1、邵逸夫全院性質量監控指標一覽表2009General Statistics 一般統計資料Statistics 統計項目資料收集負責人Who collect data?資料收集處Where collect data?資料收集時間How often collect data?分析頻率How often analyze data?建議質量趨勢/差異分析工具Recommendation of Trend/variation analysis Tools入院病人數Admissions病案室HID住院病房Inpatient unit每月Monthly每月Monthly直方圖Bar chart出院病人數Di

2、scharges病案室HID住院病房Inpatient unit每月Monthly每月Monthly直方圖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控制圖Control chart t留觀病人Observation Patients病案室HID急診室ER每月Monthly每月Monthly直方圖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、制圖Control chart圍手術期死亡率Perioperative Mortality Rate病案室HID住院病房Inpatient unit每月Monthly每月Monthly控制圖Control chart急診病人數ER Visits病案室HID急診室ER每月Monthly每月Monthly直方圖Bar chart住院病人手術例數Inpatient Operative encounters病案室HID手術室Main OR每月Monthly每月Monthly直方圖Bar chart門診病人手術例數Outpatient Operative encounters病案室HID門診手術室OPD

4、-OR每月Monthly每月Monthly直方圖Bar chart新生兒Deliveries病案室HID婦產科OB/GY每月Monthly每月Monthly直方圖Bar chartStatistics 統計項目資料收集負責人Who collect data?資料收集處Where collect data?資料收集時間How often collect data?分析頻率How often analyze data?建議質量趨勢/差異分析工具Recommendation of Trend/variation analysis Tools剖腹產率Cesarean Section Rate病案室HI

5、D婦產科OB/GY每月Monthly每月Monthly直方圖Bar chart每年員工離院率Annual turnover rate (HR)郭杏雅（人事部）HR人事部HR每年Yearly每年Yearly控制圖Control chartJCI要求的質量監控指標QPS標準 QPS Standards監測指標WhatMonitor Indicators資料收集負責人Who資料收集處/樣本量Where/Samples資料收集時間When分析頻率Analysis建議質量趨勢/差異分析工具Recommendation of Trend/variation analysis ToolsQPS.3.1臨床監

6、控包括病人評估 Clinical monitoring includes patient assessment 大病史完成超過24小時H & P completed > 24hr質量管理辦公室QM Office周末和周一入院的新病人New Admission on Monday每月Monthly每月Monthly控制圖Control chartQPS.3.2Clinical monitoring includes laboratory 臨床監控包括實驗室服務檢驗科急診檢驗報告>60分鐘(CBC,UA,CX7)EmergencyLab report>60(CBC,UA,

7、CX7)費春榮（檢驗科）Laboratory檢驗科/100個Laboratory/ 100 Samples每月Monthly每月Monthly控制圖Control chart臨床危急值Lab. clinic panic質量管理辦公室至少50例At least 50 cases每月Monthly每月Monthly控制圖Control chartQPS.3.3Clinical monitoring includes radiology 臨床監控包括放射影像服務放射科放射診斷與病理診斷符合率Radiology Diagnosis consist with Pathology Diagnosis胡紅杰

8、（放射科）Radiology至少50例At least 50 cases每月Monthly每月Monthly控制圖Control chart甲片率First level film rate胡紅杰（放射科）Radiology放射科Radiology每月Monthly每月Monthly控制圖Control chart個人放射劑量監測Individual radiation monitor朱雅芳（保健科）Staff health promotion放射區域Radiation areas每季Quarterly每季Quarterly控制圖Control chartQPS標準 QPS Standards監

9、測指標WhatMonitor Indicators資料收集負責人Who資料收集處/樣本量Where/Samples資料收集時間When分析頻率Analysis建議質量趨勢/差異分析工具Recommendation of Trend/variation analysis ToolsQPS.3.4Clinical monitoring includes surgical procedures臨床監控包括外科手術操作。二次手術率Return to OR with same problem祁海歐（手術室）OROR每月Monthly每季Quarterly控制圖Control chartPACU留觀2小時

10、PACU observation 2hrs祁海歐（手術室）ORPACU每月Monthly每季Quarterly控制圖Control chart術前1小時抗生素使用祁海歐（手術室）OROR每月Monthly每月Monthly控制圖Control chart髖關節置換術Hip Replacement袁方（質量管理辦公室）骨科每月Monthly每季Quarterly控制圖Control chartQPS.3.6Clinical monitoring includes the use of antibiotics and other medications 臨床監控包括抗生素及其它藥物的使用抗生素使用

11、Antibiotics use藥房Pharmacy department出院和急診病歷Discharge and ER Charts每月Monthly每月Monthly直方圖Bar chart藥物的合理使用Medication use with reasonable藥房Pharmacy department住院和門診病歷Inpatient and outpatient 每月Monthly每月Monthly直方圖Bar chart麻醉處方書寫合格率compliance with anesthesia prescription藥房Pharmacy department病人區域Patient car

12、e area每月Monthly每月Monthly直方圖Bar chartClinical monitoring includes medication errors and Near Miss臨床監控包括給藥錯誤及蹤近錯誤。給藥錯誤Medication Error質量管理辦公室和藥劑科QM&Pharmacy department涉及藥品管理和使用區域Areas Involved medication use and management 每月Monthly每月Monthly控制圖Control chart藥物不良反應監測Monitoring the aderverse reaction

13、s of medication藥房Pharmacy department藥房Pharmacy department每季Quarterly每季Quarterly控制圖Control chartQPS.3.7Clinical monitoring includes the use of anesthesia臨床監控包括麻醉的使用麻醉期間的不良事件Adverse events during anesthesia麻醉科Anesthesia department手術OR每月Monthly每月Monthly直方圖Bar chartQPS.3.8Clinical monitoring includes th

14、e use of blood and blood products臨床監控包括全血及血制品的使用。紅細胞輸血指征的符合率Compliance with transfusion indicator of Red Cell blood 劉志偉（檢驗科）Laboratory department檢驗科檢驗科Laboratory department每月Monthly每月Monthly直方圖Bar chartQPS.3.9Clinical monitoring includes the availability, content, and use of patient records臨床監控包括病歷的

15、提供、內容和使用門診復診病歷在20分鐘內送至門診護士站Previous medical record sent to outpatient nursing sataion within 20 minutes病案室HID門診Outpatient每半年Semiannualy每半年Semiannualy控制圖Control chart現病歷檢查Open charts review醫務科、質量管理辦公室Medical Affair, QM病房/每個Attending 2 份病歷Unit/2 Charts per Attending每月Monthly每月Monthly直方圖Bar chartQPS.3.

16、10Clinical monitoring includes infection control, surveillance, and reporting臨床監控包括感染的控制、監測及報告CVC相關感染 院感科Infection control department住院病人Inpatient每月Monthly每月Monthly控制圖Control chart呼吸機相關性肺炎感染率Ventilation patients developed with pneumonia莊一渝（ICU）院感科Infection control departmentICU每月Monthly每月Monthly直方圖B

17、ar chart手術切口感染率Surgical site infection rate院感科Infection control department住院病人Inpatient藥劑科）Pharmacy department直方圖Bar chartQPS.3.11Clinical monitoring includes clinical research臨床監控包括臨床研究臨床研究符合要求率Compliance with clinic research Requirement葛松林（科教科）Education &research department科教科Education &re

18、search department每個項目Each program每個項目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為管理領域的監控指標QPS.3.12Managerial monitoring includes the procurement of routinely required supplies and medicat

19、ions essential to meet patient needs管理監控包括滿足病人基本需求所必須的用品及藥品的常規獲取。臨時使用一次的藥品發送One Dose medication delivery time藥劑科Pharmacy department計算機Computer每月Monthly每月Monthly直方圖Bar chartQPS.3.13Managerial monitoring includes reporting of activities as required by law and regulation管理監控包括法律和法規所要求的活動的報告。傳染病、腫瘤、性病、職

20、業病報卡漏報率Infectious diseases, tumors, venereal diseases report to CDC 朱亞芳（保健科）Staff health promotion病人區域Patient care area每月Monthly每月Monthly直方圖Bar chart實驗室質控Laboratory quality control 費春榮（檢驗科）Laboratory 檢驗科Laboratory 每月Monthly每月Monthly控制圖Control chart病理科質控Pathology quality control金梅(Pathology Dept.)病理科

21、Pathology Dept.每月Monthly每月Monthly控制圖Control chart放射科質控Radiology quality control胡紅杰（Radiology Dept.）放射科Radiology Dept.每月Monthly每月Monthly控制圖Control chartQPS.3.14Managerial monitoring includes risk management管理監控包括風險管理壓瘡Decubitus ulcers胡紅鴦（APN）病人區域Patient care area每月Monthly每月Monthly控制圖Control chart因果圖F

22、ish bone chart病人墜床/滑倒Patient Fall Rate質量管理科QM病人區域Patient care area每月Monthly每月Monthly控制圖Control chart利器損傷Sharp injuries朱雅芳、質量管理辦公室、院感科保健科Staff health romotion每月Monthly每月Monthly控制圖Control chart心肺復蘇病人Code blue patients徐秋萍 潘紅英（危重醫學科）病人區域Patient care area每月Monthly每月Monthly控制圖Control chart因果圖Fish bone cha

23、rQPS.3.15Managerial monitoring includes utilization management管理監控包括醫療資源合理使用管理。急診留觀>72小時ER observation>72hr潘紅英（ER）ER每季Quarterly每季Quarterly直方圖Bar chartMRI檢查陽性率胡紅杰（Radiology Dept.）放射科Radiology Dept.每月Monthly每月Monthly控制圖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直方圖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控制圖Control chartQPS.3.16Managerial monitoring includes patient and family expectations and satisfaction管理監控包括病人及其家屬的期望值及滿意度住院病人滿意率Inpatient satisfaction質量管理辦公室QM住院病房Inpatient unit每月Monthly每月Monthly直方圖

25、Bar chart門診病人滿意率Outpatient satisfactionQPS.3.17Managerial monitoring includes staff expectations and satisfaction管理監控包括員工的期望值及滿意度員工滿意率Staff satisfaction孔向紅（黨辦）員工Staff每年Annually每年Annually直方圖Bar chartQPS.3.18Managerial monitoring includes patient demographics and diagnoses管理監控包括病人群體統計和診斷門診、住院、手術病人最高5個診斷疾病分析Top five primary medical diagnoses of outpa