全院性質(zhì)量監(jiān)控指標(biāo)一覽表

GeneralStatistics一般統(tǒng)計(jì)資料Statistics統(tǒng)計(jì)項(xiàng)目資料采集負(fù)責(zé)人Whocollectdata住院病人數(shù)病案室HIDAdmissions出院病人數(shù)病案室HIDDischarges平均住院日病案室HIDAveragelengthofstayinhospital留觀病人病案室HIDObservationPatients住院病人死亡率病案室HIDInpatientMortalityrate圍手術(shù)期死亡率病案室HIDPerioperativeMortalityRate急診病人數(shù)病案室HIDERVisits住院病人手術(shù)例數(shù)病案室HIDInpatientOperativeencounters門診病人手術(shù)例數(shù)病案室HIDOutpatientOperativeencounters再生兒病案室HIDDeliveriesStatistics統(tǒng)計(jì)項(xiàng)目資料采集負(fù)責(zé)人Whocollectdata剖腹產(chǎn)率病案室HIDCesareanSectionRate

資料采集處Where資料采集時(shí)間How解析頻率建議質(zhì)量趨勢(shì)/差異解析工具collectdataoftencollectdataHowoftenRecommendationofanalyzedataTrend/variationanalysisTools住院病房每個(gè)月每個(gè)月直方圖InpatientunitMonthlyMonthlyBarchart住院病房每個(gè)月每個(gè)月直方圖InpatientunitMonthlyMonthlyBarchart住院病房每個(gè)月每個(gè)月控制圖InpatientunitMonthlyMonthlyControlchartt急診室每個(gè)月每個(gè)月直方圖ERMonthlyMonthlyBarchart住院病房每個(gè)月每個(gè)月控制圖InpatientunitMonthlyMonthlyControlchart住院病房每個(gè)月每個(gè)月控制圖InpatientunitMonthlyMonthlyControlchart急診室每個(gè)月每個(gè)月直方圖ERMonthlyMonthlyBarchart手術(shù)室每個(gè)月每個(gè)月直方圖MainORMonthlyMonthlyBarchart門診手術(shù)室每個(gè)月每個(gè)月直方圖OPD-ORMonthlyMonthlyBarchart婦產(chǎn)科每個(gè)月每個(gè)月直方圖OB/GYMonthlyMonthlyBarchart資料采集處Where資料采集時(shí)間How解析頻率建議質(zhì)量趨勢(shì)/差異解析工具collectdataoftencollectdataHowoftenRecommendationofanalyzedataTrend/variationanalysisTools婦產(chǎn)科每個(gè)月每個(gè)月直方圖OB/GYMonthlyMonthlyBarchart每年員工離院率Annualturnoverrate(HR)QPS標(biāo)準(zhǔn)QPSStandards臨床監(jiān)控包括病人評(píng)估ClinicalmonitoringincludespatientassessmentClinicalmonitoringincludeslaboratory臨床監(jiān)控包括實(shí)驗(yàn)室服務(wù)Clinicalmonitoringincludesradiology臨床監(jiān)控包括放射影像服務(wù)

郭杏雅（人事部）HR人事部HR每年每年控制圖ControlchartYearlyYearlyJCI要求的質(zhì)量監(jiān)控指標(biāo)監(jiān)測(cè)指標(biāo)What資料采集負(fù)責(zé)人Who資料采集處/資料采集時(shí)解析頻率建議質(zhì)量趨勢(shì)/差MonitorIndicators樣本量間WhenAnalysis異解析工具Where/SamplesRecommendationofTrend/variationanalysisTools質(zhì)量管理辦公室周末和周一住院的每個(gè)月每個(gè)月控制圖大病史完成高出24小時(shí)QMOffice新病人NewMonthlyMonthlyControlchartH&Pcompleted>24hrAdmissiononMonday急診檢驗(yàn)報(bào)告>60費(fèi)春榮（檢驗(yàn)科）檢驗(yàn)科/100個(gè)每個(gè)月每個(gè)月控制圖分鐘(CBC,UA,CX7)LaboratoryLaboratory/100MonthlyMonthlyControlchartEmergencySamples檢驗(yàn)科Labreport>60′(CBC,UA,CX7)臨床緊迫值質(zhì)量管理辦公室最少50例每個(gè)月每個(gè)月控制圖Lab.clinicpanicAtleast50casesMonthlyMonthlyControlchart放射診斷與病理診胡紅杰（放射科）最少50例每個(gè)月每個(gè)月控制圖斷吻合率RadiologyRadiologyAtleast50casesMonthlyMonthlyControlchartDiagnosisconsistwithPathologyDiagnosis放射科level胡紅杰（放射科）放射科每個(gè)月每個(gè)月控制圖甲片率FirstfilmrateRadiologyRadiologyMonthlyMonthlyControlchart個(gè)人放射劑量監(jiān)朱雅芳（保健科）放射地域每季每季控制圖測(cè)IndividualStaffhealthpromotionRadiationareasQuarterlyQuarterlyControlchartradiationmonitorQPS標(biāo)準(zhǔn)QPSStandardsClinicalmonitoringincludessurgicalprocedures臨床監(jiān)控包括外科手術(shù)操作。Clinicalmonitoringincludestheuseofantibioticsandothermedications臨床監(jiān)控包括抗生素及其他藥物的使用

監(jiān)測(cè)指標(biāo)WhatMonitorIndicators二次手術(shù)率ReturntoORwithsameproblemPACU留觀〉2小時(shí)PACUobservation〉2hrs術(shù)前1小時(shí)抗生素使用髖關(guān)節(jié)置換術(shù)HipReplacement抗生素使用Antibioticsuse藥物的合理使用Medicationusewithreasonable麻醉處方書寫合格率compliancewithanesthesiaprescription

資料采集負(fù)責(zé)人Who資料采集處/資料采集時(shí)解析頻率建議質(zhì)量趨勢(shì)/差樣本量間WhenAnalysis異解析工具Where/SamplesRecommendationofTrend/variationanalysisTools祁海歐（手術(shù)室）OR每個(gè)月每季控制圖ORMonthlyQuarterlyControlchart祁海歐（手術(shù)室）PACU每個(gè)月每季控制圖ORMonthlyQuarterlyControlchart祁海歐（手術(shù)室）OR每個(gè)月每個(gè)月控制圖ORMonthlyMonthlyControlchart袁方（質(zhì)量管理辦公骨科每個(gè)月每季控制圖室）MonthlyQuarterlyControlchart藥房出院和急診病歷每個(gè)月每個(gè)月直方圖PharmacydepartmentDischargeandERMonthlyMonthlyBarchartCharts藥房住院和門診病歷每個(gè)月每個(gè)月直方圖PharmacydepartmentInpatientandMonthlyMonthlyBarchartoutpatient藥房病人地域每個(gè)月每個(gè)月直方圖PharmacydepartmentPatientcareareaMonthlyMonthlyBarchart質(zhì)量管理辦公室和藥涉及藥品管理和使每個(gè)月每個(gè)月控制圖Control劑科用地域MonthlyMonthlychartQM&PharmacyAreasInvolved給藥錯(cuò)誤departmentmedicationuseandClinicalmonitoringincludesMedicationErrormanagementmedicationerrorsandNearMiss藥物不良反應(yīng)監(jiān)測(cè)藥房藥房Pharmacy每季每季控制圖Control臨床監(jiān)控包括給藥錯(cuò)誤及蹤近錯(cuò)MonitoringtheaderversePharmacydepartmentdepartmentQuarterlyQuarterlychart誤。reactionsofmedicationClinicalmonitoringincludesthe

麻醉時(shí)期的不良事件麻醉科手術(shù)每個(gè)月每個(gè)月直方圖

useofanesthesia臨床監(jiān)控包括麻醉的使用Clinicalmonitoringincludestheuseofbloodandbloodproducts臨床監(jiān)控包括全血及血制品的使用。Clinicalmonitoringincludestheavailability,content,anduseof

AdverseeventsduringAnesthesiadepartmentORMonthlyMonthlyBarchartanesthesia紅細(xì)胞輸血指征的吻合率劉志偉（檢驗(yàn)科）檢驗(yàn)科每個(gè)月每個(gè)月直方圖CompliancewithLaboratorydepartment檢驗(yàn)科MonthlyMonthlyBarcharttransfusionindicatorofLaboratoryRedCellblooddepartment門診復(fù)診病歷在20分鐘內(nèi)送病案室HID門診每半年每半年控制圖至門診護(hù)士站PreviousOutpatientSemiannualySemiannualyControlchartmedicalrecordsenttooutpatientnursingpatientrecords臨床監(jiān)控包括病歷的供應(yīng)、內(nèi)容和使用

sataionwithin20minutes現(xiàn)病歷檢查Opencharts醫(yī)務(wù)科、質(zhì)量管理辦公病房/每個(gè)Attending2每個(gè)月每個(gè)月直方圖review室MedicalAffair,QM份病歷Unit/2ChartsMonthlyMonthlyBarchartperAttendingCVC相關(guān)感染院感科住院病人每個(gè)月每個(gè)月控制圖ControlClinicalmonitoringincludesInfectioncontrolInpatientMonthlyMonthlychartinfectioncontrol,surveillance,departmentandreporting呼吸機(jī)相關(guān)性肺炎感染率莊一渝（ICU）ICU每個(gè)月每個(gè)月直方圖臨床監(jiān)控包括感染的控制、監(jiān)測(cè)Ventilationpatients院感科MonthlyMonthlyBarchart及報(bào)告developedwithpneumoniaInfectioncontroldepartment手術(shù)切口胃染率Surgicalsiteinfectionrate臨床研究吻合要求率ClinicalmonitoringincludesCompliancewithclinicclinicalresearchresearchRequirement臨床監(jiān)控包括臨床研究3.12—3.20為管理領(lǐng)域的監(jiān)控指標(biāo)Managerialmonitoringincludes臨時(shí)使用一次的藥品發(fā)送theprocurementofroutinelyOneDosemedicationrequiredsuppliesanddeliverytimemedicationsessentialtomeetpatientneeds

院感科住院病人藥劑科）Pharmacy直方圖InfectioncontrolInpatientdepartmenBarchartdepartmentt葛松林（科教科）科教科每個(gè)項(xiàng)目每個(gè)項(xiàng)目描述Education&researchEducationEachEachDescriptiondepartment&researchprogramprogramdepartment藥劑科計(jì)算機(jī)每個(gè)月每個(gè)月直方圖PharmacydepartmentComputerMonthlyMonthlyBarchart管理監(jiān)控包括滿足病人基本需求所必定的用品及藥品的老例獲取。Managerialmonitoringincludesreportingofactivitiesasrequiredbylawandregulation管理監(jiān)控包括法律和法規(guī)所要求的活動(dòng)的報(bào)告。

傳生病、腫瘤、性病、職業(yè)病報(bào)卡漏報(bào)率Infectiousdiseases,tumors,venerealdiseasesreporttoCDC實(shí)驗(yàn)室質(zhì)控Laboratoryqualitycontrol病理科質(zhì)控Pathologyqualitycontrol放射科質(zhì)控Radiologyqualitycontrol

朱亞芳（保健科）病人地域每個(gè)月每個(gè)月直方圖StaffhealthpromotionPatientcareareaMonthlyMonthlyBarchart費(fèi)春榮（檢驗(yàn)科）檢驗(yàn)科Laboratory每個(gè)月每個(gè)月控制圖LaboratoryMonthlyMonthlyControlchart金梅(Pathology病理科每個(gè)月每個(gè)月控制圖Dept.)PathologyDept.MonthlyMonthlyControlchart胡紅杰（Radiology放射科每個(gè)月每個(gè)月控制圖Dept.）RadiologyDept.MonthlyMonthlyControlchartManagerialmonitoringincludesriskmanagement管理監(jiān)控包括風(fēng)險(xiǎn)管理Managerialmonitoringincludesutilizationmanagement管理監(jiān)控包括醫(yī)療資源合理使用管理。Managerialmonitoringincludespatientandfamilyexpectationsandsatisfaction管理監(jiān)控包括病人及其家屬的希望值及滿意度

壓瘡胡紅鴦（APN）病人地域每個(gè)月每個(gè)月控制圖DecubitusulcersPatientcareareaMonthlyMonthlyControlchart因果圖Fishbonechart病人墜床/滑倒質(zhì)量管理科病人地域每個(gè)月每個(gè)月控制圖PatientFallRateQMPatientcareareaMonthlyMonthlyControlchart利器傷害朱雅芳、質(zhì)量管理辦保健科Staffhealth每個(gè)月每個(gè)月控制圖Sharpinjuries公室、院感科romotionMonthlyMonthlyControlchart心肺復(fù)蘇病人徐秋萍潘紅英病人地域每個(gè)月每個(gè)月控制圖Codebluepatients（危重醫(yī)學(xué)科）PatientcareareaMonthlyMonthlyControlchart因果圖Fishbonechar急診留觀>72小時(shí)潘紅英（ER）ER每季每季直方圖ERobservation>72hrQuarterlyQuarterlyBarchartMRI檢查陽(yáng)性率胡紅杰（Radiology放射科每個(gè)月每個(gè)月控制圖Dept.）RadiologyDept.MonthlyMonthlyControlchart床位使用率病案室HID住院病房每個(gè)月每個(gè)月直方圖AveragepercentageofInpatientunitMonthlyMonthlyBarchartbedsoccupancy平均住院日病案室HID住院病房每個(gè)月每個(gè)月控制圖ControlAveragelengthofstayInpatientunitMonthlyMonthlychart質(zhì)量管理辦公室住院病房每個(gè)月每個(gè)月直方圖住院病人滿意率QMInpatientunitMonthlyMonthlyBarchartInpatientsatisfaction門診病人滿意率Outpatientsatisfaction

Managerialmonitoringincludes員工滿意率孔向紅（黨辦）員工Staff每年每年直方圖staffexpectationsandsatisfactionStaffsatisfactionAnnuallyAnnuallyBarchart管理監(jiān)控包括員工的希望值及滿意度

Managerialmonitoringincludespatientdemographicsanddiagnoses管理監(jiān)控包括病人集體統(tǒng)計(jì)和診斷Managerialmonitoringincludesfinancialmanagement管理監(jiān)控包括財(cái)務(wù)管理Managerialmoni