管理組評鑑簡報

Transcription

1 疾病別認證的國際趨勢 孫茂勝副院長 2014 年 12 月 12 日 1

2 Outline 一 JCIA 及 JCI-CCPC 簡介二 申請 JCI-CCPC 的文件準備及時程規劃三 JCI-CCPC 條文解析四 JCI-CCPC 進行模式及準備重點五 彰基 JCI-CCPC 執行成效 2

3 何謂 JCIA Joint Commission International Accreditation (J.C.I.A.) JCI 屬美國醫療衛生機構認證聯合委員會 (JCAHO) 下設的國際醫療品質部門 JCI 總部位於美國芝加哥, 是國際醫療品質評鑑最具公信力的單位 JCI 依據評鑑標準對美國以外的醫療衛生機構進行認證, 至 2014 年 12 月 8 日止, 全球已有 714 家機構, 遍佈 63 個國家通過認證, 台灣有 14 家醫院通過 ( 含醫院評鑑 9 家 學術性醫療中心醫院 3 家 非住院醫療 2 家 ) 3 Adapted from: (8 Dec. 2014)

4 臺灣通過 JCIA 認證醫院 年度 受評院所 ( 醫院 ) 次數 彰化基督教醫院 3 rd 評鑑 和信醫院 3 rd 評鑑 彰濱秀傳醫院 2 nd 評鑑 臺北醫學大學附設醫院萬芳醫院雙和醫院臺安醫院童綜合醫院 2 nd 評鑑 3 rd 評鑑 2 nd 評鑑 1 st 評鑑 2 nd 評鑑 義大醫院 2 nd 評鑑 年度受評院所 ( 非住院醫療 ) 次數 諾貝爾眼科診所 1 st 評鑑 大學眼科 2 nd 評鑑 维育牙醫診所及植牙中心 (Voluntary Withdrawal) 含 : 醫院評鑑 9 家 學術性醫療中心醫院 3 家 非住院醫療 2 家 敏盛醫院 (Voluntary Withdrawal) 年度受評院所 ( 學術性醫療中心醫院 ) 臺灣大學醫學院附設醫院 2 nd 評鑑 林口長庚紀念醫院 1 st 評鑑 14 家認證效期內 中國醫藥大學附設醫院 2 nd 評鑑 4 Adapted from: (8 Dec. 2014)

5 大陸通過 JCIA 認證醫院 (1) 年度 受評院所 ( 醫院 ) 次數 廣州祁福醫院 4 th 評鑑 北京和睦家醫院 3 rd 評鑑 上海和睦家醫院 2 nd 評鑑 天津泰達國際心血管病醫院 2 nd 評鑑 北京燕化醫院 2 nd 評鑑 北京市健宮醫院 2 nd 評鑑 南京華世佳寶婦產醫院 2 nd 評鑑 洛陽正骨醫院 2 nd 評鑑 青海紅十字醫院 (Voluntary Withdrawal) 深圳和美婦兒醫院 1 st 評鑑 天津寧河縣人民醫院 1 st 評鑑 成都安琪兒婦產醫院 1 st 評鑑 鄭州人民醫院 1 st 評鑑 烏海市婦幼保健院 1 st 評鑑 年度 受評院所 ( 醫院 ) 次數 南京友誼整形醫院 1 st 評鑑 湖南省兒童醫院 1 st 評鑑 浙江象山縣第一人民醫院 1 st 評鑑 江蘇鎮江市第一人民醫院 1 st 評鑑 海南現代婦嬰醫院 1 st 評鑑 深圳市蛇口人民醫院 1 st 評鑑 湖南旺旺醫院 1 st 評鑑 湖南省腫瘤醫院 1 st 評鑑 廣州復大腫瘤醫院 1 st 評鑑 北京嫣然天使兒童醫院 1 st 評鑑 蘭州市西固區人民醫院 1 st 評鑑 廣州現代醫院 1 st 評鑑 浙江蒼南縣人民醫院 1 st 評鑑 廣州市婦幼保健院 1 st 評鑑 廣州市婦幼保健院 1 st 評鑑 5 Adapted from: (8 Dec. 2014)

6 大陸通過 JCIA 認證醫院 (2) 年度 受評院所 ( 學術性醫療中心醫院 ) 次數 浙江杭州邵逸夫醫院 3 rd 評鑑 上海復旦大學附屬華山醫院 2 nd 評鑑 上海兒童醫學中心 2 nd 評鑑 浙江大學醫學院附屬第一醫院 1 st 評鑑 浙江大學醫學院附屬第二醫院 1 st 評鑑 上海復旦大學附屬兒科醫院 1 st 評鑑 新疆醫科大學第一附屬醫院 1 st 評鑑 年度 受評院所 ( 非住院醫療 ) 次數 廣州和睦家診所 1 st 評鑑 含 : 醫院評鑑 28 家 學術性醫療中心醫院 7 家 非住院醫療 1 家 36 家認證效期內 6 Adapted from: (8 Dec. 2014)

7 JCI 評鑑服務範圍 醫院 (Hospital) 教學醫院評鑑 (Academic Medical Center Hospital) 門診醫療 (Ambulatory Care) 臨床實驗室 (Clinical Laboratory) 居家照護 (Home Care) 長期照護 (Long Term Care) 初級照護 (Primary Care) 醫療運輸 (Medical Transport ) 共計 9 項 臨床照護計畫認證 (Clinical Care Program Certification) 7 Adapted from: (9 Jan. 2014)

8 CCPC 在全球醫院的發展分析 世界通過 CCPC 的國家及醫院家數 洲 數值 國家總數醫院家數通過之國家 亞洲 歐洲 1 1 丹麥 非洲 0 0 中南美洲 2 8 巴西 哥倫比亞 大洋洲 0 0 合計 中國 印度 約旦 卡達 新加坡 韓國 台灣 泰國 阿聯酋 菲律賓 8 Adapted from: 8 Dec. 2014

9 CCPC 在全世界通過醫院家數統計 (1) 國家醫院計畫名稱 台灣 (Taiwan) ( 4 ) 彰化基督教醫院 Changhua Christian Hospital World s First Place 台北醫學大學附設醫院 Taipei Medical University Hospital 台北醫學大學 -- 萬芳醫院 Taipei Medical University Wan Fang Medical Center 台北醫學大學 -- 雙和醫院 Taipei Medical University Shuang Ho Hospital 1. Asthma Program 2. Chronic Kidney Disease Program 3. COPD Program 4. Diabetes Mellitus Program 5. HIV/AIDS Management Program 6. Primary Stroke Program 7. Breast Cancer Program 8. HCC Liver Cancer Program 9. Childhood Asthma Program 1. Chronic Kidney Disease Program 1. Acute Myocardial Infarction Program 1. Primary Stroke Program 9

10 CCPC 在全世界通過醫院家數統計 (2) 國家醫院計畫名稱 中國 (China) ( 1 ) 約旦 (Jordan) ( 1 ) 新加坡 (Singapore ) ( 1 ) 阿聯酋 (United Arab Emirates) ( 1 ) 印度 (India) ( 1 ) TEDA International Cardiovascular Hospital King Hussein Cancer Center Changi General Hospital Rashid Hospital Apollo Hospital, Hyderabad 1. Heart Failure Program 2. Acute Myocardial Infarction Program 1. Cancer Program 1. Acute Myocardial Infarction Program 2. Heart Failure Program 1. Acute Myocardial Infarction Program 1. Primary Stroke Program 10

11 CCPC 在全世界通過醫院家數統計 (3) 國家醫院計畫名稱 韓國 (Korea) ( 2 ) EWHA Womans University Medical Center Severance Hospital, Yonsei University College of Medicine 1. Primary Stroke Program 1. Primary Stroke Program 哥倫比亞 (Colombia) ( 1 ) 丹麥 (Denmark ) ( 1 ) 菲律賓 (Philippines) ( 2 ) Hospital Universitario Fundación Santa Fe de Bogotá Amager Hospital St. Luke's Medical Center - Global City St. Luke's Medical Center - Quezon City 1. Joint Replacement Program 1. Asthma Program 1. Primary Stroke Program 1. Primary Stroke Program 11

12 CCPC 在全世界通過醫院家數統計 (4) 國家醫院計畫名稱 泰國 (Thailand) ( 6 ) Bangkok Hospital Medical Center World s Second Place 1. Primary Stroke Program 2. Acute Myocardial Infarction Program 3. Cancer Program 4. Diabetes Mellitus Program 5. Heart Failure Program 6. Pain management Program 7. Traumatic Brain Injury Program Bumrungrad International Kluaynamthai Home Care 1. Primary Stroke Program 2. Acute Myocardial Infarction Program 3. Chronic Kidney Disease Program 4. Diabetes Mellitus Program 1. Primary Stroke Program Sikarin Hospital 1. Primary Stroke Program 12

13 CCPC 在全世界通過醫院家數統計 (5) 國家醫院計畫名稱 泰國 (Thailand) ( 6 ) 卡達 (Qatar) ( 2 ) Samitivej Srinakarin Hospital World s Third Place Vejthani Hospital National Centre for Cancer Care and Research, Doha (NCCCR) Hamad General Hospital 1. Primary Stroke Program 2. Acute Myocardial Infarction Program 3. Cancer Program 4. Asthma Program 5. Joint Replacement Program 6. Pain management Program 1. Joint Replacement Program 2. Diabetes Mellitus Program 3. Heart Failure Program 1. Palliative Care Program 1. Primary Stoke Program 13

14 CCPC 在全世界通過醫院家數統計 (6) 國家醫院計畫名稱 巴西 (Brazil) ( 7 ) Associação do Sanatório Sírio - Hospital do Coração Hospital TotalCor Amil Total Care Cincinato Braga SP Hospital Israelita Albert Einstein Hospital Paulistano Hospital Santa Palula Total Care Unidade Jardins 1. Acute Myocardial Infarction Program 2. Heart Failure Program 1. Acute Myocardial Infarction Program 2. Heart Failure Program 1. Asthma Program 2. COPD Program 1. Diabetes Mellitus 2. Primary Stroke Program 1. Palliative Care Program 2. Primary Stroke Program 1. Primary Stroke Program 1. Heart Failure Program 14

15 FMS Hospital leadership QPS Communication ACC ACC ACC Coordination 社區 call center ACC ACC PFR AOP COP PFE ASC MMU IPSG ACC ACC ACC 社區 call center Integration ACC ACC ACC Interaction PCI SQE MCI 15

16 Patient Care Model 全人 全家人 全社區 全隊 全程 16

17 17 Patient Care Model 商標專利

18 JCIA and CCPC Clarification Joint Commission International Accreditation (J.C.I.A.) Clinical Care Program Certification (C.C.P.C) 認證 (Accreditation) 主管機關對某人或某機構給予正式認可, 證明其有能力執行某特定工作之程序 驗證 (Certification) 對能力之認可 對符合標準之認可 對某一項產品 過程或服務能符合規定要求, 由第三者出具書面保證之程序 18 資料來源 : 財團法人全國認證基金會

19 JCI-CCPC 的發展歷程 First Edition: Joint Commission International Standards for Disease or Condition- Specific Care (Effective 2005) Second Edition: Joint Commission International Standards for Clinical Care Program Certification (Effective 2010) 19

20 可申請 CCPC 認證的計畫項目 Acute Myocardial Infarction 急性心肌梗塞 Asthma 哮喘 Cancer (all Types) 癌症 ( 任何類型的癌症 ) Chronic Kidney Disease (stage I to IV) 慢性腎病 ( 一至四期 ) Chronic Obstructive Pulmonary Disease (COPD) 慢性阻塞性肺病 Diabetes Mellitus (types 1 and 2) 糖尿病 (1 型 /2 型 ) End Stage Renal Disease 晚期腎病 Heart Failure 心力衰竭 HIV/AIDS Management 愛滋病管理 Joint Replacement (all Types) 關節置換 ( 任何類型的關節置換 ) Pain Management 疼痛管理 Palliative Care (all Types) 緩和療護 ( 任何類型的緩和療護 ) Primary Stroke 初級中風 Transplantation (all Types) 移植 ( 任何類型的移植 ) Traumatic Brain Injury 創傷性腦傷害共計 15 項 20 Adapted from:

21 醫院參加 CCPC 的優點和理由 (1) Giving organizations a competitive advantage 提升機構的競爭力 : 通過認證後, 可更公開的向外界證明通過認證的醫院相較於其他同層級醫院, 施行的 CCPC 是非常關心病人的安全, 可提供更高品質的照護 Strengthening community confidence 強化民眾的信心 : 將病人及家屬納入照護過程中成為伙伴, 尊重他們的權利及意見, 亦可提供病人及付費者有更好的選擇就醫之機會 Obtaining recognition from insurers, associations, employers, and other stakeholders 贏得相關機構認同 : 參加評鑑或認證以提升醫療品質已是趨勢, 通過認證可強化合作機構的信賴與認同感, 以更好的照護品質要求更好的給付 21 Adapted from: Clinical Care Program Certification Survey Process Guide. Joint Commission International Accreditation, 2010.

22 醫院參加 CCPC 的優點和理由 (2) Validating high-quality care to patients 高品質照護的保證 :JCI 總部致力於提升病人安全與照護品質, 所以訂定高標準的認證條文, 通過認證是高品質照護的保證 Helping organizations organize and strengthen their improvement efforts 持續的品質改善 : JCI 總部是依據目前醫療 科技的發展趨勢來訂定認證條文, 可以幫助機構持續改善, 並走在時代先端 Enhancing staff education 提升員工的教育 :JCI 委員是受過完整的訓練, 在專業領域的學經歷都是佼佼者, 在查核同時也會提供教育, 協助改善機構的內部作業和流程 22 Adapted from: Clinical Care Program Certification Survey Process Guide. Joint Commission International Accreditation, 2010.

23 醫院參加 CCPC 的優點和理由 (3) Improving risk management 加強風險的管理 : 導入風險管理的概念, 幫助機構改善或降低不良事件 建立不良事件及安全相關議題及時通報的醫院文化, 以提升病人安全, 及減少醫療和財務風險 Facilitating staff recruitment 增加員工的滿意度 : 通過認證是高品質照護的保證, 可使照護提供者更有自信 更進步, 願意共同投入工作, 因此可以增加召募及留任率 Promoting team-building skills for staff 促進團隊的合作 : 認證條文必須靠團體運作才能達到, 參加認證可以讓團隊在以病人為中心的基礎下, 強化彼此合作關係 23 Adapted from: Clinical Care Program Certification Survey Process Guide. Joint Commission International Accreditation, 2010.

24 病人加入 CCPC 照護團隊的好處 CCPC 的照護團隊 以 international, evidence based clinical guideline ( 具實證的國際級照護指引 ), 提供更好的照護品質 整個團隊 (multi-disciplinary) 積極主動的介入照護 設有監測的品質指標, 如 : 指引遵循率 (compliance rate) 病人滿意度 等, 以提供高品質且一致性的照護 24

25 什麼時候該參加 CCPC 當您的照護團隊 對臨床照護指引無共識 照護計畫缺乏個別化 照護計畫未整合且未詳加記錄 臨床護理人員須照護之病人數太多 缺乏明確的跨團隊合作機制 未建置成果導向之品質指標 缺乏深究問題的決心 擔心影響病人的觀感 未完全的以病人為中心 就是加入 CCPC 的時機 25

26 醫策會疾病照護品質認證與 JCI-CCPC 26 認證名稱 醫策會 -DSCCP 疾病照護品質認證 (Disease Specific Care Certification Program) JCI-CCPC 臨床照護計畫認證 (Clinical Care Program Certification) 起始年份 2008 年 2005 年 認證條文 3 章 / 9 節 / 23 個基準 6 章 / 48 條標準 / 188 個評量細項 評鑑手法 Patient-Focused Method Tracer Methodology 可認證計畫 3 種, 包含 : 冠狀動脈疾病 急性冠心症 急性心肌梗塞 15 種, 包含 : 急性心肌梗塞 哮喘 癌症 ( 任何類型的癌症 ) 慢性腎病 ( 一至四期 ) 慢性阻塞性肺病 糖尿病 (1 型 /2 型 ) 晚期腎病 心力衰竭 愛滋病管理 關節置換 ( 任何類型的關節置換 ) 疼痛管理 緩和療護 ( 任何類型的緩和療護 ) 初級中風 移植 ( 任何類型的移植 ) 創傷性腦傷害

27 Outline 一 JCIA 及 JCI-CCPC 簡介二 申請 JCI-CCPC 的文件準備及時程規劃三 JCI-CCPC 條文解析四 JCI-CCPC 進行模式及準備重點五 彰基 JCI-CCPC 執行成效 27

28 JCI-CCPC 章節及標準說明 (1) CCPC 第 2 版共有 6 個章節 48 個標準及 188 個評量細項 (Effective 1 July 2010) CCPC 第 3 版共有 6 個章節 46 個標準及 184 個評量細項 (Effective 1 January 2015) 章節名稱 International Patient Safety Goal, IPSG Program Leadership and Management, PLM Delivering or Facilitating Clinical Care, DFC Support Self-Management, SSM Clinical Information Management, CIM Performance Measurement and Improvement, PMI 28 Adapted from:

29 JCI-CCPC 章節及標準說明 (2) 章節 標準 (STD) 第 2 版 (2010-7) 第 3 版 (2015-1) 評量細項 (ME) 第 2 版 (2010-7) 第 3 版 (2015-1) IPSG PLM DFC SSM CIM PMI 合計 Adapted from:

30 Outline 一 JCIA 及 JCI-CCPC 簡介二 申請 JCI-CCPC 的文件準備及時程規劃三 JCI-CCPC 條文解析四 JCI-CCPC 進行模式及準備重點五 彰基 JCI-CCPC 執行成效 30

31 章節 JCI-CCPC 章節及標準 標準 (STD) 第 2 版 (2010-7) 第 3 版 (2015-1) 評量細項 (ME) 第 2 版 (2010-7) 第 3 版 (2015-1) IPSG PLM DFC SSM CIM PMI 合計 Adapted from:

32 IPSG.1 Standard Identify Patients Correctly ( 提昇病人辨識的正確性 ) Message 明訂病人辨識的政策和流程 (P&P) 供相關人員遵循 32 Adapted from: (4 Feb. 2014)

33 IPSG.2 Standard Improve Effective Communication ( 促進有效的溝通 ) Message 處理口頭及電話醫囑之政策和流程 Write Down Read Back Confirm 的核對機制 Adapted from: (4 Feb. 2014) 33

34 IPSG.3 Standard Improve the Safety of High-Alert Medications ( 促進高警訊藥品的安全性 ) Message 高警訊藥品應有特殊的標示及存放 高濃度藥品, 不可放置於護理站或藥局以外的單位 Adapted from: (4 Feb. 2014) 34

35 IPSG.4 Standard Ensure Correct-Site, Correct-Procedure, Correct-Patient Surgery ( 確保手術部位 程序和病人的正確性 ) Message WHO Surgical Safety Checklist Sign In Time Out Sign Out Check 該完成的檢驗 / 檢查 35 Adapted from: (4 Feb. 2014)

36 IPSG.5 Standard Reduce the Risk of Health Care-Associated Infections ( 降低醫療照護相關感染之風險 ) Message 明訂醫院之手部衛生計畫及感染管制計畫 有監測機制, 確認執行對策的有效性 36 Adapted from: (4 Feb. 2014)

37 IPSG.6 Standard Reduce the Risk of Patient Harm Resulting from Falls ( 降低病人跌倒所導致傷害之風險 ) Message 建置跌倒防制計畫並主動提報相關作為 監測跌倒發生率及跌倒傷害率 嚴重事件要進行 RCA 37 Adapted from: (4 Feb. 2014)

38 PLM-- PLM.1~.15 PLM.1 Leadership roles in the program are clearly defined. ( 清楚定義計畫領導者的角色 ) PLM.2 The program is designed, implemented, and evaluated collaboratively. ( 計畫的制訂 執行及評核, 都是透過共同合作的機制 ) PLM.3 The program is relevant and meets the needs of the target population and/or health care service area. ( 計畫的設計是符合目標照護族群的需求 ) PLM.4 The scope and level of care and/or services offered by the program are provided to patients and, when appropriate, families. ( 計畫服務範圍和層級, 要讓病人知道 ; 需要時亦要讓家屬知道 ) 38

39 PLM-- PLM.1~.15 PLM.5 The scope and level of care and/or services provided are uniform and comparable for patients with the same acuity and type of disease or condition being managed, regardless of their ability to pay or the source of payment. ( 計畫提供的服務範圍和層級要具備一致性, 不因病人的經濟能力而有所不同 ) PLM.6 Eligible patients have access to the care and/or services provided by the program. ( 符合收案條件的病人, 有邀請加入計畫 ) PLM.7 The program operates in an ethical manner. ( 計畫的運作符合倫理的規範 ) 39

40 PLM-- PLM.1~.15 PLM.8 The program complies with applicable laws and regulations. ( 計畫的運作符合法律和規範 ) PLM.9 PLM.10 The program has current reference and resource materials readily available. ( 計畫採用現況的參考指引和資源, 並方便人員取得 ) Facilities where patients receive care maintain and implement a program that provides a safe and secure physical environment. ( 確保病人有安全及保全的就醫環境 ) PLM.11 Facilities where patients receive care maintain and implement an emergency management program. ( 病人照護單位訂有緊急應變計畫 ) 40

41 PLM-- PLM.1~.15 PLM.12 Facilities where patients receive care maintain and implement a program to ensure that all occupants are safe from fire and smoke. ( 病人照護單位訂有防火計畫, 確保所有到院者避免受到火 煙的傷害 ) PLM.13 Facilities where patients receive care maintain and implement a program for inspecting, testing, and maintaining medical equipment and documenting results. ( 病人照護單位訂有醫療設備的檢測及維修計畫, 並留下記錄 ) 41

42 PLM-- PLM.1~.15 PLM.14 Facilities where patients receive care maintain and implement emergency processes in the event of water, power, gas, or communication failures. ( 病人照護單位訂有水 電 醫用氣體等公用系統運作失常之緊急處理流程 ) PLM.15 Facilities where patients receive care maintain and implement a program to ensure that all staff members receive education and training about their roles in providing a safe and effective environment. ( 病人照護單位訂有完善的教育訓練計畫, 每位員工都熟知自己在提供病人安全的就醫環境上應扮演的角色 ) 42

43 DFC-- DFC.1~.7 DFC.1 All clinical staff are qualified, competent, and appropriately trained. ( 所有照護團隊成員都經過適當的教育訓練, 具備足夠的資格與能力 ) DFC.2 All clinical and nonclinical staff are oriented to the program and to their specific job responsibilities. ( 所有照護團隊成員都給予計畫相關的職前教育, 使其了解自己的工作職責 ) DFC.3 There are continuous, ongoing professional practice evaluations of the quality and safety of the clinical care provided by each staff member. ( 所有團隊成員的專業照護品質和安全, 要有持續性的評估機制 ) 43

44 DFC-- DFC.1~.7 DFC.4 The program uses a standardized process originating in clinical practice guidelines or evidence-based practice to deliver or facilitate the delivery of clinical care. ( 本計畫引用具實證基礎的臨床照護指引, 以提供標準化的照護 ) DFC.5 All clinical staff are knowledgeable about the adapted or adopted clinical practice guidelines and implement activities that are consistent with the clinical practice guidelines. ( 團隊成員都熟知本計畫之臨床照護指引, 並據此提供一致性的照護 ) DFC.6 The program tailors the standardized process to meet the patient s needs. ( 本計畫致力於導入符合病人需求之標準化的照護流程 ) 44

45 DFC-- DFC.1~.7 DFC.7 Concurrently occurring conditions and comorbidities are managed, or the information necessary for their management is communicated to the appropriated clinical staff. ( 收案病人的共病同時要給予治療, 並針對相關重要訊息與其他照護此病人的臨床人員溝通 ) 45 Adapted from: (4 Feb. 2014)

46 SSM-- SSM.1~.5 SSM.1 The program involves the patient and, when appropriate, the family in making decisions about managing their diseases or conditions. ( 在執行疾病相關的醫療決策時, 有病人及家屬的參與 ) SSM.2 The program addresses the patient s and, when appropriate, the family s readiness, willingness, and ability to learn. ( 在進行病人及家屬的教育前, 有先評估其受教之接受度 意願和能力 ) SSM.3 The program addresses the patient s and, when appropriate, the family s educational needs. ( 計畫的設計有重視病人及家屬的教育需求 ) 46

47 SSM-- SSM.1~.5 SSM.4 The program materials are consistent with the clinical guidelines and relevant and appropriate to the population served. ( 教育內容和資料符合臨床照護指引的規範及服務對象的需求 ) SSM.5 The program addresses lifestyle changes that support selfmanagement regimens. ( 計畫提及支持病人及家屬自我照護的方案及作法 ) 47

48 CIM-- CIM.1~.7 CIM.1 The confidentiality, security, and retention of patient information are protected. ( 有妥善保護病人的機密資料 ) CIM.2 The program identifies those authorized to have access to and/or to make entries in the patient clinical record. ( 要確認那些人員是被授權可以進入查詢或異動病人的資料 ) CIM.3 The program uses standardized diagnosis codes, procedure codes, symbols, abbreviations, definitions, and methods for adding comments/addenda. ( 記錄病人資料時, 使用標準化的診斷碼 處置碼 代號 縮寫 定義及方法 ) 48

49 CIM-- CIM.1~.7 CIM.4 CIM.5 CIM.6 Information management processes meet the program s internal and external information needs. ( 資料管理流程符合計畫內部和外部的需求 ) The program gathers information about the patient s disease or condition from clinical staff and settings across the continuum of care. ( 有收集 整合臨床人員或其他機構關於病人疾病資訊的流程, 以支持連續性照護 ) The program shares information about the patient s disease or condition across the entire continuum of care to any relevant setting or clinical staff. ( 有和臨床人員或其他機構分享病人疾病資訊, 以支持連續性照護 ) 49

50 CIM-- CIM.1~.7 CIM.7 The program initiates, maintains, and makes accessible a health or clinical record for every patient. ( 每位收案病人的病歷資料都有進行維護及記錄 ) 50 Adapted from: (4 Feb. 2014)

51 PMI-- PMI.1~.8 PMI.1 PMI.2 The program has an organized, comprehensive approach to performance improvement. ( 本計畫有建置具組織性 全方位的品質改善策略 ) The program maintains data quality and integrity. ( 維護收集之資料的品質和完整性 ) PMI.3 PMI.4 The program uses measurement data to evaluate and to improve processes and outcomes. ( 運用收集之資料以評量並改善流程和執行成效 ) The process for identifying, reporting, managing, and tracking sentinel events is defined and implemented. ( 訂定並執行警訊事件之確認 通報 處理及追蹤流程 ) 51

52 PMI-- PMI.1~.8 PMI.5 PMI.6 The process for identifying, reporting, managing, and tracking errors and adverse events is defined and implemented. ( 訂定並執行疏失或不良事件之確認 通報 處理及追蹤流程 ) The process for identifying, reporting, managing, and tracking near-miss events is defined and implemented. ( 訂定並執行跡近錯誤事件之確認 通報 處理及追蹤流程 ) PMI.7 PMI.8 The program collects and analyzes data regarding variance from the clinical practice guidelines to improve the standardized process. ( 收集及分析臨床照護指引執行上的差異, 加以修正以標準化照護流程 ) The program evaluates patient and family perceptions of the quality of care. ( 針對病人及家屬進行照護品質的滿意度調查 ) 52

53 Outline 一 JCIA 及 JCI-CCPC 簡介二 申請 JCI-CCPC 的文件準備及時程規劃三 JCI-CCPC 條文解析四 JCI-CCPC 進行模式及準備重點五 彰基 JCI-CCPC 執行成效 53

54 CCPC 評分方式 評分等級 (Scoring Guideline) 分類 定義 給分 Fully Met 完全符合 或 完全執行 10 分 Partially Met 部份符合 5 分 Not Met 不符合 或 未執行 0 分 Not Applicable 對於評量細項的特定需求, 若於醫院無需實 施或不適用, 則被評為 不適用 54 Adapted from: Clinical Care Program Certification Survey Process Guide. Joint Commission International Accreditation, 2010.

55 CCPC 認證合格之判定 須符合以下要點 : 沒有任一個標準 (Standard), 有一個以上的評量細項 (MEs) 得分為 0 沒有任一個國際病人安全目標 (IPSG), 有一個以上的評量細項 (MEs) 得分為 0 每項標準 (Standard) 平均得分要 每項國際病人安全目標 (IPSG) 平均得分要 5 所有章節之標準 (Standard) 得分總和平均要 9 55 Adapted from: Clinical Care Program Certification Survey Process Guide. Joint Commission International Accreditation, 2010.

56 認證結果 認證合格之醫院 : 於評鑑後 天內收到正式評鑑報告 (Official Survey Findings Report) 醫院須針對報告中 Not Met 項目, 於收到報告後 45 天內提出策略改善計畫 (Strategy Improvement Plan, SIP) 未認證合格之醫院 : 亦於評鑑後 天內收到初步評鑑報告 (Preliminary Survey Findings Report) 將進行追蹤焦點訪查 (Follow-Up Focused Survey) 56 Adapted from: Clinical Care Program Certification Survey Process Guide. Joint Commission International Accreditation, 2010.

57 CCPC On-site Survey 以 Asthma Program 為例 57 Adapted from: (8 Dec. 2014)

58 58 For CCPC On-site Survey

59 Survey Agenda--day 1 Day 1 ( ) Time Topic Opening Conference and Introductions, Agenda Review Presentation of Overview of Clinical Care Services and PI Measures Review of Performance Measure Data Surveyor Document Review, as Needed Unit Visits/Tracer Activity Surveyor Lunch//Planning Unit Visits/Tracer Activity Review any issues as needed with Program Director 59

60 Survey Agenda--day 2 Day 2 ( ) Time Topic Daily debriefing Review of first day survey activities Further discussion of selected Four PI Measures, as needed Closed Medical Record Review Surveyor Interviews with Program Outpatients Surveyor Lunch//Planning SQE Review for Physicians, Nurses, and Other Staff Surveyor Computer Integration of Report Exit Conference 60

61 61 CCPC Asthma On Site Survey

62 迎賓 評鑑首日, 委員對院長室成員前來迎接倍感溫馨 62

63 Opening Conference 院長室長官及委員致詞 團隊成員介紹及計畫主持人簡報 63

64 Orientation Program staff introduction Presentation of Overview of Clinical Care Services and PI Measures 64

65 Introduction Presenter: Dr. Cheng-Hsiung CHEN 65

66 Qualifications Board certified Medical Doctor Board certified Pulmonary Physician Director of the ward of Chest Department Member of Taiwan Society of Pulmonary and Critical Care Medicine 66

67 Leadership Role and Duties Outline the objectives, missions and goals Formulate and review the annual working plan Manage various indices of medical service quality Monitor patient safety and prevent on accident event Make preliminary decisions on the facility and technique access and renewal Regulation of medical care staff, adequately reply to staff feedback and improve communication 67

68 Orientation Program staff introduction Presentation of Overview of Clinical Care Services and PI Measures 68

69 Orientation to the Clinical Care Program Standards/Issues To Be Addressed Introduction to the clinical care program by program leaders PLM.1 to PLM.9 DFC.4 to DFC.7 69

70 Unit Visits/Tracer Activity 委員至各單位實地訪查環境安全 病人照護流程 70

71 71 CCPC Asthma On Site Survey

72 Daily Debriefing 早上由委員針對第一天訪查重點進行建議, 由團隊成員針對委員建議進行回覆 72

73 Closed Medical Record Review 病歷審查是 CCPC 必要項目 73

74 Medical Record Review Tool (1) Medical Record Medical Record Medical Record Medical Record STD Documentation Requirement Measurable Elements # # # # DX: DX: DX: DX: Y N N A Y N N A Y N N A Y N N A CONSENTS PLM.6 Eligible patients have access to the care and/or services provided by the program 3.Patients are given multiple opportunities to participate in the program. 給病人有多次參與該計畫的機會 PLM.7 The program operates in an ethical manner 2.The program respects the patient s right to decline participation in the program 該計畫有尊重病人拒絕參與該計劃的權利 74

75 Medical Record Review Tool (2) Medical Record Medical Record Medical Record Medical Record STD Documentation Requirement Measurable Elements # # # # DX: DX: DX: DX: Y N N A Y N N A Y N N A Y N N A ASSESSMENTS DFC.6 The program tailors the standardized process to meet the patient s needs. 1.The program defines the patient assessment process, including family risks. 該計畫有定義病人評估的程序, 包括家屬風險的評估 2. An assessment is completed for all patients within the time frame determined by the program. 病人完整的評估應在計畫訂定的時間內完成 3.The assessment is used to develop a plan of care. 依據評估的結果發展病人的照護計畫 75 4.The program uses a specified method for prioritizing the needs of patients. 該計畫運用特殊方式以決定病人需求之優先順序

76 Medical Record Review Tool (3) Medical Record Medical Record Medical Record Medical Record STD Documentation Requirement Measurable Elements # # # # DX: DX: DX: DX: Y N N A Y N N A Y N N A Y N N A CARE DELIVERY DFC.6 The program tailors the standardized process to meet the patient s needs. 5.The program implements interventions based on prioritization of needs and identified patient risks. 該計畫依據病人需求優先順序和已確認之病人風險介入照護 6.The prioritization method is tailored to meet the targeted population s age and developmental needs. 優先順序的選取方式切合目標族群的年齡和發展需求 7.The program continually evaluates, revises, and implements the plan of care to meet the patient s ongoing needs. 該計畫持續進行評估 更新和執行照護計畫, 以符合病人需求 76

77 Medical Record Review Tool (4) Medical Record Medical Record Medical Record Medical Record STD Documentation Requirement Measurable Elements # # # # DX: DX: DX: DX: Y N N A Y N N A Y N N A Y N N A OTHERS DFC.7 Concurrently occurring conditions and comorbidities are managed, or the information necessary for their management is communicated to the appropriate clinical staff 1.Care is coordinated for patients with multiple diseases and/or who are managed by multiple clinical care programs 針對多種疾病和 / 或多個臨床照護計畫管理之病人之照護是經過協調的 2.When concurrently occurring conditions are identified, relevant information is communicated to appropriate clinical staff treating or managing the condition(s) 當有其他共病時, 病人之相關訊息有傳送給適當的治療或管理此情況之臨床工作人員 77

78 Medical Record Review Tool (5) Medical Record Medical Record Medical Record Medical Record STD Documentation Requirement Measurable Elements # # # # DX: DX: DX: DX: Y N N A Y N N A Y N N A Y N N A CIM.3 The program uses standardized diagnosis codes, procedure codes, symbols, abbreviations, definitions, and methods for adding comments/addend a. 1.Standardized diagnosis codes are used and the use monitored 使用標準化的診斷代碼並監測使用狀況 2.Standardized procedure codes are used and the use monitored. 使用標準化的處置代碼並監測使用狀況 4.Standardized symbols are used, and those not to be used are identified and monitored 使用標準化的符號, 且訂定不得使用的符號清單, 並監測使用狀況 5. Standardized abbreviations are used, and those not to be used are identified and monitored. 使用標準化的縮寫, 且訂定不得使用的縮寫清單, 並監測使用狀況 78

79 Staff Qualification and Education Review 人員資格審查是 CCPC 查核要點 79

80 Program Staff Qualifications Worksheet (1) Standard DFC.1 DFC.2 Measurable Element All clinical staff have educational backgrounds, experience, training, and/or certification consistent with the program s mission, goals, and objectives. 臨床人員的教育背景 經驗 訓練和 / 或認證, 符合計畫的任務 目標和目的 Core criteria for hiring clinical staff in the program include, at a minimum, current licensure, relevant education, training and experience, and current competence. 該計畫聘用臨床人員的核心標準, 最低限度包括, 目前的證照 相關的教育 訓練和經驗, 以及現況的能力 Core criteria for evaluating clinical staff in the program include, at a minimum, current licensure and current competence. 該計畫評核臨床人員的核心標準, 最低限度包括, 目前的證照和現況的能力 Professional education, advanced training, and experience are verified from primary sources. 專業教育 進階訓練和工作經驗, 要經由原始機構驗證 Current licensure and certifications are verified from primary sources 目前證照和認證要經過原始機構驗證 Orientation provides information and necessary training appropriate to program responsibilities. 職前訓練應提供符合該計畫職責的資訊和必要訓練 The competence of all clinical staff is assessed when new techniques or responsibilities are introduced and periodically within the time frames defined by the program 當新技術或職責加入時, 所有臨床人員的執行能力要在該計畫訂定時限內完成評核 80

81 Program Staff Qualifications Worksheet (2) Standard DFC.2 DFC.3 DFC.5 Measurable Element Ongoing in-service and other education and training activities are relevant to the program s needs. 持續進行的在職教育 其他教育以及訓練活動, 要符合該計畫需求 The performance of individual staff members is reviewed when indicated by findings of quality improvement activities. 透過品質改善活動之成效的呈現, 檢討個人的表現 There is an ongoing professional practice evaluation of each staff member documented in the staff member s file that includes at least one documented evaluation each year. 團隊成員之專業能力評估資料應記錄於各自資料檔案中, 並至少每年一次 Corrective action is taken when deficiencies or substandard performance are identified. 當團隊成員之專業表現不良或不符合標準時, 要採取糾正措施 Clinical staff have been educated about clinical practice guidelines and their use. 臨床人員有被教育臨床照護指引的內容和使用 Clinical staff consistently follows the 臨床人員一致遵循所選定的臨床照護指引 Assessment activities are consistent with clinical practice guidelines. 各項評估活動應與臨床照護指引一致 Intervention activities are consistent with clinical practice guidelines. 各項醫療處置與介入活動應與臨床照護指引一致 81

82 Asthma Program Exit Conference 委員授與認證初報 /Asthma 團隊與委員合影 82

83 Final Survey Finding Report Letter

84 Outline 一 JCIA 及 JCI-CCPC 簡介二 申請 JCI-CCPC 的文件準備及時程規劃三 JCI-CCPC 條文解析四 JCI-CCPC 進行模式及準備重點五 彰基 JCI-CCPC 執行成效 84

85 通過評鑑及認證之紀錄 : 3 次 JCI 醫院評鑑 9 個 CCPC Program 85

86 美國以外世界第一 日止共計通過 9 個 JCI-CCPC 照護計畫 (11 次的認證經驗 ) 86

87 87

88 88

89 89

90 彰基 CCPC 成功經驗分享 JCI 亞太地區辦公室副主任 Joyce 蒞院參訪 90

91 91

92 謝謝聆聽 敬請指教 92