外文翻译译文

杭州电子科技大学

毕业设计（论文）外文文献翻译

毕业设计（论文）题目

基于业务流程再造的人民医院门诊流程设计

翻译题目业务流程再造—治本还是治标？

系工业工程

专业工业工程

姓名许路思

班级10038511

学号10036812

指导教师阮渊鹏

业务流程再造——治本还是治标？①

以一个英国医疗保健的视角来看

Anjali Patwardhan

英国伯明翰健康服务管理中心

Dhruv Patwardhan

英国纽卡斯尔大学

【摘要】

目的——由于不断上升的医疗成本和对提高效率、性价比和生产率方面改进的性能证明的重视，以及近来满意度降低的患者和利益相关方在一定程度上的需求，改革的压力在政治驱动下与日俱增。在新浸入的昂贵的科技和药物背景下，越来越多的消费者对优质的服务有所期望。与此同时，医疗系统管理人员和医务人员发现很难解决需求和质量要求。临床医生感到沮丧，因为他们的贡献不被承认。管理人员同样感到沮丧，因为与临床医生缺乏有意义的交流，这加剧了向更高效系统转型的需求，这样的系统能满足所有关于成本效益和可持续优质服务的观点。很多起先被管理质量大师们应用于工程行业的策略已经被应用于医疗行业，而成功与否很大程度上取决于它们所应用的医疗保健系统的类型。

设计/方法/途径——业务流程再造在过去和最近的出版物中被认为是一种质量管理工具。

发现——本文认为，在适当情况下应用业务流程再造以及选择好需要进行质量改进的机构是其成功的关键。它当然“不适用于每一个人”。

独创性/价值——本论文就分析英国医疗保健业的经验，提出了关于业务流程再造的关键评估。关于选择组织和同意现实预期的经验教训得以解决。自1987年以来美国医疗保健对业务流程再造进行评估和审查，得不到经验教训的原因很可能在于单位的选择以及事实上以前从未同时对两个完全不同的单位进行过比较。然而，英国两个试点的研究得出了有益的见解。

关键词：业务流程再造，全面质量管理，持续改进，医疗管理，医疗卫生服务，联合王国

论文类型：观点

医疗保健业质量管理史

为了了解医疗保健机构如何对工业开发工具产生兴趣，以及业务流程再造（BPR）

①Anjali Patwardhan, Dhruv Patwardhan．Business process re-engineering–saviour or just another fad? [J]．International Journal of Health Care Quality Assurance，2008，21(3)：289-296．

如何作为一种选择出现，我们就要回顾医疗保健全国实证项目(NDP)中的质量改进项目，它在1987年作为一个实验项目实施(Godfrey, n.d.)。

总共有21家医疗保健机构参与并承诺支持这项为期八个月的研究。目的是为了看看工业质量改进方法在医疗保健业中的适用性。这些医疗保健机构提供的支持包括免费顾问、材料、培训课程和评审。赞助公司包括许多美国的领导机构，如康宁、福特、惠普、IBM（国际商用机器）和施乐公司。很明显，在这个项目的评估的最后阶段，21家医疗保健机构中有15家取得了显著的发展——主要体现在财政及病人满意度的增长，目标和项目计时，以及在研究和开发中的投资。该全国实证项目延续了三年，最终演变成了改善医疗保健的研究所，这个研究所是一个不以营利为目的的组织，致力于提供医疗保健质量管理的领导。此后，业务流程再造出现了，为在缓慢的进步中挫败的组织中的管理人员提供了一项选择，而不是围绕整个组织去进行全面质量管理(TQM)。全面质量管理的主要目标是改变一个组织的结构、文化和对病人/消费者的服务，而不是以组织为中心(Harvey和Millett,1999)。

为什么要改变？

传统的医疗保健体系通常被临床医生所“统治”(Shutt,2003)，因为病人是直接结果。也就是说，使病人从疾病中康复是所有直接参与病人护理的专家们的唯一责任。医疗保健研究中的复杂性与多样性显示，结果可能包含很多决定因素，即配药学，病理学，技术支持和信息技术。它同样显示了成本控制和高质量的治疗需要团队合作、沟通和时间管理等(Shutt,2003)。罗伊·格里菲思先生在二十世纪八十年代初开始发展医院综合管理，使临床医生更多地参与资源管理举措（DHSS，1984）。如今，除了政治动机以外，逐步上升的医疗保健成本、增长的优质护理需求、服务的性价比、病人的期望和在管理医疗保健体系的第三方付款人这些因素都促进了改变。以上因素都推动了医疗保健体系向更高效体制转变的需要。

什么是业务流程再造？

业务流程再造，也叫业务转化和流程改变管理，是1900年弗雷德里克·泰勒在其文章《科学管理原则》中被引入到了商界(维基百科，2006)。1990年，哈默和钱皮（1993）引入企业再造，业务流程再造由此诞生。

业务流程再造是“对组织内和组织间的工作流程和步骤进行分析和设计”（Devenport和Short，1990）。另一方面，Teng等人（1994）将业务流程再造定义为对现有业务流程进行重要分析和彻底改善，从而在业绩度量上获得突破性的进步。与之相似，哈默和钱皮把业务流程再造定义为对业务流程进行根本的再思考和彻底的再设计，以在关键时期业绩度量中取得卓越的改进，如成本、质量、服务和速度。以一个医疗保健的观点来看，业务流程再造是一种对业务的现有习惯和流程及其相互作用

进行再思考的管理途径。它试图通过应用基础且根本的途径，即减少或取消非增值活动以及重建流程、结构或文化来提高潜在的流程效率（McNulty和Ferlie，2000）。但是，在医疗保健领域，广泛多样的病患群使沿着这条线路重新设计医疗保健服务成为一个复杂的项目，因此使得其对环境和时间的改变异常敏感。

业务流程再造基本特点

医疗保健的业务流程再造方法意味着重新开始，并利用以病人为中心的方法对服务进行再思考。事后看来，业务流程再造认为停滞是由流程中不必要的步骤和潜在错误引起的。人们推测，通过消除这些错误来对流程进行再设计很大程度提高了医疗质量。业务流程方法因此引发了人们对戏剧性结果的期待。结果就是投资的高收益能被预期。泰勒在其业务流程再造框架中解释了这种具有战略计划的流程（维基百科，2006）：

?定义业务流程再造的目的和目标；

?识别出满足客户需求的要求；

?定义项目范围，包括适当的活动，例如绘制流程图；

?利用力场分析对环境进行评估；

?再造业务流程和活动；

?实现流程再设计；

?监控新设计的成败。

业务流程再造与全面质量管理

在医疗保健方面，将BPR与其它流行的质量管理工具相比较能帮助我们体会到它的主要特征并使其更加突出（Harvey和Millett，1999）。全面质量管理（TQM）或持续质量改进（CQI）指强调在工作流程中增值的改进和在一个开放时间段内的输出的程序和举措。相比之下，业务流程再造倾向于离散的项目，其目的是在一个时间框架内彻底地再设计并改善工作流程。一些人认为全面质量管理对于医疗保健行业的质量提升是最适合的，尽管它的增值效果是逐步且缓慢的，但却是整体全面的方法。在实践中，全面质量管理和业务流程再造是以客户为导向，它们都鼓励管理人员和从业人员以客户为视点。两者都是涉及过程控制的团队方法。倾向于全面质量管理的人认为现有的医疗方法和体系大体上是对的，但需要加以改进。另一方面，业务流程再造的支持者们认为医疗保健的体系和做法是有缺陷的，需要更换。那些使用全面质量管理的人期望并相信业绩会逐步上升，他们反对那些寻找戏剧性结果的业务流程再造专家。全面质量管理的目的是在所有步骤中提高所有利益相关者的等级，而业务流程再造的目标仅为具体指定的范围。全面质量管理的关键点是标准化和支持性文件。它相信持续且有成本效益的成绩，并且最小化流程和系统缺陷，阻止而不是修正问题（Field

和Swift，1996）。另一方面，那些使用业务流程再造方法的人是灵活的，并且他们认为标准化会增加流程的复杂性（Harvey和Millett，1999）。虽然如此，业务流程再造是一项巨大的改变，这导致了员工的反对。此外，它是一个自上而下的方法，因此管理层的支持和承诺是成功的关键。因此，当用于“病态组织”时，创新是一个充满风险的过程。

全面质量管理的增量法在另一方面遵循循序渐进的方法，主要是自下而上。它涉及到员工，并且通常以戴明环原则为基础，通过计划、实施、研究、行动（PDSA）进行直接改善。因此全面质量管理适合在任何组织中进行质量改进，尽管可能需要一些修正，以适应环境。当不同的流程应用于不同情况时，管理型医疗保健体系的应用会产生不同的结果。因此业务流程再造可能不适用于每一个人，因为它在病态组织中或在存在根本缺陷的系统中效果会更好（Bashein等，1994）。全面质量管理方法是关于文化的改变，因为它被构建于实践中，与每天的日常事务挂钩。业务流程再造方法是一个以目标为导向的流程，它对时间很敏感，因为如果没有按计划完成目标，就可能面临失败的危险。全面质量管理的主要促成者是统计流程控制，而业务流程再造的促成者是信息和技术（Harvey和Millett，1999）。

将业务流程再造应用于医疗服务质量改进的优势

将业务流程再造运用于医疗领域是对组织中管理人员的失败作出的回应，他们意识到全面质量管理的递增论和它获得组织范围改变的能力都失败了。国王学院医院的经历（Grimes，2000；Harrison等，1992）表明，在这种其它的努力和方法都失败的情况下，业务流程再造可能是将效率达到前所未有水平最好的尝试。改变的驱动力量是对于发展为更高效系统的渴望，该系统能满足消费者对服务质量和性价比的需求（Bowns和McNulty，1999）。同时，业务流程再造使在不必花费更多的情况下维持这种质量成为可能，尽管我们知道医疗花费正在急剧上升。在国王项目里，第三个也是最重要的渴望是提高专业人才的工作满意度，他们认为这是他们应得的。

业务流程再造的目的是以医疗保健为导向、以病人为中心，而不是组织的需求。该方法侧重于对流程进行再思考并重新设计，给员工详细机会重访细节服务，从而指出需要改进的地方。它取消了流程中所有非增值和不必要的步骤，使服务更有效率。尽管它被自上而下的管理，被管理人员和领导所统治，在核心层面上做出决定来增强团队的能力。业务流程再造方法提供了一个灵活的工作环境、文化和工作实践。这对困难重重且业绩不佳的组织是有价值的。在这种危机中，再造可能是使组织生存的唯一方式（Harvey和Millett，1999）。当发现主要结构和文化有缺陷明显导致是业绩不佳的原因时，业务流程再造是处理这种场景最好的方式——从国王学院医院的经历中可以明显得出（Bowns和McNulty，1999）。

业务流程再造在医疗保健质量改善中的限制

我们知道，业务流程再造是一个自上而下的方法，员工可能会抵制。它被自治的临床专业人员引用为“一个残忍且不适合的技术”（Jones，1996）。医疗保健领域中临床医生是关键角色，因此，在此实施业务流程再造不仅困难，而且不安全（McNulty 和Ferlie，2000）。因此，业务流程再造可能导致所有权丧失、员工积极性减弱，因为他们没有加入计划和改变管理。一般情况下，雇员不太容易理解这种变化过程（Jones，1996）：

质量似乎不太可能来临，如果再造以刚性和机械的方式自上而下强制进行……如果要进行有效且可持续的组织变革，这就需要雇员积极参与，相互学习，而不是勉强遵守管理者的命令。

欧洲公共服务体系的质量改进体现了医疗保健体系中作为工具的全面质量管理和业务流程再造。它承认许多包括全面质量管理和再造在内的能提高质量的业务办法，都没有考虑到医疗保健的复杂性和专业化知识的本质。用于大部分这些项目的语言和价值观对临床医生而言很陌生，他们将其视为一种潮流而拒绝。看来，如果业务流程再造要提高相同幅度的质量，就需要大规模文化和结构的改变。彻底的隔夜转型听起来给人印象深刻，但不现实。结构和文化的改变需要时间去发展、被接受并且被各级吸收，尤其是在医疗保健机构里。简而言之，业务流程再造是一个高成本且高风险的项目。

70%的企业不能达到他们的目标——业务流程再造的成功率为30%。另一方面，回顾一下文献资料，在医疗保健领域中没有成功的数据。大部分时间里业务流程再造承载着不切实际的范围和期望，这可能是导致70%失败率的原因。其自上而下的性质和成功取决于持续的管理承诺和卓越的领导，这不容易被测量，也可能达不到所需的阈值。业务流程再造可能只能在时间上改变一个单位。若要变得有意义，它随后需要持续质量改进的运作。一旦发生变化，以业务流程再造为基础的改变需要持续质量改进项目来维持结果。业务流程再造不人性化的过程始终备受争议——从Jones（1996）的言论中可以明显看出

这种观点被视为促进想法，你可以设计一个完美的流程，它严格按照你的计划准确地执行，组织的机器将完美运作。整个过程有关可靠性一方的设置问题上，业务流程再造显然忽略了人类创造性在工作流程中的重要作用。

正如我们刚才提出的，业务流程再造通常在一个时间上对一个流程进行创新，而不是整个组织的方法。因此，流程的更改可能不会对那些可以被测量的整体组织业绩造成影响，尤其是那些能被消费者感觉到的。换句话说，业务流程再造可能对一个特殊的流程能产生巨大作用，但几乎不能对整个组织业绩产生影响。一个简单的提高住院病人的例子说明了业务流程再造不能独立地改善服务，还需要改善日常护理、门诊

病人、初级保健和急诊服务。以上所有都对组织的住院病人的服务有影响，因为它们相互联系并相互依赖。此外，在这种情况下很难评估业务流程再造的效果，因为国家医疗服务组织缺乏特殊的度量标准（Bowns和McNulty，1999）。

业务流程再造适用于医疗保健体系的程度

英国业务流程再造医疗保健经验来自于两个中央资助试点的研究：

(1)伦敦国王学院医院（KCH）；以及

(2)莱斯特皇家医院（LRI）。

国王学院医院项目由布鲁内尔团队进行评估（Packwood等，1998；Grimes，2000），莱斯特皇家医院计划由谢菲尔德和华威评估（Bowns和McNulty，1999）。评估期间这些组织的雇员分享了他们的业务流程再造经验。结果两个研究都产生了有趣且有价值的发现，它们强调业务流程再造能在何种程度上应用于医疗保健体系。然而两家医院是两种截然不同的极端，即国王学院医院在研究期间是一个“病态”的单元，而莱斯特皇家医院是最好的教学医院之一（McNulty和Ferlie，2000），几乎没有什么可改善的。在试点研究结束后，报告很明显地显示两家医院都没有达到预期，尤其是巨大的改变和在业务流程再造项目开始时预计的改善。两家医院都减少了等待时间，且诊断流程更迅速。除了这些改进，国王学院医院还节约了一百万英镑（Grimes，2000）——归因于通过消除非增值活动并绘制流程图和对更新的系统提高效率来“减少浪费”（Packwood 等，1998）。这表明了业务流程再造不适用于每一个人，选择好业务流程再造能够应用的单元对于达到理想的效果很重要。当两家医院进行试点研究时，他们也继续推进在流程中不同层面上的通用的和核心的改进举措，因此很难将成功单独归功于业务流程再造，也很难评估其对整体改善的相对贡献。

一种能识别出合适的子流程来应用业务流程再造的方法是挨家挨户绘制流程图，这有助于抓住所有流程构成要素并应用精益方法（Jones和Mitchell，2006）。通过识别增值活动来突出非增值活动。每个非增值活动都能被测量和分析，以评估其影响和消除该活动的方法。资源可用性、截止日期、成本、通用技术等都迫切需要改变来帮助用户选择正确的改善工具。此外，如刚才所说，管理变革的成功与团队士气、所有权和动机密切相关。因此，想要在医疗保健服务业实现质量，两个来自不同文化背景、拥有不同知识领域的关键员工群体——管理人员和临床医生，需要作为一个团队来工作。如果要完成一个困难的任务，理解和合作是至关重要的（Shortell等，1998）。然而，业务流程再造在考虑流程中的人因时的不足可能使它很难融入到医疗保健服务。业务流程再造方法听起来令人印象深刻但是却不现实是因为温和的结构和文化改变需要时间去发展，尤其是在医疗保健机构中。我们相信业务流程再造能够帮助改进医疗服务，如果它是经过精心的策划并勤勉地去应用。简而言之，尽管业务流程再造

有限制因素，它仍有能力实现显著的结果，因为它迫使员工将方案或过程作为一个整体从外部思考问题并按时完成工作（Bowns和McNulty，1999）。

结论和建议

医疗保健业是比任何制造业更复杂的系统。作为一个主要以人为构成要素的服务提供者，它具有安全和效率问题，而不是成本和功效，正是这一点才使医疗保健业与其他行业分离开来。业务流程再造和其它提高服务质量的单个方法类似，它可能不适用于医疗保健业（Shortell和Ferlie，2001），因为它又许多子流程组成。它在不同水平上有许多利益相关者，而且它的内部消费者和外部消费者有多种多样的需求。我们接受业务流程再造可以作为改善一些子过程或子单元活动的工具。在莱斯特皇家医院发生的一个例子尝试在床位管理、病理学和门诊服务创新等活动中将业务流程再造作为质量改善工具，但是没有将该方法应用于临床医生的精确度要求很高的地方和该方法很难被接受的地方。因此，在这些领域中，人们对这些方法在质量改善上的适用性的意见喜忧参半。也就是说，全面质量管理和业务流程再造在理想情况下应始终遵循持续质量改进方法来持续有效地改善服务。简而言之，为企业设计的质量管理工具应经过适当的选择，小心谨慎地应用于医疗服务业。

参考文献

Bashein, B.J., Markus, M.L. and Riley, P. (1994), “Preconditions for BPR success: and how to prevent failures”, Information Systems Management, V ol. 11 No. 2, pp. 7-13. Bowns, I.R. and McNulty, T. (1999), Re-engineering Leicester Royal Infirmary –Executive Summary, School of Health and Related Research, University of Sheffield, Sheffield.

Devenport, T. and Short, J. (1990), “The new industrial engineering information technology and BPR”, Sloan Management Review, Summer, pp. 11-27.

DHSS (1984), Health Services Management: Implementation of the NHS Management Inquiry, DHSS Circular HC (84) 13, DHSS, London.

Field, S.W. and Swift, K.G. (1996), Effecting a Quality Change: An Engineering Approach, Arnold, London.

Godfrey, B. (n.d.), “Quality health care”, Quality Digest, available at: https://www.wendangku.net/doc/b18302468.html,/sep96/health.htm (accessed on 15 October 2006).

Grimes, K. (2000), Changing the Change Team, King’s College Hospital, London. Hammer, M. and Champy, J. (1993), Reengineering the Corporation: A Manifesto for Business Revolution, Harper Business Books, New York, NY.

Harrison, S., Hunter, D., Marnoch, G. and Pollitt, C. (1992), Just Managing: Power and Culture in the NHS, Macmillan, Basingstoke.

Harvey, S. and Millett, B. (1999), “OD, TQM and BPR: a comparative approach”, Australian Journal of Management and Organizational Behavior, V ol. 2 No. 3, pp. 30-42. Jones, D. andMitchell, A. (2006), Lean Thinking forthe NHS: A Report Commissioned by the NHS Confederation, pamphlet RA 395.G7, NHS Confederation, London.

Jones, M. (1996), “Re-engineering”, in Warner, M. (Ed.), International Encyclopedia of

Business and Management, Routledge, London.

McNulty, T. and Ferlie, E. (2000), Reengineering Health Care: The Complexities of Organisational Transformation, Oxford University Press, Oxford.

Packwood, T., Pollitt, C. and Roberts, S. (1998), “Good medicine? A case study of business process reengineering in a hospital”, Policy and Politics, V ol. 26 No. 4, pp. 401-15. Shortell, S. and Ferlie, E. (2001), “Improving quality of healthcare in the United Kingdom and the United States: a framework for change”, The Milbank Quarterly, V ol. 79 No. 2, May,pp. 281-315.

Shortell, S.M., Waters, T.M. and Clarke, K.W.B. (1998), “Physicians as double agents: maintaining trust in an era of multiple accountabilities”, Journal o f the American Medical Association, V ol. 280 No. 12, pp. 1102-8.

Shutt, J.A. (2003), “Balancing the health care scorecard”, Managed Care, September, pp. 42-6.

Teng, J.T.C., Grover, V. and Fiedler, K. (1994), “Business process reengineering: charting a stra tegic path for the information age”, California Management Review, V ol. 36 No. 3,pp. 9-31.

wikipe dia (2006), “Frederick Winslow Taylor”, available at: https://www.wendangku.net/doc/b18302468.html,/wiki/Frederick_Winslow_Taylor (accessed 2 December 2006).

补充阅读

Davies, H.T.O. (2000), “Organizational culture and quality of health care”, Quality in Health Care, V ol. 9 No. 2, pp. 111-9.

Malhotra, Y. (1998), “Business process redesign: an overview”, IEEE Engineering Management Review, V ol. 26 No. 3, pp. 214-25.

Pollitt, C. (1996), “Bu siness approaches to quality improvement: why are they hard for the NHSto swallow?”, Quality in Health Care, V ol. 5 No. 2, pp. 104-10.

Raymond, L., Bergeron, F. and Rivard, S. (1980), “Determinants of business process reengineering success in small and large enterprises: an empirical study in the Canadian context”, Journal of Small Business Management, V ol. 36, pp. 72-85.

通讯作者

Anjali Patwardhan can be contacted at: doctoranjali@https://www.wendangku.net/doc/b18302468.html,

外文翻译考核表

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(文档含英文原文和中文翻译) 中英文翻译原文：

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