全面質(zhì)量管理與醫(yī)院管理

TotalQualityManagement&Hospitalmanagement

全面質(zhì)量管理與醫(yī)院管理夏萍NancyXiaGuangdongProvinceHospitalofTCM.案例1某醫(yī)院婦產(chǎn)科值班助產(chǎn)士帶著護(hù)校的實(shí)習(xí)生值小夜班。22時(shí)30分，兩人一同處置完兩個(gè)產(chǎn)婦后，助產(chǎn)士去取夜餐?；貋砗螅瑢?shí)習(xí)護(hù)士預(yù)備給嬰兒配奶，并問助產(chǎn)士怎樣配方，奶粉和水的比例怎樣掌握？答：“普通配就行了〞。給嬰兒喂奶完后，即給上午出生的3名嬰兒配葡萄糖水。實(shí)習(xí)護(hù)士從壁櫥最底層的3瓶粉劑中隨手拿出其中已用過的一瓶問助產(chǎn)士：“這是不是葡萄糖？〞她連頭也未抬，信口回答：“是！〞實(shí)習(xí)護(hù)士便配成“糖水〞喂了3名嬰兒。次日凌晨1時(shí)30分，第一例嬰兒出現(xiàn)呼吸衰竭，搶救50分鐘后無效，于2時(shí)20分死亡。醫(yī)務(wù)人員進(jìn)展討論，以為嬰兒死得忽然，診斷不清，以致?lián)尵入y以奏效。4時(shí)40分，第2例嬰兒出現(xiàn)面部紫紺，呼吸困難；5分鐘后第3例女嬰也出現(xiàn)一樣病癥。立刻請(qǐng)來兒科主治醫(yī)師會(huì)診，思索是亞硝酸鈉中毒，雖經(jīng)積極搶救，終因中毒較重，兩名女嬰相繼死亡。

.案例1分析事后查實(shí)，此3瓶粉劑是已存放十幾年的亞硝酸鈉鹽。由于本科教師人實(shí)習(xí)學(xué)生不需配亞硝酸鈉溶液，因此未向?qū)嵙?xí)護(hù)士闡明此3瓶粉劑是劇毒藥，不能隨意動(dòng)用，同時(shí)也未加鎖。上述案例3名嬰兒死于硝酸鈉中毒。此藥為劇毒藥品，本應(yīng)由專人妥善保管，上鎖存放，但竟然在新生兒配奶用的壁櫥內(nèi)存放此劇毒藥達(dá)幾十年，雖曾有數(shù)人發(fā)現(xiàn)，均未引起注重，足見管理上的嚴(yán)重失職。特別是作為帶教教師的助產(chǎn)士，面對(duì)實(shí)習(xí)護(hù)士，明知櫥內(nèi)有劇毒藥，本應(yīng)仔細(xì)擔(dān)任，謹(jǐn)慎從事，放手不放眼，而她卻不親身查對(duì)，順口便答“是〞。以致呵斥3名嬰兒死亡，完全喪失了一個(gè)醫(yī)務(wù)人員應(yīng)有責(zé)任感，是一種失職犯罪行為。助產(chǎn)士是本案的主要責(zé)任者，本例定為一級(jí)醫(yī)療責(zé)任事故。.案例2患者女性，24歲，因腰痛1年，逐漸加重住院。檢查：體溫37度，發(fā)育營養(yǎng)中等，第9、10腰椎明顯凸，拾物實(shí)驗(yàn)〔+〕。脊柱X線片第9、10腰椎骨破壞、死骨構(gòu)成，第9-11腰椎有椎旁膿腫。診斷為第9、10腰椎結(jié)核。某大醫(yī)院骨科醫(yī)師甲以個(gè)人名義被邀作主刀醫(yī)師，在全麻下經(jīng)胸做病灶去除加植骨手術(shù)。術(shù)中清病灶時(shí)，刮出一黃豆粒大小的白色物，助手和本院醫(yī)師乙疑為脊髓，再叫甲看。但甲沒有仔細(xì)視物就說是“膿苔〞〔后經(jīng)病理證明是脊髓組織〕。術(shù)后患者呈緩和性截癱。經(jīng)當(dāng)?shù)刂委熀妥o(hù)理后，轉(zhuǎn)入甲所在醫(yī)院。截癱平面不見下降，自主膀胱構(gòu)成，但因善后處置了糾紛，住院2年或始出院回當(dāng)?shù)丿燄B(yǎng)。.案例2分析此案例明顯屬于術(shù)者操作過失，以致刮傷脊髓。據(jù)資料稱，術(shù)者是一名有相當(dāng)教學(xué)和臨床閱歷的高年資骨科醫(yī)師，當(dāng)助手對(duì)刮出物提出疑問時(shí)，不予注重，也不仔細(xì)查看刮出組織的外觀，固執(zhí)己見仍繼續(xù)手術(shù)，使患者永久性截癱，呵斥終身殘廢。本例定為二級(jí)醫(yī)療責(zé)任事故。.案例3患者男性，52歲，患膽囊炎、膽結(jié)石住院。在延續(xù)硬膜外麻醉下行膽囊切除及膽總管取石術(shù)后。術(shù)者甲〔進(jìn)修醫(yī)師〕、第一助手〔帶教醫(yī)師〕、第二助手〔實(shí)習(xí)生〕、器械護(hù)士〔丙〕、巡回護(hù)士〔丁〕?？p合腹膜前，醫(yī)師乙三次吩咐護(hù)士清點(diǎn)紗布，丙、丁兩護(hù)士均報(bào)告術(shù)者紗布數(shù)無誤，可以關(guān)腹。手術(shù)終了后，把病員平安送回病房。數(shù)日后患者腹痛、嘔吐，于術(shù)后第13日晚因粘連性腸梗阻再次手術(shù)探查，開腹后反縣腹腔留有一條紗布，取出后清洗腹腔關(guān)腹。術(shù)后患者恢復(fù)較好，住院2個(gè)月，痊愈出院。.案例3分析本案例關(guān)腹前醫(yī)師乙三次敦促丙、丁護(hù)士清點(diǎn)物品，但由于二人任務(wù)態(tài)度不仔細(xì)，很不擔(dān)任任地報(bào)告“紗布無誤〞，使紗布遺留在腹腔中，致腸梗阻發(fā)生及病員二次手術(shù)之苦。丙、丁二人屬失職行為，為本例事故的主要責(zé)任者，定為三級(jí)醫(yī)療責(zé)任事故。.Overview引見TotalQualityManagementisamanagementapproachthatoriginatedinthe1950'sandhassteadilybecomemorepopularsincetheearly1980's.TotalQualityManagement,TQM,isamethodbywhichmanagementandemployeescanbecomeinvolvedinthecontinuousimprovementoftheproductionofgoodsandservices.Itisacombinationofqualityandmanagementtoolsaimedatincreasingbusinessandreducinglossesduetowastefulpractices..TheTQMphilosophyofmanagementiscustomer-oriented.Allmembersofatotalqualitymanagement(control)organizationstrivetosystematicallymanagetheimprovementoftheorganizationthroughtheongoingparticipationofallemployeesinproblemsolvingeffortsacrossfunctionalandhierarchicalboundaries..SomeofthecompanieswhohaveimplementedTQMincludeFordMotorCompany,PhillipsSemiconductor,SGLCarbon,MotorolaandToyotaMotorCompany.

.DefinitionofTQM

全面質(zhì)量管理TQMisamanagementphilosophythatseekstointegrateallorganizationalfunctions(marketing,finance,design,engineering,andproduction,customerservice,etc.)tofocusonmeetingcustomerneedsandorganizationalobjectives..TQMviewsanorganizationasacollectionofprocesses.Itmaintainsthatorganizationsmuststrivetocontinuouslyimprovetheseprocessesbyincorporatingtheknowledgeandexperiencesofworkers.ThesimpleobjectiveofTQMis"Dotherightthings,rightthefirsttime,everytime"..TQMisinfinitelyvariableandadaptable.Althoughoriginallyappliedtomanufacturingoperations,andforanumberofyearsonlyusedinthatarea,TQMisnowbecomingrecognizedasagenericmanagementtool,justasapplicableinserviceandpublicsectororganizations.TQMmustbepracticedinallactivities,byallpersonnel,inManufacturing,Marketing,Engineering,R&D,Sales,Purchasing,HR,etc.PrinciplesofTQMThekeyprinciplesofTQMareasfollowing:ManagementCommitmentPlan(drive,direct)Do(deploy,support,participate)Check(review)Act(recognize,communicate,revise).EmployeeEmpowermentTrainingSuggestionschemeMeasurementandrecognitionExcellenceteams.FactBasedDecisionMakingSPC(statisticalprocesscontrol)>12DOE>13,FMEA>14The7statisticaltoolsTOPS(FORD8D-TeamOrientedProblemSolving).ContinuousImprovementSystematicmeasurementandfocusonCONQExcellenceteamsCross-functionalprocessmanagementAttain,maintain,improvestandards.CustomerFocusSupplierpartnershipServicerelationshipwithinternalcustomersNevercompromisequalityCustomerdrivenstandards.SPC-StatisticalProcessControl

統(tǒng)計(jì)過程控制Statisticalprocesscontrolistheapplicationofstatisticalmethodstoidentifyandcontrolthespecialcauseofvariationinaprocess.

>9.DOE-DesignofExperiments

實(shí)驗(yàn)設(shè)計(jì)ADesignofExperiment(DOE)isastructured,organizedmethodfordeterminingtherelationshipbetweenfactors(Xs)affectingaprocessandtheoutputofthatprocess(Y).

OtherDefinitions:

1-Conductingandanalyzingcontrolledteststoevaluatethefactorsthatcontrolthevalueofaparameterorgroupofparameters.

2-"DesignofExperiments"(DoE)referstoexperimentalmethodsusedtoquantifyindeterminatemeasurementsoffactorsandinteractionsbetweenfactorsstatisticallythroughobservanceofforcedchangesmademethodicallyasdirectedbymathematicallysystematictables.

.FMEA-FailureModesandEffectsAnalysis失效方式和效果分析Aprocedureandtoolsthathelptoidentifyeverypossiblefailuremodeofaprocessorproduct,todetermineitseffectonothersub-itemsandontherequiredfunctionoftheproductorprocess.TheFMEAisalsousedtorank&prioritizethepossiblecausesoffailuresaswellasdevelopandimplementpreventativeactions,withresponsiblepersonsassignedtocarryouttheseactions.

Failuremodesandeffectsanalysis(FMEA)isadisciplinedapproachusedtoidentifypossiblefailuresofaproductorserviceandthendeterminethefrequencyandimpactofthefailure.

>9.TheConceptofContinuousImprovementbyTQM繼續(xù)質(zhì)量改良TQMismainlyconcernedwithcontinuousimprovementinallwork,fromhighlevelstrategicplanninganddecision-making,todetailedexecutionofworkelementsontheshopfloor.Itstemsfromthebeliefthatmistakescanbeavoidedanddefectscanbeprevented.Itleadstocontinuouslyimprovingresults,inallaspectsofwork,asaresultofcontinuouslyimprovingcapabilities,people,processes,technologyandmachinecapabilities.從宏觀的戰(zhàn)略方案和決策到詳細(xì)任務(wù)中的細(xì)節(jié)實(shí)施，全面質(zhì)量管理主要與任務(wù)中的繼續(xù)改良有關(guān)。這源于這樣一種理念：錯(cuò)誤和缺陷是可以防止的。由于繼續(xù)改良的才干，員工，過程，技術(shù)等緣由，在任務(wù)中的各個(gè)方面由此產(chǎn)生了了繼續(xù)改良的結(jié)果.繼續(xù)改良的目的不僅僅是提高改良的結(jié)果，更重要的是提高未來發(fā)明更好結(jié)果的改良才干。才干改良的五個(gè)重要要素是：需求方，提供方，技術(shù)，運(yùn)作，員工才干。Continuousimprovementmustdealnotonlywithimprovingresults,butmoreimportantlywithimprovingcapabilitiestoproducebetterresultsinthefuture.Thefivemajorareasoffocusforcapabilityimprovementaredemandgeneration,supplygeneration,technology,operationsandpeoplecapability..AcentralprincipleofTQMisthatmistakesmaybemadebypeople,butmostofthemarecaused,oratleastpermitted,byfaultysystemsandprocesses.Thismeansthattherootcauseofsuchmistakescanbeidentifiedandeliminated,andrepetitioncanbepreventedbychangingtheprocess.TQM的一個(gè)重要原那么是錯(cuò)誤能夠是由人為要素呵斥的，但是絕大多數(shù)的錯(cuò)誤是由于有缺陷的系統(tǒng)或流程所呵斥的，至少也是由于這樣有缺陷的系統(tǒng)或流程而提供了錯(cuò)誤產(chǎn)生的時(shí)機(jī)。這意味著這樣的錯(cuò)誤是可以被鑒別和消除的，經(jīng)過改良流程可以預(yù)防錯(cuò)誤的反復(fù)發(fā)生。.Therearethreemajormechanismsofprevention:如何預(yù)防？Preventingmistakes(defects)fromoccurring(Mistake-proofingorPoka-Yoke).Wheremistakescan'tbeabsolutelyprevented,detectingthemearlytopreventthembeingpasseddownthevalueaddedchain(Inspectionatsourceorbythenextoperation).Wheremistakesrecur,stoppingproductionuntiltheprocesscanbecorrected,topreventtheproductionofmoredefects.(Stopintime).從源頭阻止錯(cuò)誤的產(chǎn)生不能完全預(yù)防錯(cuò)誤產(chǎn)生的環(huán)節(jié)，要早期檢查以防止錯(cuò)誤朝下一個(gè)環(huán)節(jié)發(fā)生。反復(fù)發(fā)送錯(cuò)誤的環(huán)節(jié)，要及時(shí)停頓其運(yùn)作過程以防止更多缺陷的產(chǎn)生，直到流程被矯正。.ImplementationPrinciplesandProcesses怎樣實(shí)施？何時(shí)實(shí)施？.ApreliminarystepinTQMimplementationistoassesstheorganization'scurrentreality.Relevantpreconditionshavetodowiththeorganization'shistory,itscurrentneeds,precipitatingeventsleadingtoTQM,andtheexistingemployeequalityofworkinglife.Ifthecurrentrealitydoesnotincludeimportantpreconditions,TQMimplementationshouldbedelayeduntiltheorganizationisinastateinwhichTQMislikelytosucceedTQM實(shí)施的一個(gè)根本步驟是對(duì)組織目前情況的評(píng)價(jià)。組織的歷史、目前需求、突發(fā)事件和現(xiàn)有員工的素質(zhì)都是TQM實(shí)施有關(guān)的先決條件。假設(shè)組織當(dāng)前的情況不包括這些重要的前提條件，TQM應(yīng)該推遲實(shí)施，直到組織到達(dá)這樣一種形狀，既在組織內(nèi)實(shí)施TQM極有能夠勝利的形狀。.Ifanorganizationhasatrackrecordofeffectiveresponsivenesstotheenvironment,andifithasbeenabletosuccessfullychangethewayitoperateswhenneeded,TQMwillbeeasiertoimplement.Ifanorganizationhasbeenhistoricallyreactiveandhasnoskillatimprovingitsoperatingsystems,therewillbebothemployeeskepticismandalackofskilledchangeagents.Ifthisconditionprevails,acomprehensiveprogramofmanagementandleadershipdevelopmentmaybeinstituted.Amanagementauditisagoodassessmenttooltoidentifycurrentlevelsoforganizationalfunctioningandareasinneedofchange.AnorganizationshouldbebasicallyhealthybeforebeginningTQM.Ifithassignificantproblemssuchasaveryunstablefundingbase,weakadministrativesystems,lackofmanagerialskill,orpooremployeemorale,TQMwouldnotbeappropriate..CQIinthehealthcareindustry

繼續(xù)質(zhì)量改良在醫(yī)療效力管理上的運(yùn)用80年代，CQI運(yùn)用于醫(yī)療效力質(zhì)量管理，獲得了較好效果。1992年美國衛(wèi)生組織結(jié)合評(píng)審委員會(huì)〔JCAHO〕經(jīng)過新方案，要求全美一切院長必需經(jīng)過繼續(xù)質(zhì)量改良的原那么、方法的培訓(xùn)。實(shí)際證明，CQI可以減少醫(yī)療效力中的過失、并發(fā)癥以及傷口感染，減少病人用藥不合理景象及不按時(shí)服藥景象，降低病人圍手術(shù)期死亡率，從根本上提高質(zhì)量，降低醫(yī)療本錢于減少浪費(fèi)。.MethodandProcesses方法與步驟CQI提出了醫(yī)療效力的9項(xiàng)評(píng)價(jià)目的：效力程度適宜性繼續(xù)性有效性效果效率患者稱心度平安性及時(shí)性.明確義務(wù)劃定醫(yī)療效力范圍明確醫(yī)療效力重要方面確定目的建立評(píng)價(jià)規(guī)范搜集整理資料評(píng)價(jià)提出建立行動(dòng)提高醫(yī)療質(zhì)量評(píng)定效果保證質(zhì)量提高的連續(xù)性與相關(guān)個(gè)人與集體交流結(jié)果組織指點(diǎn)；設(shè)計(jì)和開展繼續(xù)提高質(zhì)量的道路；選定提高和評(píng)價(jià)的重點(diǎn)；明確主要功能和流程，治療及其他組織的活動(dòng)確定關(guān)鍵功能和治療程序成立提供醫(yī)療效力目的的小組；選定目的確定每一個(gè)目的規(guī)范選擇規(guī)范評(píng)價(jià)方式明確引薦目的的來源和資料搜集方式；設(shè)計(jì)最終資料的搜集方式和其他途徑搜集資料確定評(píng)價(jià)實(shí)績；思索有利于確定重點(diǎn)的反響信息；確定評(píng)價(jià)的重點(diǎn)；著手評(píng)價(jià)評(píng)價(jià)醫(yī)療效力能否得到提高〔A〕；假假設(shè)沒有〔B〕，采取新的行動(dòng)方案，反復(fù)〔A〕和〔B〕，直到提高可以實(shí)現(xiàn)和維持，繼續(xù)監(jiān)視，周期性評(píng)價(jià)監(jiān)測重點(diǎn)小組吧結(jié)論、結(jié)果和措施與指點(diǎn)、相關(guān)個(gè)人、組織和效力部門進(jìn)展交流，必要時(shí)江信息廣泛傳播，留意搜集得到的反響信息.Principleoftotalqualitymanagement

inhospital醫(yī)院全面質(zhì)量管理的原那么和理念顧客第一>25全員參與>26過程管理>27繼續(xù)質(zhì)量改良數(shù)據(jù)化原那么系統(tǒng)性原那么.病人，病人家屬外部顧客社區(qū)居民與醫(yī)院提供效力相關(guān)單位社會(huì)公益機(jī)構(gòu)醫(yī)院顧客醫(yī)院固定性人員內(nèi)部顧客研討生