共生视域下分级诊疗协作网络合作伙伴关系评价及关系治理研究

The hierarchical medical service is the most significant and difficult part in the next phase of health care reform, and its practice has been in a full swing. Based on the principle of “discovering the rules, explaining the phenomena and guiding the practice”, the symbiosis theory will be introduced into this project for understanding the hierarchical collaborative network, and the cooperative partnership and relationship governance will be taken as the breakthrough point so as to deconstruct the fresh practice in the field of health policy and construct the symbiotic integration strategy. A research path abiding by the principle of exploration, development and demonstration” and social bionics research method will be used. This project will propose a metaphor that the hierarchical cooperative network is compared to a symbiotic system, in order to understand the practice operation rules, and interpret the symbiosis characteristics such as drive, unit, environment, benefit, development obstacle and mechanism. This project will scan the status of partnership quality of the hierarchical collaborative network. Besides, this project intend to put forward a series of concepts, such as motivation, goal, structure, mechanism and strategy of the relationship governance of the hierarchical collaborative network, and develop relevant measurement tools and conduct a large sample survey as well. Based on the process of hierarchical medical service in China, this project will take refining scientific topic, theory construction and empirical investigation, which will be helpful to reveal the insightful, relatively stable and inherently linked attributes and characteristics toward the process of the hierarchical medical service. Further more, it is beneficial to promote understanding and construct the theoretical framework of the hierarchical medical service, and then contribute to the guide practice in turn.

分级诊疗制度建设是医改下一阶段的“重中之重”、“难中之难”，且实践已如火如荼。项目以“发现规律，解释现象，指导实践”为设计原则，将共生理论引入分级诊疗协作网络情景，并以合作伙伴关系评价及关系治理为选题，以此解构我国卫生政策领域鲜活的实践，构建一体化共生治理策略。以“探索性、开发式和实证型”为综合路径，借助社会仿生研究法，将分级诊疗协作网络隐喻成共生系统，以此探究实践的运作规律，诠释网络共生的驱力、单元、环境、益处、发展阻碍、机制等共生特征；拟描扫分级诊疗协作网络合作伙伴关系质量现状；拟提出分级诊疗协作网络关系治理的动因、目标、结构、机制和策略等系列构念，再依次开发测量工具并进行大样本实地调查。基于我国分级诊疗真实的卫生政策进程，提炼出科学话题并理论构建及实证调查，益于揭示分级诊疗活动过程中比较深刻的、相对稳定的、并具有内在联系的属性和特征，增进对分级诊疗理解、构建全新理论框架并反哺于实践。

项目背景：卫生健康服务体系割裂；缺乏服务连续性和系统性；服务主体间缺乏合作，呈竞争姿态；系统绩效不高；基建上重复投资和扩建，服务上重复接诊和检查，功能上重复建设和模仿；高层级医院虹吸基层机构资源；分级诊疗格局尚未建立。. 核心内容：研究以生态视角审视卫生政策演进历程；分级诊疗政策与卫生健康服务整合的理论进程以及医联体和医共体研究进展；执行分级诊疗政策时的多元策略性行为；优质卫生人力资源下沉策略；医联体和医共体视角定量分析合作伙伴关系、合作失灵、合作关系质量与建设成效，提出一体化共生治理策略。. 重要结果：①建国以来，卫生与健康领域形成以“医疗”“健康”“卫生”为关键词的多中心政策语言网络，健康服务生态体系正在生成；②分级诊疗与整合医疗兴起，形成了“以人为本、整合型、多层次、连续性、价值导向、智慧化、本土化、韧性可持续的高质量发展”为特征的改革取径；③分级诊疗学术叙事呈现萌芽、加速和规范三阶段，存在愿景观、体系观及制度观三重内涵；整合医疗叙事一直在持续更新与迭代；④“政府-组织-个体”三层级行动者多采用多元策略性行为，促进或抑制着分级诊疗的政策效能；⑤结构与能动双元力量和机制助推了分级诊疗和医联体的政策创建与扩散；⑥诊疗协作网络存在合作失灵或效果不佳的现象；⑦诊疗协作网络合作治理体系不健全且治理能力不足，威胁着政策的可持续发展；⑧高质量合作可促进协作网络的建设成效和绩效，核心领导者的政策企业家精神至关重要；⑨持续建设我国健康服务生态体系，以一体化共生治理为理论引导推进改革进程。. 关键数据及其科学意义：两轮次分别收集176份医联体及158份医共体问卷；定性访谈48名医联体和医共体运行参与者；利用多类型政策文本、实证数据和实践案例进行扎根理论、定性比较分析、统计分析和解释结构模型分析。在科学意义上，推动了卫生政策生态话语建立、增加了卫生政策的演化视角、提出了合作伙伴关系和共生治理策略。