欢迎访问山西省卫生和计划生育委员会网站!

多措并举持续改善医疗质量,保障医疗安全

发布时间: 2018-05-06 11:55:51   发布人:本站编辑   文章来源:本站原创  浏览

为扎实推进2018--2020年的进一步改善医疗服务行动计划,促进医疗服务规范化、常态化、科学化,持续增强人民群众看病就医的获得感,现从我省受国家卫生计生委通报表扬的2015--2017年度优质服务示范医院、科室、个人中,按照改善医疗服务不同主题,选取10个独具特色的典型,每周一例进行连续报道,充分发挥典型示范作用,推动改善医疗服务工作再上新台阶,更好地满足人民群众日益增长的健康服务需求。

主题四:保障医疗安全(总第七期)

示范医院:大同煤矿集团有限责任公司总医院

 

多措并举持续改善医疗质量,保障医疗安全

 

一、基本情况

大同煤矿集团有限责任公司总医院是隶属于大同煤矿集团的三级甲等综合医院,是全国优质护理示范工程重点联系医院,山西省首家通过“中国胸痛中心”认证医院,山西省唯一通过国家电子病历六级认证医院,中国卒中中心联盟(CSCA)“综合卒中中心”认证单位,国家脑防委“高级卒中中心”建设单位,全国工伤康复定点医院、国家矿山医疗救护省级分中心。

2015年荣获国家卫生计生委医政医管局指导、健康界传媒主办的“改善医疗服务行动计划全国医院擂台赛”的“2015年度创新服务示范医院”、2015年度改善服务创新亮点展示评选活动“改善服务创新医院”;2016年9月,医院的“预约诊疗的延伸--碎片预约”获国家卫生计生委医政医管局指导、健康界传媒主办的“改善医疗服务行动计划全国医院擂台赛”主题二“推进预约诊疗服务十大人气案例”;荣获工信部2017年度中国信息技术服务产业贡献奖。

二、所做工作

大同煤矿集团有限责任公司总医院在“进一步改善医疗服务行动计划”中,不断完善质量管理体系,多措并举,特别是通过信息化建设提升管理水平,针对在医疗质量、医疗安全管理中存在的难点和不足,重点从医疗质量实时监控、持续改进临床路径管理、诊疗行为的信息化闭环管理、临床药物合理使用以及应用品管圈抓质量等方面入手开展工作,极大提升了医疗质量和安全管理水平。

三、亮点工作

(一)依托实时预警监控体系提高医疗质量

利用数字化技术,通过建立医疗质量缺陷防控机制,采取实时监控手段,实现医疗质量和安全的持续改进。目前医院信息化实时监控系统主要包括:医疗风险预警、重点患者质控、电子临床路径、电子会诊和电子交接班、抗菌素使用、单病种质量控制、预约诊疗、不良事件、跌倒及坠床高风险患者的实时监控、临床用血、医技等质量控制、医院感染疑似病例监测与预警等涉及医务、护理、院感、后勤保障等19大类,涵盖全院所有临床科室及全部住院患者。

(二)规范电子临床路径管理

医院临床路径管理委员会制定了“写你所做的、做你所写的、总结有用的、完善不足的”临床路径原则,根据病历调查、临床专家论证、诊疗指南、规范等制订符合本院实际诊疗规范的临床路径实施方案;全部实施电子版临床路径(包括将麻醉纳入临床路径管理),建立电子临床路径质控体系(包括:入路径患者质控、变异与退出情况质控、路径患者登记与数据统计分析),将路径实施与绩效考核挂钩并持续改进完善。

目前医院临床路径实施病种由2010年最开始的6个病种增加到目前145个病种,病种涵盖所有临床科室。2017年完成例数33039例,占全年出院人数的66.1%

(三)实施信息化的闭环管理

医院将信息化的闭环管理应用于用药、检验、检查、手术、输血、危急值处置等医疗活动以及消毒供应物品追溯、医用耗材
全生命周期管理等方面,每个重要环节都实现数据管理,同时严格遵循PDCA质量管理原理,按照闭环管理思路,找出流程中的缺失环节、隐性不安全因素等,并通过相应的系统功能进行整改,明确各个环节责任人,做到全员追踪、全程追溯,从而保证患者的诊疗安全。

 

1.输血闭环管理

输血的闭环管理从临床医生下达配血医嘱后,临床从标本采集、临床与外勤标本交接、外勤与输血科的标本交接、配血的过程、配血完成后输血科与外勤人员的血液制品的交接、外勤与临床科室血液制品的交接、临床护士双人核对并为患者进行输血操作、输血过程中的巡视、输血过程中患者有无输血不良反应及上报、输血结束、输血袋由临床经外勤送返至输血科每一个环节都必须经过对血袋、患者腕带条码、护士和输血科工作人员以及外勤工作人员工牌等PDA扫描或点击完成,并实时监控。

2.手术闭环管理

围绕围手术期的关键节点从临床下达手术通知后麻醉科进行手术安排,从麻醉医师、手术室护士进行术前访视、手术室麻醉科与临床对手术患者的交接、进入手术室、进入手术房间、麻醉前核查、术前的三方静默核查(以现场录音的方式)、手术器械的核查、手术结束的核查、以及出手术间、进恢复室、出恢复室、患者出手术室、麻醉科与临床的患者交接、麻醉医师的术后访视,每一个环节都必须经过对患者腕带、麻醉医师、手术室护士、手术医师和临床护士的工牌及手术房间、恢复室、器械包条码进行PDA扫描或点击完成,并实时监控。                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               

(四)利用品管圈抓质量

自2012年以来,医院最先在全省引进品管圈管理方法,持续改进护理质量和安全,业务内涵建设得到了扎实推进,并逐渐扩展到临床、医技,从最初的6个主题圈发展到目前66个主题圈。品管圈工作遵照“提升质量、保障安全、创新服务、培养人才”的活动指导方针,推行全员参与、全方位展开、全过程追踪的“三全管理”,实现医疗质量与安全的持续改进。

医院对品管圈取得优秀成果的项目进行分析总结,提炼为标准化的工作流程或改进措施,将成熟的标准作业流程向全院推广。医院品管圈多次参加各类比赛,获得过全国医院品管圈大赛二等奖、三等奖,多次获得山西省品管圈大赛一等奖。

(五)其它方面

如利用DRGs评价科室质量,规范医疗行为,通过防、控结合的手段,有效处置医疗纠纷,认真做好三级随访等。

四、下一步工作安排

1.继续以信息化为抓手,不断完善和拓展相关功能和应用,打造全过程的质量安全控制体系;

2.将DRGs评价体系充分应用在学科评价、手术分级、疑难重症管理以及科学的绩效机制建立等方面,以此推动医院技术水平、医疗安全水平的提升。

3.继续通过严格药品管理、做实临床路径、执行单病种付费等规范医疗行为,提升医院管理水平、有效降低医疗费用。