全院性質(zhì)量監(jiān)控指標計劃一覽表

1、GeneralStatistics一般統(tǒng)計資料Statistics統(tǒng)計工程資料收集負責人Whocollectdata?資料收集處Wherecollectdata?資料收集時間Howoftencollectdata?分析頻率Howoftenanalyzedata?建議質(zhì)量趨勢/差異分析工具RecommendationofTrend/variationanalysisTools入院病人數(shù)AdmissionsHID住院病房Inpatientunit每月Monthly每月Monthly直方圖Barchart出院病人數(shù)DischargesHID住院病房Inpatientunit每月Monthly每月Mo

2、nthly直方圖Barchart平均住院日AveragelengthofstayinhospitalHID住院病房Inpatientunit每月Monthly每月Monthly限制圖Controlchartt留觀病人ObservationPatientsHID急診室ER每月Monthly每月Monthly直方圖Barchart住院病人死亡率InpatientMortalityrateHID住院病房Inpatientunit每月Monthly每月Monthly限制圖Controlchart圍手術期死亡率PerioperativeMortalityRateHID住院病房Inpatientunit每

3、月Monthly每月Monthly限制圖Controlchart急診病人數(shù)ERVisitsHID急診室ER每月Monthly每月Monthly直方圖Barchart住院病人手術例數(shù)InpatientOperativeencountersHIDMainOR每月Monthly每月Monthly直方圖Barchart門診病人手術例數(shù)OutpatientOperativeencountersHID門診手術室OPD-OR每月Monthly每月Monthly直方圖Barchart新生兒DeliveriesHID婦產(chǎn)科OB/GY每月Monthly每月Monthly直方圖BarchartStatistics統(tǒng)

4、計工程資料收集負責人Whocollectdata?資料收集處Wherecollectdata?資料收集時間Howoftencollectdata?分析頻率Howoftenanalyzedata?建議質(zhì)量趨勢/差異分析工具RecommendationofTrend/variationanalysisTools剖腹產(chǎn)率CesareanSectionRateHID婦產(chǎn)科OB/GY每月Monthly每月Monthly直方圖Barchart每年員,離院率Annualturnoverrate(HR)郭杏雅人事部HR人事部HR每年Yearly每年Yearly限制圖ControlchartJCI要求的質(zhì)量監(jiān)控

5、指標QPS標準QPSStandards監(jiān)測指標WhatMonitorIndicators資料收集負責人Who資料收集處/樣本量Where/Samples資料收集時間When分析頻率Analysis建議質(zhì)量趨勢/差異分析工具RecommendationofTrend/variationanalysisToolsQPS.3.1臨床監(jiān)控包括病人評估Clinicalmonitoringincludespatientassessment大病史完成超過24小時H&Pcompleted>24hr質(zhì)里官理辦公至QMOffice周末和入院的新病人NewAdmissiononMonday每月Mont

6、hly每月Monthly限制圖ControlchartQPS.3.2Clinicalmonitoringincludeslaboratory臨床監(jiān)控包括實驗室效勞檢驗科急診檢驗報告>60分鐘(CBC,UA,CX7)EmergencyLabreport>60'(CBC,UA,CX7)費春末檢3巫科Laboratory檢驗科/100個Laboratory/100Samples每月Monthly每月Monthly限制圖Controlchart臨床危急值Lab.clinicpanic質(zhì)里官理辦公至至少50例Atleast50cases每月Monthly每月Monthly限制圖Con

7、trolchartQPS.3.3Clinicalmonitoringincludesradiology臨床監(jiān)控包括放射影像效勞放射科放射診斷與病理診斷符合率RadiologyDiagnosisconsiswithPathologyDiagnosis胡紅杰放射科Radiology至少50例Atleast50cases每月Monthly每月Monthly限制圖Controlchart甲片率Firstlevelfilmrate胡紅杰放射科Radiology放射科Radiology每月Monthly每月Monthly限制圖Controlchart個人放射劑量監(jiān)測Individualradiationm

8、onitor朱雅芳(保健科)Staffhealthpromotion放射區(qū)域Radiationareas每季Quarterly每季Quarterly限制圖ControlchartQPS標準QPSStandards監(jiān)測指標WhatMonitorIndicators資料收集負責人Who資料收集處/樣本量Where/Samples資料收集時間When分析頻率Analysis建議質(zhì)量趨勢/差異分析工具RecommendationofTrend/variationanalysisToolsQPS.3.4Clinicalmonitoringincludessurgicalprocedures臨床監(jiān)控包括外

9、科手術操作.二次手術率ReturntoORwithsameproblem祁海歐手術室OROR每月Monthly每季Quarterly限制圖ControlchartPACU留觀2小時PACUobservation>2hrs祁海歐手術室ORPACU每月Monthly每季Quarterly限制圖Controlchart術前1小時抗生素使用祁海歐手術室OROR每月Monthly每月Monthly限制圖Controlchart雕關節(jié)置換術HipReplacement坦方質(zhì)里官理辦公室骨科每月Monthly每季Quarterly限制圖ControlchartQPS.3.6Clinicalmonito

10、ringincludestheuseofantibioticsandothermedications臨床監(jiān)控包括抗生素及其它藥物的使用抗生素使用Antibioticsuse藥房Pharmacydepartment出院和急診病歷DischargeandEFCharts每月*Monthly每月Monthly直方圖Barchart藥物的合理使用Medicationusewithreasonable藥房Pharmacydepartment住院和門診病歷Inpatientandoutpatient每月Monthly每月Monthly直方圖Barchart麻醉處方書寫合格率compliancewithan

11、esthesiaprescription藥房Pharmacydepartment病人區(qū)域Patientcarearea每月Monthly每月Monthly直方圖BarchartClinicalmonitoringincludesmedicationerrorsandNearMiss臨床監(jiān)控包括給約錯誤及蹤近錯誤.給約錯誤MedicationError質(zhì)里官理辦公至和藥劑科QM&Pharmacydepartment涉及藥品治理和使用區(qū)域AreasInvolvedmedicationuseandmanagement每月Monthly每月Monthly限制圖Controlchart藥物不良反

12、響監(jiān)測Monitoringtheaderversereactionsofmedication藥房Pharmacydepartment藥房Pharmacydepartment每季Quarterly每季Quarterly限制圖ControlchartQPS.3.7Clinicalmonitoringincludestheuseofanesthesia臨床監(jiān)控包括麻醉的使用麻醉期間的不良事件Adverseeventsduringanesthesia麻醉科Anesthesiadepartment可OR每月Monthly每月Monthly直方圖BarchartQPS.3.8Clinicalmonitor

13、ingincludestheuseofbloodandbloodproducts臨床監(jiān)控包括全血及血制品的使用.紅細胞輸血指征的符合率CompliancewithtransfusionindicatorofRedCellblood劉志偉檢驗科Laboratorydepartment檢驗科檢驗科Laboratorydepartment每月Monthly每月Monthly直方圖BarchartQPS.3.9Clinicalmonitoringincludestheavailability,content,anduseofpatientrecords臨床監(jiān)控包括病歷的提供、內(nèi)容和使用門診復診病歷在2

14、0分鐘內(nèi)送至門診護士站Previousmedicalrecordsenttooutpatientnursingsataionwithin20minutesHID門診Outpatient每半年Semiannualy每半年Semiannualy限制圖Controlchart現(xiàn)病歷檢查Openchartsreview醫(yī)務科、質(zhì)量治理辦公室MedicalAffair,QM病房/每個Attending2份病歷Unit/2ChartsperAttending每月»Monthly每月Monthly直方圖BarchartQPS.3.10Clinicalmonitoringincludesinfect

15、ioncontrol,surveillance,andreporting臨床監(jiān)控包括感染的限制、監(jiān)測及報告CVCt目關感染院感科Infectioncontroldepartment住院病人Inpatient每月Monthly每月Monthly限制圖Controlchart呼吸機相關性肺炎感染率Ventilationpatientsdevelopedwithpneumonia什渝ICU院感科InfectioncontroldepartmentICU每月Monthly每月Monthly直方圖Barchart手術切口感染率Surgicalsiteinfectionrate院感科Infectionco

16、ntroldepartment住院病人Inpatient藥劑科Pharmacydepartment直方圖BarchartQPS.3.11Clinicalmonitoringincludes臨床研究符合要求率葛松林科教科科教科每個工程每個工程描述clinicalresearch臨床監(jiān)控包括臨床研究CompliancewithclinicresearchRequirementEducation&researchdepartmentEducation&researchdepartmentEachprogramEachprogramDescriptionThemanagerialare

17、asidentifiedinstandardsQPS.3.10throughQPS.3.18areincludedintheorganization'squalitymonitoring3.12-3.20為治理領域的監(jiān)控指標QPS.3.12Managerialmonitoringincludestheprocurementofroutinelyrequiredsuppliesandmedicationsessentialtomeetpatientneeds治理監(jiān)控包括滿足病人根本需求所必須的用品及藥品的常規(guī)獲取.臨時使用一次的藥品發(fā)送OneDosemedicationdeliveryt

18、ime藥劑科Pharmacydepartment計算機Computer每月Monthly每月Monthly直方圖BarchartQPS.3.13Managerialmonitoringincludesreportingofactivitiesasrequiredbylawandregulation治理監(jiān)控包括法律和法規(guī)所要求的活動的報告.傳染病、腫瘤、性病、職業(yè)病報卡漏報率Infectiousdiseases,tumors,venerealdiseasesreporttoCDC朱亞芳(保健科)Staffhealthpromotion病人區(qū)域Patientcarearea每月Monthly每月M

19、onthly直方圖Barchart實驗室質(zhì)控Laboratoryqualitycontrol費春末檢Ik科Laboratory檢驗科Laboratory每月Monthly每月Monthly限制圖Controlchart病理科質(zhì)控Pathologyqualitycontrol金梅(PathologyDept.)病理科PathologyDept.每月Monthly每月Monthly限制圖Controlchart放射科質(zhì)控Radiologyqualitycontrol胡紅杰(RadiologyDept.)放射科RadiologyDept.每月Monthly每月Monthly限制圖Controlcha

20、rtQPS.3.14Managerialmonitoringincludesriskmanagement治理監(jiān)控包括風險治理壓瘡Decubitusulcers胡紅鴦APN病人區(qū)域Patientcarearea每月Monthly每月Monthly限制圖Controlchart因果圖Fishbonechart病人墜床/滑倒PatientFallRate質(zhì)里官理科QM病人區(qū)域Patientcarearea每月Monthly每月Monthly限制圖Controlchart利器損傷Sharpinjuries朱雅芳、質(zhì)量治理辦公室、院感科保健科Staffhealthromotion每月Monthly每月M

21、onthly限制圖Controlchart心肺復蘇病人Codebluepatients徐秋萍潘紅英危重醫(yī)學科病人區(qū)域Patientcarearea每月Monthly每月Monthly限制圖Controlchart因果圖FishbonecharQPS.3.15Managerialmonitoringincludesutilizationmanagement治理監(jiān)控包括醫(yī)療資源合理使用治理.急診留觀>72小時ERobservation>72hr潘G(ER)ER每季Quarterly每季Quarterly直方圖BarchartMRI檢查陽性率胡紅杰(RadiologyDept.)放射科R

22、adiologyDept.每月Monthly每月Monthly限制圖Controlchart床位使用率AveragepercentageofbedsoccupancyHID住院病房Inpatientunit每月Monthly每月Monthly直方圖Barchart平均住院日AveragelengthofstayHID住院病房Inpatientunit每月Monthly每月Monthly限制圖ControlchartQPS.3.16Managerialmonitoringincludespatientandfamilyexpectationsandsatisfaction治理監(jiān)控包括病人及其家屬

23、的期望值及滿意度住院病人滿意率Inpatientsatisfaction質(zhì)里官理辦公至QM住院病房Inpatientunit每月Monthly每月Monthly直方圖Barchart門診病人滿意率OutpatientsatisfactionQPS.3.17Managerialmonitoringincludesstaffexpectationsandsatisfaction治理監(jiān)控包括員工的期望值及滿意度員工滿意率Staffsatisfaction孔向紅黨辦員工Staff每年Annually每年Annually直方圖BarchartQPS.3.18Managerialmonitoringincludespatientdemographicsanddiagnoses治理監(jiān)控包括病人群體統(tǒng)計和診斷門診、住院、手術病人最高5個診斷疾病分析Topfiveprimarymedicaldiagnosesofoutpatie