醫(yī)療品質(zhì)政策規(guī)劃藍(lán)圖課件

醫(yī)療品質(zhì)政策規(guī)劃藍(lán)圖行政院衛(wèi)生署醫(yī)事處2008.11.6什麼是醫(yī)療品質(zhì)“thedegreetowhichhealthservicesforindividualsandpopulationsincreasethelikelihoodofdesiredhealthoutcomesandareconsistentwithcurrentprofessionalknowledge”「一種增加個(gè)人或群體預(yù)期照護(hù)結(jié)果可能性的程度，且與現(xiàn)有專業(yè)知識(shí)一致」InstituteofMedicine1990安全是醫(yī)療品質(zhì)的基礎(chǔ)每年約44,000~98,000的美國人因?yàn)獒t(yī)療行為死亡。居當(dāng)年十大死因第八位(高於乳癌、交通事故、愛滋病死亡的人數(shù))。國家花費(fèi)：每年約170~290億美元。IOMreport,199921世紀(jì)的醫(yī)療品質(zhì)改革方向重視病患安全結(jié)果為導(dǎo)向的治療計(jì)畫病人為中心的考量及時(shí)性的醫(yī)療照護(hù)有效率的醫(yī)療行為公平的提供醫(yī)療照護(hù)醫(yī)療品質(zhì)的內(nèi)涵Safety

(First,donoharm)

PracticeconsistentwithCurrentKnowledge.(evidencebased)Customization

(patientcenteredness)Accountability(performance/outcomeoriented)Patient/FamiliesPerformanceEvidence-basedSafety品質(zhì)概念圖JAMA2005,2384-2390ToerrishumanBadsystems,notbadpeoplePatientsafetyisthefirstChangingpracticestoimprovesafetyPatientsafety的挑戰(zhàn)對(duì)於系統(tǒng)觀（systemtheory）的了解運(yùn)用有限舊習(xí)慣很難改變

（即使很簡(jiǎn)單的事）資訊科技的導(dǎo)入“知易行難”安全的本質(zhì)繫乎“人際關(guān)係”

NextStepAfterToErrIsHumanCulturechangeSenseofUrgencyLearntoworklikeateamDevelopdifferentsystemofaccountabilityMostimportantisLeadership

病人安全文化的營(yíng)造FromindividualerrortosystemfailureFrompunitivetotrustFromsecretivetotransparentFromprovidercenteredtopatientcenteredFromindividualperformancetomultidisciplinaryteamworkFromTop-downaccountabilitytobottom-upmoralauthority策略Leadership鼓勵(lì)通報(bào)

（learningfromerrors)強(qiáng)化團(tuán)隊(duì)合作訓(xùn)練標(biāo)竿學(xué)習(xí)

（病安年度目標(biāo)）賦權(quán)病人(Mann,2006)BethIsraelDeaconessMedicalCenterContemporaryOB/GYN(Sexton,2006)JohnsHopkins(Pronovost,2003)JohnsHopkinsJournalofCriticalCareMedicine醫(yī)療機(jī)構(gòu)安全作業(yè)建議建立機(jī)構(gòu)安全的文化滿足人力與能力的需求加強(qiáng)訊息的傳遞與溝通提供必要的特殊設(shè)備與照護(hù)流程推廣安全用藥措施ANationalQualityForumConsensusReport2003共識(shí)條件Specificity:流程或做法明確Benefit:減少病人死亡、罹病或降低警訊事件Effectiveness:具實(shí)證基礎(chǔ)Generalizability:適用於多數(shù)機(jī)構(gòu)Readiness:必要技術(shù)或?qū)２虐踩鳂I(yè)

NQFHospitalConsensusStandards2007採取措施預(yù)防呼吸器相關(guān)肺炎有效預(yù)防中央靜脈導(dǎo)管相關(guān)之血行性感染給予每位出院病患出院計(jì)畫與摘要加護(hù)單位之醫(yī)師應(yīng)有專業(yè)訓(xùn)練與認(rèn)證醫(yī)療人員每年接受流行性感冒疫苗接種在執(zhí)行知情同意時(shí)可要求病人或法定代理人重複重要之資訊(teachback)安全作業(yè)

NQFHospitalConsensusStandards2007對(duì)選擇性手術(shù)病患進(jìn)行缺血性心臟病風(fēng)險(xiǎn)評(píng)估，並考慮投與乙型阻斷劑預(yù)防發(fā)作對(duì)住院病患於住院時(shí)進(jìn)行褥瘡風(fēng)險(xiǎn)評(píng)估並定期檢視對(duì)住院病人常規(guī)評(píng)估發(fā)生深部靜脈栓塞(VTE/DVT)的風(fēng)險(xiǎn)並給予必要的預(yù)防措施對(duì)於長(zhǎng)期使用口服抗凝血?jiǎng)┎∪藨?yīng)有特殊之照護(hù)計(jì)畫或流程安全作業(yè)

NQFHospitalConsensusStandards2007發(fā)生嚴(yán)重醫(yī)療不良事件時(shí)，應(yīng)予病人或家屬及時(shí)、透明、清楚的溝通口頭醫(yī)囑或電話危險(xiǎn)值通報(bào)的接收者，應(yīng)紀(jì)錄並完整覆誦醫(yī)療機(jī)構(gòu)儘可能使用單一劑量調(diào)劑(unit-dose,unit-of-use)針對(duì)高危險(xiǎn)藥物建立使用規(guī)範(fàn)或指引以減少傷害安全作業(yè)

NQFHospitalConsensusStandards2007導(dǎo)入電腦輔助開方系統(tǒng)(computerizedprescriberorderentrysystem)評(píng)估合適的護(hù)理人力確保放射檢查、檢體與其他診斷檢驗(yàn)標(biāo)示的正確性(therightstudyislabeledfortherightpatientattherighttime)建立標(biāo)準(zhǔn)作業(yè)以避免手術(shù)病人、部位、術(shù)式的錯(cuò)誤“Knowingisnotenough;

wemustapply.

Willingisnotenough;

wemustdo.”

-GoetheResearchtosupportsolutionsSafetyandqualityisascienceResearchtoprovidetheevidenceofsuccessResearchcannotmakeimprovementPractice!Practice!Practice!PDSASDSAThecentrallinebundleHandhygieneUseofmaximalbarrierprecautionsChlorhexidineforskinantisepsisOptimalinsertionsiteandsitecareDailyreviewoflinenecessityTipsforsuccessSTOPthelineEmpowernursestostoplineplacementifimpropertechniquesareusedLeadershipsupport&cultureEvidenceStandardequipmentspackChecklist,centrallinecartsClinicalappropriateness67家醫(yī)院，103個(gè)ICU感染率從2.4%降至0

下一步…Newinterventionstargetedatharm:PreventPressureUlcers...byreliablyusingscience-basedguidelinesfortheirpreventionReduceMRSAInfection…byreliablyimplementingscientificallyproveninfectioncontrolpracticesPreventHarmfromHigh-AlertMedications...startingwithafocusonanticoagulants,sedatives,narcotics,andinsulinReduceSurgicalComplications...byreliablyimplementingallofthechangesincarerecommendedbytheSurgicalCareImprovementProject(SCIP)DeliverReliable,Evidence-BasedCareforCongestiveHeartFailure…toreducereadmissionsGetBoardsonBoard….Definingandspreadingthebest-knownleveragedprocessesforhospitalBoardsofDirectors,sothattheycanbecomefarmoreeffectiveinacceleratingorganizationalprogresstowardsafecare策略推動(dòng)實(shí)證基礎(chǔ)的品質(zhì)改善活動(dòng)選定主題標(biāo)竿學(xué)習(xí)標(biāo)準(zhǔn)作業(yè)鼓勵(lì)醫(yī)師參與為何需要醫(yī)師參與?醫(yī)院內(nèi)很少有事情不需要醫(yī)師的”O(jiān)rder”而可執(zhí)行醫(yī)療品質(zhì)不會(huì)只單純?yōu)椤狈?wù)品質(zhì)”品質(zhì)改善需要全員參與醫(yī)師扮演的角色Champions*MedicalLeadership/CommitteemembersProjectleader-testofchangeAdopter-physicianwillingtocooperateCautiouslaggard病人為中心

Patient/familiescentered

什麼是病人為中心的照護(hù)“Understandingandrespectingpatients’values,preferencesandexpressedneedsisthefoundationofpatient-centeredcare”---HarveyPicker

病人為中心的思維從病人的眼中了解其需求尊重病人的價(jià)值、偏好與需求協(xié)調(diào)、整合的醫(yī)療照護(hù)模式克服語言的障礙減輕身體的不適提供情感上的支持將病人的親友納入支持網(wǎng)絡(luò)協(xié)助轉(zhuǎn)診或出院病人/家屬的參與醫(yī)療品質(zhì)是在醫(yī)療過程中取得病患的合作與參與FacilityplanningPatientcareroundsPatienteducationprogramComplementarytherapytaskforcePolicyreviewSafetyroundsDisclosure策略改變思維使用病友了解的文字或說明建立夥伴關(guān)係績(jī)效

PerformanceWhatisHealthcarePerformancePatientcenteredPatientfocusResponseEffectivenessImprovingHealthClinicalfocusPatientsafetyAccessibilityEfficiencyCost/Expenditu