全院性質(zhì)量監(jiān)控指標一覽表

GeneralStatistics一般統(tǒng)計資料Statistics統(tǒng)計項目資料采集負責人Whocollectdata住院病人數(shù)病案室HIDAdmissions出院病人數(shù)病案室HIDDischarges平均住院日病案室HIDAveragelengthofstayinhospital留觀病人病案室HIDObservationPatients住院病人死亡率病案室HIDInpatientMortalityrate圍手術(shù)期死亡率病案室HIDPerioperativeMortalityRate急診病人數(shù)病案室HIDERVisits住院病人手術(shù)例數(shù)病案室HIDInpatientOperativeencounters門診病人手術(shù)例數(shù)病案室HIDOutpatientOperativeencounters再生兒病案室HIDDeliveriesStatistics統(tǒng)計項目資料采集負責人Whocollectdata剖腹產(chǎn)率病案室HIDCesareanSectionRate

資料采集處Where資料采集時間How解析頻率建議質(zhì)量趨勢/差異解析工具collectdataoftencollectdataHowoftenRecommendationofanalyzedataTrend/variationanalysisTools住院病房每個月每個月直方圖InpatientunitMonthlyMonthlyBarchart住院病房每個月每個月直方圖InpatientunitMonthlyMonthlyBarchart住院病房每個月每個月控制圖InpatientunitMonthlyMonthlyControlchartt急診室每個月每個月直方圖ERMonthlyMonthlyBarchart住院病房每個月每個月控制圖InpatientunitMonthlyMonthlyControlchart住院病房每個月每個月控制圖InpatientunitMonthlyMonthlyControlchart急診室每個月每個月直方圖ERMonthlyMonthlyBarchart手術(shù)室每個月每個月直方圖MainORMonthlyMonthlyBarchart門診手術(shù)室每個月每個月直方圖OPD-ORMonthlyMonthlyBarchart婦產(chǎn)科每個月每個月直方圖OB/GYMonthlyMonthlyBarchart資料采集處Where資料采集時間How解析頻率建議質(zhì)量趨勢/差異解析工具collectdataoftencollectdataHowoftenRecommendationofanalyzedataTrend/variationanalysisTools婦產(chǎn)科每個月每個月直方圖OB/GYMonthlyMonthlyBarchart每年員工離院率Annualturnoverrate(HR)QPS標準QPSStandards臨床監(jiān)控包括病人評估ClinicalmonitoringincludespatientassessmentClinicalmonitoringincludeslaboratory臨床監(jiān)控包括實驗室服務(wù)Clinicalmonitoringincludesradiology臨床監(jiān)控包括放射影像服務(wù)

郭杏雅（人事部）HR人事部HR每年每年控制圖ControlchartYearlyYearlyJCI要求的質(zhì)量監(jiān)控指標監(jiān)測指標What資料采集負責人Who資料采集處/資料采集時解析頻率建議質(zhì)量趨勢/差MonitorIndicators樣本量間WhenAnalysis異解析工具Where/SamplesRecommendationofTrend/variationanalysisTools質(zhì)量管理辦公室周末和周一住院的每個月每個月控制圖大病史完成高出24小時QMOffice新病人NewMonthlyMonthlyControlchartH&Pcompleted>24hrAdmissiononMonday急診檢驗報告>60費春榮（檢驗科）檢驗科/100個每個月每個月控制圖分鐘(CBC,UA,CX7)LaboratoryLaboratory/100MonthlyMonthlyControlchartEmergencySamples檢驗科Labreport>60′(CBC,UA,CX7)臨床緊迫值質(zhì)量管理辦公室最少50例每個月每個月控制圖Lab.clinicpanicAtleast50casesMonthlyMonthlyControlchart放射診斷與病理診胡紅杰（放射科）最少50例每個月每個月控制圖斷吻合率RadiologyRadiologyAtleast50casesMonthlyMonthlyControlchartDiagnosisconsistwithPathologyDiagnosis放射科level胡紅杰（放射科）放射科每個月每個月控制圖甲片率FirstfilmrateRadiologyRadiologyMonthlyMonthlyControlchart個人放射劑量監(jiān)朱雅芳（保健科）放射地域每季每季控制圖測IndividualStaffhealthpromotionRadiationareasQuarterlyQuarterlyControlchartradiationmonitorQPS標準QPSStandardsClinicalmonitoringincludessurgicalprocedures臨床監(jiān)控包括外科手術(shù)操作。Clinicalmonitoringincludestheuseofantibioticsandothermedications臨床監(jiān)控包括抗生素及其他藥物的使用

監(jiān)測指標WhatMonitorIndicators二次手術(shù)率ReturntoORwithsameproblemPACU留觀〉2小時PACUobservation〉2hrs術(shù)前1小時抗生素使用髖關(guān)節(jié)置換術(shù)HipReplacement抗生素使用Antibioticsuse藥物的合理使用Medicationusewithreasonable麻醉處方書寫合格率compliancewithanesthesiaprescription

資料采集負責人Who資料采集處/資料采集時解析頻率建議質(zhì)量趨勢/差樣本量間WhenAnalysis異解析工具Where/SamplesRecommendationofTrend/variationanalysisTools祁海歐（手術(shù)室）OR每個月每季控制圖ORMonthlyQuarterlyControlchart祁海歐（手術(shù)室）PACU每個月每季控制圖ORMonthlyQuarterlyControlchart祁海歐（手術(shù)室）OR每個月每個月控制圖ORMonthlyMonthlyControlchart袁方（質(zhì)量管理辦公骨科每個月每季控制圖室）MonthlyQuarterlyControlchart藥房出院和急診病歷每個月每個月直方圖PharmacydepartmentDischargeandERMonthlyMonthlyBarchartCharts藥房住院和門診病歷每個月每個月直方圖PharmacydepartmentInpatientandMonthlyMonthlyBarchartoutpatient藥房病人地域每個月每個月直方圖PharmacydepartmentPatientcareareaMonthlyMonthlyBarchart質(zhì)量管理辦公室和藥涉及藥品管理和使每個月每個月控制圖Control劑科用地域MonthlyMonthlychartQM&PharmacyAreasInvolved給藥錯誤departmentmedicationuseandClinicalmonitoringincludesMedicationErrormanagementmedicationerrorsandNearMiss藥物不良反應(yīng)監(jiān)測藥房藥房Pharmacy每季每季控制圖Control臨床監(jiān)控包括給藥錯誤及蹤近錯MonitoringtheaderversePharmacydepartmentdepartmentQuarterlyQuarterlychart誤。reactionsofmedicationClinicalmonitoringincludesthe

麻醉時期的不良事件麻醉科手術(shù)每個月每個月直方圖

useofanesthesia臨床監(jiān)控包括麻醉的使用Clinicalmonitoringincludestheuseofbloodandbloodproducts臨床監(jiān)控包括全血及血制品的使用。Clinicalmonitoringincludestheavailability,content,anduseof

AdverseeventsduringAnesthesiadepartmentORMonthlyMonthlyBarchartanesthesia紅細胞輸血指征的吻合率劉志偉（檢驗科）檢驗科每個月每個月直方圖CompliancewithLaboratorydepartment檢驗科MonthlyMonthlyBarcharttransfusionindicatorofLaboratoryRedCellblooddepartment門診復診病歷在20分鐘內(nèi)送病案室HID門診每半年每半年控制圖至門診護士站PreviousOutpatientSemiannualySemiannualyControlchartmedicalrecordsenttooutpatientnursingpatientrecords臨床監(jiān)控包括病歷的供應(yīng)、內(nèi)容和使用

sataionwithin20minutes現(xiàn)病歷檢查Opencharts醫(yī)務(wù)科、質(zhì)量管理辦公病房/每個Attending2每個月每個月直方圖review室MedicalAffair,QM份病歷Unit/2ChartsMonthlyMonthlyBarchartperAttendingCVC相關(guān)感染院感科住院病人每個月每個月控制圖ControlClinicalmonitoringincludesInfectioncontrolInpatientMonthlyMonthlychartinfectioncontrol,surveillance,departmentandreporting呼吸機相關(guān)性肺炎感染率莊一渝（ICU）ICU每個月每個月直方圖臨床監(jiān)控包括感染的控制、監(jiān)測Ventilationpatients院感科MonthlyMonthlyBarchart及報告developedwithpneumoniaInfectioncontroldepartment手術(shù)切口胃染率Surgicalsiteinfectionrate臨床研究吻合要求率ClinicalmonitoringincludesCompliancewithclinicclinicalresearchresearchRequirement臨床監(jiān)控包括臨床研究3.12—3.20為管理領(lǐng)域的監(jiān)控指標Managerialmonitoringincludes臨時使用一次的藥品發(fā)送theprocurementofroutinelyOneDosemedicationrequiredsuppliesanddeliverytimemedicationsessentialtomeetpatientneeds

院感科住院病人藥劑科）Pharmacy直方圖InfectioncontrolInpatientdepartmenBarchartdepartmentt葛松林（科教科）科教科每個項目每個項目描述Education&researchEducationEachEachDescriptiondepartment&researchprogramprogramdepartment藥劑科計算機每個月每個月直方圖PharmacydepartmentComputerMonthlyMonthlyBarchart管理監(jiān)控包括滿足病人基本需求所必定的用品及藥品的老例獲取。Managerialmonitoringincludesreportingofactivitiesasrequiredbylawandregulation管理監(jiān)控包括法律和法規(guī)所要求的活動的報告。

傳生病、腫瘤、性病、職業(yè)病報卡漏報率Infectiousdiseases,tumors,venerealdiseasesreporttoCDC實驗室質(zhì)控Laboratoryqualitycontrol病理科質(zhì)控Pathologyqualitycontrol放射科質(zhì)控Radiologyqualitycontrol

朱亞芳（保健科）病人地域每個月每個月直方圖StaffhealthpromotionPatientcareareaMonthlyMonthlyBarchart費春榮（檢驗科）檢驗科Laboratory每個月每個月控制圖LaboratoryMonthlyMonthlyControlchart金梅(Pathology病理科每個月每個月控制圖Dept.)PathologyDept.MonthlyMonthlyControlchart胡紅杰（Radiology放射科每個月每個月控制圖Dept.）RadiologyDept.MonthlyMonthlyControlchartManagerialmonitoringincludesriskmanagement管理監(jiān)控包括風險管理Managerialmonitoringincludesutilizationmanagement管理監(jiān)控包括醫(yī)療資源合理使用管理。Managerialmonitoringincludespatientandfamilyexpectationsandsatisfaction管理監(jiān)控包括病人及其家屬的希望值及滿意度

壓瘡胡紅鴦（APN）病人地域每個月每個月控制圖DecubitusulcersPatientcareareaMonthlyMonthlyControlchart因果圖Fishbonechart病人墜床/滑倒質(zhì)量管理科病人地域每個月每個月控制圖PatientFallRateQMPatientcareareaMonthlyMonthlyControlchart利器傷害朱雅芳、質(zhì)量管理辦保健科Staffhealth每個月每個月控制圖Sharpinjuries公室、院感科romotionMonthlyMonthlyControlchart心肺復蘇病人徐秋萍潘紅英病人地域每個月每個月控制圖Codebluepatients（危重醫(yī)學科）PatientcareareaMonthlyMonthlyControlchart因果圖Fishbonechar急診留觀>72小時潘紅英（ER）ER每季每季直方圖ERobservation>72hrQuarterlyQuarterlyBarchartMRI檢查陽性率胡紅杰（Radiology放射科每個月每個月控制圖Dept.）RadiologyDept.MonthlyMonthlyControlchart床位使用率病案室HID住院病房每個月每個月直方圖AveragepercentageofInpatientunitMonthlyMonthlyBarchartbedsoccupancy平均住院日病案室HID住院病房每個月每個月控制圖ControlAveragelengthofstayInpatientunitMonthlyMonthlychart質(zhì)量管理辦公室住院病房每個月每個月直方圖住院病人滿意率QMInpatientunitMonthlyMonthlyBarchartInpatientsatisfaction門診病人滿意率Outpatientsatisfaction

Managerialmonitoringincludes員工滿意率孔向紅（黨辦）員工Staff每年每年直方圖staffexpectationsandsatisfactionStaffsatisfactionAnnuallyAnnuallyBarchart管理監(jiān)控包括員工的希望值及滿意度

Managerialmonitoringincludespatientdemographicsanddiagnoses管理監(jiān)控包括病人集體統(tǒng)計和診斷Managerialmonitoringincludesfinancialmanagement管理監(jiān)控包括財務(wù)管理Managerialmoni