The four healthcare logics.

IntroductionIn pursuit of building person-centered health systems, patient and family engagement (PE) has emerged as a strategy to promote care quality, well-being, and patient experience in hospitals. Institutional logics suggests that institutions are guided by dominant belief systems referred to as logics that represent the fundamental narratives that shape an organization’s ethos, decision-making processes and behaviors. In healthcare, four logics have been identified: public management (i.e., community health and well-being), market (i.e., efficiency and cost containment), medical professional (i.e., care quality), and care professional (i.e., patient well-being). The objective of this research was to explore what hospital documents reveal about the hospital’s goals for PE and how staff and patient and family partners understand and describe such goals.MethodsThis study employed critical discourse analysis of organizational documents and interviews with 25 participants representing diverse roles (patient and family partners, clinicians, managers, and executives) in one hospital system.ResultsThis study found a strong emphasis on the medical and care professional logics in organizational documents and 25 participant interviews: nine managers and directors, nine clinicians, five patient and family partners and two executive leaders. Managers and clinicians understood and described the hospital’s PE goals in the context of their institutional roles and responsibilities, such as improving patient satisfaction, using clinical tools, and designing new programs. There was also a shared emphasis on the care professional logic in all participant groups and in multiple organizational documents by articulating patients as the primary focus of hospital goals. There was some indication of the public management logic, primarily by executives and directors in their goals to engage communities and somewhat by clinicians and managers in their discussion on equity, diversity, and inclusivity initiatives at the hospital. Finally, there were two mentions of the market logic, one in a single organizational document and by two managers, which referred to the sustainability of health services.ConclusionsThis study explored what hospital documents convey about goals for PE and how participants understand and describe such goals. Future research on how hospital goals are practiced could provide the data to determine the role of market logic in operationalizing hospital goals.

引言
为构建以患者为中心的医疗体系，患者与家属参与（Patient and Family Engagement, PE）已成为提升医院护理质量、患者福祉与就医体验的核心策略。制度逻辑（institutional logic）理论指出，各类组织由主导性信念体系所指引，这类信念体系即所谓“逻辑”，其承载着塑造组织精神、决策流程与行为模式的核心叙事。在医疗领域，现已明确四类制度逻辑：公共管理逻辑（聚焦社区健康与福祉）、市场逻辑（追求效率与成本管控）、医疗专业逻辑（关注护理质量）与照护专业逻辑（关注患者福祉）。本研究旨在探究医院文件中所体现的患者与家属参与目标，以及医护人员、患者及家属伙伴如何理解并阐释此类目标。

研究方法
本研究针对某医院系统的组织文件开展批判性话语分析（critical discourse analysis），并对25名覆盖多岗位的参与者开展访谈，参与者涵盖患者与家属伙伴、临床医护人员（clinicians）、管理人员与行政高管（executives）。

研究结果
本研究在组织文件与25名参与者的访谈中均发现，研究对象对医疗专业逻辑与照护专业逻辑存在显著侧重：受访参与者具体构成为9名管理人员与主管、9名临床医护人员、5名患者与家属伙伴以及2名行政高管。管理人员与临床医护人员结合自身岗位权责，理解并阐释医院的患者与家属参与目标，例如提升患者满意度、应用临床工具以及设计全新照护项目。在所有参与者群体与多数组织文件中，均体现出对照护专业逻辑的共同侧重，即明确将患者作为医院目标的核心关注对象。研究同时发现了公共管理逻辑的相关体现：主要由行政高管与主管在其社区参与目标中提及，临床医护人员与管理人员在讨论医院的公平性、多样性与包容性举措时也偶有涉及。最后，市场逻辑仅被提及两次：一次出现在单份组织文件中，另一次由两名管理人员在谈及医疗服务可持续性时提及。

研究结论
本研究探究了医院文件中所传递的患者与家属参与目标，以及参与者如何理解并阐释此类目标。未来可针对医院目标的落地实践开展相关研究，以获取支撑数据，明确市场逻辑在医院目标落地过程中的具体作用。