持续质量改进在医院感染管理中的应用

目的应用持续质量改进(CQI)的管理理念,探索CQI在医院感染管理中的应用,提高医院感染管理质量。方法将不同层次、不同知识结构的管理者和员工组成若干个医院感染管理CQI项目组;各项目组根据各自的标准、规范进行动态的评估,不断寻求医疗活动中的不良因素,及时发现隐患,确定项目名称、目标、具体实施方案并落实执行,以达到医院感染管理的持续质量改进。结果通过医院感染管理CQI小组的持续监测,不断发现和解决问题,使医院感染质量控制达到一个较好的水平。结论实施医院感染CQI管理,各级管理者在医疗活动中能主动寻找安全隐患并予以解决,强化了各级管理者的质量管理意识和医务人员的参与意识;实施过程管理、环节管理的全方位、全过程管理,使质量标准落实到各级医院感染管理工作中,有效控制了薄弱环节,医院感染质量明显提高。     

Hospital responses to a data-driven statewide quality improvement project

BACKGROUND: The overall success of any continuous quality improvement (CQI) project lies in the ability to measure changes resulting from the project and to show that changes have resulted n improved care. METHOD: A software tool was developed to categorize hospital responses and activities implemented by hospitals as a result of the Cooperative Cardiovascular Project CCP). Information was captured regarding the hospital's acceptance of data and the educational/interventional strategies implemented. Hospital size, number of acute myocardial infarction patients treated, indicator performances, and type of presentation given (on-site versus regional visit) was entered to allow analysis of factors affecting the response. RESULT: sixty-one of 107 hospitals responded to the peer review organization. Of those, 49% planned further educational activities and 75% planned to implement some form of CQI activity. Comparison of responses in relation to the type of presentation received suggested that on-site presentations are associated with higher response rates and more intense quality improvement efforts. This also could be attributed to other factors such as hospital size, teaching environment, or number of acute myocardial infarction patients treated. CONCLUSION: The system developed allowed us to collate hospital improvement efforts as a result of CCP. The system is limited in its ability to identify those activities taking place before CCP. Further development and refinement of the tool is warranted to document quality improvement efforts and determine best strategies for peer review organization intervention.     

The search for value: a quality improvement cycle linking process, outcomes, and patient satisfaction

American industry has been implementing continuous quality improvement (CQI) for several years. The business community and accrediting organizations are applying pressure to health care organizations to implement CQI to assure the delivery of cost-effective, quality health care services. In their rush to embrace the demands of industry, health care organizations must realize that many within their ranks long ago adopted the philosophy of CQI without calling it by name. The key is to adapt the concepts of CQI to existing quality improvement efforts rather than simply following a new recipe. By looking primarily at hospital systems like administration and finance, health care organizations may not be significantly addressing the clinical system. Consumers, however, want patient care to be addressed immediately. The author reflects on his experience that process improvement, not personnel change, is the key to successes in health care management.     

Incorporation of continuous quality improvement in a hospital dietary department's quality management program

What techniques or steps are necessary to overcome obstacles and achieve the incorporation of continuous quality improvement (CQI) methods in existing quality management programs? Education of staff, identification of customers' expectations, and implementation of a plan to administer activities are critical to a positive outcome of CQI efforts. Our article outlines one approach to the transition from quality assurance to CQI using the FOCUS-PDCA® technique. We use the example of improving the timeliness of late tray deliveries to demonstrate how to implement the conversion to CQI using the FOCUS-PDCA® technique. The dietetics practitioners may apply the sequential steps described in the article to successfully incorporate the CQI concept in most hospital dietary department's quality management activities.     

Promoting clinical involvement in hospital quality improvement efforts: the effects of top management, board, and physician leadership.

STUDY QUESTION: An examination of the effects of top management, board, and physician leadership for quality on the extent of clinical involvement in hospital CQI/TQM efforts. DATA SOURCES: A sample of 2,193 acute care community hospitals, created by merging data from a 1989 national survey on hospital governance and a 1993 national survey on hospital quality improvement efforts. STUDY DESIGN: Hypotheses were tested using Heckman's two-stage modeling approach. Four dimensions of clinical involvement in CQI/TQM were examined: physician participation in formal QI training, physician participation in QI teams, clinical departments with formally organized QA/QI project teams, and clinical conditions and procedures for which quality of care data are used by formally organized QA/QI project teams. Leadership measures included CEO involvement in CQI/TQM, board quality monitoring, board activity in quality improvement, active-staff physician involvement in governance, and physician-at-large involvement in governance. Relevant control variables were included in the analysis. PRINCIPAL FINDINGS: Measures of top management leadership for quality and board leadership for quality showed significant, positive relationships with measures of clinical involvement in CQI/TQM. Active-staff physician involvement in governance showed positive, significant relationships with clinical involvement measures, while physician-at-large involvement in governance showed significant, negative relationships. CONCLUSIONS: Study results suggest that leadership from the top promotes clinical involvement in CQI/TQM. Further, results indicate that leadership for quality in healthcare settings may issue from several sources, including managers, boards, and physician leaders.     

Can quality circles improve hospital-acquired infection control?

It is a fundamental principle of continuous quality improvement (CQI) that processes should be the objects of quality improvement. The objective of this study was to improve process quality concerning the prevention of hospital-acquired infections in surgical departments and intensive care units by a continuous quality improvement (CQI) approach based mainly on quality circles. This approach was evaluated in a prospective controlled intervention study in medium-size acute care hospitals (four intervention and four control hospitals). During two intervention periods (each 10 months) four external physicians with training in hospital epidemiology and infection control introduced and supervised quality circles in the intervention hospitals. Process quality was assessed by interviewing senior staff members before the first and after the second intervention period using standardized questionnaires. The gold standard process quality was defined on the basis of the CDC/HICPAC-guidelines for the prevention of hospital-acquired infections. Most of the evaluated aspects of process quality belonged to the HICPAC-categories IA and IB respectively, the CDC category I. Fifty quality circle sessions were performed in the four intervention hospitals of which 28 were dealing directly with key subjects in infection control. In the intervention hospitals, 19.8% of evaluated aspects of process quality which concerned the prevention of hospital-acquired infections were improved compared to only 6.9% in the control hospitals (P<0.05). Sixty-six point seven percent of positive changes in process quality were initiated by the results of the quality circles. Our study demonstrates that a CQI approach based on infection control quality circles can lead to a substantial improvement of process quality regarding the prevention of hospital-acquired infections.     

Continuous quality improvement and physician training

Continuous quality improvement (CQI) is a system of management that permits individuals to develop an organized approach to improvement. The fundamental tenets of CQI are applicable at the bedside and in the training of residents because they permit the development of a consistent approach to clinical variability and uncertainty. When the principles of CQI are applied to the daily practice of medicine, they not only enhance the educational process but also provide a framework for the continuing quest for knowledge. In that context, these principles can provide a continuing stimulus and challenge to physicians and can enhance the patient-physician relationship that lies at the core of any effort to integrate CQI into patient care.     

A continuous quality improvement pilot study: impact on nutritional care quality

OBJECTIVE: All long-term care facilities are supposed to engage in quality improvement activities in an effort to improve care quality. The purpose of this pilot study was to teach long-term care staff how to conduct continuous quality improvement (CQI) related to nutritional care. METHODS: Research staff conducted CQI training in one 48-bed pilot site with designated staff members. Supervisory staff were taught a standardized direct observational protocol, which was implemented weekly by both facility and research staff, to monitor defined nutritional care processes under the control of direct care staff. In addition, direct care staff received feedback on a weekly basis about care process implementation. RESULTS: Following initial training and 12 weeks of CQI implementation, there were improvements in all 5 nutritional care processes related to the adequacy and quality of daily feeding assistance care provision according to both facility and research staff data. Weekly CQI implementation required approximately 1 hour of supervisory staff time and less than 15 minutes of direct care staff time to receive feedback. IMPLICATIONS: Both initial training and weekly CQI implementation were effective and required less than 2 hours of total staff time per week. Long-term care staff in this pilot site were able to improve nutritional care quality using a standardized direct observational protocol to guide CQI activities.     

Cultivating quality. CQI helps a system's members provide efficient, effective care to their clients

In 1990 the SSM Health Care System (SSMHCS), St. Louis, introduced its employees to continuous quality improvement (CQI), a new management paradigm focusing on process, customers, and statistical thinking. For nearly a year before the introduction of CQI, a system implementation team studied CQI and its impact on businesses and healthcare providers. Team members were struck by the close correlation between the system's own mission and CQI principles. When it had completed its study, the team began to develop strategies for implementing CQI. System leaders committed themselves to ensuring that CQI would address both clinical and managerial processes, encouraging managers and medical staff to support CQI, establishing a structure at each entity to support involvement in the process, fostering a high level of awareness in CQI, recognizing employees who make significant contributions to the effort, offering education programs, and communicating successes and encouraging their replication. Before any facility appointed a quality improvement team and began to apply CQI principles, its administrative council (leadership team) was required to work through a series of readiness screens. The implementation process has involved redefining the manager's role as one of empowering employees, cultivating and securing physician involvement, and educating employees and physicians about processes. In the early phases of implementation, the major barriers the system has faced have involved time-the time required of administrators and managers to teach CQI courses and the time it takes teams to work through the SSMHCS CQI model and adapt the system to CQI implementation.     

A Hospital-to-Nursing Home Transfer Process Associated With Low Hospital Readmission Rates While Targeting Quality of Care,Patient Safety,and Convenience: A 20-Year Perspective

BackgroundSafe patient transfer from hospitals to skilled nursing facilities (SNFs) is one of the most logistically challenging safety problems in the US medical system.ProblemThe authors describe a community that experienced inefficient transfers in the 1990s, spurring development of continuous quality improvement (CQI) methods to develop transfer forms and processes to improve efficiency.MethodsThe community established a Geriatric Forum for educational and process improvement purposes. Attendees consist of anyone involved with care of older patients in the community. Over the years, minor environmental changes forced periodic adjustments to transfer processes. The need for adjustment is identified by asking the simple question, “Have any problems occurred with transfers lately?” When problems are identified, forum attendees make process changes. The current forms and processes are discussed in detail.ResultsInitial improvement in efficiency of transfers also produced improvements in patient safety and quality of medical care according to periodic internal surveys. During 2009, this community’s 30-day rehospitalization rate of patients discharged to a SNF was 14.75%, lower than any national or state average reported rate.ConclusionsDeveloping hospital-to-SNF transfer methods focusing on the traditional CQI goals of efficiency, patient safety, and quality of care also yields lower hospital readmission rates. Because the methodology is that of CQI, a widely taught skill, similar programs could be established between any hospital and the SNFs to which it discharges patients. The particular examples of transfer forms and processes described might be helpful to other programs.     

The development of measures of organizational citizenship behaviour and changes in job behaviours related to quality management in health care.

A study was conducted at two tertiary care hospitals in Canada for the purpose of developing instruments to measure organizational citizenship behaviours (OCB) and changes in job behaviours that occur as a result of participation on hospital quality improvement (CQI) teams. Semi structured interviews were conducted among 52 hospital employees in order to elicit critical incidents of OCB and changes in job behaviours related to CQI. The results of the staff interviews were used to develop a measure of OCB in the hospital setting, and a measure of changes in job behaviours related to CQI. 39 employees, who were drawn from the major departments within the two hospitals on the basis of their membership on CQI teams, participated in a test of the psychometric properties of the two research instruments. Exploratory factor analysis, employing an orthogonal rotation, yielded two factors that accounted for 30% of the variation among the OCB items. The Cronbach alpha for items loading highly on the first factor was .88. The factor was labelled 'OCB directed towards individuals within the organization'. This factor was dominated by items reflecting the kinds of extra-role job behaviours employees engage in to assist patients, family members, visitors, and other employees within the organization. The Cronbach alpha for items loading highly on the second factor was 0.71. The second factor was labelled 'organizationally directed OCB', and consisted of behaviours that reflected an impersonal form of OCB in the hospital setting. Factor analysis, employing an orthogonal rotation, yielded four factors that accounted for 48% of the variation among the items measuring changes in job behaviours related to CQI. The four factors were labelled 'problem-solving', Cronbach alpha 0.82; 'customer awareness', Cronbach alpha 0.79; 'use of CQI knowledge', Cronbach alpha 0.77; and 'organizational interests', Cronbach alpha 0.79. The two OCB factors were moderately correlated, there were no significant correlations among any of the factors measuring changes in job behaviours related to CQI, and the problem-solving job behaviours factor was moderately correlated with the two OCB factors. Directions for future research are discussed.     

Delivering effective health care through teamwork: the role of pharmaceutical care management.

In recent years, there has been significant interest in the application of continuous quality improvement (CQI) and total quality management (TQM), and patient-focused care (PFC) in health care organisations around the globe. The hospital industry has substantially embraced the concepts of CQI and TQM with the belief that these concepts and programmes will lead to an improvement in both the quality and efficiency with which health services are delivered. The objective of this article is to achieve better outcomes in health care services with fewer resources by studying the implementation of patient-focused care in the health care provision context and particularly in the area of pharmaceutical care management as an integrated process in the delivery of health care in a hospital setting. The changes in health care provision have in many instances meant that the provision of pharmaceutical services needed re-assessing.     

"以顾客为中心",不断提高医院整体质量

文章将工业理论中的持续性质量提高理论运用于卫生领域，结合医院现代管理理念．提出医院在一定的质量标准下．通过对医院质量和病人满意度的调查，找出医院存在的问题．提出改进措施。文章认为提高医院的质量应该“以顾客为中心”．以提高管理质量和内部顾客(医务人员)的质量(临床质量和服务质量)为根本，不断改善医院总体质量，提高医院的经济效益和社会效益。     

The CQI paradigm: a pathway to nurse empowerment in a community hospital

Anderson Area Medical Center instituted continuous quality improvement (CQI) hospitalwide two years ago. Three teams were challenged with identifying and improving processes related to accounts receivable. X-ray report turn-around-time, and emergency department patient satisfaction. Nursing participation was sought for all three teams. An eight-step CQI process was used to identify, analyze, and improve these three processes. Substantial nursing participation in these pilot CQI teams led to further participation in many other CQI teams optimizing clinical processes. Nursing personnel gained opportunities to make significant contributions to the enhancement of clinical and administrative processes in a large hospital. Nurses learned to work with other members of the health care team outside of their traditional domains, and this, combined with formalized training in the team process, is empowering.     

Does quality improvement implementation affect hospital quality of care?

The authors examined how the association between quality improvement (QI) implementation in hospitals and hospital clinical quality is moderated by hospital organizational and environmental context. The authors used Ordinary Least Squares regression analysis of 1,784 community hospitals to model seven quality indicators as a function of four measures of QI implementation and a variety of control variables. They found that forces that are external and internal to the hospital condition the impact of particular QI activities on quality indicators: specifically data use, statistical tool use, and organizational emphasis on Continuous Quality Improvement (CQI). Results supported the proposition that QI implementation is unlikely to improve quality of care in hospital settings without a commensurate fit with the financial, strategic, and market imperatives faced by the hospital.     

运用CQI改进护理品质的问题与对策

目的探讨护理CQI项目开展中存在的问题及对策。方法应用回顾性分析方法,对2013年全院各护理单元开展的CQI项目进行分析,发现存在的问题,分析原因、提出相应的对策。结果全院65个CQI项目,由科室正护士长或主持工作的副护士长组织开展,其中任职1~3年的护士长存在问题较多,护士长群体对质量管理工具选择单一、使用不熟练,团队协作意识不够。结论对护士长进行QCI专业培训,加强新上岗护士长质控能力的培训,建立团队质量改进的激励机制,能提高护士长运用质量管理工具的能力,提升护理质量。     

News Letter

The authors examined how the association between quality improvement (QI) implementation in hospitals and hospital clinical quality is moderated by hospital organizational and environmental context. The authors used Ordinary Least Squares regression analysis of 1,784 community hospitals to model seven quality indicators as a function of four measures of QI implementation and a variety of control variables. They found that forces that are external and internal to the hospital condition the impact of particular QI activities on quality indicators: specifically data use, statistical tool use, and organizational emphasis on Continuous Quality Improvement (CQI). Results supported the proposition that QI implementation is unlikely to improve quality of care in hospital settings without a commensurate fit with the financial, strategic, and market imperatives faced by the hospital.     

Continuous quality improvement: a survey of American and Canadian healthcare executives

The continuous quality improvement (CQI) movement, while experiencing great popularity years ago, has been declining in interest across other industries. This article studied American and Canadian hospital executives who have embraced the concept of CQI and will continue to be committed to CQI efforts in the future. Executives of CQI hospitals strongly believe that CQI is not a fad and is essential to their organizations' survival. The majority of the hospital executives in the sample have a good understanding of CQI. The drive to provide quality service to both internal and external customers is the primary motivation for being involved with CQI. Some unsuccessful CQI efforts can be attributed to a lack of CQI skills, poor planning, and insufficient staffing. Close to 90 percent of the respondents expected their involvement with CQI to increase significantly in the future. This result implies that CQI is still being considered and will maintain its role as an effective management tool in the healthcare sector.     

Design and Implementation of an Integrated, Continuous Evaluation, and Quality Improvement System for a State-Based Home-Visiting Program

To describe the design and implementation of an evaluation system to facilitate continuous quality improvement (CQI) and scientific evaluation in a statewide home visiting program, and to provide a summary of the system's progress in meeting intended outputs and short-term outcomes. Help Us Grow Successfully (HUGS) is a statewide home visiting program that provides services to at-risk pregnant/post-partum women, children (0-5?years), and their families. The program goals are to improve parenting skills and connect families to needed services and thus improve the health of the service population. The evaluation system is designed to: (1) integrate evaluation into daily workflow; (2) utilize standardized screening and evaluation tools; (3) facilitate a culture of CQI in program management; and, (4) facilitate scientifically rigorous evaluations. The review of the system's design and implementation occurred through a formative evaluation process (reach, dose, and fidelity). Data was collected through electronic and paper surveys, administrative data, and notes from management meetings, and medical chart review. In the design phase, four process and forty outcome measures were selected and are tracked using standardized screening and monitoring tools. During implementation, the reach and dose of training were adequate to successfully launch the evaluation/CQI system. All staff (n?=?165) use the system for management of families; the supervisors (n?=?18) use the system to track routine program activities. Data quality and availability is sufficient to support periodic program reviews at the region and state level. In the first 7?months, the HUGS evaluation system tracked 3,794 families (7,937 individuals). System use and acceptance is high. A successful implementation of a structured evaluation system with a strong CQI component is feasible in an existing, large statewide program. The evaluation/CQI system is an effective mechanism to drive modest change in management of the program.     

Continuous Quality Improvement: Status of Canadian Health Care Organizations

The Canadian Council on Health Services Accreditation (CCHSA) surveyed its client groups to determine how involved they had become in continuous quality improvement (CQI) activities. This was a follow up to a 1992 survey. Most of the participating organizations indicated they had adopted a CQI philosophy. A major factor influencing this decision was the use of the CCHSA's client-centred standards.This article outlines the gains organizations have realized by implementing CQI, and the extent to which organizations have implemented CQI principles, methods and tools. The information from this survey has been used to develop the accreditation program for the year 2000 — “The AIM Project: Achieving Improved Measurement.”