成本控制和成本管理戰(zhàn)略【外文翻譯】

1、<p><b>　　外文翻譯</b></p><p><b>　　原文</b></p><p>　　Cost-Containment and Cost-Management Strategies</p><p>　　Material Source: Author: Alan f.

2、Goldberg ,William P. Fleming</p><p>　　The leadership and boards of trustees of all healthcare organizations are the ultimate stewards of the limited resources available to best meet community needs. The stra

3、tegic planning process leads the organization down a clear path of setting priorities, making choices, and taking action. The day a new cancer center opens or the latest technology arrives is an exciting one for the comm

4、unity.</p><p>　　After the ribbon cutting, these new programs become the responsibility of the hospital's service line directors or clinical managers. Their staffing is based on projections and other as

5、sumptions that may or may not be on point but have a direct impact on the operations and finances of the organization. </p><p>　　As part of normal decision making for a hospital's new initiatives, a paye

6、r mix and revenue stream were predicted. Now two significant environmental events have made projections more uncertain and put aggressive cost management on center stage: the economic downturn and payment reform.</p&g

7、t;<p>　　The economic downturn affecting hospitals began in the fall of 2008. Its broad impact on the organization was described by Goldberg and Petasnick (2010):</p><p>　　With credit markets drying up

8、, unemployment rising, consumer confidence eroding, and employee morale shaken, healthcare system executives had their hands full. The combined result of the turmoil made the old adage "cash is king" truer than

9、 ever. As consumers pulled back and individuals lost health insurance, hospitals experienced losses in volume for elective, nonemergent healthcare. Financial operating results suffered. Meanwhile, losses in investment va

10、lues eliminated the safety net reserves c</p><p>　　Because of the economic downturn and high unemployment, which led to income declines and individuals losing job-based healthcare coverage, Medicaid enrollme

11、nt is projected to increase 10.5 percent in fiscal 2010.</p><p>　　When you couple this with significant declines in state and federal revenue, there is a shortfall in meeting financial obligations. Not surpr

12、isingly, Medicaid cost containment is being put into place. Thirty-two states plan to reduce or freeze provider payments in fiscal 2010 and 48 states will do so in 2011 (National Governors Association 2010).</p>&

13、lt;p>　　With the passage of healthcare reform—the Patient Protection and Affordable Care Act signed into law March 23, 2010—major expansions to cover the uninsured are scheduled to take place on January 1, 2014. Though

14、 this brings clarity to elements of longer-term financial planning for the uninsured, the underinsured, and those with bad debt, payment reform means there will be trade-offs. Anticipated provider cuts in the next few ye

15、ars means there will be no surge in revenue in 2014. The difficult eco</p><p>　　One outcome of the act is the intense interest in cost-containment and costmanagement strategies. Much of this interest is driv

16、en by the need to achieve an organization-established financial goal and bridge the gap when requests and planned expenditures exceed available funds. However, cost management has grown far beyond the purview of finance

17、as payment reform initiatives have an impact on quality and process improvement and now carry financial rewards or penalties. Pertinent examples include </p><p>　　Beyond making internal comparisons of perfor

18、mance to budget, flexing resources to meet changing patient volumes and requirements, and comparing one's organization to similar institutions and available databases, how does one manage cost? It all starts with too

19、ls and programs such as labor resource benchmarking and analysis of the management span of control.</p><p>　　In practice, benchmarking is a nonstandardized term. For most, benchmarking means some kind of com

20、parison, such as an organization benchmarking itself to a best-practice organization:</p><p>　　1. Benchmarking is a process where our results are compared to a database of similar institutions.</p>&l

21、t;p>　　2. Benchmarking is where our organization tracks and compares to itself.</p><p>　　3. Benchmarking is where our organization is compared to a performance standard set by an outside organization.</

22、p><p>　　Cost management depends on staffing management decisions, which are best supported by benchmark process number three. Typically, 60 percent of a hospital's expense is labor, with a majority of that

23、expense in nursing. In many organizations this process is driven by operations or finance and is an intricate part of ongoing management and focus of the dashboard. The benchmarking described in number three should not b

24、e a one-time process, but rather should be done by an outside organization on an o</p><p>　　Many hospitals appear to have bloated management ranks based on analysis of title, pay grade, or who attends manage

25、r meetings. Although it is common in finance or IT to find individuals who are called manager or director and who manage Programs and not staff, in other departments managers should have direct reports to earn this desig

26、nation.</p><p>　　Span-of-control studies have concluded that, based on hospital organizational charts and position title, too many managers often do not have enough staff reporting to them. This finding is

27、 based strictly on job titles and organization charts. When the actual job is examined and defined, benchmarking experts often find it is not a management-level position, and if it is reclassified the hospital's span

28、 of control falls within the correct range. As a staff retention strategy, titles have inflate</p><p>　　Norwood Hospital in Massachusetts is a 264-bed facility with a full range of patient care services, inc

29、luding its Small Miracles Family Birthing Center, a modern emergency department, up-to-date radiation oncology services, extensive endoscopic services, advanced laparoscopic and neurological surgery, and a cardiac cathet

30、erization lab. The hospital provides exceptional care to the more than 300,000 people in Norwood and 16 surrounding communities. It is located in the competitive Boston market.</p><p>　　A new era began when

31、Norwood Hospital became Caritas Norwood Hospital in 1997 after acquisition by Caritas Christi Health Care, the second-largest healthcare system in New England. In 2009, the official name was changed to Norwood Hospital,

32、A Caritas Family Hospital. In a recently announced precedent-setting deal, Caritas Christi Health Care was purchased by Cerberus Capital Management, a private equity firm.</p><p>　　With operating margins typ

33、ically a bit above or below breakeven each year, cost management has always been a priority. Norwood Hospital focuses on these key principles for its departments, service lines, and managers:</p><p>　　? Crea

34、te an environment of transparency where the information is shared and comments and questions are encouraged.</p><p>　　? Create an environment where the managers are expected to achieve or exceed their goals,

35、 such as clinical and patient excellence and performance, and take steps to flex staff and other resources to meet the demands of changing volume.</p><p>　　? Provide the managers with timely data, including

36、custom-developed labor benchmarks, revised and updated by consultants on site with continued outside periodic review, so the productivity goals and expectations are clear.</p><p>　　Managers benefit from acce

37、ss to state-of-the-art productivity information and the ability to compare data and experiences with other peer hospitals in the Caritas Christi Health Care system. Those comparisons can be particularly helpful; they are

38、 done in a system framework—system groups of health information management directors or patient care executives—and one-on-one. This analysis leads to managers who have the information, tools, and resources to manage the

39、ir areas and perform to expectatio</p><p>　　? Managers are expected to achieve staff targets and control overtime, use of perdiems, and agency personnel, or to identify why these factors aren't controlle

40、d and develop an action plan for solutions.</p><p>　　? Managers see other managers' results and can question why they are not achieving their benchmarks. A spirited discussion ensues through e-mail and

41、other exchanges. A sense of community is created for management, yet accountability is still the focus. Poor performance has ramifications.</p><p>　　Here are some examples of how Norwood Hospital has increas

42、ed productivity:</p><p>　　? Early enabling of EMR technology in a community setting</p><p>　　? Use of value engineering, better workflow, and systems flow in redesigned areas such as the emergen

43、cy department</p><p>　　? Use of external customized productivity benchmarks to measure and monitor labor resources</p><p>　　Norwood Hospital also has conducted a span-of-control project to ident

44、ify the need for management or staff reductions if overages are identified. To achieve continued success, these reviews have to establish the baseline benchmarks. Benchmarks are then refreshed as new programs and technol

45、ogy are implemented. Without this refreshing, FTE creep—an increase in full-time-equivalent staff because leadership won't deny unjustified FTE requests—can occur.</p><p>　　At Norwood Hospital and the Ca

46、ritas Christi Health Care system, the expectation is to provide the highest quality patient eare with dignity; with all the changes coming to healthcare, meeting that expectation will continue to be a financial challenge

47、. System functions such as finance, human resources, and IT are consolidated and centrally located. Functions are outsourced as appropriate. It is not a one-size-fits-all system strategy, and it recognizes the need for l

48、ocal management input and cont</p><p>　　So many cost-containment strategies exist that each one could have its own article devoted to it. However, if an organization wants the most benefit in the shortest ti

49、me frame, it should concentrate on performing an on-site labor resource benchmarking and a span-of-control analysis.</p><p>　　REFERENCES</p><p>　　Goldberg, A, 1. and W. D. Petasnick. 2010. "

50、;Managing in a Downturn: How Do You Manage in a Global Financial Recession?' journal of Healthcare Management 55 (3): 149-153.</p><p>　　National Covernors Association. 2010. Fiscal Survey of States. Wash

51、ington, DC: National Association of State Budget Officers.</p><p>　　U.S. Congress. House. 2010. Patient Protection and Affordable Care Act. 111th Cong., 2nd sess. Public Law 111-148, sec. 3 025.</p>

52、<p>　　U.S. Congress. House. Tlie American Recovery and Reinvestment Act of 2009. 111th Cong., 1st sess. Public Law 111-5, sec. 4101 and 4102.</p><p><b>　　譯文</b></p><p>　　成本控制和成

53、本管理戰(zhàn)略</p><p>　　資料來(lái)源: 作者：Alan f. Goldberg ,William P. Fleming</p><p>　　領(lǐng)導(dǎo)和各醫(yī)療機(jī)構(gòu)的受托人委員會(huì)是在以最好地滿足社會(huì)需要的有限資源的最終管家。在戰(zhàn)略規(guī)劃過(guò)程的領(lǐng)導(dǎo)下組織確定優(yōu)先次序，作出選擇，并采取明確的行動(dòng)路徑。等到那一天新的癌癥中心開設(shè)或最新的技術(shù)到來(lái)，也是會(huì)成為令

54、人興奮的社區(qū)之一。</p><p>　　剪彩后，這些新方案成為醫(yī)院的董事或臨床服務(wù)項(xiàng)目經(jīng)理的責(zé)任。他們的預(yù)測(cè)是基于工作人員和其他假設(shè)，可能會(huì)或可能不會(huì)在那個(gè)點(diǎn)上，但在行動(dòng)和組織的財(cái)政狀況會(huì)產(chǎn)生直接影響。</p><p>　　作為醫(yī)院的新舉措正式?jīng)Q定的一部分，可以對(duì)付款人的收入來(lái)源結(jié)構(gòu)和決策進(jìn)行預(yù)測(cè)?，F(xiàn)在，有兩個(gè)重大環(huán)境事件使得預(yù)測(cè)更加不確定，從成本管理的挑戰(zhàn)來(lái)說(shuō)是：經(jīng)濟(jì)低迷和支付方式改革。

55、</p><p>　　在2008年秋天經(jīng)濟(jì)低迷開始影響醫(yī)院。它對(duì)組織的影響可以用Goldberg和Petasnick（2010年）來(lái)描述：隨著信貸市場(chǎng)枯竭，失業(yè)上升，消費(fèi)者信心削弱，以及員工士氣動(dòng)搖，醫(yī)療制度行政人員忙的不可開交。該風(fēng)暴的綜合結(jié)果使那句古老的格言“現(xiàn)金為王”比任何時(shí)候都更真實(shí)。由于消費(fèi)者收回和個(gè)人失去的健康保險(xiǎn)，使醫(yī)院經(jīng)歷了為選修、非急診醫(yī)療服務(wù)的巨額損失。財(cái)務(wù)經(jīng)營(yíng)業(yè)績(jī)受到影響。同時(shí)，取消了投資價(jià)

56、值損失由安全網(wǎng)建立的儲(chǔ)備營(yíng)業(yè)外收入。許多醫(yī)院和醫(yī)療系統(tǒng)都不得不考慮裁員，推遲或制定或取消資本密集型項(xiàng)目。所有都被要求重新考慮其戰(zhàn)略計(jì)劃。</p><p>　　由于經(jīng)濟(jì)不景氣和 較高的失業(yè)率，導(dǎo)致收入下降和個(gè)人失去在工作的基礎(chǔ)上的醫(yī)療保險(xiǎn)，醫(yī)療保險(xiǎn)人數(shù)預(yù)計(jì)將在2010財(cái)年增加10.5個(gè)百分點(diǎn)。</p><p>　　當(dāng)你在這個(gè)州和聯(lián)邦收入都有顯著下降，就有短缺來(lái)滿足財(cái)政義務(wù)。毫不奇怪，醫(yī)療費(fèi)用

57、控制正在到位。三十二個(gè)國(guó)家計(jì)劃以減少或凍結(jié)2010財(cái)年的供應(yīng)商付款，在2011年48個(gè)州將采取這樣的措施（全國(guó)州長(zhǎng)協(xié)會(huì)2010年）。</p><p>　　隨著醫(yī)療改革的，2010年3月23日病人保護(hù)和支付得起的醫(yī)療保障法案通過(guò)并成為法律，同時(shí)開始大規(guī)模擴(kuò)建，以支付定于2014年1月1日的地方投保。雖然這會(huì)為無(wú)醫(yī)療保險(xiǎn)，保險(xiǎn)不足，與不良債務(wù)帶來(lái)清晰的長(zhǎng)期財(cái)務(wù)規(guī)劃，支付改革意味著將有有所權(quán)衡。在未來(lái)數(shù)年的預(yù)期削減意味

58、著供應(yīng)商在2014年的收入將不會(huì)激增。困難的經(jīng)濟(jì)時(shí)期創(chuàng)造了一個(gè)使廣大利益相關(guān)者的很好理解的環(huán)境。因此，病人和醫(yī)院的員工知道他們面臨的財(cái)政挑戰(zhàn)。</p><p>　　該法律的其中一個(gè)結(jié)果是對(duì)成本控制和成本管理戰(zhàn)略的濃厚興趣。這種關(guān)注多半是需要實(shí)現(xiàn)一個(gè)組織的金融目標(biāo)，在要求和計(jì)劃支出超過(guò)可用資金時(shí)縮小差距。然而，成本管理已經(jīng)成長(zhǎng)遠(yuǎn)遠(yuǎn)超出職權(quán)范圍內(nèi)的金融，作為支付改革措施深深影響質(zhì)量和進(jìn)程的提高，現(xiàn)在也會(huì)帶來(lái)財(cái)政獎(jiǎng)勵(lì)或

59、處罰。相關(guān)的例子包括通過(guò)對(duì)某些早期診斷入院后30天出院，并拒絕支付獎(jiǎng)金的電子健康記錄（美國(guó)國(guó)會(huì)2010年，2009年）</p><p>　　除了內(nèi)部的性能比較預(yù)算，收縮資源以滿足不斷變化病人數(shù)量和要求，并比較自己的組織機(jī)構(gòu)和現(xiàn)有同類數(shù)據(jù)庫(kù)，一個(gè)管理成本如何？這一切都始于基準(zhǔn)，如勞動(dòng)力資源的控制和管理跨度分析工具和方案。</p><p>　　在實(shí)踐中，標(biāo)桿是一個(gè)非標(biāo)準(zhǔn)化的術(shù)語(yǔ)。對(duì)于大多數(shù)，標(biāo)

60、桿基準(zhǔn)等手段本身作為一個(gè)最佳實(shí)踐組織組織的一些比較，類型：</p><p>　　1標(biāo)桿是在我們的研究結(jié)果相比，同類院校數(shù)據(jù)庫(kù)的過(guò)程。</p><p>　　2標(biāo)桿管理是我們的跟蹤和比較組織本身。</p><p>　　3標(biāo)桿管理是我們的組織相比，性能標(biāo)準(zhǔn)由外部機(jī)構(gòu)設(shè)置。</p><p>　　成本管理取決于人事管理決策，這是最好的基準(zhǔn)進(jìn)程排名第三的

61、支持。通常情況下，60醫(yī)院的費(fèi)用百分之勞動(dòng)，一組在護(hù)理費(fèi)用占多數(shù)。在這個(gè)過(guò)程中許多組織是由業(yè)務(wù)或者財(cái)務(wù)管理是一個(gè)持續(xù)的和復(fù)雜的儀表板的重點(diǎn)部分。基準(zhǔn)測(cè)試中排名第三的描述不應(yīng)該是一次性的過(guò)程，而是應(yīng)該由一個(gè)外部機(jī)構(gòu)持續(xù)進(jìn)行。</p><p>　　許多醫(yī)院似乎已經(jīng)臃腫的管理隊(duì)伍的基礎(chǔ)上題分析，薪酬等級(jí)，或者誰(shuí)參加經(jīng)理會(huì)議。雖然這是在金融共同或它來(lái)尋找誰(shuí)被稱為經(jīng)理或主管，誰(shuí)個(gè)人管理等部門管理人員應(yīng)直接報(bào)告，獲得這個(gè)稱號(hào)

62、方案，而不是工作人員。</p><p>　　斯潘的控制研究得出結(jié)論認(rèn)為，根據(jù)醫(yī)院的組織結(jié)構(gòu)圖與職稱，有太多的經(jīng)理人往往沒有足夠的工作人員向他們匯報(bào)。這一發(fā)現(xiàn)是基于嚴(yán)格的職稱和組織結(jié)構(gòu)圖。這一發(fā)現(xiàn)是基于嚴(yán)格的職稱和組織結(jié)構(gòu)圖。當(dāng)實(shí)際的工作是審查和確定，標(biāo)桿專家經(jīng)常發(fā)現(xiàn)這是不是管理水平位置，如果是重新歸類醫(yī)院的控制范圍內(nèi)正確的范圍內(nèi)。由于工作人員留用策略，職稱有夸大隨著時(shí)間的推移證明這樣做的主要工作支付正常工資的等級(jí)

63、制度在人力資源工作人員不承認(rèn)的水平。這種組織行為導(dǎo)致組織內(nèi)部的管理層次太多。</p><p>　　在馬薩諸塞州諾伍德醫(yī)院，位于波士頓的市場(chǎng)競(jìng)爭(zhēng)，是一個(gè)有病人護(hù)理服務(wù)以及現(xiàn)代化的急診室，它包括家庭分娩中心，最多最新的放射腫瘤科服務(wù)，豐富的內(nèi)鏡服務(wù)，先進(jìn)的腹腔鏡手術(shù)和神經(jīng)系統(tǒng)全套264個(gè)床位的設(shè)施，以及心導(dǎo)管室。醫(yī)院提供特殊照顧的人超過(guò)30萬(wàn)和16諾伍德周邊社區(qū)。</p><p>　　當(dāng)在19

64、97年成為諾伍德醫(yī)院后，一個(gè)新的時(shí)代開始了。由明愛基督保健，在新英格蘭地區(qū)的第二大收購(gòu)明愛醫(yī)療體系諾伍德醫(yī)院。，2009年，正式更名為諾伍德香港明愛家庭醫(yī)院。在最近公布的先例處理中，明愛基督保健購(gòu)買了Cerberus資本管理私人股權(quán)公司。</p><p>　　通過(guò)經(jīng)營(yíng)利潤(rùn)通常是位高于或低于盈虧平衡，每年的利潤(rùn)，成本管理一直是一個(gè)優(yōu)先事項(xiàng)。諾伍德醫(yī)院側(cè)重于為政府部門，這些服務(wù)項(xiàng)目主要原則和經(jīng)理：</p>

65、<p>　　?建立一個(gè)透明的環(huán)境下的信息共享，鼓勵(lì)提出意見和問(wèn)題。</p><p>　　?創(chuàng)造一個(gè)經(jīng)理人有望實(shí)現(xiàn)或超過(guò)他們的目標(biāo)，如病人的臨床和卓越性能，并采取彈性工作人員和其他資源措施，以滿足不斷變化的環(huán)境容量的要求。</p><p>　　?提供及時(shí)的數(shù)據(jù)，包括定制開發(fā)的勞工標(biāo)準(zhǔn)，修訂和更新，現(xiàn)場(chǎng)咨詢外繼續(xù)進(jìn)行定期審查，因此，生產(chǎn)力的目標(biāo)和期望是明確。</p>

66、<p>　　經(jīng)理人受益于得到國(guó)家的最先進(jìn)生產(chǎn)力的信息和對(duì)數(shù)據(jù)進(jìn)行比較的能力，并與香港明愛基督醫(yī)療體系醫(yī)院分享其他同行的經(jīng)驗(yàn)。這些比較特別有幫助，他們是在一個(gè)系統(tǒng)框架，特別是一對(duì)一系統(tǒng)的健康信息管理病人護(hù)理管理人員。這一分析導(dǎo)致經(jīng)理?yè)碛行畔?、工具和資源來(lái)管理其地區(qū)和執(zhí)行的期望。由于使用這些信息的結(jié)果：</p><p>　　?經(jīng)理人員的目標(biāo)希望實(shí)現(xiàn)目標(biāo)和控制加班費(fèi)、perdiems的使用、機(jī)構(gòu)人員或確定這

67、些因素為什么不能得到控制，并制定一項(xiàng)行動(dòng)計(jì)劃，尋求解決辦法。</p><p>　　?經(jīng)理看到其他經(jīng)理的結(jié)果，可以問(wèn)為什么他們沒有達(dá)到他們的基準(zhǔn)。一個(gè)通過(guò)電子郵件和其他交流熱烈的討論隨之而來(lái)。社區(qū)意識(shí)是管理造就的，但責(zé)任仍是重點(diǎn)，是一年來(lái)表現(xiàn)欠佳的后果。</p><p>　　以下是如何提高生產(chǎn)力諾伍德醫(yī)院擁有一些例子：</p><p>　　?早期的一個(gè)社區(qū)環(huán)境中啟用電

68、子病歷技術(shù)</p><p>　　?利用價(jià)值工程，更好的工作流程，重新設(shè)計(jì)的領(lǐng)域和系統(tǒng)流程，如急診科</p><p>　　?外部客戶生產(chǎn)力的基準(zhǔn)來(lái)衡量和監(jiān)控勞動(dòng)力資源</p><p>　　如果確定了超支的需要諾伍德醫(yī)院也會(huì)進(jìn)行整體范圍的控制項(xiàng)目，確定為管理或裁減工作人員。為了實(shí)現(xiàn)持續(xù)的成功，這些評(píng)論必須建立基線基準(zhǔn)。然后刷新為基準(zhǔn)的新方案和技術(shù)實(shí)施。如果沒有這個(gè)令人耳

69、目一新，工作人員增加的FTE會(huì)有所變化，因?yàn)轭I(lǐng)導(dǎo)人不會(huì)拒絕不合理的FTE的請(qǐng)求。</p><p>　　諾伍德明愛醫(yī)院和基督醫(yī)療制度體系，期望能夠?yàn)椴∪颂峁┳罡哔|(zhì)量的服務(wù)，隨著醫(yī)療保健的變化，這些預(yù)期將繼續(xù)成為一個(gè)金融挑戰(zhàn)。系統(tǒng)的功能，如財(cái)務(wù)、人力資源和IT位于市中心，而適當(dāng)?shù)墓δ芡獍?，這不是一個(gè)放之四海而皆準(zhǔn)的系統(tǒng)戰(zhàn)略，它認(rèn)識(shí)到地方管理有關(guān)具體問(wèn)題的投入和控制的需要。</p><p>