医疗品质政策规划蓝图课件

醫療品質政策規劃藍圖行政院衛生署醫事處2008.11.6什麼是醫療品質“thedegreetowhichhealthservicesforindividualsandpopulationsincreasethelikelihoodofdesiredhealthoutcomesandareconsistentwithcurrentprofessionalknowledge”「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」InstituteofMedicine1990安全是醫療品質的基礎每年約44,000~98,000的美國人因為醫療行為死亡。居當年十大死因第八位(高於乳癌、交通事故、愛滋病死亡的人數)。國家花費：每年約170~290億美元。IOMreport,199921世紀的醫療品質改革方向重視病患安全結果為導向的治療計畫病人為中心的考量及時性的醫療照護有效率的醫療行為公平的提供醫療照護醫療品質的內涵Safety

(First,donoharm)

PracticeconsistentwithCurrentKnowledge.(evidencebased)Customization

(patientcenteredness)Accountability(performance/outcomeoriented)Patient/FamiliesPerformanceEvidence-basedSafety品質概念圖JAMA2005,2384-2390ToerrishumanBadsystems,notbadpeoplePatientsafetyisthefirstChangingpracticestoimprovesafetyPatientsafety的挑戰對於系統觀（systemtheory）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”

NextStepAfterToErrIsHumanCulturechangeSenseofUrgencyLearntoworklikeateamDevelopdifferentsystemofaccountabilityMostimportantisLeadership

病人安全文化的營造FromindividualerrortosystemfailureFrompunitivetotrustFromsecretivetotransparentFromprovidercenteredtopatientcenteredFromindividualperformancetomultidisciplinaryteamworkFromTop-downaccountabilitytobottom-upmoralauthority策略Leadership鼓勵通報

（learningfromerrors)強化團隊合作訓練標竿學習

（病安年度目標）賦權病人(Mann,2006)BethIsraelDeaconessMedicalCenterContemporaryOB/GYN(Sexton,2006)JohnsHopkins(Pronovost,2003)JohnsHopkinsJournalofCriticalCareMedicine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ANationalQualityForumConsensusReport2003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

NQFHospitalConsensusStandards2007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(teachback)安全作業

NQFHospitalConsensusStandards2007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

NQFHospitalConsensusStandards2007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用規範或指引以減少傷害安全作業

NQFHospitalConsensusStandards2007導入電腦輔助開方系統(computerizedprescriberorderentrysystem)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(therightstudyislabeledfortherightpatientattherighttime)建立標準作業以避免手術病人、部位、術式的錯誤“Knowingisnotenough;

wemustapply.

Willingisnotenough;

wemustdo.”

-GoetheResearchtosupportsolutionsSafetyandqualityisascienceResearchtoprovidetheevidenceofsuccessResearchcannotmakeimprovementPractice!Practice!Practice!PDSASDSAThecentrallinebundleHandhygieneUseofmaximalbarrierprecautionsChlorhexidineforskinantisepsisOptimalinsertionsiteandsitecareDailyreviewoflinenecessityTipsforsuccessSTOPthelineEmpowernursestostoplineplacementifimpropertechniquesareusedLeadershipsupport&cultureEvidenceStandardequipmentspackChecklist,centrallinecartsClinicalappropriateness67家醫院，103個ICU感染率從2.4%降至0

下一步…Newinterventionstargetedatharm:PreventPressureUlcers...byreliablyusingscience-basedguidelinesfortheirpreventionReduceMRSAInfection…byreliablyimplementingscientificallyproveninfectioncontrolpracticesPreventHarmfromHigh-AlertMedications...startingwithafocusonanticoagulants,sedatives,narcotics,andinsulinReduceSurgicalComplications...byreliablyimplementingallofthechangesincarerecommendedbytheSurgicalCareImprovementProject(SCIP)DeliverReliable,Evidence-BasedCareforCongestiveHeartFailure…toreducereadmissionsGetBoardsonBoard….Definingandspreadingthebest-knownleveragedprocessesforhospitalBoardsofDirectors,sothattheycanbecomefarmoreeffectiveinacceleratingorganizationalprogresstowardsafecare策略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*MedicalLeadership/CommitteemembersProjectleader-testofchangeAdopter-physicianwillingtocooperateCautiouslaggard病人為中心

Patient/familiescentered

什麼是病人為中心的照護“Understandingandrespectingpatients’values,preferencesandexpressedneedsisthefoundationofpatient-centeredcare”---HarveyPicker

病人為中心的思維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FacilityplanningPatientcareroundsPatienteducationprogramComplementarytherapytaskforcePolicyreviewSafetyroundsDisclosure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

PerformanceWhatisHealthcarePerformancePatientcenteredPatientfocusResponseEffectivenessImprovingHealthClinicalfocusPatientsafetyAccessibilityEfficiencyCost/Expenditu