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활동기준원가분석에 의한 종합병원 일반병동 간호행위의 상대가치수가 추정 : Resource-Based Relative Value Scale and Nursing Fees in General Hospital's Wards : Activity-Based Costing Analysis

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Authors
윤호순
Advisor
김진현
Major
간호학과
Issue Date
2012-02
Publisher
서울대학교 대학원
Abstract
본 연구는 병원의 원가시스템 속에서 일반병동 간호활동에 대한 원가와 수익간의 관련성을 탐색하고, 상대가치 진료수익에 대한 간호활동의 경제적 가치를 추정하기 위하여 수행된 탐색적 조사연구이다. 이를 위하여 활동원가계산시스템(ABC)이 구축된 1개 종합병원의 일반 병동에서 2010.1.1-12.31까지의 1년간의 간호활동과 관련 자료를 바탕으로, 우리나라 건강보험수가 체계에 내재된 간호업무 보상형태에 따라 별도보상 간호활동과 간호관리료 보상에 포함된 활동으로 분류하여 활동원가를 분석하고, 선행연구에서 도출한 기준간호(reference nursing activities)의 상대가치점수를 적용하여 간호활동의 상대가치수가를 추정하였으며, 연구 결과는 다음과 같다.
12개의 일반병동에서 수행된 간호활동은 140개로 조사되었으며, 진료비 상대가치에서 별도수가에 반영되는 별도보상 간호활동 71개, 간호관리료 보상 간호활동 69개로 분류되었다.
상대가치수가 추정을 위해 기준간호(reference nursing activities)와 대응조합(mapping)된 활동은 140개중 106개로 별도수가에 반영되는 별도보상 간호활동 71개와 35개의 간호관리료보상 간호활동으로 분류되었다.
별도보상간호 활동 중 빈도가 가장 높은 행위는 경구투약으로 나타났으며, 일반정맥주사, 정맥주사시작, 근육주사, 피하/피내주사, 외용약 도포 등이 10위 이내 다빈도 행위에 포함되어 투약영역의 간호활동 빈도가 높다는 것을 확인하였다. 간호관리료보상 간호활동은 낙상예방 간호, 수면돕기, 환의 및 린넨교환, 활동보조, 활력징후 측정(routine vital sign), 식사입력 및 변경, OCS관련업무, 검사전 후 환자간호, 섭취량 배설량 측정 등의 순으로 빈도가 높았다.
간호단위 연간 총원가는 간호사 총인건비 7,309,576천원(90%), 재료비 367,506천원(4%), 경비 477,446천원(6%)를 합산한 8,154,528천원 으로 집계되었다.
140개 간호활동에 사용한 총 시간 21,134,733분을 활동별로 시간비(spent time rate)를 구하고, 인건비 총액 7,309,577,162원을 각 활동의 시간비에 따라 할당하여 활동별 총 할당원가(assigned cost)를 구하고, 이를 다시 활동건수(activity quantity)로 나누어 건당 원가비(cost driver rate)를 산출하였다. 기타행정업무 영역의 시간비율이 32.6%로, 투약간호(25.04%), 상담 및 교육(10.24%), 측정 및 관찰(9.37%), 안전 및 안위(6.77%), 운동 및 자세유지(4.31%), 영양간호(3.70%), 위생간호(2.78%), 배설간호(2.65%), 호흡간호(2.51%), 영적간호(0.04%)영역 순으로 나타났으며, 건당원가 비는 호흡측정 344원부터 심폐소생술 16,033원까지로 나타났다.
별도보상간호활동의 총원가는 2,761,567,804원(38%), 간호관리료 보상 간호활동의 총원가는 4,548,009,358원(62%)로 나타났으며, 재료비와 경비를 포함시킨 별도보상 배부원가는 3,081,178천원으로, 간호단위 배부원가는 5,073,353천원으로 산출되었다. 각 배부원가의 합은 간호단위 총원가 8,154,530천원과 대응하여 일치된다.
간호단위별 수익으로 인식한 간호관리료의 간호단위별 평균은 185,523천원, 총액은 2,226,271천원으로 산출되었으며, 간호단위 배부원가와 비교한 결과 간호단위별 평균 손익은 -237,257천원, 총 손익 -2,847,081천원으로 나타나 간호관리료의 원가 보전율은 44%라고 할 수 있다.
상대가치 수가 추정에 필요한 자료로서 간호단위별 평균 근무 간호사수는 15명, 병동별 간호사 1인당 연평균 인건비 41,366천원으로, 단위시간(분)당 인건비는 326원으로 조사되었다. 병동간호사의 근무시간 중 상대가치 수가산출 대상 간호활동에 투입된 시간비율은 86%이었으며, 이를 근거로 산출한 환산지수(F)는 19.913원이었다. 이를 개별 간호활동의 상대가치 점수와 종합병원의 종별 가산율 1.25를 반영하고, 간접비 10%를 더하여 106개의 상대가치 행위수가를 구하였으며, 그 범위는 128원(체중/신장/복위측정)~28,398원(복막투석)으로 나타났다.
71개의 별도보상 간호활동을 1202개의 수가코드와 대응하여 산출한 진료수익에 대한 간호활동별 상대가치 평균 원가율은 33%로,
1사분위수의 원가율은 11.25%, 2사분위수(중앙값)38%이며, 3사분위수의 원가율 76%로서 원가율의 사분위의 범위는 64.5%로 나타났다.
The purposes of this study are to explore the relationship between cost and revenue within the hospital ABC system and to estimate the relative value cost by applying RBRVS of reference nursing activities derived from the preceding study about the nursing activities for inpatients in general wards.
In this study, the nursing activities were categorized into 2 groups. Based on the data of a general hospital from 01 January 2010 to 31 December 2010, practicing in general wards in accord with the nursing service reward type is inherent in Korea health insurance system. The following results were also found out in this exploratory research.
Nursing activities performed in 12 general wards were identified as 140 items and also classified into 71 separate reward nursing activities reflected in the independent fee in medical RBRVS and 69 items included comprehensive nursing management fee.
To estimate the relative value cost of nursing activities, 106 activities were mapped with reference nursing activities. The 140 nursing activities were categorized into 71 separate reward nursing activities and 35 comprehensive nursing management activities. Oral medicine administration, general intravenous administration, IV insertion, IM injection, subcutaneous/ intradermal injection, and external applications are included within the top 10 most frequent acts. Therefore, the medication administration was identified that it had a high frequency among nursing domains.
Nursing activities included nursing management service as having a high frequency in order of prevention fall, care for sleeping, change clothing & sheet, assist patient to transfer, manual check for routine V/S, adjust diet to patient's condition, sharing OCS(result confirm/order printing. etc), pre & post diagnostic test management, monitor intake and output.
The total cost of nursing units were calculated as 8,154,528,000 won where 7,309,576,000won(90%) is from the total nurse labor costs, 367,506,000 won(4%) for materials, and 477,446,000 won(6%) for expenses in a year.
To analyze the activity cost, the cost driver rate was calculated by dividing the assigned cost with activity quantity and assigning the total nurse labor costs (7,309,577,162 won) in each activity as spent time rate on the total hour of 21,134,73 minutes used in 140 nursing activities.
Spent time rate of administrative tasks was 32.6%, succeeded by medication care(25.04%), counseling & education(10.24%), measuring & observation(9.37%), safety & comfort(6.77%), mobility & posture (4.31%), nutrition(3.70%), hygiene(2.78%), elimination(2.65%), respiration(2.51%), spiritual care(0.04%) and cost rate ranged from 344 won for manual check respiration to 16,033 won for CPR.
The total cost for medical support nursing service showed 2,761,567,804 won (38%) and the other cost included nursing management fee with 4,548,009,358 won(62%). The total distributed cost for medical support nursing service including material cost and expenses were calculated as 3,081,178,000 won and the total distributed cost for nursing management showed 5,073,353,000 won.
The average per nursing unit and the sum which were estimated as revenue per nursing unit were calculated as 185,523,000 won and 2,226,271,000 won respectively. The average of the profits and loss is -237,257,000 won and a total of -2,847,081,000 won for the 12 nursing units as the results of comparison with total distributed cost for nursing management service. It means that the cost recovery portion is only 44% of nursing management service in ward.
For price estimation using RBRVS, data regarding the number of average working nurses per ward (15) , average annual labor costs per nurse (41,366,000 won) and labor costs per minute (326 won) are needed. In the nurses working hours, only 86% of the nursing activities can be calculated by RBRVS and based on this finding, conversion factor (F) was calculated (19.913 won) multiplied by the relative value score of individual nursing activity(Vi) and 1.25 incentive rate for general hospital then added to the 10% indirect cost comprised the nursing activity price. The range went from 128 won (for measuring weight/height/abdominal circumference) to 28,398 won (for peritoneal dialysis).
The average contribution rate per nursing activity on the total medical revenue was 33%. This was calculated from 1202 codes of price corresponding to the 71 items of nursing activities for medical support nursing service. The interquartile range showed 64.5%, third quartile with 75.75% and 11.25% for the first quartile.

keywords : Nursing activity, ABC, Cost, RBRVS,
Nursing management fee
Language
kor
URI
https://hdl.handle.net/10371/156165

http://dcollection.snu.ac.kr:80/jsp/common/DcLoOrgPer.jsp?sItemId=000000000085
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College of Nursing (간호대학)Dept. of Nursing (간호학과)Theses (Ph.D. / Sc.D._간호학과)
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