了，失败原因不明不放过；患者投诉了，患者不满意的原因不明不放过；患者出现并发症，并发症的原因不明不放过；纠纷处理了，当事人认识不到位的不放过。

患者死亡，手术失败、出现并发症、纠纷投诉等情况在医院屡见不鲜。对于患者的死亡，医生往往会分析 “患者病情太重”、“病情变化太快了”、“我们已经尽力了”等各种原因；对于并发症，医生往往会寻找 “这是正常的并发症”、“这种病就会有这种并发症”等各种借口；对于纠纷投诉，医生往往会解释 “我已经做到位了”、　“我已经跟家属沟通过了”、“我又没错，是家属无理取闹”。很多情况下，医生可以凭借各种理由、各种借口“蒙混过关”，但仔细分析，真的是这样吗？

当我们遵循 “五个不放过”原则，认真剖析，追根溯源，分析隐藏在这些问题背后的深层次原因时，就会发现诸多死亡病例在病情评估、严重程度的判断上有失误，在病情观察、细节处理方面有疏忽；手术病例在适应证、禁忌证把握上有不当，在围手术期处理上有欠缺；对并发症的防范措施不到位；与患者及家属的医患沟通不到位；甚至医院管理制度有漏洞等一系列问题。此时，各种理由、各种借口在事实面前显得是多么的无力！

“五个不放过”为我们很好地总结和归纳了医疗质量管理的切入点。医院将死亡、手术失败、并发症病例及纠纷投诉作为切入点，抽丝剥茧，仔细分析医疗过程的每个环节，会发现医疗质量方面存在的诸多问题。

“五个不放过”时刻提醒我们，凡事要透过表面现象看本质。一般患者死亡、手术失败、出现并发症、纠纷投诉中，最容易隐藏医疗质量问题，绝不能简单地以所谓的 “理由”和 “借口”懈怠了医院内部严格的医疗质量管理，否则类似的情况必然还会发生。

“五个不放过”是推进医疗质量持续改进的有力 “武器”。坚持 “五个不放过”查找医疗质量存在的问题，通过PDCA循环不断改进，必将能有效提高医疗质量，提高医院管理水平。

在医院管理不断走向精细化的年代，医疗质量管理也由终末管理向环节管理转变，“五个不放过”就是一把打开环节质量管理大门的 “钥匙”，坚持 “五个不放过”，必将成功做好环节质量管理。

我们从2009年开始，对医院所有的死亡病例本着 “五个不放过”的精神和要求注意筛查、逐一讨论、逐一反思，构成医院科室和医生对于医疗质量关键环节和患者生命的警醒、警示。通过认真的讨论、分析、思考，来形成有效的医院对医疗质量管理最后一道防线的构建。

JCI和新一轮的三甲医院评审标准都是使用循迹追踪法来开展医疗质量管理与督查的，而我们医院构建的医疗质量管理回路也是从死亡病例中循迹追踪的，这里面有几个重要的环节。

一是坚持每日进行对医疗、护理总值班的抽查和医务处护理部的巡视、检查，查找薄弱环节和问题。二是坚持每周或双周，医院组织一次医疗护理和行风的联合督查行动，由院领导轮流带队，各职能科室参加，抽查十二项核心制度的落实情况，对于检查中发现的问题，下发限期整改通知书。三是坚持要求院领导、科主任与名医、首席专家每月进行一定数量的病历质控，通过病历质控来查找问题，提升医疗质量与水平。四是坚持每季度以死亡病例讨论为主题的季读课，医院选择一到两个死亡纠纷病例，组织院内外专家参与点评、分析和讨论，并请所在科室提出相应的整改措施，以整改来促进医疗质量的提升。五是坚持每半年举行医疗纠纷追究与评判，对所发生的病例组织科学的评判，明确责任，一方面让医务人员自行分析，并进行解释，另一方面让专家评判，并且根据最后的结果，让相关人员与科室进行整改。六是坚持每年开展一次医疗安全警示教育周（或月）的活动，将一年来发生的医疗意外事件、院内感染事件，进行大讨论和警示教育。在此基础上，医院还通过 “金点子征集”等活动方式，收集建议、意见和方案，逐一加以整改和落实。

无锡市第二人民医院医疗质量管理品管圈是坚持 “五个不放过”的医疗质量管理理念，找准医疗质量管理的切入点，运用循迹追踪法发现整个系统存在的问题，通过PDCA循环对问题加以分析、讨论、改进，同时形成日、周、月、季、年周而复始的有效的医疗质量管理循环。

随着社会经济的发展和人民生活水平的不断提高，人们健康观的变化，必然带来卫生需要增长和疾病谱变化，对医学人才需求也随之增长，导致医学人才供求关系失衡，刺激人才需求。在今后相当长时期内，这种趋势不会得到缓解。要真正认识医院竞争就是科技的竞争，关键是人才的竞争，拥有了人才，就能把握主动，赢得医院竞争的优势。

医院人才——人才，用系统工程和协同论的思想可分为三个层次并且由五个要素组成。三个层次是指；一是合格人才，即根据本科专业分工和自身具备的条件，经过选拔培养达到合格要求者；二是专科人才，即在合格人才的基础上，即具有本专科综合水平，又具有本专科技术的尖子人才；三是杰出人才，即在专科人才基础上，对本专业确有创造、发现与发明，或在某项技术上有重大革新和突破。而五个要素则指人才应具备的德、智、能、绩、健。

人才是社会人群中的精英。他们的情感和智慧既有与常人相同的一面，又有其特殊的一面；后者是由于他们在认识世界、改造世界活动能力和地位决定的。

对医院人才来说，凡在医学实践中，具有一定的专业知识和专门技能，对本职工作的规律有所把握并善于积累资料、总结经验、创造价值而造福人类者，均可称为医院人才。

2013年9月，由我主要研究的课题 《医院 “人才树”工程的构建——提升学科带头人与普通员工群体素质项目》获亚洲医院管理奖人力资源发展类卓越奖，这次中国大陆仅有两家医院获奖，我们是其中之一（另一家为华西医院）。这个项目源于我们医院十多年坚持不懈抓人才培养，是历经十多年对人才培养体系不断完善、实践、再修正、再构建，最终实现人才培养精细化管理。

“人才树”工程的特点主要可概括为三方面：

一是引入 “树型结构”理论。破除以往人才培养模式单一、局限的弊端，从医院人才队伍涵盖的不同技术层次及发展阶段要素分类，层层递增，实施阶梯状分层培养。按 “基底—树干—树冠”三级培养体系，对应普通医务人员和新职工群体—技术骨干群体—精英群体。基底（普通医务人员和新职工群体）以确立终身学习理念、实施全员职业养成教育为主；树干（技术骨干群体）以创新人才培养机制、实施助推成长计划为主；树冠（精英群体）以加强能力业绩考核、拓展学术辐射力为主。三者间相互依存，梯式发展，协调合作。

二是引入职业路径理论，实施职业生涯整体规划。自员工入院第一天起，直至退休之日止，贯穿其整个职业生涯，针对不同职业阶段提出不同的成长目标，实现人才发展的个性化培养。即从专业技术人员起步教育、中青年学术骨干培养及高层次人才选拔等入手，既注重整体队伍素质提高，又突出重点人才的培养，坚持全面提升与重点培养相结合，创新人才培育、使用及激励机制，最大限度地发挥人才潜能，在实践中逐步探索出了一条符合医院情况、独具特色的人才建设之路。

三是 “人才树”工程具有的 “两个一、两个三”的特点。其中 “两个一”是指一种人才管理工具和一本小册子；“两个三”是指针对群体的三级培养体系和个体医学人才成长的三个阶段。

“一种人才管理工具”　“人才树”工程的 “树形”是对人才梯队的形象比喻，既代表了集体的人才组成，也象征着人才的成长过程。这是一种管理工具，它把医院对不同层次人员的管理纳入其中，形成一种可测量、可奖励、可动态培养的体系。这一工具，我描述为一种 “函数工具”，它对医院整体医疗水平起着放大、缩小的作用：医院管理得好，学科建设和人才培养的效果就被放大；医院管理得不好，学科建设和人才培养的效果就会大打折扣。

“人手一本小册子”　在无锡市第二人民医院，有一本每位员工都有的小手册——《卫技人员系统培训与考核办法》。在这本手册上，不同职称、不同学历的员工，从入职到退休每一年需要完成的任务、考核目标，都有明确、细致的要求。

“群体三级培养体系”　从医院人才结构的全体而言，“基底—树干—树冠”人才培养模式被描述成一个 “树形”结构。其中 “基底”就是医院刚刚入院的普通中青年员工，“树干”包括35～45岁的中青年骨干、副高和中级职称的技术骨干，是医院加速培养的对象，“名医”、“首席”、“专家”这些省市重点学科的带头人，作为 “树冠”，主要发挥他们的技术引领、科研创新和名医诊疗作用。医院对三种对象采取三种不同层次的培养举措，对他们有不同层次的管理要求，以此搭建强有力的医院人才梯队。

“个体医学人才成长三个阶段”　“人才树”工程引入职业路径，在员工入院第一天起到退休的整个职业生涯各阶段提出不同的目标，为每个员工量身定制科学的职业路径规划，以实现员工个人与医院发展目标。从个人职业生涯来看，总体需经历三个阶段：一是学习阶段，为实习或刚工作时期，需要基础的积累；二是成长阶段，也是最为漫长的一个阶段，在实践中进行自我发展和自我提高；三是成熟阶段，经过漫长的积累和锤炼，能将自身能力应用自如，是发挥主导作用的一个阶段。不同的阶段有着不同的路径和目标。

该项目贯穿员工整个职业生涯，从业务素质、技术水平、科学研究等方面都有量化规定，明确考核和奖惩，从而最快速度促进员工的培养和成长，提升医院的内涵，强化员工的素质和服务水平，给患者提供更优质的医疗服务。

如果说前几年我们医院的人才树工程比较好地解决了树冠人才的引领作用以及临床技术的水平发挥，和基底人才的储备与基础教育问题，那么对于树干人才来说，我们侧重于他的国际眼光的培养、专科技术的提升、综合能力的打造，这些方面都有较大的进步和进展。但是，这些树干人才也出现了思想不稳定、前途不明朗、业务作用发挥不理想等困惑，这是我们充分认识到由于树冠人才的作用与价值链的形成与影响对树干人才产生了一定的消极作用与不良影响，有必要促使我们在充分发挥树冠人才的临床作用的同时，也要采取一些特殊措施，来引导和培养树干人才作用的独特发挥，并且要让树干人才看到他们自己与树冠人才的区别和不同，并寻找自我作用的发挥渠道与方法，这是我们在 “人才树”工程中的新发现、新认识与新重点。第一，要突出树干人才的阶段性明确目标，在专科技术、临床能力、科研创新、学习能力的培养方面，都要有明确的方向与指标。第二，要有适合树干人才特点的竞赛方式，让树干人才寓教于乐，在经常性、反复性、特定性的临床医疗工作中，寻找到可比较的、可促进的方式方法，如积分赛、征文赛、年排名等。第三，要有一定强度的激励方式，树干人才往往在收入上与树冠人才会有较大的差异，也会比较看重业务收入上的区别，对优秀树干人才给予一定强度的正向激励，是具有积极意义的，不仅对个体具有鼓励作用，而且对于群体而言，也有正向的引领作用，会有事半功倍的效果。

树干人才关乎医院发展的未来，也是树冠人才与基底人才的连接和交叉，对于每家医院来说，都是一个非常重要而又容易相对忽视的一个群体，当树冠人才兴旺发达，正在发挥业务、临床、科研引领作用的同时，提早启动对树干人才的关心、激励与帮助，将单纯的人才培养工程，转化为培养与使用相结合的创新工程，具有极其重要的意义与价值。

四十到四十五岁的黄金年龄是一个人成长的重要阶段，也是一个人作用发挥的重要阶段，我们要让这样一批中青年骨干医务人员与后备学科带头人，与普通的医务人员有所区别，要形成对他们培养使用的新倾斜、新扶持。这是医院人才激励行动的关键之所在。

“人才树”工程是基于人才成长需求的培养模式，寻求人才建设与培养切合点，探索人才管理的创新实践，是提升医学人才队伍建设的管理工具，是构建医院精益管理链的关键环节，更是实现医院人才管理战略化的不竭动力，需要我们在具体的医院管理实践过程中进行不断创新。

医院的绩效与薪酬管理始终是一所医院管理的基础、支点和杠杆。其意义是通过测量每个医务人员、每个医疗部门以及每家医院的工作、效率、效益、效能，来发挥其独特作用的。

可以说，医院的绩效管理是医院院长的眼睛、尺子，它可以发现与测量被管理者、被管理部门的工作水平、工作意义、工作价值。医院的薪酬管理，这是医院院长的钱包、账本，它可以动态性地支付与回报被管理者、被管理部门的工作、劳动、创造所必须支付的报酬。

每个医院都有着自己的绩效与薪酬体系，但是有些院长与医院管理者没有充分认识到医院绩效与薪酬管理的独特杠杆作用与测量意义。在医院管理中，存在着为了考核而考核，甚至 “先进轮流做”的现象，没有发挥绩效管理的正确导向与竞赛接力作用。

这样的绩效管理对于医院来说是非常有害的。薪酬是医院对于贡献者和贡献部门的一种报酬，它是对绩效管理的一种应答机制，也应当是动态的、连贯的、相应的一种医院日常管理机制。

但目前许多医院都还没有将绩效与薪酬管理直接关联，往往存在着绩效考核归人事部门掌握或进行，而薪酬管理则属于财务部门，这两者尚没有完全的关联度。

据我们了解，大约三分之一的医院是完全不关联的，三分之一是部分关联的，三分之一是基本关联的。我们要通过公立医院改革与医院管理创新，倡导医院的绩效与薪酬管理能够全部实现关联。

绩效是一个多维建构，观察和测量的角度不同，其结果也会不同，从不同的学科领域出发来认识绩效，所得到的结果也会有所差异：

从管理学的角度看——绩效是组织期望的结果，是组织为实现其目标而展现在不同层面上的有效输出，它包括个人绩效和组织绩效两个方面。

从行为学的角度看——绩效是一种个人或组织的行为能力判断，它可以区分个人或组织行为能力的高低。

从经济学的角度看——绩效与薪酬是员工和组织之间的对等承诺关系，绩效是员工对组织的承诺，而薪酬是组织对员工所作出的承诺。

从社会学的角度看——绩效意味着每一个社会成员按照社会分工所确定的角色承担他的那一份职责。现代医院管理较多的研究是组织的控制、运行谋划，而业绩的判断和组织与个人不同作用机制的研究尚不足。

医院的绩效考核是医院对照目标或绩效管理的标准，采用科学的考评方法来评定员工和部门履职、任务完成和发展情况，并将结果反馈给考评者的工作过程。

从医院管理的角度来看，最重要的是需要测量医院被管理部门和学科带头人的绩效，因为他们的价值最为重要，并且具有动态管理的意义。

从医院的绩效管理的角度来看，最重要的是要看需要测量哪些要素、哪些指标、哪些标准，并通过这些测量来激励被管理者与被管理部门努力将工作做得更好。

医院绩效考核结果的几种运用效能：一是能对科室及其员工的贡献度进行排名；二是能客观评价科室和员工对医院整体工作的适应性（个性、资质、习惯、态度、能力等）；三是能对表现卓越的科室和员工的出色程度及潜力进行衡量，并给予考评；四是能正常记录和反映出各科室和员工的工作表现过程，并达到规范、培养、引导各科室和员工行为优化的目的；五是科室和员工正常工作状态下完成医院目标和自身工作业绩的一种最基本的正式管理制度和方法。

医院绩效考核在医院管理中的应用：绩效考核主要运用于部门与个人的工作业绩比较，如：科室目标管理责任制的考核。也运用于重点工作项目的开展，如重点攻关项目课题的责任制等，是现代医院管理者们最常使用的管理方法。

我们的卫生行政部门在这方面没有足够的重视与足够的研究，上级部门对医院的考核要么流于形式，缺乏杠杆作用；要么过于烦琐，使医院面面俱到、无所适从；要么千年一贯制，缺少动态性的变革，使医院没有动力、没有激励。

从目前全国范围内来看，尚没有发现一个省市、一个地区、一个县域出现完全科学性、完全领先性的医院绩效和薪酬考核标准、体系与创新。这一方面是与我国的公立医院自身的改革创新能力不强有关，更重要的是另一方面，它也许和我们在这一方面的顶层设计缺陷与不足有关。

从全国来看，我国的医疗卫生事业，大约百分之九十是由公立医院构成的。但是在公立医院中，普遍存在着人浮于事、忙闲不均和一部分人员异常辛苦忙碌而一部分人员无所事事、奖罚不明等现象与问题。我们亟待提出创新性、科学性、实用性、指导性、动态性的医院绩效与薪酬管理体制与方法，这是我国公立医院改革与医院管理创新的一个重大现实课题。

从各家医院来看，许多医院院长虽然都已充分认识到医院绩效与薪酬管理的极端重要性，但是，苦于一方面没有统一的、科学的、权威的顶层设计，畏惧于其带来的复杂性、被动性和在医院员工和部门中带来的强烈刺激作用。所以有时故意淡化绩效与薪酬管理的杠杆作用，采用年度、月度的简单要求来表达，没有科学的设计、测量与管理。另一方面，医院院长在绩效与薪酬管理的创新理论方面缺乏足够的研究与重视，往往只是人事部门、财务部门、考核部门提出一些方法和管理方式来进行，缺乏全院性的统筹研究与创新实践。

也有一些院长囫囵吞枣似的引进国外与先进医院的绩效与薪酬管理方法，没有从自己本身医院的实际情况与需要出发，来加以设计、再创新、再研究。所以我国的公立医院在绩效与薪酬管理方面是比较落后的，与广大医务人员的需求不相适应，与现实的医院管理需要也不相适应。

精益管理始终是医院绩效管理的卓越目标，从2004年开始的平衡计分卡绩效考核探索，到如今的战略计分卡绩效管理，十年来，走出的每一步，都代表着我们对精细化管理的理解和践行更为深刻，也使绩效管理和分配在医院精益管理链上发挥更为积极的作用。

如今第二人民医院采用的是基于平衡计分卡的全面纵横设计的要素式绩效分配办法，我们称之为战略计分卡系统。医院的奖金分配早在开始实施平衡计分卡管理后就不再与收支结余直接挂钩了。

我们采用的是：基于平衡计分卡基础上的战略计分卡系统。即医院采用平衡计分卡的形式对医院、部门、个人绩效进行评价，并将平衡计分卡中代表劳动、技术、管理、风险等核心要素的主要指标参与员工薪酬分配的一种新方法。

“纵到底——涵盖年度所有薪酬”。在对分配总额划分条块时，一方面应考虑保健因素与激励因素的平衡，另一方面也需要考虑短期、即时激励与长期、阶段性激励的平衡。因此，在总额控制下可以将职工分配划分为如下几个方面：

一是基本工资，指按月为职工发放的以档案工资为基础的薪酬部分。医院按照责任、风险、利益相一致的原则，拿出职工原档案工资中的部分补贴，按岗位分类、分级及管理职务系数等进行重新分配，原档案工资封存。分配总量约占分配总额的30%。

二是月度绩效奖，是分配的主体部分，主要突出平衡计分卡财务和内部运行质量两个维度的考核，体现了短期关联度高的要素激励作用。月度绩效奖分配时充分考虑风险程度、劳动强度、管理难度等要素，初步实现了按劳分配与按生产要素分配相结合。月度绩效奖，按月分配，及时激励，分配量约占总额的30%～35%。其中临床医生是以主诊组为考核单元的月度绩效奖分配，同时设立月度医疗安全责任奖；医技人员则根据其工作特点，分别采用按工作量为主和以成本控制为主的两种分配方法；护士分配是以实行护理部垂直管理为基础，对护理人员实行两级分配；机关人员是在事业部制管理基础上，根据考核期内的实际工作情况进行浮动，实行绩效奖浮动系数；后勤人员则根据岗位特点，分别以量与质为考核单位进行。

三是年度绩效奖，是分配的主体部分，它是对短期内不能全面评价的科研、创新、满意度等指标的年度综合评价基础上，根据全年业绩贡献对薪酬做出的分配，体现了长期性、综合性的激励作用。年终奖以平衡计分卡为考核工具，突出四个维度的综合平衡，根据医院总体目标完成情况和考核结果对全院职工进行分配。分配总量约占分配总额的30%。

四是单项奖，是分配的另一个有效补充，是医院对年内的重点工作和做出突出成绩的工作的奖励，主要体现即时激励。一般分为两类：一是符合无锡市医管中心年度单项奖励条件的工作，由其核定额度，一般于年终进行分配；二是医院重点工作、重大项目的单项奖励，一般于重点工作开展或结束时分配，用于即时激励，提高积极性。分配总量视重点工作开展而变化，约占分配总额的5%～10%。

“横到边——涵盖医院所有人群”。一是高层管理者，主要包括医院院长、副院长等。这一层面的人员绩效分配应从医院整体目标和个人职责完成情况进行双重考核，以年薪为载体，效能为主要标准，强化考核激励约束机制。二是核心骨干，包括医院学科带头人、重点职能科室负责人等。这一层面的人员绩效分配应从专（学）科科室管理和个人自身业务发展、科研情况进行双重考核，以年薪为载体，重点体现责任、风险、管理等要素。三是医生，是直接面对患者，直接参与诊断、治疗的人员，是医疗服务的直接提供者。这一层面的人员绩效分配重点体现劳动（劳动强度）、风险、技术要素。四是医技人员，指运用专门诊疗技术或设备，协同临床各科诊疗疾病的部门人员。这一层面的人员绩效分配主要实行效率、效益考核。五是护士，护理服务质量直接影响医院形象和患者满意度，这一层面的人员数量在医院中占大比例，其绩效分配主要体现岗位差异下的劳动、风险要素。六是机关员工，主要指医院职能部门员工。这一层面人员绩效分配主要体现管理、责任要素。七是后勤员工，指为医院基本运行提供物质保障的部门人员，包括各类维修、物资供应、收费等人员。这一层面人员的绩效分配主要体现劳动要素，即劳动强度和工作量。

要素式绩效与薪酬分配战略的实施对内部核心人员起到了明显的激励作用，充分体现分配与责任、技术、管理、业绩、贡献以及劳动强度挂钩，体现向高风险、高技术、高贡献岗位倾斜，最大限度调动学科带头人的积极性，确保了这支核心人才队伍的稳定。

无锡市第二人民医院自2004年起引入平衡计分卡的绩效评价和考核体系，经过近八年的探索和完善，逐渐从最初的单一层次的平衡计分卡考核分配发展为全面纵横、多层次的涵盖所有人员、全部薪酬的基于平衡计分卡下的要素式分配。这样的方法对于其他公立医院在考核分配上也是一个现实可行的参照。突出体现在以下方面：

一是整体性。有效地统一了医院、科室、个人的三者之间的绩效目标，与薪酬分配全面挂钩，实现了上级部门对医院、医院对科室、科室对个人的绩效考核与薪酬分配的全方位、整体性覆盖。

二是平衡性。对一个地区同级别医院之间、科室与科室之间、员工之间的绩效考核，统一了标准。特别是对于不同岗位、贡献度不同的员工之间，实现了有效的平衡和公平，有效地调动了员工的积极性。

三是科学性。该方法着力于医院发展效益与效率的平衡、服务与顾客的平衡、运作与结果的平衡、学习创新与发展潜能的平衡。对下的导向作用更加突出，科主任只需要对照具体考核指标，根据科室工作予以分解落实，将全年工作的重点放在提高工作质量和效率、追求技术的不断进步、注重资源合理配置与有效利用、加强成本和患者费用水平控制上来，保证医院战略目标的实现。

四是创新性。该方法不再依赖以前单纯的经济考核、工作量指标的考核，并将此权重下调，增加了顾客满意度、学习创新、服务流程的维度，实现了服务效率、社会公益性、员工积极性等的综合平衡，具有较强的创新性。

五是可操作性。这种考核与分配方法实现了医院经济管理与综合目标管理的结合，使医院长期战略在短期目标中得以体现。在此基础上，以平衡、促进医院各项工作协调发展为前提，努力纠正和强化当前工作中的 “短板”，并通过量化设计后形成可操作性目标，最终达到调动全院各类人群积极性的目的。

六是可持续性。科学、量化的考核指标分解，使得这种基于平衡计分卡的医院要素式绩效与薪酬体系具有较强的可复制性和重复性，适用于全国大多数医院的长期操作，可持续性强。

从2004年到2014年，无锡市第二人民医院基于平衡计分卡之上的绩效管理与薪酬体系已经走过了整整十年。十年中，我们看着第一张简单而略显粗糙的 “医院平衡计分卡”从我们的手中诞生，看着绩效分配从实施前的与收支结余关联经历数次调整走向了要素式分配的道路，如同孕育和培养一个孩童般看着他从稚嫩走向成熟，从蹒跚学步到步履坚定。

这其中无数观点的对撞，无数思路的否定与肯定，都只表达了医院管理者一个坚定的信念——精益求精。涓涓细流，汇聚成河，指标、标准、考核、分配……绩效和薪酬管理的每一个环节细化组成了精细化的绩效管理链，也将成为医院精益管理链上更为牢固的一环。

医院的服务战略是要求院长要将医院的服务管理上升到战略管理层面上，动用自己的决策力与可调配资源，将医院的服务能力、服务意识、服务环境、服务流程打造好。使医院成为人性化、温馨化、个性化、舒适化的医疗场所。在医院医疗服务之中，处处体现以患者为中心的服务理念，以优良技术、温馨服务、满意流程来服务病患与社会。

在21世纪，医院的服务战略已经不是医院创新与卓越的额外选择。这是健康服务业与社会先导性产业的立足之本与存在之基。不管大医院、小医院，不管公立医院、民营医院，一概如此。医院的服务战略理念应当信奉的是：追求卓越，永续创新。

医院服务——医院管理的战略性命题

“服务”的定义：服务是人或组织的活动，一般是围绕一种可触知或可支配的产品交易来开展，目的是更好地满足消费者的需求和预期。

医院医疗服务是医院以患者及一些有医疗需求的人群为主要服务对象，以医疗技术为基本服务手段，满足人们的健康需求，给群众带来利益的一系列医疗产出和非物质形态的服务。

医院服务具体包含两个方面：一是医疗技术的服务，就是为患者治好病；另一个是情感的服务，让患者觉得舒服、舒心。患者对医院的评价，其实还是基于情感、感觉方面的评价，感受到技术好、态度好、便民、利民，就觉得医院的服务好。

医院的核心服务：核心服务是指顾客能从服务者中所得到的最重要的服务利益，它体现了服务者最基本的功能与价值。

显然，医院医疗的核心服务应当就是有效的救死扶伤。这里涉及医院的医疗服务的类别、医疗服务的特色、医疗服务的水准、医疗服务的承诺、医疗服务的有效性、医疗服务的创新。医院的卓越服务，不是只要几位名医与掌握一流核心技术者那样简单，那样明确，那样清晰。医院卓越的服务要有一流医疗技术做保证，要有一流医护员工队伍的素质做保证，也要有一流的医疗设施设备做保证，还要有一流的医院管理创新做保证。

医院的卓越服务是卓越医院的体现、标尺。卓越医院的桂冠也许是很难、很难。很少、很少。但卓越医院的追求，应当是每个医院、每位院长心中的目标。

很多的医院院长并未认识到医院服务的基础性、重要性、特殊性，只是将它当作一般的医疗表现形式来处置、来运营、来要求。所以医院的医疗服务从内涵上来看没有达到很高的科学性，从表现形式上来看，也落后于社会许多先导性行业的服务，更未达到满足患者与社会的医疗保障需求。

医院院长应当高度重视医院的医疗服务属性，医院的服务改进与管理创新，完全是投入较少、成本较小、周期较短、效果明显的一种医院管理活动，同时对于任何一家医院而言，都可以称之为医院管理无止境，医院服务也是无止境的。

医院的服务必须是一个动态性的、持续改善的、流程再造式的永续创新式的过程。医院的服务改善是医院管理的战略性命题，是一门深奥的医院管理应用领域，在这个领域中，医院院长、医院管理者和每一个医护人员都有很大的创造与创新劳动的空间。

从医院院长和医院管理者的角度来看，医院的服务应当是从医院的员工教育与医院服务宗旨的确立为起点，每时每刻提醒和教育全体医务人员都要以尊重患者、爱护患者、尊重生命的理念来从事医疗服务这一神圣的职业劳动。

案例：梅奥——患者需求至上

一位梅奥员工，他从梅奥的分部飞往位于明尼苏达州的本部，他抵达了芝加哥之后，由于暴风雨很多航班被取消和延误，他和很多人聚集在登机口前。他听到好几个人在窃窃私语，其中有一个人这样说，明天早上我在梅奥有一个预约，第二个人说，明天早上我也在梅奥有一个体检，时间是早上的十点半，那么，还有一个人他说因为我有一个抽血的检查，所以我现在已经开始没有吃任何东西了。这些人都是为了一个同样的目标，他们都要去梅奥。但是他们被告知的信息是下一个航班是凌晨四点，也就是说，他们飞到明尼苏达州的时候，肯定是会错过在梅奥的预约。

这样一位梅奥的员工就站起来向大家说，我在梅奥工作，我会帮助你们的。他知道如果当时要从这个地方开车到罗切斯特去是不可能的，因为暴风雪已经阻碍了人们的通行，于是就打电话给航空公司，问有没有到另外一个地方的机票，因为从那个地方开车到罗切斯特更快更方便。他所得到的答复是可以，去那个地方的航班是有空位的，他挂了电话以后，就对这些即将成为梅奥患者的人说：让我们一起去这个地方，我保证可以把你们开车送到罗切斯特小镇，经过一番短暂的协调以后，所有人都坐上了那趟航班。

他们一行就在凌晨的时候坐上了这趟航班，抵达小镇的时间已经一点了，他在当地租了一辆小车，开车把他们送到梅奥所在的罗切斯特小镇，在车上他们互相分享着自己的生活，家庭经历，也分享着他们在医学上所遇到的困难。这四位患者都是来自美国的东部，他们来自亚历山大、费城，他们所看的科室也不同，他们到达当地已经是早上的四点半了，每一个人在和他告别的时候，都热情地拥抱了他，并且说：我们永远不会忘记您。

从这个故事里传递出来的文化信息是什么呢？这样一名梅奥的员工，刚刚结束了自己的出差，他本可以在那个晚上走进芝加哥的希尔顿大酒店美美地睡上一晚，对他来说，明天工作不工作是没关系的，但是他自愿站出来为那四位患者承担责任，帮助他们。

希望大家也能努力地思考这样一个问题，为什么这位梅奥员工会这样做？如果是你，你会为走到你们医院的每一位患者做同样的事吗，或者说你们单位的其他员工也会这样做吗？那么你们机构的文化理念是什么？可以说梅奥所关注的和所高兴看到的就代表了梅奥的文化，他是梅奥医院的基础。

医院服务创新探索

探索之一：推行优质服务 “五个一”

“一医一患一诊室”充分尊重患者隐私权。2004年我院在全省率先推出该项举措，即在原有空间条件受限的情况下，对门诊各诊室进行一个医生、一个患者、一个诊室的集中整治，为医患之间创造了一个独立的诊疗空间。

“一个窗口发药”优化就诊流程——对门诊药房采取了 “窗口大一点、高度降一点、距离近一点、流程简一点、速度快一点”的改造，在全市率先采用柜台式发药模式。使从前的排长队 “人等药”变成了如今的 “药等人”，据统计该举措实行以来，患者取药时间平均缩短了20分钟。

“一站式服务中心”提供 “管家”式贴心服务。针对 “便捷、高效”两大主题，2009年医院在门诊开设了包括集中预约、分诊导医、便民措施、药物咨询、审批报销、方便门诊、投诉处理等服务功能，平均每年为10万多名患者提供服务，真正做到减少患者往返。

“168后勤服务一条专线”解决患者后顾之忧。对全院后勤服务功能进行整合，开设院内 “168”服务热线，只需一个电话，为住院患者提供所有生活、设施保障，检查陪送服务及营养饮食供应。我们承诺：凡住院患者错过就餐时间，拨打 “168”热线后，20分钟内热腾腾的伙食就会送达患者床头。

“一条红腕带”开辟生命急救绿色通道。2007年6月，我院推行急诊患者腕带识别系统，对危重患者系上红腕带标识，实行红腕带患者优先就诊、优先检查、优先治疗；并设立急救免费专线电话，提前做好院前急救准备，为患者诊治赢取宝贵的时间；危重患者实行床边入院手续办理制；畅通急诊抢救通道，实行入院、检查、手术一条龙服务。

探索之二：多中心制门诊服务的探索

在传统的门诊诊疗模式中，医院已习惯于按内科、外科、妇科、儿科等一级专科的分科模式开设门诊，后逐步实施二级专科和三级专病门诊，这种门诊的设置是从医疗诊治的角度来设立的，往往患者感觉就诊不方便。

“中心化”诊疗模式实践步骤：

一是建立 “中心”服务平台。我们以大型医院的门诊患者疾病谱及实际需求为研究对象，针对需要2个以上相关专科提供诊疗服务的人群，以病种为单位，结合医院优势学科特色，率先推出了脑科联合门诊、胸痛冠心病联合门诊等八个中心化门诊，实现了从单科门诊模式向多科联合门诊模式转变。每个诊疗中心的医务人员由院部指定的相应专科的副高以上人员组成。多科医师对同一患者进行联合诊疗，多科沟通提出最佳诊疗方案。

二是选择 “中心”诊疗适应证。合理选择 “中心”诊疗的适应证，我们规定一是在同一专科就诊3次以上，或在多个专科就诊仍未明确诊断或诊疗效果不佳的患者；二是在就诊时，同时合并多系统疾病，需要多个专科协同会诊的患者；三是外地患者在当地就诊诊疗效果不佳，需要请专家会诊的患者；四是对以往诊疗效果不满意的患者。

三是制定 “中心”运行制度。我们在制定诊疗中心的相关医疗工作制度和服务制度的基础上，同时规定疑难病例的可预约诊疗，由患者通过电话或现场向工作人员说明基本病情，工作人员根据患者病情确定需要参与诊疗的专家及诊疗日期，提醒患者就诊时需要携带的医学资料，如病历、检验报告单及影像学资料等。对于一些年龄较大、病情较急的患者，医院开通检查、治疗绿色通道，必要时由工作人员陪同检查、陪同治疗。

四是宣传 “中心”诊疗程序。“中心化诊疗”实施后，为了让广大患者知晓我院这一服务举措，医院在各门诊、急诊室、病房都向患者做了宣传和发放告知材料，在报刊和电视台都作了宣传，让患者可以 “有备而来”。

“中心化”门诊服务流程再造就是利用流程再造的理论和方法对原有门诊服务流程进行根本性的再思考和彻底性的再设计，从而获得诸如质量、成本、服务、速度等方面的进一步改善，最大限度地满足患者的需求，强化科有特色、人有专长，最终使患者受益。

医疗中心化设置的目的，在于系统完成人员整合、技术整合、设备整合和患者资源整合。将具有同一系统疾病专业的医生整合在一个中心范围内，实现医疗人力资源的整合，和疾病不同治疗方法整合，以体现 “以人为本、以患者为主体”的医学医疗新方式。

“中心化诊疗”推出后，得到了广大病患的接受和欢迎，此举措获得了2011～2012年度无锡市卫生系统服务创新奖。

探索之三：脑科 “中心化”发展的新模式

2008年起，医院在实施重点发展专科战略思想的指导下，以神经外科、神经内科为主体，联合神经放射、病理、检验、康复等专科成立了无锡市首个脑科中心，自此脑科中心走上了发展的快车道。

脑科中心的五个 “联合”工作机制——脑科中心正式成立以来，坚持 “以患者为中心”，以提高医疗技术水平和服务质量为宗旨，大力开展科技创新、管理创新，本着突出特色和注重实效的原则，实施精细化管理，建立了神经内外科以及相关影像、病理、康复的五个 “联合”工作机制：一是单病种疾病的联合规范化诊治，如：脑卒中的多学科合作、规范化诊治；二是建立了联合查房制度，脑神经专科开展了每月2次的神经内外科联合查房，中心主任和神经内外科等医师共同对患者进行查房，大大丰富了三级查房的内涵；三是开设了脑病联合会诊中心。我们开设了每周三下午的脑病联合会诊中心，聚集了神经内外科、神经放射影像、神经内分泌、神经眼科等专科的副主任医师以上的专家，共同对患者进行会诊，对患者的诊断、鉴别诊断以及进一步的治疗措施大家共同商讨，从而制订患者的诊疗最佳方案；四是开展了每周1次的联合脑科学术周会（Neuroscience Meeting/Friday Lunch Meeting）。每周五的中午进行了脑科学术周会，神经内外科、神经放射、神经病理、检验等科室人员参加。开展从病史到辅助检查、治疗、手术结果、病理结果等的病例讨论，以及外来学者、本院医师特别是年轻骨干医师等做专题报告；五是开设了脑科联合急诊。我们自2009年起在急诊室增加了脑科急诊。将神经内外科的急诊进行调整与合并，成立了脑科急诊。脑病患者统一在脑科急诊就诊，方便了患者，也提高了脑病的抢救成功率。

脑科中心近年来成熟开展一系列 “品牌手术”，脑血管病规范化诊疗、防治卒中单元管理、缺血性脑血管病超早期溶栓治疗等诊疗技术也走在国内前列。目前该中心实现年门急诊量5000余人次、抢救危重患者3000余人次，抢救成功率达90%以上。脑科中心大力开展国家级、省级新技术新项目，近年来共获得3项国家自然科学基金的资助，打开科研新局面，科研立项及论文发表逐年上升。2011年获评江苏省医学 “创新团队”及 “领军人才”，并成为国家卫生计生委脑卒中筛查与防治基地。

探索之四：搭建预约化中心平台

过去，医院的门诊、检查都是各科室自行预约和安排的，因此，常有患者反映很不方便。因此，在注重门诊诊疗服务流程再造与改进的同时，注意提升医院检查部门的工作效能和缩短预约时间，也是一项具有极其重要意义的医院医疗服务创新。

医院要搭建全院性的预约诊疗中心、预约检查中心。一方面需要有信息化的支撑与平台。另一方面也需要将医院各项检查、科室的管理纳入统一的门诊部协调管理的范畴之中。统一为患者提供CT、MRI、胃镜、肠镜、B超、特殊检验等预约服务。这样可以实现患者的诊疗活动快捷有效。

医院集中预约平台的特点——医院实行集中预约平台，是未来医院发展的方向，也是便民、利民、节约人力物力财力的一种好的办法。这种好处也是显而易见的：一是方便了患者。患者不必再为了检查东找西找科室，也不必为了检查东凑时间西凑时间，只需到统一的一个地方，集中预约，统一安排一个合适的检查时间，只需按时来检查即可；二是统一管理。集中预约后，医院管理也变得井井有序，各个功能检查科室门前，少了熙熙攘攘的人群，少了因插队引起的口角。患者按时按序进行检查，同时因人多手杂引起的丢失事件也大为减少；三是便于统筹。进行集中预约检查后，检查的效率明显提升，一方面得益于医务人员积极性的提升，另一方面也因科学合理的检查安排，使得医务人员的工作节奏更加紧凑，工作安排更加有序。

预约平台的构建是医院服务创新一定阶段的必然发展路径，虽然需要克服的困难不少、需要协调解决的问题不少，但是对于患者和医院管理的意义更重要，所以预约平台的搭建是医院服务创新的重要内容。

探索之五：医院自助挂号体系的形成

自2004年，我院即进行了预约挂号的积极尝试，医院专门成立了预约工作小组，由门诊部、信息科、护理部等部门负责，制订了预约工作方案，设立专人负责预约工作；建立了基于HIS的预约平台，预约的方式包括电话、网络、现场，在内容上也不断增加，由专家门诊、普通门诊的预约增加到中心化门诊、夜间专家门诊的预约，而高级专家疑难病例会诊中心的患者则全部通过预约而来。

医院与崇安区各社区卫生服务中心建立合作关系后，医院又增设了社区预约，社区患者可直接到所在社区卫生服务中心预约我院门诊，2011年以来通过社区预约的患者达9000余人次，被称为 “身边的三甲医院”。我院还与号码百事通建立合作关系，并以此为平台扩大我院的预约人群。

在对口支援基础上，2014年12月份，我们选择了江海社区进行半紧密型医联体试点工作，通过多措并举将三级医院的服务延伸到社区，每日安排专科医生到社区开展门诊，并在社区设立病房进行收治。此外，还安排一名副主任到该社区优势专科担任该专科副主任，帮助该专科更好发展。

推行 “24小时预约挂号”服务，在门诊安放24台自助服务机，提供24小时自助挂号和收费服务，可预挂7天内各类专家门诊和普通门诊号，支持银联卡支付。同时，与工商银行合作，推出 “先诊疗后付费”服务，有效缩短患者等候时间。目前日均有300余人次通过自助服务机进行挂号、交费或预授权，门诊预约就诊率达到95%以上。我院还向自费患者发放带有电子钱包功能的 “普仁卡”，自费患者将通过 “普仁卡”或 “银联卡”就诊，医保患者将通过 “医保卡”就诊，这也是我院即将推出 “先诊疗后结算服务”的第一步。

此外，医院还在门诊、急诊人流量较大的场所安置了自助饮料机、自动售报机，使患者在看病之余，轻松实现各种便捷化服务。

探索之六：腔镜中心 “工作室点名制”

过去，我们医院胃镜室还是那么多医生、那么多胃镜，由于绩效考核方法还是趋向于 “大锅饭”式，与多劳与优劳的挂钩体现不明显。以至于因为需空腹准备，大家上班每天只上午做胃镜，每天只做30～40个，肠镜也只每周预约一二个下午，每次只预约5～10个。所以，胃肠镜检查在许多医院都成为看病难、等候长、预约慢的瓶颈。如：前一阶段，我们无锡市许多医院曾经胃镜预约超过二周以上、肠镜预约超过一个月以上。

面对这样的医疗窘境，我参照了专家点名门诊的方式，实行五位正、副主任医师工作室制、挂牌上岗、点名诊疗、工效挂钩、每日实行一个专家点名、其他专家做普通检查的方式进行。大大调动了医者们的积极性，他们以更优质的医疗服务对待患者、珍惜每个患者的选择与评价。现在，他们一天的工作量已经超过了100多台胃镜量，增长100%以上。胃镜已基本取消了预约。

探索之七：“八项服务承诺”治理服务顽疾

在全院开展 “治顽症，提服务”活动，重点对群众反映最强烈的、最不满意的热点问题进行专项研究，总结归纳出当前较为突出和亟须整改的八大 “顽症”，向社会、向员工作出公开承诺。

公立医院的改革任务主要有两类，一类是涉及公立医院体制方面的改革。这类改革是根本性的改革，需要顶层设计。院长往往很难改变。另一类是涉及医院内部运行系统的改革。这类改革是院长可以主导的，往往收效也是短平快的。

因此，我们呼吁医院的院长和医院管理者要重视医院管理体制的改革，更要重视和参与并主导医院运行机制的改革。

医院实行机关事业部制改革是这方面一个有力的着手点和突破点。医院机关现行体制的瓶颈——一是多头管理。医院部门之间职能交叉，工作中各职能部门在工作指标考核和管理上会出现管理重叠、多头下达指标现象，机关效能和威信下降；二是协调困难。各职能部门是平级的，在涉及多个部门的工作协调上，会存在协调困难、互相推诿的情况；三是效能低下。因涉及职能部门多，办理各项审批手续繁杂，导致机关服务办事效率和满意度低下。

为建立科学高效协调的公立医院内部管理机制，探索现代医院管理制度，2010年，在坚持部门内设科室总数不变的前提下，我们按照事业部制要求，将医院原有20多个职能部门和临时机构整合重组为7个部，实行部主任负责制，对外履行原职能部门管理责任，将原有人员和部门实行职能归并。对内实行统一管理，人员统一调配，富余人员充实临床一线，精简高效。

部门设置形式：

建立医疗发展部（含医务处、科教科、教学办、GCP、信息科、医患沟通办公室），负责全院医疗质量、教学科研、医患沟通及信息管理。

建立护理部（含护理部、医院感染管理科、客户服务中心等），负责全院护理管理工作，加强院感管理，完善客户服务系统。

建立综合部（含院办、人事科、监察科、图书馆、车队、总机班等），负责医院日常行政事务、人力资源管理以及机关日常事务管理。

建立党群工作部（含党办、宣传科、工会、团委、纪委等），负责医院日常党务工作，做好群团组织工作，党风廉政管理工作。

建立资产财务部（含财务科、考核办、医保办、审计科等），负责医院经济管理、医保管理、绩效管理、审计管理工作等。

建立保障部，增挂采购中心（含总务科、设备科、基建办、保卫科、三产办和药品采购工作等），负责全院后勤保障系统的管理，基本建设的管理，安全保卫的管理，三产的管理，以及药品采购、设备采购、耗材采购、后勤物资采购等工作。

建立门诊部（含门诊部、预防保健科、体检中心等），负责门急诊部的日常管理，预防保健工作管理，职工医疗工作，体检工作等。

管理方式——由部主任统一协调、统一管理，并直接对院领导班子负责。部内原职能科室对外仍履行先前管理责任，相关负责人仍保持原有职级不变，并负责做好本业务范畴和条线内相关工作，在此基础上，按照部主任统一领导，协同做好部内工作。

人员设置——各部设部长1名，副部长1～2名，原科长助理作为部委员充实到部门管理团队。对外履行原职能部门管理责任，做好沟通汇报工作。对内实行统一管理、统一调配。

协调沟通——各大部在整合的基础上，依据科内人员情况合理分工，制定各部的职责和分工，实施方案和具体工作计划。对半年试行情况总结反馈，对事业部制改革存在的问题进行协调和整改，对部分人员进行调整，探索出适合医院发展的医院管理方式。

医院事业部制改革从真正意义上实现了 “机构更简、关系更顺、年龄更优、素质更强、效率更高”五个突破，创新医院的内部管理架构，真正做到了 “职能到位、职责到位”，降低了管理重心，缩短了管理跨度，规范了管理权责，提高了管理效能，更有效地解决了当前医院部门间因职能交叉或多头管理造成的协调困难、效率不高、执行力不强等现象。

建立新型诊疗组的医疗模式。我国医院一直以来实行的是三级医师负责制，在临床科室的整个医疗活动中，逐级负责，逐级请示。这种体系表面上顺应了医疗体系，较好地体现了医疗责任、医疗管理。但是它却存在着根本的弊端。

这种弊病主要体现在：主任医生并不每天查房，难以起到对于科室的整体掌控。同时，患者在三级医疗体系中，难以选择到自己心仪的医生，而一般是采用按病种被安排到各个病区就医。

在这种模式下，医生没有积极性、竞争性，更没有患者的选择性，医院的绩效也难与医生的医疗服务相挂钩，很容易出现 “干好干坏、干多干少都是一个样”的现象，也容易存在 “不管你医疗水平如何，一样当主任”的现象。

2000年以来，国内掀起了一股主诊医师负责制的改革热潮，但由于主诊医师负责制在医院实施中会遇到一些困难和障碍，目前在我国尚没有得到卫生行政部门的正式认可和普遍推广。

主诊医师负责制是国外医院管理中普遍运用并取得成功的医疗管理模式，在国外被称为 “Attending”负责制，是由一名Attending，一名Fellow和一名以上Resident组成的一个医疗小组，主诊医师率领该医疗小组全权负责实施患者门诊、住院、手术、会诊、出院后随访等一系列医疗活动。

从2004年8月开始，我们在脑外科、消化内科、胸外科等科室进行主诊医师负责制试点，2009年在全院范围内进行科主任领导下的主诊医师负责制改革。

我们医院倡导的 “科主任领导下的主诊医师负责制”，赋予主诊组一定的医疗权和自主权，同时还要保证科主任能够统筹协调整个科室，强调科主任协调作用的关键性。

主诊医师负责制是由一个主诊医师带领若干名主治或住院医师组成一个诊疗小组，全面负责并实施患者的接诊、住院、诊疗操作（包括手术等）及出院随访等工作的一种医疗管理模式，其根本目标就是充分调动科主任、主诊医师、年轻医务人员三方的积极性，实现患者选医生，主诊医生对患者实施全程负责。

主诊组的设置——根据各科室、病区的床位数及医生人数来设置主诊组。主诊组原则上 “因岗设人、以岗定责”，每个病区40～50张床位，设置2～3个主诊组，各医疗组的组合通常采取双向选择。允许 “高职低配、低职高配”，可根据临床工作的需要按1∶1∶1（即1名主诊医师、1名主治医师、1名住院医师）、1∶1∶2或1∶2∶4等几种形式构成。主诊医师全面负责组内的医疗活动，拥有医疗终结权，带领主诊组完成各项诊治工作，保证连续性、及时性、完整性。疑难危重病例则要求提交全科讨论，并服从科室讨论意见，把好本组医疗质量关、安全关。主诊医师还要担负起对下级医生的培养、研究生指导等教学科研工作。

主诊医师的资格与遴选——主诊医师一般由从事临床工作一定年限的副主任医师以上职称人员担任，若科室高职人员不足则可视情况由表现突出的高年资主治医师担任，具有丰富的临床理论和实践经验，科研教学能力突出，并具有一定的管理水平。主诊医师实行竞聘上岗，通常经过本人申请、科主任提名、专家组和医院职能部门的综合权重考核，经院学术委员会讨论后产生，一般聘期为1～2年。此外主诊医师不搞 “终身制”，实行动态管理，对不能胜任主诊医师的随时进行调整，医院按照每年绩效考评结果，对排名靠后者进行滚动进出式的重新遴选。根据科室人员结构也可设立后备主诊医师或副主诊医师和自由主诊医师（部分精力充沛的老专家）。

双向选择——主诊医师确定后，与下级医师经双向选择组成诊疗小组，即主诊医师选择下级医师，下级医师选择主诊医师。每位下级医师只能选择一名主诊医师，主诊医师可根据科室人员情况，选择3～4名下级医师。在双向选择过程中，如果没有下级医生选择主诊医师，则该主诊医师资格则被取消；如果下级医师没有被任何一名主诊医师选择，则该医师可能被调至其他工作岗位。

实施过程的管控——我院采取有效措施加强对主诊医师负责制改革工作的督查和管控。一是举行全院性的观摩，组织全院科主任、主诊医师对推行较好的科室进行观摩，将好的经验进行交流、推广；二是开展主诊医师、主管医师及住院医师查房质量三级检查评讲，邀请科主任对主诊医师查房进行观摩并进行讲评，同样由医务处组织对主管医师和住院医师查房进行观摩和讲评；三是完善督导制度，定期了解主诊医师负责制的施行情况，及时对施行过程中存在的问题进行处理，如对主诊组设置进行调整，处理科主任与主诊医师关系等。

主诊组的考核与分配——主诊医师负责制的实质内容是医院的管理会计核算体系发生了根本性的变化，即利益分配的路径发生了变化，划小了核算单位。我院主诊医师负责制考核以主诊组为单元，采用小组成本核算，而各主诊组绩效由医院统一考核，考核的指标主要包括出院患者数、手术科室手术量、完成床日数、平均住院天数、药占比、人均费用、有效收入、四级手术率、危重患者比例。

实行主诊医师负责制后，引入了竞争激励机制，充分调动了医务人员积极性，工作效率大幅提升，门急诊人次、出院人次、床位使用率等均有明显提高。

主诊医师负责制改革促使主诊医师和各诊疗组高度重视医疗质量，大大提高了四级手术率、疑难危重患者比例、甲级病案率和抢救成功率等医疗质量和技术关键指标，保障了医疗质量和安全，促进了技术进步和创新。

主诊医师负责制充分尊重患者的选择权、知情权，满足了患者选医生的需求，体现了“以患者为中心”的理念，有效缩短了平均住院天数，降低了人均费用，大大提高了患者满意度。

新型护理责任组的改革。2012年，我们借鉴了主诊医生负责制的方法，创造性地开展了新型护理责任组的模式—— “全程精细化（优质）护理责任组”的改革。

这个新模式和原优质护理责任组有着显著的区别：区别之一是对责任组长的专科选拔要求更为严苛，工作标准要更为提高；区别之二是不仅仅进行单纯的分组，而是配合护士岗位设置、人力资源调配、考评模式、分配制度等一系列系统性的工作一起开展。

新型护理责任组的五个特点

特点一：科学建组。医院根据各科室实际开放床位及床位使用情况设置责任组及责任组长数量。经个人申报、科室推荐、资格审核、公示答辩、院长办公会讨论、双向选择等程序，确定了70个护理责任组。当病区内符合责任组长遴选条件人数大于计划的设置人数时，科内进行择优双选，择优双选后落选人员如本人不服从在全院范围内进行调整的则自动丧失责任组长资格。

特点二：完善能级对应，分级管理。我们医院以护理责任组模式为前提，制定能级护士新标准，对全院护士进行了重新分级按N1～N4级的能级对应原则重新完善分级，新的护士分级与精细化护理责任组模式密切结合，并注意N1～N4级护士结构搭配合理。不同层级护士分管不同病情的患者，体现职责能力、落实护理责任。

特点三：建立适应全程精细化护理责任组模式的护理流程。在人力调配上结合医院和科室实际，原则性与灵活性相结合，打破一刀切，实行差别化的人力比，如根据工作需要，建立了准时制（Just In Time）应急护理人力资源调配系统；对康复、特需病房实行“12小时班”；神经内科病房实行 “一月连续夜班”制；急诊、重症病房实行 “责任组8小时连续负责制”；眼科病房推行 “APN班”等，把排班真正 “弹”起来。

特点四：完善考核，优胜劣汰。首先完善对护士的考核，医院以建立护士岗位管理制度为核心，推进医院人事制度改革，坚持按需设岗、按岗聘用、竞聘上岗。护理部建立了与之相适应的考核办法，对新遴选的责任组长耐心指导，每半年进行滚动管理。对排名位于前六位的护理组和责任组长予以表彰和重奖，对于排名靠后工作能力差和工作积极性不高的责任组长予以告诫乃至取消资格。其次完善了护理组工作质量的考评体系。制定了包括工作量指标、质量指标、满意度、学习与创新四个维度的考核细则及各级满意度测评表、工作量统计表、护理组专科护理质量考核表。建立了护理组三级督查SOP，完善了护理二班督导岗，增设了每天 “护理主任代表值班制”和 “服务巡查员每日督查制”，对发现的问题随时进行指导。

特点五：改革护士收入分配制度。医院根据实际表现和工作业绩，建立科学的绩效考核和分配体系。护理部实行独立绩效考核，以 “高风险、高强度、高质量、高收入”为原则。在绩效分配上，与科室的护理工作量、岗位风险、护理质量（护理服务满意度）和护士能级挂钩，向临床一线倾斜、提高夜班津贴，逐步提高护士收入。2013年，我们对此项改革又进行了深化，实行了与医疗主诊组相结合的新的护理责任组模式。新的护理责任组模式确定后，我们又再次修订了对各护理组的工作评价，从以往对科室考核细化到对每个护理组的考核细化，通过工作量、医疗质量、成本效益、满意度等20多项指标进行综合评价、考核。

如果把前面所提到的医疗质量、技术服务、医院管理、人力资源等视作医院精益管理链上的几个链接点，那么文化无疑就又是节点、又是那条链子，通过营造一种全员自主改善的医院文化，所有精细化管理的理念和工具才能发挥作用。

在医院精益管理链中，文化既可以是其中的一个节点，又可以是整个链条，贯穿全部。优秀的医院文化是实现精益管理的必要条件，也是提高精细化管理制度执行力的保证。

医院管理在任何时候都必须遵循 “文化在先，行为在后”的客观规律。很难想象在粗放、浮躁、散漫的医院文化氛围中，去运行一条精细、协同、高效的医院管理链。

医院文化管理可以说是院长的管理锦囊。中国的医院管理理论体系的研究与发展中，医院文化建设则是一个短腿。在中国的公立医院改革与实践中，医院文化建设则更处于一种自生、自发、自流的状态。医院的文化建设，事实上很重要。它是医院管理的灵魂、空气、土壤、环境与氛围。是医院任何管理的基础与根基。医院文化建设是医院物质文明与精神文明建设的总和。它包含了医院的管理哲学，医院的价值观，医院的规范与行为准则，医院的团队建设，医院的文化活动等。

国外许多先进的国家、地区及医院，现在已经开始重视医院文化建设。在美国的梅奥诊所，他们推行的是一种团队学习的文化，要求员工终身学习。在瑞典的卡罗琳斯卡医院，他们倡导的是一种创新文化，鼓励员工打破围墙，发展转化医学。

在香港的那打素医院，他们奉行的是一种素养文化，从提高素质、管理风险、对策指引等途径入手，提高全员队伍的素质。在新加坡的莱佛士医院，他们崇尚的是一种服务文化，他们向新加坡顶级服务明星的新加坡航空公司、新加坡莱佛士酒店学习服务，使医院的医疗服务更优质。

医院的文化建设要形成一种特色，一种品牌，一种卓越。这需要院长与医院领导者们的不断学习与创新思维。也需要医院精英们、业务技术骨干们的锦上添花与率先垂范。更需要医院全体员工的广泛认同、共同推进、全面实施。这是医院文化建设的三个层次与三个步骤。医院文化的管理作用是重要的。它可以让医院领导者的行政命令依托一种文化力量来引导员工自觉遵循，最终变成高效的执行力。同时它也能变成无形的 “紧箍咒”，约束少数落后员工的不规范、不守纪的错误行为。

医院文化管理不受时间、空间和区域的限制，它可以表现为个体的、群体的、散在的、广泛的等多种形式，存在于医院发展的各个时段、各道环节和各种场合。

探医院文化具有重要的管理作用

一是导向作用。医院文化积淀和创新所形成的医院管理哲学、医院人文精神等都具有极强的导向性与引领性。院长动机、领导意图如果通过文化的作用转变为医院的战略目标、管理愿景，就更加容易得到广大职工的认同和奋斗。

二是凝聚作用。文化最重要的作用方式就是保持较强的凝聚作用。医院管理有起伏、有危机、有创新，但更多的还是一种常态管理，要使医院这个特殊的团队保持一种良好的管理态势，最重要、最有效的管理方法就是通过医院文化的力量将全体员工团结在一起，形成 “院荣我荣，院衰我耻”的境界。

三是熏陶作用。医院文化是一种活动，更是一种氛围，一种环境。工作在其中的人多多少少都会打上它的烙印。我们经常会说一个医院走出来的人，往往会有同一种或相近的饱含这家医院色彩的素质和行为品质。院长和医院管理者要重视医院文化的熏陶作用机制，有许多时候，氛围和团队的群体要求都会是一种无声的命令、无声的行为规范。

四是协调作用。医院管理的组织系统中，协调是非常重要的功能。医院科室、医院员工之中有高、低、快、慢、大、小之分，因此，在我们的医院管理工作中就更加需要相互之间的配合、协调与调适。管理中各个组织与成员的协调共事，文化是具有重要的协调作用的。医院文化建设的水平具有强化与弱化、扩大与缩小医院行政命令的效应。

五是认同作用。医院文化建设的目的就是要使自己的组织和成员更多地产生认同作用，表现为接受医院行政管理的决定与措施、参与并发挥积极作用。院长的管理在团队成员中具有认同作用就是推动力，具有怀疑或反对作用就是阻力。认同能产生激昂奋进的精神，认同也能产生自觉遵循的要求。

六是竞争作用。医院文化建设所产生的竞争作用，主要表现为：一是群体上的创新性和先进性上要与兄弟单位争第一，不落后，这是非常可贵的集体荣誉感；二是个体上的不落后性，力争各方面表现优良，多获表扬与激励，这是非常可贵的积极性。

七是约束作用。医院文化建设在医院管理中会形成一个看不见的手，约束着各个部门、成员的行为与作用。形成了医院中的一种微观的社会心理环境。医院文化的约束功能主要针对以下几种：一是不勤奋，不珍惜；二是不遵章，不守纪；三是不团结，不努力；四是不学习，不创新；五是不配合，不支持；六是不奉献，不提升。

八是升华作用。从医院管理的角度看，医院文化建设的升华作用在于：促进新知识的产生，鼓励创新；促进医院管理的规范化，鼓励员工遵循；促进团队学习，提升员工群体素质；促进员工忠诚度，形成具有合力的团队精神。

普仁文化的新内涵

每个医院都有自己的文化特质与特征，无锡市第二人民医院经过106年历史的积淀与发展，形成了具有自己鲜明特色的普仁文化。归纳一下普仁文化的内涵，主要为：精益文化、创新文化、学习文化、竞争文化、健康文化。

精益文化

我们倡导并探索实施医院精细化管理，将精益理念灌输全院员工、贯穿整个管理过程、整个医疗流程。精益带给大家一种理念，做任何事都要认真负责、追求完美。无论是学习，还是工作，讲究专注地做好每一件事、在每一个细节上精益求精、力争最佳。精益文化要求我们要有认真严谨的态度，需要我们确立勤勉踏实的作风，需要我们养成深入思考的习惯，需要我们坚定永不满足的信念，将 “精益”始终贯穿于学习、工作、生活中。

创新文化

“科技文化周”促使创新成为医院发展的主旋律。医院把提高学科建设水平、加大技术创新、重视人才培养作为医院工作的重中之重，把科技创新大会作为医院每年年初必开的重要工作会议。

医院每年3月，在院庆期间都要隆重举行 “科技文化周”活动，这样的活动已经持续多年。在院庆科技文化周活动中，医院要开展形式多样、丰富多彩的系列活动，如一场高水平的学术报告会：邀请国内院士或者著名的专家学者来院授课；一场院庆升旗仪式，凝聚全院职工的爱院热情；举办一场 “学科建设与技术创新大会”等。近年来，医院学科建设取得长足进步。

“金点子”活动点燃创新火花。2005年起，医院开始每年组织 “金点子”活动，针对医院发展规划、医院重点工作以及工作中遇到的瓶颈、急需解决的问题等情况都拿出来和大家一起讨论，一年一个讨论主题，群策群力，集思广益。这样的活动一方面能充分调动全院职工的积极性，另一方面这样的 “头脑风暴法”，可以使医院发展中的很多问题就在这一个个小点子中迎刃而解！

学习文化

“早、晚读课”。2004年7月起，我们针对中高级职称人员和初级职称人员分别开设了每月一次的 “早晚读课”，利用早晨上班之前一小时或下午下班后一小时的时间进行继续医学教育，即 “早读课”和 “晚读课”。迄今共开展早读课185场次，累计57972人次；晚读课98场次，累计17339人次，先后邀请了国内知名院长、学者来院授课，从医院管理、科研攻关、前沿技术、设备使用等多方面进行介绍，加快了医务人员的知识更新步伐。

新职工学习。2009年11月起，新职办每周利用晚自习安排不同的课程2～3次，主要内容为思想品质、“三基”理论学习和专业技能讲座，重点临床理论、临床实践、临床操作技能、病历书写质量等。学习中将理论和实践相结合，书本学习和临床实际工作相结合，安排夜急诊手术观摩，并结合学习中的薄弱环节加强教育，取得了很好的反响和实效！自2009年11月份新职办成立以来，截至2014年3月合计集中晚自修514场次，夜急诊观摩594场次，安排主题活动（医护分开）32场，各类讲座144场次，出勤率均在95%以上。

员工征文活动让院长了解员工的心声。员工怎样释放个性？如何培养会思考的员工？这看似许多复杂的问题，实际上只需要一个简单的方法就可以实现——员工征文。针对覆盖全院的重大事件、具有特殊意义的重要时刻，或者看似微不足道的 “小事”，我们常常给职工出 “命题作文”，不限体裁和风格，诗歌、散文、记叙、甚至微小说都行，只要把他们对于命题的所思、所感都表达出来。院长通过开展员工征文活动，好比找到医院文化建设的风向标，知道如何塑造更接地气的医院文化。因为没有人比员工更了解自己医院的文化了，没有一种文化可以脱离员工的行为而存在。

竞争文化

乒乓引领竞争意识。2011年我们医院的普仁乒乓球俱乐部从夺得第一个冠军开始，普仁号角正式吹响，乒乓球这个小球，始终伴随着无锡市第二人民医院日渐强壮的脉搏活跃地跳动着。俱乐部虽然成立时间不长，但发展势如破竹，锐不可挡。通过比赛，极大地丰富了职工的业余文化生活，增进了彼此的友谊，提升了团队凝聚力，激发了广大职工对体育运动的兴趣，提高了身体素质，充分展现了第二人民医院人奋发向上、朝气蓬勃的良好精神风貌。

健康文化

全员开展每天学习半小时，运动半小时。2013年下半年，我们在医院开展了 “每天学习半小时、运动半小时”的健康行活动。每天学习半小时，就是要求大家坚持学习、团队学习、专业学习。医院要求科室每月都要组织和承办学术讲座、医学新进展介绍、病例讨论及主题沙龙等业务学习活动。每月遴选面向全院的开放性讲座，每周二、三中午一小时。迄今为止，共组织全院性的开放性讲座24次，参加人员6000多人次。

每天运动半小时，就是要求大家立足岗位、坚持锻炼、坚持运动，倡导多种形式的体育锻炼活动。医院转化医学平台也定期开展面向临床的一小时专题短训班。医院坚持组织好早读课、晚读课、季读课。工会组织大家骑自行车、蠡湖徒步走、打篮球、踢足球，举办各种形式的乒乓球、羽毛球比赛，让每一天都充实快乐，活动得到了全院员工的积极响应。

构建医院精益管理链的思索

一是从医院的核心工作——医疗质量效果品管圈提升。

二是要从人才队伍建设与学科建设两大重要内涵上深化与提升。

三是要打造适合医院特点的精益化绩效与薪酬奖惩体系。

四是要从效率、效益、效能三方面追求与提升医院服务。

五是要积极探索公立医院运行机制改革创新模式。

六是要蔚成医院团队精益求精的学习文化。

精细化管理的精益供应链理论与协同论理论对于提高医院的精细化管理水平具有重要作用。它们应当成为我们推进医院科学管理的重要抓手和科学方法。

构建医院精益管理链，各医院可以从各自的实践出发，结合不同阶段的医院管理任务，选择自己认为最为重要的几个要素，凝练成为医院精益管理的核心链条，通过PDCA的循环和医院精益管理的三角形工具的作用机制，让这种齿状结构的链条越抓越紧，形成医院科学管理的履带效应。

构建医院精益管理链，是一个开放式议题。由于各医院院长和医院管理者的认识不同，抓的要素不同，采用的策略不同，可能会收到不一样的效果，但是它对于每个医院的科学管理是必将有助的。值得大家学习、思考、探索、再创新。

Establishing New Modal of Lean Hospitals with Asian Characteristics--Form a Hospital Lean Management Chain

I.Lean Management and Lean Management Chain

From the perspective of social development，the development of lean management is closely related to automobile industry.

Large-scale production of Ford Motor has influenced the manufacturing industry of the whole 20th century，indicating that line and standard production is an important initial stage.

Differentiation production of General Motor stimulated special needs of customers so that GM adjusted its own production and service capability，thus enteringthe intermediate stage of scientific management.

“Lean Management” of Toyota was formed based on the former two stages， and has improved many enterprises’ and managers’ understanding of management ideology.It is the latest development stage of scientific management.

From the perspective of theory， lean management includes three theoretical origins， such as F.W.Taylor's scientific management，Deming's quality management and Toyota's lean management.Taylor's scientific management theory emphasizes on establishing standards by using scientific research methods and applying them to production for better performance.Major contribution of Deming's quality management theory to lean management theory is the emphasis on process flow design in advance， system and non-system causes， manager's role of managing and helping， and staff training.

Toyota's lean management focuses on less investment， including manpower， equipment，time and space，for most value.The fundamental approach of Toyota lean management is achieving sustainable improvement and excellence of process by standardization，automation and participation of staff，thus realizing higher efficiency and speed and less waste.

The essence of Toyota's lean production system is the Toyota triangle model，which is a integrated system with staff and staff development as the core.Based on this core，three modules including technology tool，management tool and philosophical idea are developing at a balanced pace.The scientific combination of those four parts forms lean culture.

In recent years， with the rise of logistics industry， in lean management studies， a new research field emerged，namely lean supply chain theory.This theory is the application of lean production and lean management in logistics industry.As hospital administrators，we should pay attention to and learn from that.

Lean supply chain， originates from lean management， integrates all the necessary procedures from product design to sale so that suppliers can response to customers’changing needs quickly.Its core is to reduce and eliminate waste and meet the maximum needs of customers by using the minimum resources.

Lean management chain is a great solution to reduce waste， lower cost， shorten operation cycle， provide enhanced customer value and improve enterprises’ competitive advantages.

Lean supply chain， different from simple enterprise and logistics management， is a new emerging management theory.The definition of lean supply chain theory given by US supply chain management association is that plans and management of all the organizations concerned in management activities， which consist of access to resources， supply and transformation of service，and process management.

Another critical part of lean supply chain is the coordination of service partners.

Chain Mechanism

First，a chain is usually a metal ring or a series of connected links used for important mechanical transmission.

Second， a chain mainly has four varieties： ①transmission chain， used for the efficient transmission of power； ②conveyor chain， used for efficient transportation of materials； ③traction chain， mainly used for pulling and lifting； ④special chain， a special function chain installed in a mechanical device.

Thirdly， a chain composes of chain plate， chain pin and axle sleeve， the precise connection of which enables long-term and highly efficient momentum.A chain is the most efficient production tool in machinery industry.

Function of chain mechanism to the system

First is action orientation.The chain mechanism guides the operation of the whole system without influence of other external or internal factors，thus enabling its integrity and orderliness.

Second is low cost and high efficiency.The most important feature of chain systematic function is low input and high output.It is a converter that can reduce internal disorder，consumption and conflicts within the system.

Third is maintaining stability.Chain mechanism tells us that dentate connection is the most stable connection.It prevents structural unbalances and maintains internal stability within the system.

Fourth is information transmission.Information is the contacts within the organization.Information and smooth logistics are prerequisite to each other.Disorder in logistics will inevitably affect information flow in a negative way，while smooth logistics enables updated and accurate information flow.

Lean Management Chain

Lean Management Chain， abbreviated as LMC， is a new concept derived from lean supply chain.Lean management chain refers to a effective process of optimizing production and service process， reducing waste， lowering cost and forming a lean management chain that targets at customer's satisfaction.Lean management chain is based on the theory of lean supply chain and functions of chains，and becomes a unique management theory.

Lean management chain has two axial directions，which are behavior management and value management.

II.Synergistic Management Theory and Its Applications

As an important trunk of system science，management synergetics emerged in 1970s.Its founder is Professor Haken，a German physicist.

According to Haken's opinion，the so-called synergy refers to the coordinated and cooperative action of sub-systems of the whole system.

Synergy is an internal manifestation of system integrity and relevance generated by interaction within the organization.It will generate synergic effect，which is an overall effect different from the simple sum of the parts.

Haken put forward many imports concepts such as order parameter， super order parameter，fast dynamic， and slow dynamic， laying a solid foundation for the research of synergetics.

Synergies are prevalent in the world.Some have not been recognized and some have already been recognized， such as political synergy， military synergy， cultural synergy and scientific synergy.Even though they occur in different fields of different forms，they have internal regularities.

Management synergy， as one important form， is in relation to management effectiveness from the perspective of systematic organization.

The definition of economics， put forward by famous American economist Mr.Ansoff， refers to the condition that when the enterprise's parts interact to produce a joint value that may be greater than the sum of the parts acting alone.In other words， with a certain amount of investment， an enterprise with a complete product line usually has higher sales revenue or lower operational cost in regards of a particular product than a company that only produces one product.That explains why an integrated value is higher than the sum of parts.

Ansoff's concept includes complementary effect and synergetic effect：the former refers to“self-organization”， namely to save costs and increase revenue through overall operation； the latter refers to a “free ride”.

Self-organization is a process where some form of overall order or coordination arises out of the local interactions between smaller component parts of an initially disordered system.The process of self-organization can be spontaneous，and it is not necessarily controlled by any auxiliary agent outside of the system.

“Free Ride” Effect

Andrew Campbell says in Strategic Synergy that generally synergy is “free ride”.When resources of a division with the company can be used in other divisions without increasing cost，synergetic effect occurs.

Management synergy is a theoretical system that uses ideas and approaches of synergertics to study management and implement management，and its objective is to realize management results in a more effective way.

For hospital administrators，they should use basic theories and approaches of synergetics to guide practices within the hospital so as to achieve coordinated operation of sub-systems and optimized allocation.As a result， a new and vibrant management system can be formed， which is the target of hospital management synergy.

In the study of management synergy，hospital management is a value chain.Internal resources such as human， financial， material and technology resources are allocated and used in an effective way so that self-organization ability can be produced.

Order parameter was introduced into system science by Haken.

Relevance between Management Synergy and Lean Management

According to research， the ideological core， main content and application methods of management synergy and lean management are closely related as follows：

Firstly， their objectives are same.Ideas of management synergy and lean management， applied in profit or non-profit organizations，both help realize maximum results and operational effectiveness and minimum cost.The essence of management synergy is self-organization，which means without external interference，a new orderly structure appears within the system and often helps to realize high efficiency and effectiveness.Meanwhile，lean management is featured as“fine， accurate， detailed and strict”， and its target is to improve efficiency and lower cost.

Secondly，management elements and content are similar.Management synergy emphasizes on a overall goal.Internal factors such as supply chain are integrated systematically so as to enhance operational efficiency and competitiveness.Lean management is conservation-oriented and peopleoriented by quantifying processes and functions.

Thirdly，they both focus on internal resource integration.Both management synergy and lean management emphasize on analysis and rational use of organization's internal functions.After clarifying functions and solving problems，all resources are integrated scientifically to higher effectiveness.Lean management requires classification and integration of tangible，intangible and knowledge resources for higher operational efficiency of the organization.

Fourthly，they have similar working platform.Management synergy and lean management both emphasize on working platforms within sub-systems， information network platform， service practice platform and people-oriented idea platform.

III.Formation of Hospital Lean Management Chain

While many public hospitals in China are struggling to expand，some hospitals in many developed countries around the world are harvesting the fruits of lean management.An America hospital management master have introduced to us the benefits of hospital lean management in his books，such as Management Lessons from the World's Most Advanced Service Organization and Lean Hospitals.

Mark Graban says at the end of his book Lean Hospitals that Toyota sets a good example in American industrial world in 2001，and we want to see our“Toyota” in medical field.At that time， there isn't a leading hospital in American medical field.Even till now， there is no model of lean management that we can learn from.But many hospitals are committed to building a lean hospital.

Today， we have shown the world that efforts have been made to build a “lean hospital” in China.Theoretically speaking，our research is to combine the latest managerial theories that are lean supply chain and synergetics with hospital management in China.Practically，it is a complete，innovative and universally applicable hospital management innovation.That means we have reached a new height of our study.

Our study of hospital lean management chain is based on the project，which won the Chinese Medical Science and Technology Award of Health Management.We have linked theory with practices and re-innovate.

In 2010 and 2012，Peking Union Medical College Press published my two treatises Introduction of Lean Management in Hospital and Building an Excellent Hospital.Based on theoretical foundation and management practice of the above two books，our hospital has made new progress in the journey of realizing hospital lean management.

Within the hospital management system，we have found out six most important subsystems of the hospital： medical quality system， talents cultivation system， performance assessment system，service procedure system，internal control system and hospital culture system.These subsystems interpenetrate and couple with one another within the system and finally form a closely integrated managerial chain.

We find out the intersections of six subsystems， connect them as a chain， and manage those key links，thus forming a hospital lean management chain.

This chain is a dynamic，cyclical and sustainable hospital management system.The chain and synergetic management techniques help improve the overall management effect of a hospital.

Based on the theoretical foundation of lean supply chain and synergetics，we have formed a hospital lean management chain，which is an innovative move.There are four major steps and features regarding the formation of hospital lean management chain.

First of all， during the process of applying lean management to our hospital， we manage all resources， factors， procedures and platforms according to the principle of lean supply chain and management synergy so as to achieve best returns.

Secondly，the establishment of hospital lean management chain needs the use of chain mechanism for seamless connection of all managerial factors，and self-organization theory for optimization of sub-systems and better results as“1+1＞2”.

Thirdly， three steps to build a hospital lean management chain： first is to choose the correct factor from the perspective of hospital director and decision-makers.The most important factor varies in different hospitals and during different periods.Second is to focusing on management and control of the chosen factor based on PDCA principles so that to achieve obvious changes.Third is to use synergetic theory so as to realize the effect of“self-organization” and “free ride”.By this way，we can build a hospital lean management chain.

Fourthly，different hospitals can build different lean management chains based on same factors including strategic management， organizational structure management， discipline construction and talent management， hospital culture management， medical quality control， service management， process management and performance management.By seizing the essence， the hospital can make full of lean management chain.

Bullwhip Effect in Hospital Management

Bullwhip effect leads to the divergence of management information from the front line to leadership.

IV.Six Major Factors of Hospital Lean Management Chain

Step one， standard medical quality system.Medical quality is closed related to patients’ life and is a priority that hospital leadership should focus on.The essence of lean medical treatment is quality.The improvement of medical quality requires the integration，optimization and sustainable development of relevant factors within the system and the formation of a PDCA cycle.

Step two，delaminated talents cultivation system.According to the characteristics of different medical talents， we launch different talent cultivation projects， focusing on the foundation that is new medical staff，and building trunk that is key technical talent and crown that is academic leader.As a result，high efficiency is realized in talent cultivation.

Step three，factor-oriented performance assessment system.The hospital aims to establish a fine internal performance assessment system that suit the current development of the hospital and apply strict，detailed and timely supervision on every aspect of hospital work.We have used the strategic factor-oriented balanced scorecard，which covers four aspects such as financial management， internal operation quality， study and innovation， and customers’ satisfaction， to push forward scientific management of the hospital.

Step four， precise service procedure system.According to the principle of BPR（Business Process Re-engineering）， the hospital continues to refine and improve medical service procedures including out-patient service， skill examination， ward management and logistics for better results.

Step five， form a “flattening” internal control system.According to the requirements of intensive management， the hospital has restructured the existing administrative， logistical， medical treatment and health care units，thus realizing a flattening hospital management system.

Step six，make hospital culture system a leading system in the hospital.Hospital culture is faith，value and code of conduct that staff adheres to during the process of medical treatment.It is a implicit，flexible and irreplaceable part of hospital management chain and contributes to the coordinated and effective development of the whole hospital.

Step 1.Create Medical Quality Control Cycle in the Hospital

Medical quality is the lifeline of a hospital and the main motivation when a patient is seeking for a hospital.Patients often judge if the hospital management is good based on medical quality.They need high quality medical service，which includes the superb and accurate medical treatment and high quality，fast and efficient medical service.The five aspects of Maslow's theory are all included in medical quality.

WHO defines medical quality from the perspective of supplier as the comprehensive capability of health service departments or organizations to use health resources to provide residents with medical and health service so as to meet their obvious and obscure needs.Foreign countries think that medical service is the gap between the actual medical and health service patients get and their expectation.

In our country， generally speaking， the narrow sense of medical quality includes technical level of medical personnel， the effect of disease prevention， etc.In its broader sense， medical quality focuses on not only effectiveness， safety and timeliness， but also patients’ satisfaction，medical work efficiency，economic effect of medical technology and the continuity of medical treatment.

1.1　Features of Medical Quality

With the social and economic development，it becomes more and more difficult to manage a hospital.The main problem is that the medical technique and service that hospital and doctors provide cannot meet the expectation of patients and the society as a whole.Many factors including medicine， risk， social， mental and environmental factors contribute to the complexity of medical service.

The hospital is a life-saving and humanitarian place.Medical service is for patients’life and health，and is quite different from the products that enterprises or agricultural industry provide.If a product is unqualified， it can be reproduced； but if medical quality is not good， patients will be gone forever.In this sense，medical quality is life of both patients and the hospital.

Firstly，medical quality is of great importance.Human life matters.Doctors and nurses deal with patients every day.Any small mistake may lead to a catastrophe and endless harm to patients and their families.So the emphasis on medical quality cannot be overstated.Hospital medical quality is extremely important and is the eternal focus of hospital management.

Secondly，emphasis on medical quality should be continuous.One-time medical safety education is not enough.As long as the hospital is in operation，there is potential risk of medical quality problem.No hospital can be sure that it has no medical quality problem.No doctor or nurse can guarantee that medical quality problem will never occur.Medical quality problem can occur any time repeatedly.

Thirdly，medical quality has the character of timeliness.The hospital can see the effect if they pay attention to medical quality during that period.Medical disputes and errors will decrease.On the contrary， if the hospital neglects medical quality， medical problem will occur frequently.The importance of medical quality should be emphasized all the time by all the staff within the hospital repeatedly.

Fourthly，medical quality is responsibility-based.Although medical quality problems can be caused by many factors such as responsibility， techniques and service， the responsibility of doctors and nurses is the most important one.Almost all mistakes that medical staffs make during operations or in giving medicines are related to the responsibility of medical staff.The sense of responsibility is an ideology，attitude and capability.

Fifthly，medical quality should be maintained in an innovative way.As medical quality is a priority all the time，it needs innovative method to maintain.If the hospital always uses one specific way to carry out medical quality education and management，the results will be not that satisfying.Hospital administrators must do research and study continuously， use innovative methods，updated cases and new ways to control medical quality.Then satisfying results will be achieved.

Doctors and the hospital's attitude towards medical quality is different from that of patients.That is a problem that we face in hospital management in China.I think many hospital directors feel that the most tricky trouble in a hospital is dealing with medical disputes and the most difficult problem in management is medical quality.It is so hard to offer satisfying medical technology and service to patients and the society as a whole.

1.2　A loop should be formed in regards of medical quality management.

Firstly，objective difficulties exist in medical quality management.Whoever have served as hospital directors or administrators would feel that medical quality management is a difficult job.But why is that so difficult？ On the one hand， patients pay a lot attention to it and sometimes treat medical staff harshly.But this is a common circumstance that can not be changed.Medical quality is closely related to patients’life.So it is understandable that patients treat it seriously.

At present， technology and level of medical treatment are not so perfect.In other words， no doctor or hospital can guarantee to cure all diseases.So it is impossible or unrealistic to avoid medical quality problem.

The subjective difficulty of medical quality management lies in medical treatment activities.Doctors in many hospitals only focus on techniques and direct visual medical effects，and often neglect medical details， such as side effects， complications， and the changes of patients’mental state.

These subjective problems in medical quality management are caused by doctors’insufficient understanding and the lack of an effective management loop that connecting hospital departments and patients.A sustainable and repeatable PDCA cycle is needed for effective medical quality management.

In 2004，Dr.QiuWenda， a Taiwanese hospital management expert， carried out QCC activity in hospital medical quality management innovatively.QCC（Quality Control Circle）is composed of people who are working in similar or complementary workplaces.They collaborate with each other， do brainstorming， and make improvement of their own professional work according to certain processes.The operation of QCC is a continuous improvement process，i.e.a PDCA process.

Among all the management tools of medical quality， “QCC” is a effective one that can bring obvious improvement in a short term.The hospital forms a quality improvement circle with front line staff as the center， implement quality management measures， discuss and find out solutions to problems，forming a top-down and effective model.Hospital staff should shift working attitude from “I have to” to “I want to”.The hospital should cultivate a culture and fixed working mode of quality improvement，find out problems and solve them.

The theories of PDCA cycle and QCC inspire us during our work in establishing hospital lean management chain.Is that possible to include hospital quality management to the chain by using those theories？

Based on management mode of QCC and PDCA，and taking into consideration of medical quality management reality，Wuxi No.2 People's Hospital has carried out establishing a QCC of medical quality management in the process of building a hospital lean management chain.

1.3　Reflections on the principles of “Five Never Let Go”

After over twenty years of hospital management work，I realized that the key of medical quality is medical effect and patients’ satisfaction rate， and to achieve better quality and higher satisfaction rate， we need to better manage and discuss death cases， many of which involve medical disputes， rescuing of critically ill patients， and failed innovation.

To some degree， discussion of death cases is of great importance in hospital management；the principles of“Five Never Let Go” show some problems that patients and their families put forward and doctors easily neglect.

The five principles are as follows： never let go of death cases with unknown causes； never let go of failed operations without finding out reasons； never let go of patients’ complaints without knowing their reasons of dissatisfaction；never let go of medical complications without clear causes；never let go of the disputes without medical staff'ss recognition of their mistakes.

Five Never Let Go

Never let go of death cases with unknown causes

Never let go of failed operations without finding out reasons

Never let go of patients’complaints without knowing their reasons of dissatisfaction

Never let go of medical complications without clear causes

Never let go of the disputes without medical staff's recognition of their mistakes

Death cases， failed operations， medical complications and disputes are common in hospitals.For death cases， doctors usually explain that“that patient's condition is too severer”， “his condition changed so quickly”， “we have tried our best”； for medical complications， doctors often find excuses such as“this complication is common” or“this illness usually comes with this complication”； for medical disputes， doctors always say “I have done my job”，　“I have told their families”， “I have done nothing wrong， it's their fault”.In many cases， doctors can muddle through with excuse.But is that really the truth？

When we strictly follow the five principles to analyze the root causes，we will find mistakes and carelessness in previous observation and judgment， improper behavior during operations， insufficient prevention of complications， lack of communication with patients and their families，and loopholes in hospital regulations.In face of reality，all reasons that doctors give are excuse.

The five principles summarize the key to medical quality management.The hospital can start from analyzing death cases， failed operation， medical complications and disputes， then look through every detail during medical treatment，and find out the existing problems.

The five principles also remind us that we should see through appearance to essence.Medical quality problems can easily hide in death cases， failed operations， medical complications and disputes.The hospital should never slack off in internal management because of the so-called“reasons” and “excuse” so as to avoid reappearance of similar cases.

The principle is a powerful“weapon” to push forward sustainable improvement of medical quality.The hospital should stick to the five principles to find out problems，solve them through PDCA cycle，and finally improve medical quality and management capability.

The era calls for hospital lean management and link management of medical quality.The five principles serve as a key to the door of link quality management.

Since 2009，our hospital has implemented the five principles， carefully reviewing every death cases and discussing its causes.All medical staff is fully aware of the importance.Through careful discuss and analysis，we have formed an effective method that is crucial in medical quality management.

1.4　Tracking method contributes to the formation of medical quality management loop.

JCI accreditation and the latest Grade A Tertiary hospital assessment both use tracking method to supervise quality management.Our hospital also uses tracking method firstly in studying death cases and then building a medical quality management loop.The important steps are as follows：

Firstly，conduct examination and inspection on medical and nursing departments on a daily basis to find out weaknesses and problems.

Secondly，carry out a joint inspection on heath care activities and moral culture weekly or every two weeks led by hospital leadership，and a selective examination of the implementation of twelve core regulations.A rectification notice will be issued once a problem is found.

Thirdly， organize quality control on patients’ records by hospital leaders， division chiefs and experts， seeking problem from patients’ records so as to upgrade medical quality and capability.

Fourthly， to carry out high quality “seasonal seminar” on death cases.The hospital selects one or two cases that involves disputes or patients’ complaints， and invite experts within the hospital to analyze medical problem and its root causes deeply，which helps the hospital to improve medical quality.

Fifthly， review and examine medical disputes every six months， clarify responsibilities.One the one hand， medical staffs analyze disputes by themselves； on the other hand， experts give judgment，and finally relevant staff make rectifications accordingly.

Sixthly， hold a medical safety warning education week/month annually， discussing medical accidents and hospital infections.On this basis， the hospital also collects suggestions， ideas and programs for further rectification by activities such as“Golden Idea Collection”.

Wuxi No.2 People's Hospital adheres to the principles of“Five Never Let Go” to form a medical quality control circle， find out problems by tracking method， analyze， discuss and make improvements by PDCA cycle，thus forming a continuous sustainable and effective medical quality management cycle.

Step 2： “Talent Tree” Project

2.1　View on hospital talent

With the rapid development of society and upgrading of people's livelihood，people's attitude towards health is changing，which will inevitably increase demand for health care and medical talents.And this circumstance will last for quite a long period in the future.The essence of competition among hospitals is talent.Those who have talents，have initiatives and advantages in competition.

Hospital talents

According to the theories of systematic project and synergetics，talent can be divided into three levels and five factors.Three levels are as follows： first is qualified talents， who are with bachelor's degree and academic abilities and recognized as qualified after selection and training；second is special talents， who have special technology on the basis of qualified talents； third is outstanding talents，who have made breakthroughs or innovations in his/her major or one technology.Five factors refer to virtue， wisdom， ability， performance and health.

Talents are elites among ordinary people.They share common personalities with common people while have special ones，which are decided by their capability and status during work.

Hospital talents refer to those who have certain academic knowledge and special skills，and can make benefits to mankind by their knowledge and experience.

2.2　Features of“Talent Tree” Project

On September 2013，the subject“Talent Tree” Project--Ladder of Growth for Medical Elites that I work on as a project leader won“Asian Hospital Management Award of Excellence in Human Resources Project of Year 2013”， making our hospital one of the two hospitals that won this award in mainland China（the other hospital is West China Hospital）.This project originates from over ten years’of hard work on talent cultivation and unremitting efforts on lean management.

First，introducing theory of tree-type structure.It gets rid of the simple and limited traditional talent cultivation model，classify talents from different technical levels and development stages， and form a “foundation-trunk-crown” system.Foundation is new and ordinary medical staff，trunk is key technical talent and crown is elite.The hospital aims to establish a life-long learning mechanism in foundation（new and ordinary medical staff）， create an innovative and helping plan for trunk（key technical talent）and carry out performance evaluation and knowledge-sharing activities in crown part（elites）.The three parts are interdependent and develop together.

Second，introducing the theory of career pathway and working out a professional career plan.In consideration of different education background， working condition and personality， we fully respect personal will and formulate personalized cultivating plan.

We start from initial education for technical personnel，cultivating young and middle-aged professionals and selecting high-level talents.We focus on not only the whole team but also key talents， adopt incentive measures， train staff creatively， thus forming a talent cultivation path with our own characteristics.

Third，　“Talent Tree” project has two features.One is that the project includes one talents management tool and one brochure；second is it focuses on three-level cultivation system for group talents and three-stage growth of individuals.

No.1 A talent cultivation tool

The“Talent Tree” project uses a metaphor.The talent team and its growth process is like a tree.The project includes all medical staff in the hospital and serves as a management tool that is measurable and dynamic.

I call it“function tool”， which has a big influence on hospital's medical work.If the hospital is well managed， the effect of discipline building and talent cultivation will be bigger； if not， the effect will be greatly reduced.

No.2 One“brochure” for each employee

In Wuxi No.2 People's Hospital，every employee has a brochure Technical Personnel Training System and Evaluation Methods，in which there are clear and detailed requirements and missions for different employee during different working stage.

No.3 Three-level cultivation system for group talents

Regarding the talent structure as a whole， the “foundation-trunk-crown” mode is like a treetype structure.Foundation refers to ordinary young staff who just enter the hospital；trunk refers to those young and middle-aged professionals and vice-senior and intermediate technical staff at the age of 35 to 45 years， who need a fast cultivating mode， and crown includes key discipline leaders at municipal and provincial levels such as famous doctors， chiefs and experts， who are meant to give guidance.The hospital adopts different measures in cultivating different talents according to different requirements so as to build a strong team.

No.4 Three growing stages of individual medical talents

“Talent Tree” Project introduces a career path， which sets up different goals for staff in different periods，and customize scientific career path for each employee so as to realize the common development of the hospital and staff.

The individual's professional career mainly has three stages： first is learning stage， which is for starters to accumulate basic skills； second is growing stage， the longest one， which is for selfdevelopment and self-improvement in practice； third is mature stage， in which the individual plays a leading role after years’of improvement.Different stages have different paths and goals.

This project covers the whole professional career of staff and specifies award and punishment measures from the aspects of professional capability，technical level and scientific research.In this way， staff will grow at the fastest speed， and hospital can have a stronger， better quality team that can offer better medical service to patients.

2.3　Re-innovation of“Talent Tree” Project in Hospital

In the past few years， our“talent tree” project focused on the leading position of crown talents and education of talents in foundation.We have made progresses in broadening the international horizon and upgrading general capability of trunk talents.

However， some these trunk talents have had unstable emotion， concerns over their future and unsatisfactory work performance，which are side effects of our emphasis on crown talents.This phenomenon inspired us to take some special measures to lead the trunk talents，make them realized their difference to crown talents，and guide them to use their capabilities to the most.That is our new findings and understanding regarding the project of“talent tree”.

Firstly，the hospital should set up clear goals and targets for trunk talents in the fields of special techniques， clinical competence， research and innovation， and learning ability.

Secondly， the hospital should organize proper competitions for trunk talents， such as point match，essay contest and annual rankings so that they can enjoy themselves while devoting themselves to regular clinical work.

Thirdly，certain incentives are needed.There is usually a certain gap between the incomes of trunk and crown talents.It is of positive significance to give excellent trunk talents some bonus，which not only encourage individuals but also set a good example to the others.

Trunk talents matter in the further development of a hospital.They are the connection between crown and foundation.It is a group of great importance but can be easily neglected.When the crown talents are playing a leading role in clinical and research work，the hospital should pay attention to and care for the trunk talents in advance，and combine training and utilization together.That is very important and significant.

The golden age of forty to forty-five is an important growing stage of individuals as well as a significant period of showing their capabilities.We should treat those young and middle-aged medical professionals differently from ordinary staff and carry out new supporting measures.That is the key to stimulation activities.

“Talent Tree” project is a talent cultivation mode based on their growing demand， a innovative practice， a management tool to build a better medical team， a key step of establishing a hospital lean management chain，as well as the inexhaustible power of realizing strategic management of hospital talents.Continuous innovation efforts should be made during the process.

Step 3：The establishment of a dynamic performance management and compensation system.

Performance and compensation management is always a foundation and lever of hospital management.It measures the work performance， efficiency and effectiveness of every medical staff，every medical department and every hospital.

We can say that performance management serves as the eyes or rulers of hospital directors.It measures the working level，significance and value of each employee and division.Hospital compensation system allows hospital directors to pay the regulated for their work and innovation dynamically.

Every hospital has its own performance and compensation system.But many hospital director and administrators are not fully aware of its special leverage effects and haven't conducted performance management scientifically and correctly.

Such performance management is harmful to the development of a hospital.Salary is the reward for contributors and their departments and a response to performance management.Compensation system should be dynamic，consistent and correspondent.

At present， many hospitals haven't directly linked performance to salary.Usually， human resources department takes care of performance appraisal while finance department is in charge of compensation management.

According to what we know，performance and compensation management are totally unrelated in one-third of hospitals，partly related in one-third of hospitals and basically related in others.We advocate that through public hospital reform and management innovation，performance and compensation management in hospitals can be fully related.

3.1　Multi-dimensional Understanding of Performance Management

“Performance is a multi-dimensional object that can be different seen from different angles”.To understand performance from different perspectives， you will get different views：

Step 4：The innovation and exploration of hospital service

Such kind of strategy urges the head of a hospital to level up the service administration to strategic administration.By using the power of decision-making and the available resources，he or she will improve the quality， awareness， environment and process of the service in a hospital， so as to build it into a place labeled with humanity， warmth and comfort.During the process of medical treatment， the hospital should hold the service concept of patient-oriented， striving to treat patients and the society with good technology，warm-hearted service and satisfactory process.

In the 21st century，the strategy of hospital service is no longer the extra choice in pursuing the innovation and excellence of a hospital， rather， it becomes the very important foundation for health&service industry and social pilot industry.Hospitals， no matter big or small， public or private， should all stick to it.The concept of the strategy of hospital service should be like this：sparing no efforts to pursue excellence and innovation.

4.1　Hospital service is the strategic topic of hospital administration

Definition of“service”： it is an activity performed by individuals or organizations.Usually，it is associated with some kinds of available products， by offering it， the demand and expectation of the consumers can be better met.

When we talk about the service of medical care，it relates to a series of medical care output and non-material form services.That means，the hospital takes patients and those with medical care needs as the main clients，by providing them the medical technologies as the basic service means，so as to meet people's healthy demand and bring benefits to them.

The hospital service covers 2 aspects： one is the service of medical technologies， which means to cure the patients； the other is the emotional service， which brings comfort and satisfaction to them.The judgment made by the patients is based on emotion and impression，if they feel the nice technologies and attitude of a hospital， if the service is convenient to them， then it is a good service.

The core service of a hospital：it refers to the most important service a client could receive.It embodies the most fundamental function and value of those who offer services.

Obviously，the core service should definitely mean effectively heal the wounded and rescue the dying.The process involves the category， feature， standard， commitment， effectiveness and innovation of medical service.

The excellent service of a hospital does not simply mean owning several famous doctors and those who master the first-class core technologies， rather， it should be guaranteed by the firstrate medical technologies， staff quality， medical equipment and administrative innovation of a hospital.

The superior service is the embodiment of a excellent hospital.Maybe it is difficult to obtain the laurel of great hospital，but it should be regarded as the aim in every hospital leader's mind and heart.

The excellent service of a hospital contains the following 3 aspects：　（1）excellence represents self-transcendence.A hospital should continuously explore its potential，trying its best to offer best medical service to patients.（2）Excellence means exceeding market needs.The relentless competition of the medical service market and the various changes of medical service demands produce the excellent service.It advocates that there is nothing best but butter adjust it and surpass the market needs.（3）Excellence is the accumulation of staff creativity.To some extent， offering excellent service is to create a new market and competition，and such kind of new competition is derived and sublimate from the creativity owns by each employee.

Many heads of the hospitals do not realize the foundational，importance and specificity of hospital service.They merely treat it as an ordinary form of medical manifestation.

Therefore， seeing from the aspect of connotation， we could find that the medical services of those hospitals do not reach high-standard scientificalness.If we look at it from the pattern of manifestation， we may also find out that its performance lags behind many pilot industries， let alone meeting the medical security need from both patients and society.

With the transformation of the concept of“disease-centered” to “patient-oriented” medical service， the hospital service has become the strategic topic of hospital administration：

（1）In favor of establishing the hospital brand image and improve competition；

（2）In favor of advancing the reform and development of hospital；

（3）In favor of adjusting hospital to meet the needs of market；

（4）In favor of training outstanding staff team；

（5）In favor of forming better cultural environment of hospital.

The leaders of hospitals should pay high attention to the quality of medical service.The service improvement and administrative innovation of a hospital are totally a kind of administrative activity with less investment， lower cost， short-time period and fruitful effects.At the same time，to every hospital， the hospital administration is endless， so does the hospital service.

The hospital service should be a dynamic and improving process of lasting innovation.The improvement of hospital service is the strategic topic and an abstract application field of hospital administration.In such an application field， the head of a hospital， the hospital administrators and the staff could contribute fully to the creation and innovation.

In the perspective of the head of a hospital and the hospital administrators，the starting point of hospital service should be the staff training and the establishment of the service tenet.The hospital should remind and train the staff at all times to conduct the holy profession with the notion of respecting patients，taking care of them and respecting life.

Mayo Clinic—patient requirement comes first

An employee of Mayo was on a airplane flying from Mayo branch to it's headquarter in Minnesota.When he arrived in Chicago， he was told that due to the rainstorm， many flights were canceled or postponed，therefore he and many others were gathering at the boarding gate.He heard some people whispering， and one of them said： “I have an appointment in Mayo tomorrow morning”， another people said： “I have a physical examination there at half past ten tomorrow morning”， and someone responded： “I am going to have a blood test， so from now on， I would not get anything to eat”.All those people have one thing in common—going to Mayo.But we were told that the next flight took off at 4am next morning， which means when we arrived in Minnesota，we would definitely miss the appointment with Mayo.

At this moment， the Mayo employee stood up and said to us：　“ I work in Mayo， and I would help you”.He realized that it is impossible to drive to Rochester from here， since the snowstorm has already cut off the road.Then he called to the airline company and asked whether there were any flights to another place，where it was faster and more convenient to drive to Rochester.He got the “yes” answer， so he told those Mayo patients to-be to go to that place together， and promised to drive them to Rochester.After a short period of coordination， all the people were on board.

4.2　The innovation and exploration of hospital service

NO.1： we carry out the good service of“ five ones”：

We offer one doctor and one consulting room for one patient，thus fully protecting the patient's right of privacy.

In 2004，our hospital took the lead in launching the new initiatives in Jiangsu province，meaning within the limited space，one patient is equipped with one doctor and one consulting room，so that an independent space of diagnosis and treatment could be created for the doctor and the patient.

We offer one medicine window，thus optimizing the medical process.

As to the chemist's shop of outpatient service，some improvements have been made to expand the medicine window， with proper geographical layout， simplify procedure and faster speed.We are taking the lead in adopting the mode of taking medicine from a counter.As we can see from its statistics， that since its implementation， the average time for taking the medicine is reduced by 20 minutes.

One-Stop Service center offers considerate service

In order to be more convenient and efficient，the clinic offered many services functions such as appointment in one place， triage and guiding service， measures convenience， pharmic counseling， examination and approval of reimbursement and complaint settling in 2009.On average，we offer services for more then 100，000 patients each year， making real convenient for the patients.

We offer special telephone line 168 for logistics services，so as to work out patient's worries

We are improving our logistics services，opening the service hot-line 168 for patients in our hospital.Once our patients dial the number 168，we would offer daily necessities， facilities， accompany service and nutrient food supply.We promise that if patients who are in our hospital miss the meal， after dialing 168，they could have the fresh food supply within 20 minutes.

One red wrist-band could open a green channel for first aid

In June 2007，our hospital put forward the wrist-band recognition system， those critically ill patients with the red wrist-band have the priority to obtain diagnosis and treatment.Besides，we have set up the free special telephone line of first aid，so that we can make preparations in advance and won the precious time for the patient.Those critically ill patients could have their hospital admission after they are in hospital.We offer a rescue channel for first aid with one package service of admission，examination and operation.

NO.2：Exploration of outpatient service with multi-centers

In the traditional diagnosis and treatment mode of outpatient service，hospitals are accustomed to the first-level branch mode of internal medicine， department of surgery， gynecology，pediatrics and so on.As the establishment of the traditional first-level branch mode is based on medical treatment， so it is not that convenient for the patients.Later on， the second-level special section and the third-level sick specially the outpatient service have been gradually implemented.

The implementation steps of multi-center diagnosis and treatment mode.

First step is to establish a center service platform.We take the medical records of patients from the large-scale hospitals and the local requirement as the objects of study.For those patients group who need at least two relevant special sections，according to its disease category while combining with our hospital's advantages，we are taking the lead of the 8 center-oriented outpatient services including the joint section for outpatients of brain department，the joint section for outpatients of thoracalgia.By doing this，we have completed the transformation of sole outpatients section to the joint section for outpatients.Medical staff from each center is designated by the hospital and the members shall have certain qualifications from the relevant special sections.Doctors from different sections will conduct a joint diagnosis and treatment for one person and proposed a best medical plan.

The second step is to choose the “center” diagnosis and treatment indication.This is available for patients who meet one of the following conditions：　（1）those who have saw the doctor in one special section for 3 times， or patients with uncertain diagnosis or poor treatment effect；（2）those who carry multiple kinds of disease and need the joint consultation from various sections；（3）patients from other places with poor treatment effect and need the joint consultation from various sections；（4）those who are not satisfied with the previous treatment result.

The third step is to lay out the “center” performing system.On the basis of making the relevant medical care working and service system of the diagnosis and treatment center，we offer the appointment for intractable cases.It goes like this：the patient tell his or her state of an illness to the medical staff through a call or on the spot， then according to the patient's condition， the staff make a confirmation of medical specialists and the treatment date，and also reminding the materials they need to carry when they see the doctor such as medical record，inspection report and iconography.For those senior patients or those with severe disease，there is a green channel of inspection and treatment，also the staff will accompany them if necessary.

The fourth is to publicize the procedure of diagnosis and treatment.After the implementation of center-oriented diagnosis and treatment， in order to make it known to the public， we have release the news and materials to patients in each section，including emergency room and sickroom.With the help of magazine and TV，patients could make preparations in advance.

The process re-engineering of center-oriented outpatient service is the second deep consideration and the second thorough design of the previous process of outpatient service.By doing so，we could make further improvement in aspects of quality， cost， service， speed and so on.Therefore，with unique feature and specialists，we could do our best to meet the needs of patients and benefits them.

The purposes of establishment of the centralized medical care is to systematically integrate staff， technology， equipment and patient resources.We hospital gather those doctors who are majoring in the same disease system and put them in one center range，thus realizing the integration of the medical staff resources and various therapies.This is a new medical way of representing“people-oriented and patient-oriented”.

After the implementation of center-oriented diagnosis and treatment，it was embraced and welcomed by large number of patients，and our hospital also won the service innovative prize of Wuxi sanitation system.

Since 2008，our hospital has gradually set up 8 medical center for diagnosis and treatment：

NO.3： The new development model of the “centralization” of brain department

Since 2008，on the guiding principle of mainly implementing the development of special sections， our hospital takes neurosurgery and neurology as the main body， combining with other special sections such as neuroradiology， pathology， inspection and physiatry department， thus establishing the first brain department center in Wuxi， from then on， the brain department center has been on the track of fast development.

Five “joint” working mechanism of the brain department center

Since its establishment， the center adhere to the principle of“patient-oriented”， taking the improvement of medical treatment level and the service quality as our goal，we encourages innovation of technology and administration， and build the five “joint” working mechanism：

First is the joint normalization diagnosis&treatment of sole disease.For example，the multisections cooperation and normalized treatment of apoplexy.

Second is to establish the joint rounds of the wards.The special section of nervicerebrales conducts a joint rounds of the wards of both neurology&neurosurgery.The director of the center and doctors from neurology&neurosurgery lead the rounds of the wards，thus making the three-level ward round more meaningful.

Third is to build the joint consultation center of brain department.We would open the center on every Wednesday afternoon.associate chief physicians from various special sections such as neurology&neurosurgery， neuro radiological imaging， neuroendocrine and neuroophfhalmosqicclinic.those doctors would discuss the diagnosis and the further medical treatment together and make the best medical proposal.

Fourth is to conduct weekly Neuroscience Meeting/Friday Lunch Meeting.The meeting will be held on Friday， with staff attended from neurology&neurosurgery， neuro radiology， ueuropathology and the inspection section.The discussion will be ranging from medical history to accessory examination， treatment， surgery and pathology results， besides， there will also be the special reports from foreign scholar and，doctors especially the young doctors from our hospital.

Fifith is to set up the joint emergency treatment of brain department.Since 2009，we added the emergency treatment of brain department to the emergency room.The establishment of emergency treatment of brain department is based on the adjustment of neurology&neurosurgery emergency treatment， therefore it is convenient for patients with brain disease to see a doctor there，and also the successful rescue rate has been increased.

In recently years， the brand department center has launched a series of“brand surgery”，besides， the normalized treatment of cerebrovascular disease， the management of the prevention of stroke unit and other medical technology is in a leading position nationwide.

At present， the clinic receives over 5000 patients per year， and successfully save over 3000 critical patients，with a successful rescue rate reaching over 90%.

The center is carrying out new projects on the nation level as well as provincial level.In recent years， we have received 3 financial aids from NSFC.Each year， the number of the research projects and paper publishing is gradually increasing.

In 2011，the center is awarded as“innovation team” and“leading talents”， and was selected as the screening and prevention base of cerebral apoplexy by the Health Ministry.

NO.4：The building of the appointment platform

In the past，the appointment of outpatient service and inspection is arranged by section itself.Therefore，patients often complain about its inconvenience.

So， when we attach great importance to the improvement of process of the outpatient service，it is also of great significance to increase efficiency and reduce the time for appointment，this is also related to the innovation of medical service.

The hospital shall set up the diagnosis&treatment as well as the inspection center of appointment.

On one hand， we need to have the information-based platform， on the other hand， we need to coordinate well the various inspection and the sections management with the clinic.So that we can offer the appointment service such as CT， MRI， gastronomy， enteroscopy， type-B ultrasonic inspection， and special inspection.By doing so， it will be more convenient and effective for patients.

The character of gathering the platform of appointment：

It is the future trend of hospital development，also a good way to save finance&energy and is convenient for people.The advantages are obvious：

Firstly，it is more convenient.There is no need for the patients to look for sections to do inspection，what they need to do is to come to one place and make an appointment of proper time.

Second is unified management.By doing this， the hospital will be in an orderly manner，with less crowd and less quarrel.Patients conduct the inspection according to the time and order.The cases of loss and missing will be reduced as well.

Third is the easy coordination and management.By doing so，the inspection efficiency is increasing.The reason contains 2 aspects.On one hand，it is due to the improvement of motivation of the staff， on the other hand， because of the reasonable arrangement， the working arrangement become more orderly.

The establishment of the appointment platform is a stage of hospital innovative service.Though we have a plenty of difficulties and obstacles to overcome，it is of great significance to both patients and the hospital management.Therefore，it is the important part of hospital innovative service.

NO.5：The forming of the self-service of registration

Since 2004，our hospital took an active try in appointment and set up a reservation working group， including the outpatient department， information office， nursing department and so on.The group made a reservation work plan and set up person in charge of reservation work.Besides， we establish a reservation platform based on the HIS， and the ways of reservation includes telephone， network， and the scene.The content is also increasing， that is besides the appointment with the specialists and general out-patient clinic， and we add the center clinic，night specialist clinic appointments.And the patients in the difficult cases center consulted by senior expert are all through the appointment of the center of the reservation.

After the hospital established cooperative relations with the Chong′an District Community Health Service Center， the hospital added a community reservation， so community patients can go to the community health service center to reserve the clinic in our hospital directly.There were more than 9000 reservations through the community reservation since 2011，so our hospital is known as“the first-class hospitals around us”.Our hospital has also established cooperative relations with “know-all number”， and takes it as a platform to expand our hospital appointment crowd.

On the basic of targeted aid，we selected the Jianghai community to start semi compact medical conjoined pilot work in the December of 2014，and extended the first-class hospital service to the community by taking many measures simultaneously，such as arranging specialists to community clinics every day and establishing wards to take care of the patients.In addition，in order to help them develop their specialist clinic better，we also arranged a deputy director to work as deputy director in the dominant special clinic in the community.

We implement the “24 hours of reservation” service in which we put 24 self-service machines in the outpatient， providing 24　hours’　self-service registration and charge services.Patients can pre-register all kinds of specialist clinic and general clinic for 7 days using union card payment.At the same time，we cooperated with the Industrial and Commercial Bank and launched the “payment after treatment” service to shorten the waiting time of patients effectively.At present， more than 300 patients use the self-service machine for registration， payment or pre-authorization，and outpatient clinic appointments rate reached more than 95%.

Our hospital also provided patients who pay at their own expense with “purenka” which has electronic purse function.Patients at their own expense can see a doctor by Purenka or“China Union Pay card”while patients with health insurance will see a doctor through Medicare Card.This is also the first step of our“payment after treatment” service.

In addition，we also placed elf-service vending machines to sell drinks and papers in the outpatient hall and emergency hall where there is larger flow of people，so that make patients can achieve various convenient services in the hospital.

NO.6： “nominative workroom” in endoscopy center

In the past， our endoscopy office had so many doctors and gastroscopes， however， as a result of the general performance appraisal methods，which had little relationship with more and better work，doctors in the endoscopy office did little work every day.Because it needs fasting preparation，doctors only arranged 30-40 patients to do gastroscopy every morning and arranged about 5-10 patients to do gastroscopy in one or two days’afternoon every week.

Therefore，gastrointestinal endoscopy has become a bottleneck in many hospitals which is very difficult to make an appointment and it cost a long time to wait.For example，it costs more than 2 weeks to make an endoscopy appointment，and more than a month to make a colonoscopy in many hospitals in Wuxi.

In the face of such a medical dilemma， I referred to the way of nominative experts’ clinic and implemented the workroom system which includes five directors and deputy directors.Every day there is one expert being nominated and others doing the ordinary examine.There work would have direct relationship with there payment， as a result， the doctors were highly motivated.They served the patients better and cherished the choice and evaluation of every patient.Now，they often arrange more than 100 gastroscopy examinations one day with an increase of more than 100%.There is no need to make a gastroscopy appointment now.

NO.7： “eight service commitments” cure the service ills

We carried out “cure service ills and improve our service” activity in our hospital which focused on the problems that are reflected by patients most intensely.We summarized eight prominent urgent“ills” and made public commitments to the community to reform.

Eight service commitments：

Two on time：

（1）to perform operations on time

（2）to begin clinic on time

Two kinds of behavior：

（3）to standardize hospital consultation

（4）to pay attention to hand hygiene

Two kinds of communication：

（5）to strengthen the communication between doctors and patients

（6）to fully cover the health education

Two services：

（7）to implement the bedside settlement

（8）to give out night snacks

Step 5.Research on the reform of public hospitals'operating mechanism

5.1　the head of hospital should highlight the mechanism reform of public hospital

There are two main tasks in the reform of public hospitals，one is related to the system reform of public hospitals.This kind of reform is a fundamental reform which needs top-level design and the head of the hospital is often difficult to change.The other is the reform of the internal operating mechanism of the hospital.This kind of reform can be directed by the head of the hospital and will often have fast effect.

Therefore，we make an appeal that the hospital's president and administrators should not only pay attention to the reform of the hospital management system，but also attach great importance to and participate in the reform of the hospital operating mechanism.

5.2　hospitals implement divisional system reform

The bottleneck of the current system of Hospital Authority

First is bull management.Different departments overlap in functions，which lead to the phenomenon of overlapping management in the work of index evaluation and management.As a result，the efficiency and authority of the functional departments decline.

Second is coordination difficulty.Various functional departments are at the same level，so when it comes to the work coordination among several departments，they usually making excuses mutually.

Third is low efficiency.Since it involves several functional departments to get approval and the procedure is very complicate，the efficiency of our service is quite low and people often get unsatisfied.

In order to establish a scientific， efficient and coordinative public hospitals’ internal management mechanism as well as to explore the modern hospital management system，we restructured and incorporated the 20 functional departments and temporary organization into seven departments in 2010.With the premise of unchanged total number of offices in the departments，the restructuring is in accordance with the requirements of divisional system.After the restructuring，the dean of each department is responsible for his department.To the external，he should perform the original responsibilities and merge the functions of original staff and offices.To the internal，we implement unified management.The staff will be deployed uniformly while the surplus employees will enrich the clinical front line.

5.3　to improve and perfect the system of supervision.

The implementation of the responsibility system which there is a attending doctor in chief is checked on a regular basis，thus ensuring the immediate settlements of any problems that may emerge when the system is carried into effect..Feasible settlements may include the readjustment of personnel in the medical treatment team in charge，and the coordination between the director of the relating hospital department and the attending doctor in chief.

Assessment and Allocation of the medical treatment team in charge

The essence of the responsibility system is to change the management of the financial accounting system fundamentally， that is to say， to change the profits distribution mode and to scale down the accounting unit.

To conduct assessment of such a system，each medical treatment team is a separate accounting unit.The cost accounting will be made in units.The performance of each team is assessed by the related department in charge，which is also formed by specially-assigned personnel of the hospital.The evaluation criteria mainly include： the number of discharged patient， the number of operation， the length of hospitalization， the ratio between the average length of hospitalization and the cost on medicine， the average valid income， the proportion of the level-4 operations， the proportion of high-risk patients.

After the implement of such a competitive and encouraging system，the initiative of our staffs is brought into full play， and the working efficiency is improved impressively， together with significant increases of outpatient number， emergency room visits， discharged patient number and usage rate of bed.

Such a systematic reform urges the attending doctors in chief and all medical treatment teams to pay high attention to the quality of the medical treatment，which in return improve the key indicators of medical treatment and technique level， such as the proportions of the level-4 operations，of the high-risk patients， of the first rate medical case， and the ratio of rescue rate.All of these ensure the quality of our medical treatment，and promote the technical progress and bring forth innovations.

Such a system fully respects the rights of our patients，including their rights to know all the attending doctors and to choose one as the chief of their treatment team.It not only reflects the patient-centered philosophy of our hospital，but also effectively reduce the average length of hospitalization，the average medical expenses and greatly improve the satisfaction degree of our patients.

5.4　the creation of a new responsible nursing team mode

In the year of 2012，having successful lessons from the implement of the responsibility system concerning the attending doctors in chief to go by，we reformed the nursing system and created a new mode of exquisite full-course responsible nursing team in charge.

This new mode has significant difference from the old high-quality responsible nursing team mode：

The first difference is that there are stricter assessments on the professional competence in certain medical section and higher standard of working ability.

The other reform is that the team， instead of a simply grouping， is divided also according to the arrangement of all the nurses， the allocation of human resources， the mode of assessment on personnel，and distribution system.

Merits of the new mode of responsible nursing team in charge

First：Scientific grouping

The allocation of nursing teams and the number of team leaders in different departments of the hospital are arranged according to the actual amount of available beds.The whole allocation process includes personal application， department recommendation， qualification assessment， public notification and reply， discussion meeting of heads of hospital， bi-directional selection between group leaders and group members.Now we have 70 nursing teams in total.

In any department，when the number of nursing staffs who fit all the criteria of being a team leader is more than the demand，there will be a meritocratic selection.Those who fall to be the group leader and refuse to accept the outcome will automatically lose the qualification of being a team leader in any of the department.

Second：Corresponding level management of human resources

In order to construct a new system of nursing team，we also set up new standard for assessing the competence of nurses.According the new standard，all of the nurses are classified into difference level from N1 to N4.Such a new improvement of nursing competence is closely coordinated with the new mode of exquisite full-course responsible nursing team，with special attention paid to the reasonable allocation of nurses of different nursing competence.Nurses of different competence levels will be arranged correspondingly to take charge of nursing difference patients，which shows the correspondence between competence and responsibility，and also ensures the specification of nursing responsibility.

Third：Flexible shift arrangement corresponding to the exquisite full-course responsible nursing mode

When it comes to the allocation of human resources，we stress on the actual situation of not only the hospital as a whole， but also every department separately， and give consideration into both basic principles and flexibility.Instead of adopting a single solution，the allocation of nursing staff in different departments is arranged according to the specific needs in each department.For example， in case of emergence， we set up a staff allocation and shift arrangement system called Just In Time； in rehabilitation unit and special wards， we carry out a 12-hour-shift system； in neurology department， there is a 12-month-consecutive-night-shift system； in emergency center and intensive care unit， we run a 8-hour-consective-full-time-responsible system； in ophthalmic unit，we conduct a system called APN shift.All of these different modes of nursing shifts ensure a real flexibility of our working shift system.

Fourth： Perfect the assessment system——Survival of the fittest.

First of all，we improve our assessment system directing to nurses.Centering on constructing a position management system of nursing staff in the hospital，the reform of personnel system is carried into practice， which insists on setting up positions according to actual needs， employing staff according to valid position，and hiring nurses through public competitions.The nursing department thus sets up a corresponding assessment system.Every new leader of the nursing group is under professional supervision and rotates every six months.Those group leaders come into the top six in the assessment will be amply rewarded.As for those of lowest ranked group leaders，who are either lack of competence or initiative，punishment from warning to the cancellation of qualification may be issued accordingly.

In the second place，we perfect the assessment system of the working performance of nursing teams.There is a four-dimension assessing criterion including indicators of amount and quality of the work being done， patients’ degree of satisfaction， the working atmosphere of learning and innovating， together with all kinds of rating forms， such as satisfaction assessment form directing to different level of related staff， statistics concerning amount of work， assessment form relating working performance of nursing team in specific department.Meanwhile，we also set up a threelayer SOP（Standard Operation Procedure）of supervising all the nursing teams.Every nursing team is supervised by another team，as well as by a responsible director of nursing department and an auxiliary superintendent（both positions are rotating among the department on a daily base），thus ensuring any problem being found being well settled.

Fifth：Reforming the income distribution system of nursing staff

We have set up a scientific performance assessment and income allocation system according to the actual working performance.The assessment of nursing department is independent from the rest of the hospital， based on a specific principle——the higher the risk， the greater the intensity，and the better the performance， the fairer income.That is to say， when it comes to the income distribution， the more work one does， the higher risk one's position accompanied， and the better performance（reflected by the patients’ degree of satisfaction）one achieves， the higher competence level one will be.Those nurses work on the frontier of taking care of patients and also those on night shift will be those first enjoying the pay raise.In the future，all the nurses will get a higher income.

In 2013，we intensify the reform， and bring into effect the new mode of responsible nursing team corresponding to the responsible attending doctor system.After the establishment of the new mode of the exquisite full-course responsible nursing team，we once again revise our evaluation standard of nursing teams.Instead of regarding each department as a single unit of assessment，we evaluate the performance of each nursing team from then on.Every team shall be assessed according to nearly 20 different indicators including the amount and quality of medical performance，the cost efficiency， the patients’ degree of satisfaction and so on.

Step 6.The order of the day：impressive daily promotion of our unique hospital culture

If we regard the above-mentioned medical performance， technical services， hospital management and human resources allocation as points of junction of the hospital lean management chain， then there is no doubt that the hospital culture shall definitely be not only the join point，but also the constituent material of the chain itself.Only through the advocating of a self-promoting hospital atmosphere， all the concepts， strategies and tools of lean management can finally come into full play.

In the hospital lean management chain，hospital culture can not only be one of the join points，but also be the chain itself.An extraordinary hospital culture is the essential condition for any lean management，and a guarantee of improving the execution of the latter as well.

The management of hospital， in any time and under any circumstance， must obey the objective law of having ones unique culture before conducting any behavior according to it.It is hard to imagine carry into effect a lean， coordinative and effective management chain in a casual， impulsive and undisciplined hospital cultural atmosphere.

6.1　Management of the Hospital Culture——Tips from Professor YI， Head of the Hospital

During the development of the study and then the establishing of the theoretical system of hospital management in China，the construction of hospital culture remains to be a shortcoming.Especially during the reform of the state-owned hospital，the promotion of the hospital culture is spontaneous and unsupervised.

In fact， the construction of hospital construction is quite important.It is the soul， the air，the soil，the whole environment and atmosphere of the hospital management.Any further management has to take root in such an atmosphere.It is the total of both the material civilization and the spiritual civilization， for its containing of the philosophy of hospital management， the values， the rules and the standard of behaviors of hospital， the team building of staff， and also the culture activities as well.

Many developed countries and areas overseas have already pay special attention to the promotion of their hospital cultures.The Mayo Clinic in USA advocates a culture called Team Learning，which emphasizes lifelong learning.In Sweden，the Karolinska University Hospital promotes a culture of continuous innovation，encouraging their staffs to break away from conventions and to develop Translational Medicine.

The Nethersole Hospital in Hong Kong advocates a culture of personal competence.Through the enhancing of individual competence， the coping of risks， the construction of strategic guidance，they successfully have improved the competence of all the employees.As for the Raffles Hospital in Singapore，they lay emphasis on a service culture.They upgrade their medical service to a higher level by learning from top-level company like Singapore Airlines and Raffles Hotel.

The hospital culture should be a unique feature，and the special mark of a hospital.It is a symbol of excellence.First of all，it needs the continuous learning and innovation of the head and directors of the hospital.Secondly，all the elite employees and backbones shall support all the promotion and take the lead as well as exert the model effects.Last but not the least，the promotion has to be widely acknowledged， conformably advanced， and fully implemented by all the staffs of the hospital.These are the three layers，as well as three steps of the construction of hospital culture.

The hospital culture can exert important influence in hospital management.It changed the executive orders of the head and directors of the hospital into a cultural strength which can guide staffs to obey the management voluntarily.This would then become a highly efficient executive power.Meanwhile，it can also be the incantation which stops certain least ambitious employees from not obeying the disciplines.

The management of hospital culture is not constrained by time and place.It can embody in different forms and take effect in different places， not matter on individuals， on a group of people， in a specific place or all over a whole area.It exists throughout the whole process， every link and every occasion of the hospital development.

6.2　Management of the Hospital Culture Can Work Wonders

Culture can play important role in hospital management

First：Guiding the Course of Development

The accumulation and innovation of the hospital culture can form unique philosophies of hospital management and humanistic spirits，all of which are great impetus that can guide the course of further development.If the motivations and intentions of the head of hospital can be changed into strategic goals and management prospects through the effects exerted by hospital culture，it is easier for those administrative orders to gain acknowledge from all the employees， who， in return，will do their best to work for those goals and prospects.

Second：Unifying and Bringing Everyone Together for the Same Goal

The most important effect of culture is to bring everyone together as a unity.There must be ups and downs during the daily operation of the hospital.Although innovation must be emphasized，what dominates is still the daily normal routine management.Culture is the most important tool which can most effectively help to maintain hospital management in a stable positive condition.It can bring together all the staffs and promote an atmosphere of“each one have a stake in the success of the hospital， and also shares its disgrace together.”

Third：Edifying and Regulating Thoughts and Conducts

The hospital culture can be embodied in activities， but it is more than an atmosphere， an environment as a whole.Everyone working in such an atmosphere will definitely be deeply influenced by it.This is why people working in the same hospital are always found to have similar thoughts and conducts.The head or administrators of a hospital must stress on the edifying function of the hospital culture.In many occasion，the atmosphere and unconscious mass requirement can be tacit but unanimous codes of behaviors.

Fourth：Coordinating Staffs

For the management system of a hospital，coordination is quite important.There must be lots of differences between different departments or between different staffs，which emphasize all the more the importance of cooperation and coordination.

To unify and realize the cooperation between all the departments and staffs，culture is the most important and crucial tool.The better promotion of the culture is，the stronger effects the administrative orders can exert.It also works the other way around.

Fifth：Bringing forth the Collective Identification

The aim of advocating certain hospital culture is to bring forth the collective identification among all the employees，the manifestations of which may include willingly acceptance of the administrative decisions and measures，voluntarily taking part in the implementing and do ones positive contribution in the process.

The “Lean” culture——We advocate and explore to implement fine management to the hospital， and to instill the concept of“lean” into all the staff， as well as the whole process of management and medical treatment.

The concept of“lean” brings us the idea of being responsible to everything and pursuing perfection.No matter we are studying or working，it always reminds us to do our best on each aspect and to make details better and more competent.

The “lean” culture requires each of us to be rigorous and diligent， to develop the habit of thinking and reflecting and to hold the belief of keeping forward.In all，it requires us to be“lean” in every aspect of our study， work and life.

Culture of innovation

Week of Science and Technology Culture-Let Innovation Become the Main Theme of Hospital Development

The hospital takes it as top priorities to increase the level of discipline construction，enhance technological innovation， and focus on talent cultivation.Every year， it will hold the Conference of Scientific and Technological Innovation，which has become a necessary and critical conference for the hospital.

In March of each year， the hospital will hold a grand “Week of Science and Technology Culture”　activity during the hospital anniversary， an activity which has been held for many years.During the activity，the hospital will carry out a series of activities in various forms and categories， such as holding a high-level symposium； inviting academicians or famous experts and scholars at home to give lessons in the hospital；holding a flag-raising ceremony in celebration of the hospital anniversary， which can gather all the hospital workers’ enthusiasm and love for the hospital； holding a conference of discipline construction and technological innovation， etc.In recent years，the discipline construction of the hospital has made striking progress.

The “Bright Ideas” Activity-Let“Bright Ideas” Kindle the Sparks of Innovation

Since 2005，the hospital has organized the “Bright Ideas” activity each year， during which，all the people will gather and discuss over the hospital development program， its key work， as well as bottlenecks and urgent problems it encounters during the development.One specific theme will be discussed each year，and the wisdom and efforts of the whole workforce will be pooled.

Activities like this can fully arouse the enthusiasm of the whole staff.Besides， the “brainstorming method” can help resolve many problems arising in the hospital development， supported by one bright idea after another.

Culture of Learning

Morning and Evening Courses-

Since July， 2004，we have opened “morning and evening courses” each month for workers with senior and secondary professional titles and those with primary titles separately.In an hour before work or after work， we give medical education to them， namely “morning courses” and“evening courses”.

Till now， we have opened 185 morning courses， with 57，972 attendees； and 98 evening courses， with 17，339 attendees.Renowned deans and scholars have been successively invited to give lessons in the hospital and make introductions in many aspects ranging from hospital management， scientific research， cutting-edge technologies， and use of equipment.It has accelerated the pace of knowledge update concerning the medical staff.

Learning by New Employees-

Since November， 2009，the Office of New Employees has organized two to three different courses each week at the time of night self-study，concentrating on ideological quality and the writing quality of medical record； learning of “three bases” theories， key clinical theories， clinical practice and clinical operation skills， as well as lectures on professional skills.During the learning，theories and practice are combined， as well as book learning and clinical practice.Besides， observations of night emergency surgeries are arranged for，and education in weak links of learning is strengthened.All of these have achieved positive responses and actual effects！

From November， 2009 when the Office of New Employees was established to March， 2014，514 night self-study and 594 observations of night emergency surgeries were organized.Besides，32 theme activities（doctors and nurses were separated）and 144 various lectures were held.All of these activities witnessed an attendance rate of over 95%.

Calling for Papers from Employees-

How does the dean know the feelings of employees？How the employees release their personalities？ How to cultivate thoughtful employees？ To solve these seemingly complicated problems，we can actually use a simple method-calling for papers from employees.

For some significant events covering the whole hospital，significant moments with special meaning， or some seemingly negligible “trifles”， we often ask employees to write a composition around a given topic.There is no restriction on genres or styles.Poems， essays， narratives， or even hint fictions can be accepted，as long as they express their thoughts and feelings about the topic.

The“Calling for Papers from Employees” activity provides direction for the construction of hospital culture.Through it，the dean also knows how to shape hospital culture favorable to the general staff.That is because nobody knows the hospital culture better than employees themselves and no culture can exist with employees being isolated.

Culture of competition

Awareness of Competition Being Raised by Table Tennis-

Since 2011 when our hospital's Puren Table Tennis Club won the championship for the first time，the horn of Puren has been blown.The small ping-pong ball has been bouncing with the increasing strong pulse of Wuxi No.2 People's Hospital.Although the Club is young，it has been developing with irresistible and unstoppable force.

Through the competition， employees’ spare-time lives have been greatly enriched， friendship among them has been enhanced， and team cohesion been strengthened.Besides， the employees’interest in sports activities has been stimulated and their physical strength been built up.All of these fully display the good spirits of the staff in Wuxi No.2 People's Hospital，who are both aspiring and vigorous.

Health Culture

Studying and Exercising for Half an Hour Respectively-

In the second half of 2013，we carried out the“Studying and Exercising for Half an Hour Respectively” health activity in the hospital.“Studying for half an hour” requires the employees to keep individual learning， team-based learning， as well as professional learning.Various departments in the hospital are required to organize and undertake professional training activities，such as academic lectures， introduction of new advances in medical science， case discussion，and theme-based salons.Every month，lectures open to the whole hospital will be selected and held in Tuesday and Wednesday， lasting for one hour each time.Till now， 24 lectures like this have been held with over 6，000 attendees.

“Exercising for half an hour” requires the employees to insist on physical activities and exercise after doing their own job well.Physical activities in various forms are advocated.The Translational Medicine Platform also regularly opens a one-hour theme-based training course，serving for clinical practice.The hospital keeps organizing morning courses，evening courses and season courses.The Trade Union organizes the staff to ride a bike， hike the Lihu Lake， play football， and hold various forms of table tennis and badminton matches，which makes each day of employees rich and full of joy.These activities have received a positive response from the employees in the whole hospital.

Our thoughts on how to construct a lean chain of hospital management

Firstly，to improve the quality control circle and more specifically quality and effects of medical care，which is the key task of the hospital.

Secondly，to improve and strengthen construction of talent team and discipline construction.

Thirdly， to build a lean system of performance， as well as rewards and punishments， which are adapted to the hospital characteristics.

Fourthly， to improve hospital services in threes aspects： efficiency， benefit and performance.

Fifthly，to actively explore a mode of innovating and reforming the operating mechanism of public hospitals.

Sixthly，to develop a learning culture featuring in continuous efforts for improvement.

Summary

The lean supply chain and collaboration theories play a critical role in raising the level of fine management.It should be our major grasps and scientific method for scientific management of the hospital.

To build a lean chain of hospital management，hospitals can choose several factors which they think important based on their own practice and management tasks at different stages，and further form a core chain of fine hospital management.Through the mechanism of triangle tools involving PDCA circulation and fine hospital management，different parts of the chain can be connected more tightly and driving effects of scientific hospital management can be achieved.

Building a lean chain of hospital management is an open-ended issue.Since different deans and managers in different hospitals have different understanding，focus on different factors and employ different strategies，then the effects of the chain might differ.But it is surely beneficial to scientific management of each hospital and it is worthy of everybody's learning， thinking， exploring and re-innovation.