The problem involved in this study is to determine the progress in the last decade of a representative number of elementary schools of Texas in their methods of reporting child growth to parents.

The information conveyed to parents on traditional report cards can be misleading. Although the use of the letter grade system has been in place for more than a century, these grades do not give parents the information they need in order to help ensure that their children are academically successful. In order to address this issue, schools must review the methods by which they communicate student progress. In this study, the parents of students in an elementary school classroom were told the benefits of using standards-based report cards and were shown how to read them. They were then provided with a standards-based report card detailing how their children performed in reading. Following the use of this report card, parents completed a questionnaire and were interviewed about their perceptions of using this revised reporting document.

The goal of Title I is to provide extra instructional services and activities that support students identified as failing or most at risk of failing the state’s challenging performance standards in mathematics, reading, and writing. Low-income schools or Title I schools are the primary target of Title I funds. A school is eligible for Title I status when 40% of the school’s students are from low income families; these students are identified by their eligibility to receive free and reduced priced meals. The purpose of this study was to determine whether there is a significant difference in elementary schools’ TVAAS Composite scores between Title I and Non-Title I schools. Specifically, this researcher examined the relationship of Title I funding with student academic growth at the elementary level. The schools were located in rural Tennessee. Data were gathered from the 2012-2013 and 2013-2014 Tennessee State Report Cards and the TNDOE to determine if there was a statistically significant difference between the 2 types of schools. Research indicated mixed reviews on the impact Title I funds have on lower socioeconomic schools. The researcher performed 5 paired t test and 8 Pearson correlation coefficients. There was a significant difference in the schools’ composite scores between Title I and Non-Title I elementary schools in Tennessee. Non-Title I elementary schools in Tennessee had higher composite scores than those of the Title I elementary schools. Results from the Pearson correlations indicated no significant relationships for mean years of teaching experience with school composite scores.

由於醫療服務具高度專業性，故醫療照護市場長期存在資訊不對等的問題。隨著消費者利益保護及病人權利運動的興起、民眾被要求在自己的健康上承擔更多的責任，積極參與健康決策、新資訊科技的發明，使得醫院醫療與服務品質資訊的收集更容易且成本更低廉，因此，歐美各國近年來積極建立健康照護市場的品質資訊，發展醫院品質報告卡，提供民眾就醫選擇所需的資訊，期望能達成保障民眾的醫療權益，同時促使醫院提升醫療與服務品質，及增進醫療照護市場運作效率的目標。 台灣自1995年起實施全民健康保險制度，醫院與中央健康保險局的特約率達90%以上，民眾享有極大的自由選擇就醫地點及醫院，然而到目前為止，仍然欠缺足夠的醫院醫療與服務品質資訊提供給民眾做為選擇醫院的參考。其次，相關研究的結果顯示，台灣民眾對於就醫選擇資訊的提供有高度的興趣，且對民眾就醫選擇決策亦有重大的影響。 目標：本研究旨在由民眾觀點篩選醫院醫療與服務品質報告卡的指標項目，及採用創新擴散理論(innovation diffusion theory)，以結構方程模式(structural equation model)探討住院病人對醫院醫療與服務品質報告卡創新特性的知覺、態度及使用意願。 方法：本研究首先以推動社會福利、關心民眾健康權益及病人團體的30位專家為研究對象，進行二回合的德菲法(Delphi method )問卷調查篩選醫院醫療與服務品質報告卡的指標項目。其次以台北縣市不同層級及權屬別的八家醫院內、外科共500位住院病人為研究對象進行面訪問卷調查，探討住院病人創新接受度、對醫院醫療與服務品質報告卡創新特性的認知、態度及使用意願，並以結構方程模式進行研究假說與架構的驗證。 結果：1.由民眾觀點所選出屬於高適用性且高重視度的指標項目計有院內感染率、手術傷口感染率、住院病人對醫師病情解說內容的滿意度、門診病人對醫師服務態度的滿意度等九項；2.只有17.2%的住院病人在填問卷前有聽過醫院醫療與服務品質報告卡這個名詞；3.有80.2%的住院病人認為醫院醫療與服務品質報告卡對選擇醫院是非常有價值或有價值的；4.住院病人對服務品質指標的瞭解程度相對地高於對醫療品質指標的瞭解程度；5.對呈現方式的瞭解程度由高至而低排序，依序為星號、百分比、長條圖；6.影響「住院病人是否看懂醫院醫療與服務品質資訊」的因素，在控制其他變項的影響後發現，教育程度愈高者、年齡愈輕者、個人平均月收入較高者，較看懂醫院醫療與服務品質報告卡範例中指標資訊；7.創新特性中，「相容性」及「結果展示性」對「對醫院醫療與服務品質報告卡的態度」具有正向的顯著影響；8.「知覺有用性」、「對醫院醫療與服務品質報告卡的態度」及「創新接受度」對「使用醫院醫療與服務品質報告卡的意願」具有正向的顯著影響；9.影響住院病人「對醫院醫療與服務品質報告卡的態度」最主要因素為「相容性」，且達到統計上的顯著水準；10.影響住院病人「使用醫院醫療與服務品質報告卡的意願」的最主要因素為「對醫院醫療與服務品質報告卡的態度」，且達到統計上的顯著水準；11.最後要特別強調的是，本研究的新發現為「知覺有用性」、「知覺易用性」、「相容性」、「結果展示性」、「創新接受度」，兩兩之間具有統計上之顯著相關，這是本研究與以往相關研究結果的最大不同發現。 結論：住院病人認為醫院醫療與服務品質報告卡對選擇醫院是有價值的，因此，建議行政院衛生署可考慮主導，整合醫院評鑑、全民健康保險申報及病人滿意度調查的資料，分區分醫院等級，評比其在高適用性且高重視度的九項指標項目之表現，以星號及百分比的形式呈現，再以小手冊及網際網路查詢的方式對外公佈，並加強對民眾的宣導教育，讓民眾可以將品質資訊運用在就醫選擇決策上，使民眾成為明智的醫療服務消費者及醫療與服務品質的共同監督者，以提升醫療體系的運作效能。 / There exists information asymmetry between providers and consumers in healthcare market due to the highly specialized knowledge in this market. Consumers were asked to bear more responsibility on their own health and to participate in the formulation of healthcare strategies and the inventions of new technology as the uprising in the movement of consumer right protection. These would result in the reduction in costs related to the medical services and information collection. Therefore, western countries have aggressively established the medical information system and developed hospital report cards in order to protect consumers’ right, to improve quality of medical services, and to increase the efficiency of healthcare market by providing service information to consumers. Taiwan initiated the National Health Insurance since 1995 with the facility contract rate reaching over 90%. This provides consumers great access to healthcare institutions. However, few service data have been provided to consumers as a reference for the choice of providers to date. In addition, previous studies showed that consumers were interested in obtaining available service information and these information have a great influence on consumers’ decision of providers. Objectives: The purposes of this study were to select indicators of hospital report cards from public’s perspective and to adopt the innovation diffusion theory and structural equation modeling to explore inpatients’ perception characteristics of innovation, attitudes toward, and willingness to use hospital report card. Materials and Methods: Firstly, we selected 30 subjects who were experts in social welfare or consumer right to participate in two rounds of Delphi investigation to select appropriate indicators of hospital report card. Secondly, we purposely ask for the permission from eight hospitals representing different accreditation levels and ownerships to allow us to select 500 medical and surgical inpatients to conduct a face-to-face interview regarding their innovativeness, perception characteristics of innovation, attitudes toward, and willingness to use hospital report cards. Finally, we used structural equation modeling (SEM) to test research hypotheses by way of. Results: We found that (1) from publics’ perspective the most applicable and important indicators include nosocomial infection rate, postoperative infection rate, inpatient’s satisfaction toward physician’s explanation, and outpatient’s satisfaction toward physician’s service attitudes; (2) only 17.2% of surveyed sample heard the term “hospital report card” before; (3) a total of 80.2% of inpatients considered hospital report cards to be very valuable or valuable for the selection of providers; (4) inpatients understood more in service indicators than clinic indicators; (5) the order of inpatients’ preference in presentation of hospital report cards was to use stars, percentages, and bar charts; (6) those who had higher education and higher monthly incomes, and were younger were more likely to understand the information provided by hospital report cards after adjusting for other factors; (7) among inpatients’ characteristics of innovation toward hospital report card, ”compatibility” and “result demonstrability” had significant positive influence on ”inpatients’ attitude toward hospital report card”; (8)”perceived usefulness”, “inpatients’ attitude toward hospital report card”, and “inpatients’ innovativeness” had significant positive influence on ”inpatients’ willingness to use hospital report card”；(9)”compatibility” had significant positive influence on “inpatients’ attitude toward hospital report card”；(10)“inpatients’ attitude toward hospital report card” had significant positive influence on ”inpatients’ willingness to use hospital report card”；(11)finally it is worth emphasize that this study had a new finding that ”perceived usefulness”, “perceived ease to use ”, “compatibility”, “result demonstrability ”,and “inpatients’ innovativeness” had significant positive correlation between each other. Conclusions: We concluded that inpatients considered hospital report cards to be valuable for the selection of hospitals. Therefore, it is recommended that hospital report cards be initiated by the Department of Health by integrating the information from hospital accreditation, medical claims data from the National Health Insurance, and survey of patient satisfactions. The rankings of hospital shown on report cards can be presented in stars or percentages, and these pieces of information can be released through booklet or Internet. In addition, consumers should be educated to use hospital information in order to monitor hospital performance and improve the efficiency of healthcare delivery system. / 目 錄 誌謝……………………………………………………………… Ⅰ 摘要……………………………………………………………… Ⅲ Abstract………………………………………………………… Ⅴ 目錄……………………………………………………………… Ⅶ 表目錄……………………………………………………………… Ⅹ 圖目錄……………………………………………………………… Ⅻ 第一章 前言……………………………………………………… 1 第一節 研究背景與動機………………………………… 1 第二節 研究目的與研究問題…………………………… 5 第三節 研究的重要性與預期貢獻……………………… 6 第二章 文獻探討………………………………………………… 8 第一節 醫院品質報告卡的沿革……………………………… 8 第二節 醫院品質報告卡的指標項目………………………… 15 第三節 醫院品質報告卡的影響與推行障礙………………… 27 第四節 醫療品質指標系統及品質報告卡的發展步驟……… 32 第五節 創新擴散理論………………………………………… 37 第六節 結構方程模式………………………………………… 43 第七節 國內外相關實證研究之結果………………………… 48 第八節 綜合討論……………………………………………… 76 第三章 以德菲法篩選醫院醫療與服務品質報告卡之指標項目. 79 壹、研究方法……………………………………………………… 79 第一節 研究設計與流程………………………………………… 79 第二節 研究對象………………………………………………… 79 第三節 研究工具………………………………………………… 81 第四節 資料處理與分析………………………………………… 95 貳、研究結果……………………………………………………… 95 第一節 問卷回收情形…………………………………………… 95 第二節 描述性統計分析………………………………………… 96 第三節 第一回合與第二回合問卷調查結果差異分析…………105 參、討論……………………………………………………………106 第一節 重要研究結果討論………………………………………106 第二節 研究限制…………………………………………………108 第四章 住院病人對醫院醫療與服務品質報告卡的認知、態度 與使用意願……………………………………………… 110 壹、研究方法………………………………………………………110 第一節 研究架構、目的與假說…………………………………110 第二節 研究對象…………………………………………………118 第三節 研究變項之操作型定義…………………………………121 第四節 研究工具…………………………………………………124 第五節 資料處理與分析…………………………………………126 貳、研究結果………………………………………………………128 第一節 問卷信度及效度的檢定…………………………………129 第二節 樣本基本特質與研究變項的統計分析…………………130 第三節 研究假說與架構的驗證…………………………………170 參、討論……………………………………………………………178 第一節 重要研究結果討論………………………………………178 第二節 研究限制…………………………………………………187 第五章 結論與建議………………………………………………188 第一節 結論………………………………………………………188 第二節 建議………………………………………………………191 參考文獻……………………………………………………………194 附錄…………………………………………………………………209 附錄一、德菲法問卷專家效度名單………………………………209 附錄二、德菲法問卷專家名單……………………………………210 附錄三、醫院品質報告卡指標項目適用性及重要性評分問卷 212 附錄四、醫院品質報告卡指標項目適用性及重要性評分問卷 (第二回合) ………………………………………………224 附錄五、住院病人對「醫院醫療與服務品質報告卡」的認知、 態度與使用意願之研究問卷專家效度名單……………246 附錄六、住院病人對「醫院醫療與服務品質報告卡」的認知、 態度與使用意願之研究…………………………………247 附錄七、醫院醫療與服務品質報告卡的範例……………………254 表目錄 表2-1品質報告卡的種類及指標項目…………………………… 20 表2-2台灣有關醫療品質指標的實證研究……………………… 50 表2-3台灣用來評估醫院醫療品質的指標彙總表……………… 56 表2-4有關民眾(病人)選擇醫院(醫師)考量因素的實證研究… 58 表2-5台灣有關醫院品質報告卡及民眾就醫選擇資訊需求的相 關研究 ……………………………………………………… 66 表3-1本研究初步選取醫院醫療與服務品質指標的來源或依據…84 表3-2本研究所採用醫院醫療與服務品質指標的操作型定義……87 表3-3問卷發放及回收情形…………………………………………96 表3-4德菲法專家問卷分析結果……………………………………99 表3-5適用性前十名指標項目及其平均值 ………………………103 表3-6重視度前十名指標項目及其平均值 ………………………104 表3-7適用性與重視度交叉分析矩陣表 …………………………104 表3-8高適用性且高重視度指標項目 ……………………………105 表3-9Wilcoxon Signed Ranks Test 檢定結果………………… 109 表4-1研究對象分配表—依層級別、權屬別及性別分 …………120 表4-2預試問卷各成份信度結果 …………………………………125 表4-3有效樣本分佈情形—依醫院別 ……………………………131 表4-4樣本個人基本特質與就醫選擇資訊搜尋及需求狀況 ……133 表4-5對醫院醫療與服務品質報告卡的認知 ……………………137 表4-6對醫院醫療與服務品質報告卡之指標及呈現方式的瞭解 程度…… ……………………………………………………139 表4-7醫院醫療與服務品質報告卡創新特性之描述性分析 ……140 表4-8醫院醫療與服務品質報告卡的態度及使用意願之描述性 分析………………………………………………………… 144 表4-9創新接受度量表之描述性分析 ……………………………145 表4-10住院病人自覺醫院醫療與服務品質報告卡對選擇醫院有 無價值影響因素的雙變項分析……………………………147 表4-11病人自覺品質報告卡對選擇醫院有無價值影響因素之複 迴歸分析……………………………………………………149 表4-12住院前有無先探聽醫院醫療與服務品質資訊影響因素的 雙變項分析…………………………………………………151 表4-13住院前有無探聽醫院醫療與服務品質資訊影響因素之複 迴歸分析……………………………………………………153 表4-14住院病人是否看懂醫院醫療與服務品質資訊影響因素的 雙變項分析…………………………………………………155 表4-15住院病人是否看懂品質資訊影響因素之複迴歸分析……157 表4-16住院病人是否需要醫院醫療與服務品質報告卡影響因素 的雙變項分析………………………………………………159 表4-17住院病人是否需要醫院品質報告卡影響因素之複迴歸分 析……………………………………………………………161 表4-18住院病人會不會參考醫院醫療與服務品質報告卡影響因 素的雙變項分析 …………………………………………163 表4-19住院病人會不會參考醫院品質報告卡影響因素之複迴歸 分析…………………………………………………………165 表4-20住院病人是否會更換就醫醫院影響因素的雙變項分析…167 表4-21住院病人會不會更換到其他的醫院看病影響因素之複迴 歸分析…… ………………………………………………169 表4-22住院病人創新接受度、對醫院醫療與服務品質報告卡創 新特性之知覺、態度與使用意願理論架構因果模式之配 適度檢定結果………………………………………………171 表4-23整體模式之多元相關平方(SMC) …………………………171 表4-24外因潛在變項與其測量變項關係之標準化係數之檢定…173 表4-25內因潛在變項與其測量變項關係之標準化係數之檢定…174 表4-26潛在變項間之因果關係的標準化係數之檢定……………174 表4-27外因潛在變項間相關係數之檢定…………………………175 表4-28研究模式的間接、直接與整體效果………………………175 表4-29研究假說檢定結果…………………………………………176 圖目錄 圖2-1Rogers的創新--決策過程典範………………………………41 圖3-1德菲法研究流程………………………………………………80 圖4-1研究架構 ……………………………………………………111 圖4-2本研究之結構方程模式關係路徑圖 ………………………177

The research in this thesis has been undertaken to develop statistical tools for monitoring adverse events in hospitals that adjust for varying patient risk. The studies involved a detailed literature review of risk adjustment scores for patient mortality following cardiac surgery, comparison of institutional performance, the performance of risk adjusted CUSUM schemes for varying risk profiles of the populations being monitored, the effects of uncertainty in the estimates of expected probabilities of mortality on performance of risk adjusted CUSUM schemes, and the instability of the estimated average run lengths of risk adjusted CUSUM schemes found using the Markov chain approach. The literature review of cardiac surgical risk found that the number of risk factors in a risk model and its discriminating ability were independent, the risk factors could be classified into their "dimensions of risk", and a risk score could not be generalized to populations remote from its developmental database if accurate predictions of patients' probabilities of mortality were required. The conclusions were that an institution could use an "off the shelf" risk score, provided it was recalibrated, or it could construct a customized risk score with risk factors that provide at least one measure for each dimension of risk. The use of report cards to publish adverse outcomes as a tool for quality improvement has been criticized in the medical literature. An analysis of the report cards for cardiac surgery in New York State showed that the institutions' outcome rates appeared overdispersed compared to the model used to construct confidence intervals, and the uncertainty associated with the estimation of institutions' out come rates could be mitigated with trend analysis. A second analysis of the mortality of patients admitted to coronary care units demonstrated the use of notched box plots, fixed and random effect models, and risk adjusted CUSUM schemes as tools to identify outlying hospitals. An important finding from the literature review was that the primary reason for publication of outcomes is to ensure that health care institutions are accountable for the services they provide. A detailed review of the risk adjusted CUSUM scheme was undertaken and the use of average run lengths (ARLs) to assess the scheme, as the risk profile of the population being monitored changes, was justified. The ARLs for in-control and out-of-control processes were found to increase markedly as the average outcome rate of the patient population decreased towards zero. A modification of the risk adjusted CUSUM scheme, where the step size for in-control to out-of-control outcome probabilities were constrained to no less than 0.05, was proposed. The ARLs of this "minimum effect" CUSUM scheme were found to be stable. The previous assessment of the risk adjusted CUSUM scheme assumed that the predicted probability of a patient's mortality is known. A study of its performance, where the estimates of the expected probability of patient mortality were uncertain, showed that uncertainty at the patient level did not affect the performance of the CUSUM schemes, provided that the risk score was well calibrated. Uncertainty in the calibration of the risk model appeared to cause considerable variation in the ARL performance measures. The ARLs of the risk adjusted CUSUM schemes were approximated using simulation because the approximation method using the Markov chain property of CUSUMs, as proposed by Steiner et al. (2000), gave unstable results. The cause of the instability was the method of computing the Markov chain transition probabilities, where probability is concentrated at the midpoint of its Markov state. If probability was assumed to be uniformly distributed over each Markov state, the ARLs were stabilized, provided that the scores for the patients' risk of adverse outcomes were discrete and finite.

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