最新医疗品质政策规划蓝图ppt课件.ppt

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1、医疗品质政策规划蓝图医疗品质政策规划蓝图什麼是醫療品質“the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge”一種增加個人或群體預期照護結果可能性的程度，且與現有專業知識一致Institute of Medicine 1990JAMA 2005,2384-2390To err is human Bad s

2、ystems, not bad peoplePatient safety is the firstChanging practices to improve safety Patient safety的挑戰對於系統觀（ system theory）的了解運用有限舊習慣很難改變 （即使很簡單的事）資訊科技的導入“知易行難”安全的本質繫乎“人際關係” Next Step After To Err Is HumanCulture changeSense of UrgencyLearn to work like a teamDevelop different system of accountabil

3、ityMost important is Most important is LeadershipLeadership LeadershipConnect to the safety & quality issueCommunicate with staffs & stakeholdersCommit to engage & support病人安全文化的營造From individual error to system failureFrom punitive to trustFrom secretive to transparentFrom provider centered to pati

4、ent centeredFrom individual performance to multidisciplinary team workFrom Top-down accountability to bottom-up moral authority 策略Leadership鼓勵通報 （ learning from errors)強化團隊合作訓練標竿學習 （病安年度目標）賦權病人(Mann, 2006) Beth Israel Deaconess Medical CenterContemporary OB/GYN(Sexton, 2006)Johns Hopkins(Pronovost,

5、2003)Johns HopkinsJournal of Critical Care Medicine實證基礎Evidence based醫療機構安全作業建議建立機構安全的文化滿足人力與能力的需求加強訊息的傳遞與溝通提供必要的特殊設備與照護流程推廣安全用藥措施A National Quality Forum Consensus Report 2003 共識條件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: 具實證基礎Generalizability: 適用於多數機構Readiness: 必要技術或專才安全作業NQF Hos

6、pital Consensus Standards 2007採取措施預防呼吸器相關肺炎有效預防中央靜脈導管相關之血行性感染給予每位出院病患出院計畫與摘要加護單位之醫師應有專業訓練與認證醫療人員每年接受流行性感冒疫苗接種在執行知情同意時可要求病人或法定代理人重複重要之資訊(teach back)安全作業NQF Hospital Consensus Standards 2007符合CDC所公佈之手部衛生指引建立病人安全文化確保照護資訊可即時、清楚的傳達給病人及每一位醫療照護者，以維持照護之持續性確保醫療照護人力的適當，並給予必要的教育訓練確保病人對生命末期處理的決定適當紀錄於病歷中安全作業NQF

7、Hospital Consensus Standards 2007對選擇性手術病患進行缺血性心臟病風險評估，並考慮投與乙型阻斷劑預防發作對住院病患於住院時進行褥瘡風險評估並定期檢視對住院病人常規評估發生深部靜脈栓塞(VTE/DVT)的風險並給予必要的預防措施對於長期使用口服抗凝血劑病人應有特殊之照護計畫或流程安全作業NQF Hospital Consensus Standards 2007發生嚴重醫療不良事件時，應予病人或家屬及時、透明、清楚的溝通口頭醫囑或電話危險值通報的接收者，應紀錄並完整覆誦醫療機構儘可能使用單一劑量調劑(unit-dose, unit-of-use)針對高危險藥物建立使

8、用規範或指引以減少傷害安全作業NQF Hospital Consensus Standards 2007導入電腦輔助開方系統(computerized prescriber order entry system)評估合適的護理人力確保放射檢查、檢體與其他診斷檢驗標示的正確性(the right study is labeled for the right patient at the right time)建立標準作業以避免手術病人、部位、術式的錯誤安全作業NQF Hospital Consensus Standards 2007藥師應積極參與藥物管理系統執行手術感染的風險評估與預防措施標準化

9、所有不應使用的縮寫、代號與處方方式藥物的標示、包裝與儲藏應標準化建立評估與預防顯影劑導致腎衰竭的標準作業“Knowing is not enough; we must apply. Willing is not enough; we must do.”- GoetheResearch to support solutionsSafety and quality is a scienceSafety and quality is a scienceResearch to provide the evidence of Research to provide the evidence of suc

10、cesssuccessResearch can not make improvementResearch can not make improvementPractice ! Practice! Practice!Practice ! Practice! Practice!PDSASDSAIHI 100,000 Lives CampaignThe six interventions from the 100,000 Lives Campaign:The six interventions from the 100,000 Lives Campaign:Deploy Rapid Response

11、 Teamsat the first sign of patient declineDeliver Reliable, Evidence-Based Care for Acute Myocardial Infarctionto prevent deaths from heart attack Prevent Adverse Drug Events (ADEs)by implementing medication reconciliationPrevent Central Line Infectionsby implementing a series of interdependent, sci

12、entifically grounded stepsPrevent Surgical Site Infectionsby reliably delivering the correct perioperative antibiotics at the proper time Prevent Ventilator-Associated Pneumoniaby implementing a series of interdependent, scientifically grounded stepsPrevent central line infections90% of cath.-relate

13、d blood stream infections (BSI) occur with CVCs (Maki DG. 1992)48% of ICU patients have CVC.The case fatality rate for cath-related BSI approaches 20% (Memel LA. Ann int Med 2000, 391-402)Attributable mortality ranges 12-25%Attributable cost per BSI is estimated 3,700-29,000 USDThe central line bund

14、leHand hygieneUse of maximal barrier precautionsChlorhexidine for skin antisepsisOptimal insertion site and site careDaily review of line necessityTips for successSTOP the lineEmpower nurses to stop line placement if improper techniques are usedLeadership support & cultureEvidenceStandard equipments

15、 packChecklist, central line cartsClinical appropriateness67家醫院，103個ICU感染率從2.4%降至0 下一步New interventions targeted at harm:New interventions targeted at harm:Prevent Pressure Ulcers. by reliably using science-based guidelines for their preventionReduce MRSA Infectionby reliably implementing scientific

16、ally proven infection control practicesPrevent Harm from High-Alert Medications. starting with a focus on anticoagulants, sedatives, narcotics, and insulinReduce Surgical Complications. by reliably implementing all of the changes in care recommended by the Surgical Care Improvement Project (SCIP) De

17、liver Reliable, Evidence-Based Care for Congestive Heart Failureto reduce readmissions Get Boards on Board.Defining and spreading the best-known leveraged processes for hospital Boards of Directors, so that they can become far more effective in accelerating organizational progress toward safe care策略

18、推動實證基礎的品質改善活動選定主題標竿學習標準作業鼓勵醫師參與為何需要醫師參與?醫院內很少有事情不需要醫師的”Order”而可執行醫療品質不會只單純為”服務品質”品質改善需要全員參與醫師扮演的角色Champions*Medical Leadership/ Committee membersProject leader- test of changeAdopter-physician willing to cooperateCautious laggard病人為中心Patient / families centered 什麼是病人為中心的照護“Understanding and respecti

19、ng patients values, preferences and expressed needs is the foundation of patient-centered care”-Harvey Picker 病人為中心的思維從病人的眼中了解其需求從病人的眼中了解其需求尊重病人的價值、偏好與需求協調、整合的醫療照護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絡協助轉診或出院病人/家屬的參與醫療品質是在醫療過程中取得病患的合作與參與Facility planningPatient care roundsPatient education programComp

20、lementary therapy task forcePolicy reviewSafety roundsDisclosure策略改變思維使用病友了解的文字或說明建立夥伴關係績效PerformanceWhat is Healthcare PerformancePatient centeredPatientfocusResponseEffectivenessImprovingHealthClinicalfocusPatient safetyAccessibilityEfficiencyCost/ExpenditureEquityContinuityTimely策略評鑑改革 (accountability)建立核心指標(performance measurement)資訊揭露(Transparency)Healthcare SystemPatient / FamiliesPatient / FamiliesPerformanceEvidence-basedSafetyProfessionalHealthcare OrganizationThanks for your attentionsQ & AQ & A46结束语结束语