全院性质量监控指标一览表

GeneralStatistics一般统计资料Statistics统计项目资料采集负责人Whocollectdata住院病人数病案室HIDAdmissions出院病人数病案室HIDDischarges均匀住院日病案室HIDAveragelengthofstayinhospital留观病人病案室HIDObservationPatients住院病人死亡率病案室HIDInpatientMortalityrate围手术期死亡率病案室HIDPerioperativeMortalityRate急诊病人数病案室HIDERVisits住院病人手术例数病案室HIDInpatientOperativeencounters门诊病人手术例数病案室HIDOutpatientOperativeencounters重生儿病案室HIDDeliveriesStatistics统计项目资料采集负责人Whocollectdata剖腹产率病案室HIDCesareanSectionRate

资料采集处Where资料采集时间How剖析频次建议质量趋向/差别剖析工具collectdataoftencollectdataHowoftenRecommendationofanalyzedataTrend/variationanalysisTools住院病房每个月每个月直方图InpatientunitMonthlyMonthlyBarchart住院病房每个月每个月直方图InpatientunitMonthlyMonthlyBarchart住院病房每个月每个月控制图InpatientunitMonthlyMonthlyControlchartt急诊室每个月每个月直方图ERMonthlyMonthlyBarchart住院病房每个月每个月控制图InpatientunitMonthlyMonthlyControlchart住院病房每个月每个月控制图InpatientunitMonthlyMonthlyControlchart急诊室每个月每个月直方图ERMonthlyMonthlyBarchart手术室每个月每个月直方图MainORMonthlyMonthlyBarchart门诊手术室每个月每个月直方图OPD-ORMonthlyMonthlyBarchart妇产科每个月每个月直方图OB/GYMonthlyMonthlyBarchart资料采集处Where资料采集时间How剖析频次建议质量趋向/差别剖析工具collectdataoftencollectdataHowoftenRecommendationofanalyzedataTrend/variationanalysisTools妇产科每个月每个月直方图OB/GYMonthlyMonthlyBarchart每年职工离院率Annualturnoverrate(HR)QPS标准QPSStandards临床监控包含病人评估ClinicalmonitoringincludespatientassessmentClinicalmonitoringincludeslaboratory临床监控包含实验室服务Clinicalmonitoringincludesradiology临床监控包含放射影像服务

郭杏雅（人事部）HR人事部HR每年每年控制图ControlchartYearlyYearlyJCI要求的质量监控指标监测指标What资料采集负责人Who资料采集处/资料采集时剖析频次建议质量趋向/差MonitorIndicators样本量间WhenAnalysis异剖析工具Where/SamplesRecommendationofTrend/variationanalysisTools质量管理办公室周末和周一住院的每个月每个月控制图重病史达成超出24小时QMOffice新病人NewMonthlyMonthlyControlchartH&Pcompleted>24hrAdmissiononMonday急诊查验报告>60费春荣（查验科）查验科/100个每个月每个月控制图分钟(CBC,UA,CX7)LaboratoryLaboratory/100MonthlyMonthlyControlchartEmergencySamples查验科Labreport>60′(CBC,UA,CX7)临床紧急值质量管理办公室起码50例每个月每个月控制图Lab.clinicpanicAtleast50casesMonthlyMonthlyControlchart放射诊疗与病理诊胡红杰（放射科）起码50例每个月每个月控制图断切合率RadiologyRadiologyAtleast50casesMonthlyMonthlyControlchartDiagnosisconsistwithPathologyDiagnosis放射科level胡红杰（放射科）放射科每个月每个月控制图甲片率FirstfilmrateRadiologyRadiologyMonthlyMonthlyControlchart个人放射剂量监朱雅芳（保健科）放射地区每季每季控制图测IndividualStaffhealthpromotionRadiationareasQuarterlyQuarterlyControlchartradiationmonitorQPS标准QPSStandardsClinicalmonitoringincludessurgicalprocedures临床监控包含外科手术操作。Clinicalmonitoringincludestheuseofantibioticsandothermedications临床监控包含抗生素及其余药物的使用

监测指标WhatMonitorIndicators二次手术率ReturntoORwithsameproblemPACU留观〉2小时PACUobservation〉2hrs术前1小时抗生素使用髋关节置换术HipReplacement抗生素使用Antibioticsuse药物的合理使用Medicationusewithreasonable麻醉处方书写合格率compliancewithanesthesiaprescription

资料采集负责人Who资料采集处/资料采集时剖析频次建议质量趋向/差样本量间WhenAnalysis异剖析工具Where/SamplesRecommendationofTrend/variationanalysisTools祁海欧（手术室）OR每个月每季控制图ORMonthlyQuarterlyControlchart祁海欧（手术室）PACU每个月每季控制图ORMonthlyQuarterlyControlchart祁海欧（手术室）OR每个月每个月控制图ORMonthlyMonthlyControlchart袁方（质量管理办公骨科每个月每季控制图室）MonthlyQuarterlyControlchart药房出院和急诊病历每个月每个月直方图PharmacydepartmentDischargeandERMonthlyMonthlyBarchartCharts药房住院和门诊病历每个月每个月直方图PharmacydepartmentInpatientandMonthlyMonthlyBarchartoutpatient药房病人地区每个月每个月直方图PharmacydepartmentPatientcareareaMonthlyMonthlyBarchart质量管理办公室和药波及药品管理和使每个月每个月控制图Control剂科用地区MonthlyMonthlychartQM&PharmacyAreasInvolved给药错误departmentmedicationuseandClinicalmonitoringincludesMedicationErrormanagementmedicationerrorsandNearMiss药物不良反响监测药房药房Pharmacy每季每季控制图Control临床监控包含给药错误及踪近错MonitoringtheaderversePharmacydepartmentdepartmentQuarterlyQuarterlychart误。reactionsofmedicationClinicalmonitoringincludesthe

麻醉时期的不良事件麻醉科手术每个月每个月直方图

useofanesthesia临床监控包含麻醉的使用Clinicalmonitoringincludestheuseofbloodandbloodproducts临床监控包含全血及血制品的使用。Clinicalmonitoringincludestheavailability,content,anduseof

AdverseeventsduringAnesthesiadepartmentORMonthlyMonthlyBarchartanesthesia红细胞输血指征的切合率刘志伟（查验科）查验科每个月每个月直方图CompliancewithLaboratorydepartment查验科MonthlyMonthlyBarcharttransfusionindicatorofLaboratoryRedCellblooddepartment门诊复诊病历在20分钟内送病案室HID门诊每半年每半年控制图至门诊护士站PreviousOutpatientSemiannualySemiannualyControlchartmedicalrecordsenttooutpatientnursingpatientrecords临床监控包含病历的供给、内容和使用

sataionwithin20minutes现病历检查Opencharts医务科、质量管理办公病房/每个Attending2每个月每个月直方图review室MedicalAffair,QM份病历Unit/2ChartsMonthlyMonthlyBarchartperAttendingCVC有关感染院感科住院病人每个月每个月控制图ControlClinicalmonitoringincludesInfectioncontrolInpatientMonthlyMonthlychartinfectioncontrol,surveillance,departmentandreporting呼吸机有关性肺炎感染率庄一渝（ICU）ICU每个月每个月直方图临床监控包含感染的控制、监测Ventilationpatients院感科MonthlyMonthlyBarchart及报告developedwithpneumoniaInfectioncontroldepartment手术切口味染率Surgicalsiteinfectionrate临床研究切合要求率ClinicalmonitoringincludesCompliancewithclinicclinicalresearchresearchRequirement临床监控包含临床研究3.12—3.20为管理领域的监控指标Managerialmonitoringincludes暂时使用一次的药品发送theprocurementofroutinelyOneDosemedicationrequiredsuppliesanddeliverytimemedicationsessentialtomeetpatientneeds

院感科住院病人药剂科）Pharmacy直方图InfectioncontrolInpatientdepartmenBarchartdepartmentt葛松林（科教科）科教科每个项目每个项目描绘Education&researchEducationEachEachDescriptiondepartment&researchprogramprogramdepartment药剂科计算机每个月每个月直方图PharmacydepartmentComputerMonthlyMonthlyBarchart管理监控包含知足病人基本需求所一定的用品及药品的惯例获得。Managerialmonitoringincludesreportingofactivitiesasrequiredbylawandregulation管理监控包含法律和法例所要求的活动的报告。

传得病、肿瘤、性病、职业病报卡漏报率Infectiousdiseases,tumors,venerealdiseasesreporttoCDC实验室质控Laboratoryqualitycontrol病理科质控Pathologyqualitycontrol放射科质控Radiologyqualitycontrol

朱亚芳（保健科）病人地区每个月每个月直方图StaffhealthpromotionPatientcareareaMonthlyMonthlyBarchart费春荣（查验科）查验科Laboratory每个月每个月控制图LaboratoryMonthlyMonthlyControlchart金梅(Pathology病理科每个月每个月控制图Dept.)PathologyDept.MonthlyMonthlyControlchart胡红杰（Radiology放射科每个月每个月控制图Dept.）RadiologyDept.MonthlyMonthlyControlchartManagerialmonitoringincludesriskmanagement管理监控包含风险管理Managerialmonitoringincludesutilizationmanagement管理监控包含医疗资源合理使用管理。Managerialmonitoringincludespatientandfamilyexpectationsandsatisfaction管理监控包含病人及其家眷的希望值及满意度

压疮胡红鸯（APN）病人地区每个月每个月控制图DecubitusulcersPatientcareareaMonthlyMonthlyControlchart因果图Fishbonechart病人坠床/滑倒质量管理科病人地区每个月每个月控制图PatientFallRateQMPatientcareareaMonthlyMonthlyControlchart利器损害朱雅芳、质量管理办保健科Staffhealth每个月每个月控制图Sharpinjuries公室、院感科romotionMonthlyMonthlyControlchart心肺复苏病人徐秋萍潘红英病人地区每个月每个月控制图Codebluepatients（危重医学科）PatientcareareaMonthlyMonthlyControlchart因果图Fishbonechar急诊留观>72小时潘红英（ER）ER每季每季直方图ERobservation>72hrQuarterlyQuarterlyBarchartMRI检查阳性率胡红杰（Radiology放射科每个月每个月控制图Dept.）RadiologyDept.MonthlyMonthlyControlchart床位使用率病案室HID住院病房每个月每个月直方图AveragepercentageofInpatientunitMonthlyMonthlyBarchartbedsoccupancy均匀住院日病案室HID住院病房每个月每个月控制图ControlAveragelengthofstayInpatientunitMonthlyMonthlychart质量管理办公室住院病房每个月每个月直方图住院病人满意率QMInpatientunitMonthlyMonthlyBarchartInpatientsatisfaction门诊病人满意率Outpatientsatisfaction

Managerialmonitoringincludes职工满意率孔向红（党办）职工Staff每年每年直方图staffexpectationsandsatisfactionStaffsatisfactionAnnuallyAnnuallyBarchart管理监控包含职工的希望值及满意度

Managerialmonitoringincludespatientdemographicsanddiagnoses管理监控包含病人集体统计和诊断Managerialmonitoringincludesfinancialmanagement管理监控包含财务管理Managerialmoni