全院性质量监控指标一览表

1、邵逸夫全院性质量监控指标一览表2009General Statistics 一般统计资料Statistics 统计项目资料收集负责人Who collect data?资料收集处Where collect data?资料收集时间How often collect data?分析频率How often analyze data?建议质量趋势/差异分析工具Recommendation of Trend/variation analysis Tools入院病人数Admissions病案室HID住院病房Inpatient unit每月Monthly每月Monthly直方图Bar chart出院病人数Di

2、scharges病案室HID住院病房Inpatient unit每月Monthly每月Monthly直方图Bar chart平均住院日Average length of stay in hospital病案室HID住院病房Inpatient unit每月Monthly每月Monthly控制图Control chart t留观病人Observation Patients病案室HID急诊室ER每月Monthly每月Monthly直方图Bar chart住院病人死亡率Inpatient Mortality rate病案室HID住院病房Inpatient unit每月Monthly每月Monthly控

3、制图Control chart围手术期死亡率Perioperative Mortality Rate病案室HID住院病房Inpatient unit每月Monthly每月Monthly控制图Control chart急诊病人数ER Visits病案室HID急诊室ER每月Monthly每月Monthly直方图Bar chart住院病人手术例数Inpatient Operative encounters病案室HID手术室Main OR每月Monthly每月Monthly直方图Bar chart门诊病人手术例数Outpatient Operative encounters病案室HID门诊手术室OPD

4、-OR每月Monthly每月Monthly直方图Bar chart新生儿Deliveries病案室HID妇产科OB/GY每月Monthly每月Monthly直方图Bar chartStatistics 统计项目资料收集负责人Who collect data?资料收集处Where collect data?资料收集时间How often collect data?分析频率How often analyze data?建议质量趋势/差异分析工具Recommendation of Trend/variation analysis Tools剖腹产率Cesarean Section Rate病案室HI

5、D妇产科OB/GY每月Monthly每月Monthly直方图Bar chart每年员工离院率Annual turnover rate (HR)郭杏雅（人事部）HR人事部HR每年Yearly每年Yearly控制图Control chartJCI要求的质量监控指标QPS标准 QPS Standards监测指标WhatMonitor Indicators资料收集负责人Who资料收集处/样本量Where/Samples资料收集时间When分析频率Analysis建议质量趋势/差异分析工具Recommendation of Trend/variation analysis ToolsQPS.3.1临床监

6、控包括病人评估 Clinical monitoring includes patient assessment 大病史完成超过24小时H & P completed > 24hr质量管理办公室QM Office周末和周一入院的新病人New Admission on Monday每月Monthly每月Monthly控制图Control chartQPS.3.2Clinical monitoring includes laboratory 临床监控包括实验室服务检验科急诊检验报告>60分钟(CBC,UA,CX7)EmergencyLab report>60(CBC,UA,

7、CX7)费春荣（检验科）Laboratory检验科/100个Laboratory/ 100 Samples每月Monthly每月Monthly控制图Control chart临床危急值Lab. clinic panic质量管理办公室至少50例At least 50 cases每月Monthly每月Monthly控制图Control chartQPS.3.3Clinical monitoring includes radiology 临床监控包括放射影像服务放射科放射诊断与病理诊断符合率Radiology Diagnosis consist with Pathology Diagnosis胡红杰

8、（放射科）Radiology至少50例At least 50 cases每月Monthly每月Monthly控制图Control chart甲片率First level film rate胡红杰（放射科）Radiology放射科Radiology每月Monthly每月Monthly控制图Control chart个人放射剂量监测Individual radiation monitor朱雅芳（保健科）Staff health promotion放射区域Radiation areas每季Quarterly每季Quarterly控制图Control chartQPS标准 QPS Standards监

9、测指标WhatMonitor Indicators资料收集负责人Who资料收集处/样本量Where/Samples资料收集时间When分析频率Analysis建议质量趋势/差异分析工具Recommendation of Trend/variation analysis ToolsQPS.3.4Clinical monitoring includes surgical procedures临床监控包括外科手术操作。二次手术率Return to OR with same problem祁海欧（手术室）OROR每月Monthly每季Quarterly控制图Control chartPACU留观2小时

10、PACU observation 2hrs祁海欧（手术室）ORPACU每月Monthly每季Quarterly控制图Control chart术前1小时抗生素使用祁海欧（手术室）OROR每月Monthly每月Monthly控制图Control chart髋关节置换术Hip Replacement袁方（质量管理办公室）骨科每月Monthly每季Quarterly控制图Control chartQPS.3.6Clinical monitoring includes the use of antibiotics and other medications 临床监控包括抗生素及其它药物的使用抗生素使用

11、Antibiotics use药房Pharmacy department出院和急诊病历Discharge and ER Charts每月Monthly每月Monthly直方图Bar chart药物的合理使用Medication use with reasonable药房Pharmacy department住院和门诊病历Inpatient and outpatient 每月Monthly每月Monthly直方图Bar chart麻醉处方书写合格率compliance with anesthesia prescription药房Pharmacy department病人区域Patient car

12、e area每月Monthly每月Monthly直方图Bar chartClinical monitoring includes medication errors and Near Miss临床监控包括给药错误及踪近错误。给药错误Medication Error质量管理办公室和药剂科QM&Pharmacy department涉及药品管理和使用区域Areas Involved medication use and management 每月Monthly每月Monthly控制图Control chart药物不良反应监测Monitoring the aderverse reaction

13、s of medication药房Pharmacy department药房Pharmacy department每季Quarterly每季Quarterly控制图Control chartQPS.3.7Clinical monitoring includes the use of anesthesia临床监控包括麻醉的使用麻醉期间的不良事件Adverse events during anesthesia麻醉科Anesthesia department手术OR每月Monthly每月Monthly直方图Bar chartQPS.3.8Clinical monitoring includes th

14、e use of blood and blood products临床监控包括全血及血制品的使用。红细胞输血指征的符合率Compliance with transfusion indicator of Red Cell blood 刘志伟（检验科）Laboratory department检验科检验科Laboratory department每月Monthly每月Monthly直方图Bar chartQPS.3.9Clinical monitoring includes the availability, content, and use of patient records临床监控包括病历的

15、提供、内容和使用门诊复诊病历在20分钟内送至门诊护士站Previous medical record sent to outpatient nursing sataion within 20 minutes病案室HID门诊Outpatient每半年Semiannualy每半年Semiannualy控制图Control chart现病历检查Open charts review医务科、质量管理办公室Medical Affair, QM病房/每个Attending 2 份病历Unit/2 Charts per Attending每月Monthly每月Monthly直方图Bar chartQPS.3.

16、10Clinical monitoring includes infection control, surveillance, and reporting临床监控包括感染的控制、监测及报告CVC相关感染 院感科Infection control department住院病人Inpatient每月Monthly每月Monthly控制图Control chart呼吸机相关性肺炎感染率Ventilation patients developed with pneumonia庄一渝（ICU）院感科Infection control departmentICU每月Monthly每月Monthly直方图B

17、ar chart手术切口感染率Surgical site infection rate院感科Infection control department住院病人Inpatient药剂科）Pharmacy department直方图Bar chartQPS.3.11Clinical monitoring includes clinical research临床监控包括临床研究临床研究符合要求率Compliance with clinic research Requirement葛松林（科教科）Education &research department科教科Education &re

18、search department每个项目Each program每个项目Each program描述DescriptionThe managerial areas identified in standards QPS.3.10 through QPS.3.18 are included in the organizations quality monitoring3.123.20为管理领域的监控指标QPS.3.12Managerial monitoring includes the procurement of routinely required supplies and medicat

19、ions essential to meet patient needs管理监控包括满足病人基本需求所必须的用品及药品的常规获取。临时使用一次的药品发送One Dose medication delivery time药剂科Pharmacy department计算机Computer每月Monthly每月Monthly直方图Bar chartQPS.3.13Managerial monitoring includes reporting of activities as required by law and regulation管理监控包括法律和法规所要求的活动的报告。传染病、肿瘤、性病、职

20、业病报卡漏报率Infectious diseases, tumors, venereal diseases report to CDC 朱亚芳（保健科）Staff health promotion病人区域Patient care area每月Monthly每月Monthly直方图Bar chart实验室质控Laboratory quality control 费春荣（检验科）Laboratory 检验科Laboratory 每月Monthly每月Monthly控制图Control chart病理科质控Pathology quality control金梅(Pathology Dept.)病理科

21、Pathology Dept.每月Monthly每月Monthly控制图Control chart放射科质控Radiology quality control胡红杰（Radiology Dept.）放射科Radiology Dept.每月Monthly每月Monthly控制图Control chartQPS.3.14Managerial monitoring includes risk management管理监控包括风险管理压疮Decubitus ulcers胡红鸯（APN）病人区域Patient care area每月Monthly每月Monthly控制图Control chart因果图F

22、ish bone chart病人坠床/滑倒Patient Fall Rate质量管理科QM病人区域Patient care area每月Monthly每月Monthly控制图Control chart利器损伤Sharp injuries朱雅芳、质量管理办公室、院感科保健科Staff health romotion每月Monthly每月Monthly控制图Control chart心肺复苏病人Code blue patients徐秋萍 潘红英（危重医学科）病人区域Patient care area每月Monthly每月Monthly控制图Control chart因果图Fish bone cha

23、rQPS.3.15Managerial monitoring includes utilization management管理监控包括医疗资源合理使用管理。急诊留观>72小时ER observation>72hr潘红英（ER）ER每季Quarterly每季Quarterly直方图Bar chartMRI检查阳性率胡红杰（Radiology Dept.）放射科Radiology Dept.每月Monthly每月Monthly控制图Control chart床位使用率Average percentage of beds occupancy病案室HID住院病房Inpatient uni

24、t每月Monthly每月Monthly直方图Bar chart平均住院日Average length of stay病案室HID住院病房Inpatient unit每月Monthly每月Monthly控制图Control chartQPS.3.16Managerial monitoring includes patient and family expectations and satisfaction管理监控包括病人及其家属的期望值及满意度住院病人满意率Inpatient satisfaction质量管理办公室QM住院病房Inpatient unit每月Monthly每月Monthly直方图

25、Bar chart门诊病人满意率Outpatient satisfactionQPS.3.17Managerial monitoring includes staff expectations and satisfaction管理监控包括员工的期望值及满意度员工满意率Staff satisfaction孔向红（党办）员工Staff每年Annually每年Annually直方图Bar chartQPS.3.18Managerial monitoring includes patient demographics and diagnoses管理监控包括病人群体统计和诊断门诊、住院、手术病人最高5个诊断疾病分析Top five primary medical diagnoses of outpa