9 TQIP TQIP 湶 TQIP

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1 95B4023 TQIP 湶

2 9 TQIP TQIP 湶 TQIP

3 1 2 4 TQIP i

4 TQIP BTS ( IHI Institute for Healthcare Improvement Breakthrough Series Model ) IHI Tool 147 ii

5 <= <= P4P 62 iii

6 Taiwan Quality Indicator Project, TQIP TQIP TQIP TQIP 5 P4P 1 1a. 2 2b A1. 5 TQIP 1 2 Double Check TQIP iv

7 TQIP TQIP2b Institute for Healthcare Improvement IHI Breakthrough Series Model charter change package TQIP 25 5 charter change package % 95.2% % % 100% % 97.9% 5 v

8 % Breakthrough Series Model TQIP Breakthrough Series Model 6 Pay for Performance P4P P4P P4P vi

9 P4P CMS 2006 PVRP Physician Voluntary Reporting Program TQIP TQIP web-site - TQIP p4p P4P TQIP p4p TQIP p4p risk adjustment TQIP vii

10 Taiwan Quality Indicator Project, TQIP TQIP TQIP - 1 -

11 TQIP performance measurement Agency for Healthcare Research and Quality, AHRQ National Healthcare Quality Report NHQR National Healthcare Disparities Report NHDRNHQR IOM Institute of Medicine2001 Crossing the Quality Chasm Safety Effectiveness Patient-Centeredness Timeliness AHRQ The National Committee for Quality Assurance NCQA The Health Plan Employer Data and Information Set HEDIS Joint Commission on Accreditation of Healthcare Organizations, JCAHO 1999 ORYX - 2 -

12 ORYX ORYX 2004 Joint Commission on Accreditation of Healthcare Organizations,JCAHO Acute Myocardial Infarction, AMI Heart Failure, HF Pneumonia, PN Pregnancy and related conditions, PRincluding newborn and maternal care Surgical Infection Prevention, SIP ORYX The Center for Medicare and Medicaid Services, CMS Quality Initiative Acute Myocardial Infarction, AMI Heart Failure, HF Pneumonia, PN Surgical Infection Prevention, SIP CMS, 2005 Quam & Smith Quam & Smith, 2005 ORYX - 3 -

13 Institute for Healthcare Improvement IHI Breakthrough Series Model, Taiwan Quality Indicator Project, TQIP Taiwan Healthcare Indicator Series, THIS core measure - 4 -

14 structure process outcome Pay for performance Accountability - 5 -

15 TQIP 1985 Quality Indicator Project QIP 1992 QIP International Quality Indicator Project IQIP QIP QIP sponsor CPS 1999 Taiwan Quality Indicator Project - 6 -

16 TQIP QIP QIP QIP QIP - 7 -

17 Hospital level QIP QIP QIP QIP - 8 -

18 50% Santell, 1994 McDonald et al, 2001; Chang et al,

19 TQIP

20 TQIP TQIP TQIP TQIP 94 1 TQIP CPS

21 CPS Conformance Assessment Surveys TQIP 1a. 2b A1. CPS 2005 Data Recheck :1 Not Exclusive 72,

22 48, Summation 8.2a,8.2b 3 Cross Check Child Measures IQIP 5 Parent Child Measure IQIP 爲 A B C D E

23 94 爲

24 TQIP ~ TQIP TQIP TQIP

25 - 16 -

26 2a 2b 2005 TQIP 2b CPS

27 Institute for Healthcare Improvement IHI Breakthrough Series Model 5 7~9 Institute for Healthcare Improvement IHI Breakthrough Series Model IHI IHI Breakthrough Series Model Breakthrough Series Model

28 7 3 charter change package 7 17 TQIP TQIP pre-work Learning Session ~9 6 charter

29 change package TQIP TQIP

30 TQIP Pay for Performance

31 completeness irrelevant missing conformity Bemmel,

32 Zosia Kmietowicz, 2004 : Bemmel, 2002 TQIP Institute for Healthcare Improvement IHI

33 IHI : 爲 Hick TA, 2003 Zosia Kmietowicz, 2004 Shaw, 1995 TQIP CPS CPS

34 Conformance Assessment Surveys, CAS Center for Medicare and Medicaid Services CMS JCAHO CMS CMS CDAC Clinical Data Abstraction Center

35 CDAC 80% CMS APU Medicare Medicare GAO Government Accountability Office 爲 CMS APU Annual Payment Update GAO CMS GAO CMS GAO on-site visit TQIP AC 1a

36 AC 2b. AC 9. AC 13. AC A1. A BCDE Data Recheck a CDC TQIP 48 blood culture+ tip

37 culture+ ICU 2b Progress note Progress note,

38 ~3 TQIP CAS A DOA 2~3

39 DOA not-exclusive ER CAS 11 10~ TQIP 1. Q&A

40 CAS 7. Double Check : 3. Double Check Leader 4. A. B

41 2. access excel 3. Conformance Assessment Surveys, CAS on site visiting Double Check

42 excel 2. TQIP Breakthrough Series Model BTS

43 Breakthrough Series Model Breakthrough Series Model Breakthrough Series Model 12~15 Collaborative Charter Director Improvement Advisor, IA Coordinator Learning Session PDSA Plan-Do-Study-Act Do

44 Study Act 93 5, % % :

45 TQIP 58 70% % % % % % % % % % % % % % TQIP

46 24 TQIP % TQIP

47 % 24 60% % 24 80% 7 3 charter change package TQIP TQIP 3 :

48 9 5 爲 F J

49 guideline Cefazolin aminoglycoside 3 OR OR protocol ~ beta lactam antibiotics 1-2gm cephalosporins

50 3 / / TQIP 2b.3b 1 2b.3d

51 2b.5b 1 2b.5d 24 2a a a a a a a a

52 2. 1 TQIP 2b.3 2b.3a 30 2b.3c 2 2b.5 2b.5a 30 2b.5c / / 5 6 IHI BTS ~ 1.5 BTS change package

53 F G 0.5 IHI F~J : 1 F G H I J % % % 100% 24 90% 100% % 100% 94 90% % % %

54 H I J % % % % % % 90 98% ( % 100% ) 90 15% % 90 21% 90% % 90% Breakthrough Series Model PDSA F Cefazolin

55 >4 re-dosing G Cefazolin 24 H TKR IV Push ATH IV Push

56 3 1000ml : 24 I J

57 Cefazolin % 95.2% TQIP 1 88% % 60 TQIP 50% % % % 5 <= % % %

58 % TQIP 88% 75 60% TQIP:50% % 100% % 97.9% TQIP % %

59 5 <= % % % % 2006 TQIP 77% 80 80% 2006 TQIP 78%

60 3 1.5% F 0/19 0% 0/38 0% G H 0/13 0% 0/10 0% I 1/41 2.4% 2/ % J 0/49 0% 1/17 5.9% 1/ / % 70.6% 1,

61 9.3% 5 2.3% 124, , % % 48,082 42, BTS 5 35 TQIP TQIP 40 98%

62 re-dose TKR 7 72 CGMP TKR

63 1 BTS F G H I 2.0~ J change package BTS 5 change package BTS

64 5 change package BTS change package ex:

65 change package guideline Cefazolin aminoglycoside OR OR protocol ~ beta lactam antibiotics gm cephalosporins / / sticker

66 TQIP b.3 2 2b.3a b.3c b.5 5 2b.5a b.5c

67 1990 Pay For Performance P4P P4P P4P P4P P4P P4P P4P measures RAND P4P P4P 50 million CMS P4P Project Hospital Quality Incentive Demonstration

68 272 CMS 50% JCAHO Pay-for-Performance

69 爲 P4P MPAC JCAHO AAFP p4p CMS P4P 9 : 1P4P

70 3 4 information technology Positive incentives CMS P4P CMS P4P P4P P4P

71 P4P RAND 20 P4P Programs 6 CMS PGP P4P demonstration Medical Group : P4P P4P

72 p4p measure RAND P4P P4P Steven Asch, 2006 evidence-base impact

74 Pay for Quality or Pay for Performance

75 B C TQIP P4P P4P P4P P4P P4P CMS 2006 PVRP Physician

76 Voluntary Reporting Program Aspirin at arrival for AMI 2. Beta blocker at time of arrival for AMI 3. Hemoglobin A1c control in patient with Type I or II diabetes, age Low-density lipoprotein control in patient with Type I or II diabetes age High blood pressure control in patient with Type I or II diabetes, age Angiotensin-converting enzyme inhibitor or angiotensin-receptor blocker therapy for left ventricular systolic dysfunction 7. Beta-blocker therapy for patients with prior myocardial infarction 8. Assessment of elderly patients for falls 9. Dialysis dose in end stage renal disease patients 10. Hemocrit level in end stage renal disease patients 11. Receipt of autogenous aterovenous fistula in end-stage renal disease patient requiring hemodialysis 12. Antidepressant medication during acute phase for patient diagnosed with new episode of major depression 13. Antibiotic prophylaxis in surgical patient 14. Thromboembolism prophylaxis in surgical patient 15. Use of internal mammary artery in CABG 16. Pre-operative beta blocker for patient with isolated CABG TQIP TQIP web-site

77 TQIP P4P TQIP p4p risk adjustment procedure /disease

78 TQIP TQIP : 爲

79 100%

80 % 95.2% % % 100% % 97.9% % 87.% 15% % % 80% 1 80% 25%

81 % % 3 0.8% 14.3% %

82 32 72 BTS 2006 TQIP 5 24 TQIP TQIP

83 24 change package BTS spread change package 4 Breakthrough Series Model

84 6 1 p4p P4P TQIP p4p TQIP TQIP p4p 1 risk adjustment

86 TQIP TQIP TQIP :

87 ; 4 2 : ,, -, 1. Alicia J. et al., 1999, Guideline for Prevention of Surgical Site Infection, Infection Control and Hospital Epidemiology, Vol.20, NO.4, pp Anonymous, 2001, Antimicrobial prophylaxis in surgery, Med Lett Drugs Ther, Vol.43, NO , pp Anonymous., 1998, Antibiotic prophylaxis in surgery: summary of a Swedish-Norweugan Consensus Conference, Scandinavian Journal of Infections Diseases, Vol.30, NO.6, pp Antimicrobial Prophylaxis in Surgery. 1999;1060: Arah, O. A., Klazinga, N. S., Delnoij, D. M. J., Ten Asbroek, A. H. A. and Custers T. 2003, Conceptual Frameworks for Health Systems Performance: a Quest for Effectiveness, Quality, and

88 Improvement International Journal for Quality in 6. Barclay, L Pay-for-performance may not improve quality, Medscape Medical News 7. Canadian Council on Health Services Accreditation, 2003, A guide to the development and use of performance indicators. Ottawa: Canadian Council on Health Services Accreditation:1996, Available at 8. Centers for Medicare & Medicaid Services CMS, 2005, Hospital Quality Initiative Overview Accessed from /9/25 9. Classen D.C., Evans R.S., Pestotnik S.L., Horn S.D., Menlove R.L., and Burke J.P., 1992, The timing of prophylactic administration of antibiotics and the risk of surgical wound infection, N Engl J Med, Vol.326, pp Dale W., Bratzler D.O., 2005, Use of Antimicrobial Prophylaxis for Major Surgery-Baseline Results From the National Surgical Infection Prevention Project, ARCH SURG, Vol.140, pp Dellinger E.P., Gross P.A., Barrett T.L., et al., 1994, Quality standard for antimicrobial prophylaxis in surgical procedures, Cli Infect Dis, Vol.18, pp Donabedian A., 1995, The Quality of Care: How Can It Be Assessed?. Quality in Health Care, Theory, Application and Evaluation, In Graham No. eds, Maryland, An aspen Publication, pp Epstein A.M., 1995, Chapter 11: The Outcomes Movements: Will It Get Us Where We Want To Go?, Quality in Health Care, Theory,

89 Application and Evaluation, pp Erbault M. et al., 2003, Promoting quality improvement in French healthcare organizations: design and impact of a compendium of models and tools, Qual Safe Health Care, Vol.12, pp Fargher N., Morse and Dale, 1998, Quality Cost: Planning the Trade-off between prevention and appraisal activities, Journal of Cost Management, Vol.12, NO.1, pp Finkler S.A., 1996, Measuring costs of quality, Hosp Cost Manag Account, Vol.7, pp Francois P. et al., 2003 Evaluating implementation of quality management systems in a teaching hospital s clinical department, International Journal for Quality in Health Care, Vol.15, NO.1, pp Future Goals and Objectives 2005, Measure Expansion and Data, Accessed from +and+objectives.htm/ 2005/12/7 19. Glezerman M. et al., 1999, A model of efficient and continuous quality improvement in a clinical setting, International Journal for Quality in Health Care, Vol.11, NO.3, pp Guideline for Prevention of Surgical Site Infection, Hospital Infections Program, National Center for Infectious Diseases, U.S. Department of Health and Human Services. Centers for Disease Control and Prevention, U.S. Public Health Service/Infection Control and Hospital Epidemiology. 1999;20: Gyssens IC. Preventing postoperative infections: current treatment recommendations. Drugs 1999;57: Review. Welch L, Teague

90 AC, Knight BA, et al. A quality management approach to optimizing delivery and administration of preoperative antibiotics. Clin Perform Qual Health Care 1998;6: Osmon DR. Antimicrobial prophylaxis in adults. Mayo Clin Proc. 2000;75: Hanssen AD, Osmon DR. The use of prophylactic antimicrobial agents during and after hip arthroplasty. Clin Orthop. 1999: Harvey G., Wensing M., 2003, Methods for evaluation of small scale quality improvement projects, Qual safe health care, Vol.12, pp Hick TA Improving physician documentation through a clinical documentation management program. Nursing Administration Quarterly 27 4 : Hofer T.P., Bernstein S.J., Hayward R.A., DeMonner S., 1997, Validating quality indicators for hospital care, Jt Comm J Qual Improv, Vol.23, NO.9, pp /12/7 27. Improve Antiretroviral ARV Management for HIV-Infected Patients: Ensure Accurate, Complete, and Updated Documentation in the Medical Record s/individualchanges/ensureaccuratecompleteandupdateddocument ationinthemedicalrecord.htm 28. Institute for Healthcare Improvement IHI The Breakthrough Series Institute for Healthcare Improvement IHI, 2003, The Breakthrogh

91 Series, Accessed from /12/ Institute of Medicine 1994, America's Health in Transition: Protecting and Improving the Quality of Health and Health Care.Accessed from ocument 2005/9/ J.van Bemmel Editor, M.A. Musen Editor, Mark A. Musen. Handbook of Medical Informatics Jarlier A. and Charvet-protat S., 2000, Can improving quality decrease hospital costs?, International Journal for Quality in Health Care, Vol.12, NO.2, pp JCAHO Principles for the Construct of Pay-for-Performance Programs Kazandjian V.A. et al, 2003, Are performance indicators generic? The international experience of the Quality Indicator Project, Journal of Evaluation in Clinical Practice, Vol.9, NO.2, pp Kazandjian V.A. et al, 2005, Understanding safer practices in health care: a prologue for the role of indicators, Journal of Evaluation in Clinical Practice, Vol.11, NO.2, pp Lonner JH, Barrack R, Fitzgerald RH, et al. Infection in total knee arthroplasty: part I. Classification, prophylaxis, and diagnosis. Am J Orthop. 1999;28: Martin CA Improving the quality of medical record documentation. Journal for Healthcare Quality :

92 38. McConkey SJ, L Ecuyer PB, Murphy DM, et al. Results of a comprehensive infection control program for reducing surgical-site infection in coronary artery bypass surgery. Infect Control Hosp Epidemiol. 1999;20: McDonald LC, Yu HT, Yin HC, et al Use and abuse of surgical antibiotic prophylaxis in hospitals in Taiwan. J Formos Med Assoc;100: Nichols, RL. Surgical antibiotic prophylaxis. Med Clin North Am. 1995:79: Quam, L. and Smith, R. 2005, What can the UK and US health systems learn from each other? BMJ 330: Santell JP. Projecting future drug expenditures 1994, Am J Hosp Pharm ; 51: Silver A, Eichorn A, Kral J, et al. Timeliness and use of antibiotic prophylaxis in selected inpatient surgical procedures. Am J Surg. 1996;171: Specification Manual for National Hospital Quality Measures 2005, Introduction and Background, Accessed from /12/7 45. Specification Manual for National Hospital Quality Measures 2005, National Hospital Quality Measure Verification Process, Accessed from /12/7 46. Steven Asch, Measures for Pay for Performance: Lessons from the US, International Hospital Federation Asian Pacific Regional Conference,

93 47. Talon D., et al., 2001 Evaluation of Current pratices in surgical antimicrobial prophylaxis before and after implementation of local guidelines, J Hosp Infect, Vol. 49, pp United States Government Accountability Office, Report to the Committee of Finance, US, Senate, CMS need more rigorous methods to ensure reliability of publicly released data, January Vaisbrud V, Raveh D, Schlesmger Y, et al. Surveillance of antimicrobial prophylaxis for surgical procedures. Infect Control Hosp Epidemiol. 1999;20: Woods R.K., Dellinger E.P., 2004, Current guidelines for antibiotic prophylaxis of surgical wounds. Available at: cle.jhtml?term=.accessed February Zosia Kmietowicz, Data collection is poor because staff don't see the point, BMJ,

94 TQIP TQIP 湶

95 TQIP 1 Chair 2 Director 3 Improvement Advisor

96 : : TQIP 1a. : ( ) : 1. (raw data)? ( ) 2. (raw data)? 3.? ( excel word ) ( ) 4. excel word ( ) ( ) 5.? Yes No Yes,? ( ) No,? 6. (SOP)? Yes No ( ) 7. : 8. ( ) ICU ( ) : 1. double check? Yes No (, ( ) ) 2. double check? 3. double check? 4. double check? / chart review ( ) 5.?

97 TQIP ( )IQIP : 1. IQIP? 2. IQIP?? 3.? Yes No 4. 1a.1~1a.5? Yes No ( )Data recheck: data recheck? data recheck ( ) : 1.? TQIP double check chart review ( ) 2.? CAS ( ) 3.CAS?. ( ) ( )

98 : : TQIP 2b. : ( ) : 1. (raw data)? ( ) 2. (raw data)? 3.? ( excel word ) ( ) 4. excel word ( ) ( ) 5.? Yes No Yes,? ( ) No,? 6. (1)? Yes No( No 7 ) (2)?? ( ) 7. (SOP)? Yes No ( ) 8. : 9. ( ) ( ) : 1. double check? Yes No (, ( ) ) 2. double check? 3. double check? 4. double check? / chart review ( ) 5.?

99 TQIP ( )IQIP : 1. IQIP? ( ) 2. IQIP?? 3.? Yes No 4. 2b.1~2b.6 a, b, c, d,? Yes No ( )Data recheck: data recheck? ( ) : 1.? TQIP,, double check chart review, ( ) 2.? CAS ( ) 3.CAS?. ( ) ( )

100 TQIP : : 9. : ( ) : 1. (raw data)? ( ) 2. (raw data)? 3.? ( excel word ) ( ) 4. excel word ( ) ( ) 5.? Yes No Yes,? ( ) No,? ( ) 6. (1)? Yes No( No 7 ) (2)?? ( ) 7. (SOP)? Yes No ( ) 8. : 9. ( ) ICU ( ) : 1. double check? Yes No (, ( ) ) 2. double check? 3. double check? 4. double check?

101 TQIP / chart review ( ) 5.? ( )IQIP : 1. IQIP? ( ) 2. IQIP?? 3.? Yes No 4. : a, b, c, d,? Yes No ( )Data recheck: data recheck? ( ) : 1. (SOP)? Yes No ( ) 2. :, coordinator, coordinator,, coordinator ( _) 3.? TQIP,, double check chart review, ( ) 4.? CAS ( _). ( ) ( )

102 TQIP : : 13. : ( ) : 1. (raw data)? ( : ) 2. (raw data)? 3.? ( excel word ) ( ) 4. excel word ( : ) ( ) 5.? Yes No Yes,? ( ) No,? ( ) 6. (1) ( )? Yes No( No 7 ) (2)?? ( ) 7. (SOP)? Yes No ( ) 8. : 9. ( ) ( ) : 1. double check? Yes No (, ( ) ) 2. double check? 3. double check? 4. double check? / chart review ( )

103 TQIP 5.? ( )IQIP : 1. IQIP? ( : ) 2. IQIP?? 3.? Yes No ~13.2 a, b, c, d,? Yes No ( )Data recheck: data recheck? ( ) : 1.? TQIP,, double check chart review, ( ) 2.? CAS ( ) 3.CAS?. ( ) ( )

104 TQIP : : A1. : ( ) : 1. (raw data)? ( ) 2. (raw data)? 3.? ( excel word ) ( ) 4. excel word ( : ) ( ) 5.? Yes No Yes,? ( : ) No,? 6. (1)? Yes No( No 7 ) (2)?? ( : ) 7. (SOP)? Yes No ( ) 8. : 9. ( ) ( ) : 1. double check? Yes No (, ( ) ) 2. double check? 3. double check? 4. double check? /

105 TQIP chart review ( ) 5.? ( )IQIP : 1. IQIP? ( : ) 2. IQIP? 3.? Yes No 4. A1.1~A1.6 a, b? Yes No ( )Data recheck: data recheck? ( ) : 1.? TQIP,, double check chart review, ( : ) 2.? CAS ( : ). ( ) ( )

106 TQIP ( ) 1a 5 ( ) 2b 5 ( ) 9 5 ( ) 13 5 ( ) A

107 TQIP 1a ICU (Progress Note) & & & ( ) 4. 5.? b (Progress Note) & & 1. & & ( )???? 2.? & & 3.? ~ Days

108 9 TQIP ( ) (Progress Note) & & 1. & 2. ICU 3. ICU 4. ICU 5. ICU? 6. ICU ICU??? ?? (Progress Note) & &

109 A1 TQIP & 1. ER ER ER 2. ER ER ER ? or 6 ER 24hrs 48hrs 72hrs

110 TQIP IHI Institute for Healthcare Improvement Breakthrough Model

111 IHI Breakthrough Series IHI Breakthrough Series Breakthrough series college Service Packet

112 (Taiwan Quality Indicator Project, TQIP) 95 Breakthrough Series Model

113

114

115 IHI Breakthrough Series (6 to 18 months time frame) Select Topic (develop mission) Expert Meeting Develop Framework & Changes Planning Group LS Learning Session AP Action Period Participants ( teams) Prework A P S D A LS 1 LS 2 LS 3 AP1 AP2 AP3* (listserv) Visits Assessments Monthly - Team Reports P S D Supports A P S Phone Conferences D Dissemination Publications, Congress. etc. Holding the Gains *AP3 continue reporting data as needed to document success

116

117

118 訉 storyboard

119

120

121 TQIP (Breakthrough Series) --- Charter (Taiwan Quality Indicator Project, TQIP) Breakthrough Series Model A

122 TQIP , % % : 24 ( ) 48 (95/6/1 ) TQIP 58 70% % % % % % % % % % % % % % TQIP 24 TQIP % 24 B

123 TQIP % 24 60% % 24 80% TQIP TQIP IQIP Breakthrough Model 1 Breakthrough Model charter

124 TQIP Pre-work Learning session 1 Learning session 2 Learning session : 3 Learning session

125 TQIP 120 2b.3a - 30 ( ~ ) (%) b.3b - 1 ( ~ ) (%) :

126 TQIP b.3d - 24 ( ~ ) (%) b.5a - 30 (2001.1~ ) (%)

127 TQIP 110 2b.5b - 1 (2003.1~ ) (%) : b.5d - 24 ( ~ ) (%)

128 TQIP a.13-0 ( ~ ) a.17-0 ( ~ ) (%) (%)

129 TQIP : 2b.3a 30 : 2005 ( 41, 80.57) : 2b.3b 1 : 2005 ( 31, 81.41)

130 TQIP : 2b.3d 24 : 2005 ( 39, 29.72) : 2b.5a 30 : 2005 ( 37, 80.17)

131 TQIP : 2b.5b 1 : 2005 ( 28, 90.59) : 2b.5d 24 : 2005 ( 37, 72.03)

132 TQIP (Breakthrough Series) --- change package ( ) 1. cefazolin 2. ( ) 60 fluoroquinolone vancomycin β-lactam vancomycin clindamycin Clostridium difficile Staphylococcus epidermidis 5. Methicillin (MRSA) MRSA MRSA vancomycin

133 TQIP 6. Cefazolin 1gm 80 2gm ( ) cefazolin cefuroxime ( ) 9. ( ) ( University of Michigan Hospitals and Health Centers Improvement of Surgical Prophylactic Antibiotic Timing ) ( Institute for Healthcare Improvement Use Prophylactic Antibiotics Appropriately ) 40~60% 25~50% Clostridium difficile 16% ( )

134 TQIP guideline Cefazolin ( aminoglycoside ) OR OR protocol 60 2~3 24 ( 4 ) beta lactam antibiotics 1-2gm cephalosporins / / ( ) ( sticker) 60 ( )

135 TQIP 2b.3b 2b.3d 2b.5b 2b.5d a a a a a a a a.20 3 * 0 * 1 * 2 * 3 * 0 * 1 * 2 *

136 = 0(1~3) = 0(1~3) : * * * * = = = =

137 = = = = TQIP 2b.3 2b.3a 2b.3c b.5 2b.5a 2b.5c 30 2 / /

138 TQIP (Breakthrough Series) --- (Breakthrough Series) ~1.5 9/8~9/9 10/20 12/

139 TQIP (Breakthrough Series) --- Overview of the BTS (from the Participant s Perspective) Prework Start with good senior leader support. Form a pilot team and develop an aim statement and focus for team's work. Begin useful data collection. Prepare story board for LS1. LS1 sotry board Get idea for improvement. Refine aim and measures. Develop plans for tests of Learning session changes for Action Period 1. Begin to collaborate. 1 Test changes and get feedback form results. Establish monthly reporting. Get Action Period 1 support form the Collaborative. More idea for change. Deeper understanding of testing and implementation. Learning session Overcoming barriers. More collaboration. 2 Test change in all areas of change package. Collaborate with colleagues. Action Period 2 "Become faculty". Begin discussing plans beyond pilot project. " Celebrate results. Plan for holding gains and spread. Get more ideas for change. Learning session Develop detailed plans for team's role in spread. 3 Continue testing and implementation of rest of change package. Monitor Action Period 3 measures to hold the gains made. Participate in spread

140 Project: PDSA TQIP PDSA : : Who: What: When: Where: ( ) ( & )? ( )

141 (Breakthrough Series) TQIP

142 TQIP 50% % " "

143 TQIP Identifying Leadership and Choosing Your Team (,, ) / ( ) / ( )

144 TQIP

145 TQIP

146 TQIP

147 TQIP

148 TQIP (Breakthrough Series)

149 TQIP (Breakthrough Series)

150 TQIP (Breakthrough Series)

151 TQIP

152 TQIP (Breakthrough Series)

153 TQIP A. (1-5) ( ) B. ( ) C. D. 1. a. b. c

154 TQIP

155 (Breakthrough Series) --- /

156 TQIP (IHI Tool) March 31, ( ) ??( )? /? /??

157 TQIP /? 2.!! (use sampling as part of the plan to collect the data) / 3. (who)? (what)? (when)? (where)?

158 TQIP (how)? ( ) vs

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$(Microsoft PowerPoint - 2_\302\345\300\370\253~\275\350\253\374\274\320\252\272\300\263\245\316_$handout$.ppt)$ 亞醫療品楊洲質漢大學指湶標的應用一二三評指實量標例必計參須畫考選實用施適步當驟指標作為工具大綱.. 一評量必須要有數據 You can not measure without comparison. Where am I? Why am I here? Where Do I Want to Be?