医疗品质政策规划蓝

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,醫療品質政策規劃藍圖,石崇良,行政院衛生署醫事處,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,1990,安全是醫療品質的基礎,每年約,44,00098,000,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,170290,億美元。,IOM report,1999,醫療品質的鴻溝,Institute of Medicine 2001,Quality problems are everywhere,.,Between the health care we have and,the care we could have lies,not just,a gap,but a chasm,.,21,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,do no harm),Practice consistent with Current Knowledge,.,(evidence based),Customization,(patient centeredness),Accountability,(performance/outcome oriented),Patient/Families,Performance,Evidence-based,Safety,品質概念圖,病人安全,Safety,JAMA 2005,2384-2390,To err is human,Bad systems,not bad people,Patient safety is the first,Changing 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 Human,Culture change,Sense of Urgency,Learn to work like a team,Develop different system of accountability,Most important is,Leadership,Leadership,C,onnect to the safety&quality issue,C,ommunicate with staffs&stakeholders,C,ommit to engage&support,病人安全文化的營造,From,individual error,to,system failure,From,punitive,to,trust,From,secretive,to,transparent,From,provider centered,to,patient centered,From,individual performance,to,multidisciplinary team work,From,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 Center,Contemporary OB/GYN,(Sexton,2006),Johns Hopkins,(Pronovost,2003),Johns Hopkins,Journal 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 Hospital 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 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.”-Goethe,Research to support solutions,Safety and quality is a science,Research to provide the evidence of success,Research can not make improvement,Practice!Practice!Practice!,PDSA,SDSA,IHI 100,000 Lives Campaign,The six interventions from the 100,000 Lives Campaign:,Deploy Rapid Response Teams,at the first sign of patient decline,Deliver Reliable,Evidence-Based Care for Acute Myocardial Infarction,to prevent deaths from heart attack,Prevent Adverse Drug Events(,ADEs,),by implementing medication reconciliation,Prevent Central Line Infections,by implementing a series of interdependent,scientifically grounded steps,Prevent Surgical Site Infections,by reliably delivering the correct,perioperative,antibiotics at the proper time,Prevent Ventilator-Associated Pneumonia,by implementing a series of interdependent,scientifically grounded steps,Prevent central line infections,90%of cath.-related 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 USD,The central line bundle,Hand hygiene,Use of maximal barrier precautions,Chlorhexidine for skin antisepsis,Optimal insertion site and site care,Daily review of line necessity,Tips for success,STOP the line,Empower nurses to stop line placeme