本研究主要在探討離島兩家公立醫院，在政府醫療整合政策下合併是否真能妥善利用當地有限資源並提升當地之醫療品質與醫療滿意度。本研究以澎湖醫療大樓落成啟用引進三軍總醫院及署立澎湖醫院醫事人力作為時間點，蒐集整理醫院經營管理資料，比較醫療大樓使用前後，醫療資源利用情形，對於民眾關切之四項議題：（一）醫療整合政策與提升當地醫療品質的關係。（二）醫療整合政策與成本效益的關係。（三）醫療整合政策與組織管理的關係。（四）醫療整合政策與民眾滿意度的關係之探討，採以質性田野調查方式作深入剖析與辯證，另對醫療品質滿意度觀察部分，則以門診就醫病患為調查對象，與質性調查結果作交叉驗證，分析探討整體社會對醫療服務品質滿意度之觀感。試圖從不同層面與角度來詮釋、剖析醫療整合政策與民眾對醫療服務品質滿意度間有無存在背後深層的意義及潛在的社會意涵。 / 本研究發現（一）政府的整合醫療政策，目的是將離島有限的資源作有效的運用，在方向上是正確的。，醫療大樓要做到何種規模須視其未來的定位與所開的床位數而定，若要求持續提供一定品質的醫療服務，政府常態性的預算補助是必要的。（二）假日緊急醫療需求無法在地圓滿解決，是澎湖地區長期以來醫療服務主要的缺口，兩院整合後目前仍未能解決該問題，是造成澎湖整體社會對醫療品質觀感不若預其的原因。（三）病患與醫療專業人員對醫療品質的認知是有差距的，這代表醫、病雙方所能掌握的醫療品質資訊是不對稱的，病患不瞭解醫界對醫療品質的評核標準，只能用直接的感受來體驗，是造成雙方在衡量醫療服務品質時出現落差的原因。（四）在組織重整過程中，「同工同酬」問題因不同公務體制無法於第一時間解決，造成員工內心不滿與不安，亦是影響整體社會對醫療服務觀感不若預其的因素。（五）在基本人口特質中，軍人、家人同住多者及醫療服務使用率較高者，這三類群體對醫療服務品質的認知有較客觀的認定，應與其對醫療服務的體驗有較多之經驗有關。（六）以模擬醫事人力供需情境分析，澎湖地區並非是一個醫事人力不足或醫療資源缺乏的地區，而是在健保制度下形成醫療資源分配不均的問題。本研究建議健保醫療給付應配合政府公共政策才是解決離島醫療問題有效的方式。（七）離島醫療成本相當昂貴，以侷限的地域、不足的消費人口及健保總額支付制度限制下，要發展在地醫療或提升至區域級醫療服務品質宜審慎考慮，建議遠距醫療合作、空中轉診後送結合軍方穩定的醫療人力支援，可能仍是最佳解決問題的模式。 / The purpose of this study is to explore how two public hospitals on Penghu Island can really make good use of limited local resources to improve medical quality and patient’s satisfaction under nation wide integration of health care policy. This study adopts qualitative research and interview method on the following four items that are of great concerns to the local general public: (1) the relationship between the integrated medical policy and improvement of local medical quality (2) the relationship between the integrated medical policy and hospital performance (3) the relationship between the integrated medical policy and organizational management (4) the relationship between the integrated medical policy and patient’s satisfaction. As to the observation of client satisfaction of medical treatment, the targets are out-patients with analysis of their satisfaction with the medical services. This study also intends to interpret from different aspects and perspectives the real social meaning presented by the relationship between the integrated medical policy and client satisfaction. / This study has discovered the following: (1) The decision of the integrated medical policy with purpose of effectively deploying limited resources on off-shore islands is correct. However to what extent a medical building should provide its service is dependent on its hospital beds capacity and the definition of its role. Regular budgetary support from the government is necessary if stable quality of medical services is desired. (2) One of the main reason about people’s satisfaction with overall medical services provided on Penghu has not met the expectation is that there still did not provide a good resolution to the urgent medical support on Holiday after the integration of two hospitals medical resources. (3) There is a gap between professional medical services providers and patients in recognizing the quality of medical services. This means that the information obtained by both parties regarding the quality of medical services is asymmetric. Patients do not understand the criteria used to review the quality of medical services and as a result, they depend on very direct feeling or experience to make the judgment, thus causing the gap. (4) During the process of reorganization, the issue of “equal work with equal compensation” did not receive appropriate attention and was not resolved properly by different governmental bureaucratic systems which led to the fact that the quality of medical services is not as good as expected. (5) Three fundamental elements of population, military personnel, families with most of their members living together, and frequent users of medical services, have possessed more objective recognition of the quality of medical services due to their more sufficient experience in using medical services. (6) a simulated analysis of demand and supply of medical services has indicated that Penghu Island shall not be regarded a region lack of medical personnel or barren of medical resources. This study suggests that the compensation provided under the National Health Insurance System must go hand in hand with government public policies to provide an effective way to resolve medical problems on off-shore islands. (7) The cost of medical services on off-shore islands is high. Under the conditions of limited population in limited areas and the per-quota-compensation provided by the National Health Insurance System, we need to carefully consider how to develop or upgrade its quality level. It is, therefore, suggested that distant medical cooperation, aerial medical transport together with stable supply of medical personnel from the military provides probably the best model for resolution of the problems.

因國人健康意識改變，就醫動機除了疾病之診斷治療之外，亦要求醫療活動之安全與品質。現行醫療訴訟實務，無論採用契約責任或侵權責任為請求權基礎，多以醫事人員是否有過失行為為主要爭點；然而，造成醫療損害的原因包括管理過失及人為過失，而醫療錯誤常發生在人與物的介面之中，此種訴訟方式將使醫療錯誤隱藏於醫事人員過失背後，無法呈現出醫療損害發生原因之全貌，亦無法對醫療品質改善及病人安全提升有所助益。本文以維護病人安全及提升醫療品質為目標，以醫院病人關係為基礎，重新定義醫院醫療服務及其內容，並建構醫院醫療服務之民事責任。 醫院之醫療服務係指「病人就醫過程中，醫院為診治病人所提供之一切專業醫療服務。」此定義涵括病人就醫過程中，所有需要專門醫事人員執行之醫療行為，及相關輔助之醫療軟硬體。 在醫院病人之醫療契約方面，病人締約目的為「以『專業』『安全』之醫療照護體系，達到控制或降低疾病可能風險的目標」，醫院依債務本旨應以「『專業』『安全』之醫療照護體系」為給付。醫院若違反其契約上給付義務，致病人受損害者，將可構成債務不履行責任。 在醫院醫療服務之侵權責任方面，無論僱用人侵權責任採推定過失或無過失責任模式，於醫療實務之適用上皆有許多缺點，而且無法對病人安全及醫療品質有所助益，我國應參考德國組織義務理論及美國醫院組織責任，建立醫院本身義務之理論基礎與具體內容，使醫院因醫療錯誤造成病人損害時，能獨立負起侵權責任。而違反保護他人法律之侵權責任因涉及法律認定之解釋問題、法律體系混淆及法律經濟因素，於醫療服務之適用仍有待研究。 醫院醫療服務是否能適用危險責任，應依立法目的、服務本質、分散風險可能性、舉證困難等因素，決定其適用可能性。鑑於侵權行為之個人責任原則無法提升醫療品質，病人亦無法得到實質賠償，美國學界開始提倡醫療企業責任，以醫院作為醫療錯誤的唯一賠償責任人，使醫院致力於醫療錯誤之防免，達到維護病人安全及提升醫療品質之效果。考量我國目前醫療環境，在醫院企業化經營下，無過失責任於醫院醫療服務之適用應有重新審視之空間，以充實我國醫療糾紛民事損害賠償法制。實務應思考何謂「醫療服務提供欠缺安全性」的概念，以促進病人安全與提升醫療品質。

所有權結構、支付制度與競爭係影響醫院績效之關鍵因子，本研究援用相關文獻之發現，推論出三項因素對醫院績效之關係，並以我國獨特之總額預算制度為研究對象，蒐集、串連與合併不同來源之資料，實證檢視衝量競爭與所有權結構對醫院營運績效與醫療品質之聯合效果。 台灣於民國91年7月實施醫院總額預算制度後，浮動點值制度之設計為醫院間引入了衝量競爭(即虛假價格競爭)，而結算後之點值則係反映出醫院間衝量競爭後之結果，醫院除了需面對支付點值所致之財務衝擊外，尚須面對自全民健保實行後，備受醫院詬病之核減制度之衝擊，因此，本文首先嘗試估算醫院受到核減與支付點值所致之財務衝擊程度。無論是國外或國內之研究，對於不同所有權結構醫院之績效表現是否有差異性，一直無法獲得一致性之結論，除了納入營運效率之績效指標外，本研究亦採用疾病別與醫院層級別之醫療品質指標來檢視不同所有權結構醫院之績效表現。更以考量核減與支付點值所致之財務衝擊程度，取代目前文獻僅以總額前、後之二元變數，評估財務衝擊程度對營運效率、醫療品質與財務績效之影響。最後，則是檢視總額預算制度下，醫院受到之財務衝擊度是否會縮小不同所有權結構醫院之營運效率與醫療品質表現之差距。 實證研究發現，不同所有權結構醫院之營運效率並未有顯著差異，但不同所有權結構醫院在某些疾病別品質指標(子宮肌瘤切除手術之住院超過7日機率與再入院率)與醫院層級品質指標(院內感染率與淨死亡率)表現上則有差異性；且公立或非營利醫院受到核減與支付點值之財務衝擊高於私立醫院，因此不同所有權結構醫院之行為與績效存有某些差異性。台灣的醫院在總額預算制度下，若受到之財務衝擊程度愈大，其營運效率會變差、醫療品質也受到負面之影響、財團法人醫院之醫務利益率與稅後淨利率也會降低，但現金流量比則會增加，故財務衝擊愈大，醫院之績效愈低。若同時考量財務衝擊度對不同所有權結構醫院之營運效率與醫療品質之聯合效果後，可發現財務衝擊雖然不會縮小公立(或非營利)醫院與私立醫院營運效率之差距，卻縮小公立(或非營利)醫院與私立醫院醫療品質之差距，故以台灣資料可部分支持「不同所有權結構醫院績效差距縮小之因素係競爭力量之崛起」之論點。 / Hospital ownership, payment system and competition are all key drivers to influence hospital performance. This research infer and depict the association of these three drivers from the related literature and empirically examined the effects of fictitious price competition due to the floating point-value system and ownership on hospital operational performance and quality of care by combing and merging different sources of data. Deduction rate of claim and the floating point-value system are the two controversial debates to the payment system. I attempt to estimate hospital financial pressures as precipitated by deduction rate of claim and floating point-value system. To investigate whether for-profit, not-for-profit, and government hospitals differ in operating performance and quality of care, five diagnose-level and two hospital-level quality indicators are selected. Different from prior research, the financial pressure is captured by hospital data instead of a binary variable (pre and post global budget) and I examine the effect of financial pressure on hospital operational efficiency, quality of care and financial performance. Finally, we test whether differences in operational efficiency and quality care among hospitals with different ownership forms will mitigate or narrow, as hospital financial pressure increases. The results show that for-profit, not-for-profit and government hospitals are far more alike than different in operational efficiency, but ownership affects not only the rate of readmission and the rate of the length of stay larger than 7 days of uterine myomectomy, but also the hospital-level quality indicators: the rate of nosocomial infection and hospital mortality rate. I also find higher financial pressure incurred at government or not-for-profit hospitals than for-profits hospitals. Given my findings, we conclude that hospital ownership status affect performance in terms of quality of care and financial pressure from rate of deduction and float point-value system. The study shows that financial pressure adversely affects operational efficiency and quality of care. As not-for proprietary hospital financial pressure increases, the profit margin and net profit ratio will decrease, but the cash flow ratio will increase. Nonetheless, deduction rate of claim and global budget has a negative impact on hospital performance. This research further considers the joint effect of financial pressure on difference between quality of care and efficiency of for-profit hospitals and the other two types. My results indicate that hospital financial pressure mitigates the difference of quality of care between for-profit hospital and not-for profit (or government) hospitals, but does not narrow the difference in quality of care between for-profit hospital and not-for profit (or government) hospitals. This finding partly supports that increased competition should force not-for-profit (or governmental) hospitals to be increasingly similar to their for-profit counterparts.