Enabling a learning healthcare system with automated computer protocols that produce replicable and personalized clinician actions

Clinical decision-making is based on knowledge, expertise, and authority, with clinicians approving almost every intervention—the starting point for delivery of “All the right care, but only the right care,” an unachieved healthcare quality improvement goal. Unaided clinicians suffer from human cognitive limitations and biases when decisions are based only on their training, expertise, and experience. Electronic health records (EHRs) could improve healthcare with robust decision-support tools that reduce unwarranted variation of clinician decisions and actions. Current EHRs, focused on results review, documentation, and accounting, are awkward, time-consuming, and contribute to clinician stress and burnout. Decision-support tools could reduce clinician burden and enable replicable clinician decisions and actions that personalize patient care. Most current clinical decision-support tools or aids lack detail and neither reduce burden nor enable replicable actions. Clinicians must provide subjective interpretation and missing logic, thus introducing personal biases and mindless, unwarranted, variation from evidence-based practice. Replicability occurs when different clinicians, with the same patient information and context, come to the same decision and action. We propose a feasible subset of therapeutic decision-support tools based on credible clinical outcome evidence: computer protocols leading to replicable clinician actions (eActions). eActions enable different clinicians to make consistent decisions and actions when faced with the same patient input data. eActions embrace good everyday decision-making informed by evidence, experience, EHR data, and individual patient status. eActions can reduce unwarranted variation, increase quality of clinical care and research, reduce EHR noise, and could enable a learning healthcare system.     

急诊科优质护理服务的实施及效果

目的探讨急诊科实施优质护理服务的方法与取得的成效。方法针对急诊科特点,开展优质护理服务,转变护理服务理念,改变工作模式和排班方式,加强护患沟通,优化急诊工作流程,开启急诊绿色通道,强化急救技能培训,改善硬件设施,实行弹性排班和责任制整体护理。结果患者的护理满意率、健康教育知晓率、就诊流程满意率、巡视病人满意率、治疗护理满意率、病室管理满意率及陪检率均比较高。结论在急诊科实施优质护理服务,有利于提高护理质量和患者对护理工作的满意度,同时可激发护士的最大潜能。     

Assuring the quality of health care for older persons. An expert panel's priorities

To select topics for quality assurance activities focusing on older patients, we convened a 14-member panel of physicians and experts in quality assurance. In two rounds of ratings, panelists rated 42 medical conditions (eg, pneumonia) in terms of their effects on patient outcomes, the availability of beneficial interventions, and the health benefits from improving current quality. They rated 27 health services (eg, adult day-care) on similar dimensions. The feasibility of doing quality assurance work on each condition and service also was rated. Using the ratings, the conditions selected for quality assurance work were congestive heart failure, hypertension, pneumonia, breast cancer, adverse effects of drugs, incontinence, and depression. Health care services selected were hospital discharge planning, acute inpatient care for the frail elderly, long-term-care facilities (intermediate-care facilities and skilled nursing facilities), home health care services, and case management.     

Health-related experimental learning for college undergraduates

Guided service experience commonly enriches medical education at the doctoral and postdoctoral levels but rarely has been offered to premedical students. Internships in health agencies were individually arranged for 198 self-selected college undergraduates in 101 different settings which emphasized the social, economic, and interpersonal factors in health care. Students served as nursing aides, clinical assistants, and health educators and in other nontechnical roles; each wrote an analytical report based upon a study plan and firsthand observations. The expectations of both students and host institutions were usually exceeded. Benefits included help in career decisions, exercise in self-directed learning, and demonstration of noncognitive qualities desired in professional work. The authors conclude that undergraduate students are competent to deal with sensitive ethical and social issues in patient care and to provide needed health services of high quality.     

云南省社区老年人居家护理需求现状调查研究

目的调查分析云南省社区老年人居家护理的需求现状,为开展社区老年人居家护理服务和制定内容规划提供依据．方法编制社区老年人居家护理需求问卷调查表,通过调查人员对105名老年人的健康功能状况、生活状况、居家护理服务需求进行走访调查．结果76．20％的社区老年人有居家护理服务需求,其中社区老年人对于Et常医疗护理需求最高．结论开展社区老年人居家护理服务能够有效加强老年人自我保健意识,提高老年人生存质量,对实现老年人健康养老有着重要的意义．     

英国卫生服务购买经验及启示

战略性购买是我国提高医保资金利用效率的关键举措。英国卫生筹资制度虽然不是社会医疗保险模式，但其卫生服务购买组织--临床委托服务组织（CCGs）为我国实施战略性购买提供了一些有益的经验。推行初级卫生保健是实现“人人享有卫生保健”的关键和基本途径。全科医生加入并领导CCGs使得采购组织能够直接了解患者需求，而且有能力跟卫生服务提供方对话，这是实施战略性购买的基本前提。另外，CCGs是自下而上由全科诊所自发形成的，有不同的规模和治理结构，完全基于各地的实际需要并有助于满足群众的需要，有利于确保服务质量的持续改进、减少不公平、保障选择权和患者参与，并促进整合型卫生服务的提供，减少住院服务利用，提高资金利用效率。     

优质护理服务持续进步 探索其长效工作机制

优质护理服务活动是推进公立医院改革、落实国家医改目标,保障和改善民生的重要举措。其内涵重在改革护理工作模式、实行责任制整体护理、全面提升护理服务水平。经过一年多的实践,这项工作取得了较好的成效,得到广大患者的拥护和称赞。为巩固优质护理服务取得的成果,并使其持续进步,最终让百姓得到更多的医疗实惠,让社会和政府满意、医护人员受鼓舞,不断探索其长效工作机制务实且必要。2011年,医院着重从5个方面进行工作：跟进制度建设、改进管理机制、拓宽职业发展平台、完善护理培训体系、建设和谐的工作氛围,使这项工作不断发展。     

Clinical data sharing improves quality measurement and patient safety

ObjectiveAccurate and robust quality measurement is critical to the future of value-based care. Having incomplete information when calculating quality measures can cause inaccuracies in reported patient outcomes. This research examines how quality calculations vary when using data from an individual electronic health record (EHR) and longitudinal data from a health information exchange (HIE) operating as a multisource registry for quality measurement. Materials and MethodsData were sampled from 53 healthcare organizations in 2018. Organizations represented both ambulatory care practices and health systems participating in the state of Kansas HIE. Fourteen ambulatory quality measures for 5300 patients were calculated using the data from an individual EHR source and contrasted to calculations when HIE data were added to locally recorded data.ResultsA total of 79% of patients received care at more than 1 facility during the 2018 calendar year. A total of 12 994 applicable quality measure calculations were compared using data from the originating organization vs longitudinal data from the HIE. A total of 15% of all quality measure calculations changed (P < .001) when including HIE data sources, affecting 19% of patients. Changes in quality measure calculations were observed across measures and organizations.DiscussionThese results demonstrate that quality measures calculated using single-site EHR data may be limited by incomplete information. Effective data sharing significantly changes quality calculations, which affect healthcare payments, patient safety, and care quality.ConclusionsFederal, state, and commercial programs that use quality measurement as part of reimbursement could promote more accurate and representative quality measurement through methods that increase clinical data sharing.     

Digital health needs for implementing high-quality primary care: recommendations from the National Academies of Sciences,Engineering, and Medicine

A National Academies of Sciences, Engineering, and Medicine committee developed a plan to implement high-quality primary care. One of the 5 key objectives was designing information technology that serves the patient, family, and interprofessional care team. The committee defined high-quality primary care as the provision of whole person, integrated, accessible, and equitable healthcare by interprofessional teams who are accountable for addressing most of an individual’s health across settings and through sustained relationships. The committee recommended 2 essential actions for digital health. The first action is developing the next phase of digital health certification standards that support relationship-based, continuous, person-centered care; simplify user experience; ensure equitable access; and hold vendors accountable. Second, the committee recommended adopting a comprehensive aggregate patient data system usable by any certified digital health tool. This article reviews primary care’s digital health needs and describes successful digital health for primary care.     

优质护理服务在精神科病房应用的效果评价

目的:探讨优质护理服务在精神科病房的应用以及实施优质护理服务对护理效果的影响。方法:选取我科一个优质护理服务示范病区为实验组,一个普通病区为对照组。2011年1～9月,实验组应用新制定的服务标准,并改变护理模式;对照组采用传统服务标准及护理模式对患者实施护理。结果:对两组患者住院期间的满意度调查评价指标进行对比,差异有统计学意义(P<0.01或P<0.05)。结论:实施优质护理服务是提高患者满意度和赢得医疗市场的重要保证,也是以人为本、以患者为中心,消除疾病痛苦,恢复患者身心健康,满足患者需要的新的服务理念。患者满意度提高,护患关系和谐,护理质量明显提高。     

人工智能在国内外老年护理领域发展情况对比分析及启示

目的/意义分析人工智能在国内外老年护理领域的发展情况,提出完善人工智能在我国老年护理领域发展的启示和建议。方法/过程从政策保障、基础数据建设、技术发展、产品设计、人才培养5方面对比分析人工智能在国内外老年护理领域发展情况。结果/结论聚焦短板弱项加强制度体系建设、改进人工智能算法实现产品功能从供给侧转向需求侧、推动健康医疗数据结构化建设以加快数据共享、注重护理信息学人才培养与推动产学研结合等系列对策建议,将有助于推动人工智能在我国老年护理领域发展。     

层级护理管理模式在现代医院中应用的效果评价

目的评价层级护理管理模式的应用效果。方法将内科护理人员按照学历、职称、工作年限三个层次组成护理小组,规定不同工作职责并进行业务培训。比较分层级管理前、后的服务热情主动度、护士技术能力、关爱与沟通能力、病情管理能力、健康教育效果。结果干预前、干预后的服务热情主动度、护士技术能力、关爱与沟通能力、病情管理能力、健康教育效果及总体评价评分比较,差异均有统计学意义（t分别为3.55、4.07、4.76、4.39、3.99、5.02,P均〈0.05）。结论实施层级护理可有效提高护理质量,提高患者满意度,并能提高护理人员的综合素质,值得临床推广应用。     

心理科护理推行ISO9000质量管理体系的体会

目的：介绍在心理科护理中推行ISO9000质量管理体系的体会。方法：制定心理科护理质量标准和评分细则，进行综合性考核，建立、健全心理科住院患者组织管理制度，落实健康教育责任制，合理调配护理人力资源，对影响护理质量的关键环节进行控制。结果：体系运行后，护理质量明显提高，各项护理服务质量考核成绩名列医院前茅，患者综合满意度为98％，个性化亲情护理服务为99％，护患纠纷与上年度相比下降了10％。结论：此项活动既规范了护理服务质量管理，又增加了患者的满意度，提高了科室的经济效益和社会效益，实现了心理科护弹服务质量的自我完善和持续改讲。     

基于供方的医养结合养老服务现状与问题的质性研究

背景　人口老龄化已成为我国面临的重大挑战之一,加之目前老年人口疾病负担加重,现代家庭养老能力弱化,养老机构供需不平衡,在目前的养老现状下,建立医养结合养老服务已成为大势所趋。目的　了解社区卫生服务中心医养结合养老服务的供应现状和开展过程中存在的问题,为更好地开展养老服务提供可行性意见。方法　2019年9-11月从朝阳区40家社区卫生服务中心各选择1名管理人员或从事医养结合养老服务工作的人员开展个人访谈,访谈内容包括访谈对象的基本信息、社区卫生服务中心人员及设备情况、访谈对象对医养结合养老服务的认知、社区卫生服务中心医养结合养老服务的开展情况及面临的问题4个部分,运用Colaizzi现象学资料七步分析法对访谈资料进行分析。结果　本研究总共回收39份有效访谈内容,回收有效率达97.5%。共提炼出七大主题：护理人员数量不能满足需求;接受过老年医学培训的医护比例较低,各中心之间差异较大;社区卫生服务中心之间康复设施发展建设不平衡;管理人员医养结合养老服务认知不统一;医养结合项目中,养老服务开展比例偏低;医养结合养老服务存在多头管理的现象;人员数量、执业、政策、资金等方面的风险较为突出。结论　健全人才培养模式和激励措施、健全相关政策及法律法规、完善长期护理保险制度试点、引导多元资金注入、丰富医养结合养老服务项目,推进社区卫生服务中心开展更高质量的医养结合养老服务。     

基于医院信息集成平台的临床护理路径系统研究

临床护理路径是一个预计的、对每日护理服务计划的说明,是多专业人员共同合作来控制品质和费用的一种临床服务模式.在临床护理路径系统的需求分析、系统设计及功能实现等方面作了深入探讨,通过医院信息集成平台和其他相关信息技术实现了可扩展的临床护理路径系统.研究表明,临床护理路径系统的建立是顺应医疗发展的必然趋势,也是全面提高护理质量的有效方法.     

责任制护理小组模式在肿瘤外科中的实践与效果

目的探讨病区责任制护理小组模式,以提高肿瘤外科护理质量。方法回顾性分析传统管理护理模式200例患者和采用责任制护理小组200例患者的护理资料。病区护士根据各自的职称由责任制护理小组分为5个小组,责任组长每组设立1名、责任护士4名,责任组长由临床经验丰富和专业知识强的主管护师承担。小组负责治疗护理工作和全部健康教育。结果实施责任制护理小组后,与传统管理模式下比较,责任制护理小组模式下患者呼叫后护士到位时间明显缩短、输液呼叫铃声次数明显减少,差异有统计学意义（P〈0.05）;责任制护理小组模式下患者的护理满意率（96%）和对疾病知识知晓率（95%）高于传统管理模式的护理满意率（81%）和对疾病知识知晓率（86%）,差异有统计学意义（P〈0.05）。结论责任制护理小组管理模式体现了人性化护理的理念,提高了护士的工作效率,提升了护理质量。     

全科医生开展性健康服务的优势及模式研究

性健康是人类健康的重要组成部分，忽视或误解性健康及错误的性健康观念会极大地影响人们的生活质量。全科医学的整体观和生物-心理-社会医学模式、以家庭为单位的原则、保护患者隐私的特点，使全科医生在开展性健康服务方面具有明显优势，而我国基层医疗卫生机构在性卫生保健知识普及、性健康问题筛查、诊治方面还有待加强。为此，香港大学深圳医院全科医学科从全科核心理念出发，通过组建性健康服务专业小组、开展性史问诊及性器官查体技能工作坊、制定诊治工作流程等方式率先开展性健康服务，探索新的服务模式，希望为国内全科医生开展性健康服务提供一些参考。     

浅谈优质护理服务在老年患者中的护理体会

目的:浅谈优质护理服务在老年患者中的实施方法和体会。方法:选取本科2010年6月-2011年8月收治的189例老年住院患者作为对照组,2011年10月-2012年12月收治的189例老年住院患者作为观察组,对照组给予常规护理服务,观察组给予优质护理服务,记录两组结果并进行对比分析。结果:观察组实施优质护理服务后与对照组相比较,住院时间明显缩短,住院费用明显降低,并发症发生率明显减少,基础护理合格率、健康教育知晓率、患者满意度显著提高,比较差异均有统计学意义(P0.05)。结论:根据老年人不同的生理、心理以及疾病特点对老年患者实施优质护理服务,提高了护理人员的自身素质和服务水平,提高了患者满意度,有利于疾病的治疗和康复。     

公立医院护理工作改革的思考

论述了＂优质护理服务示范工程＂引深的护理工作改革的重要意义,总结了开展优质护理服务示范工程取得的患者、家属、护士、医生、医院管理者和社会、政府满意的成效,分析了开展优质护理示范工程中引发的思考和需要探讨的问题,指出应逐步建立起适合我国国情、以患者为中心的责任制整体护理模式。