基于DRGs的临床医疗质量评价体系

目的按照DRGs的分组统计理论,结合医院实际情况,构建一套全面可行的医疗质量评价体系,让医疗服务水平得以可信性评价。方法利用DRGs分组工具,将某院收治病种分组,与国内排名前38位的三级综合医院相应疾病组进行核心指标完成情况比对,获得各科室各疾病组的多项指标O/E值,分析O/E值能真实评价医疗服务效能。结果运用DRGs系统,每月能准确抓取不同科室、不同疾病组和不同医师的临床诊治信息,通过横纵向对比分析,有利于找出科室质量管理缺陷,促进临床重点专科打造。结论DRGs是一种高效的医疗管理工具,基于DRGs系统构建的临床医疗质量评价指标体系能有效推动医院精细化质量管理的落实,提升医院质量管理内涵。     

基于疾病诊断相关组的医院内专科评价指标探讨

目的 通常疾病诊断相关组(DRGs)指标用于评价综合医院的能力,当用于医院内部评价时,因专科差异较大,现有指标不宜直接用于临床专科比较.本文拟探讨DRGs指标体系应用于医院内评价的问题,并提出专科能力指数及其计算方法.方法 以某院2018年DRGs分组结果及该院所在省份DRGs数据,论证现有DRGs指标体系应用于医院内...     

Operational Failures and Interruptions in Hospital Nursing

Objective. To describe the work environment of hospital nurses with particular focus on the performance of work systems supplying information, materials, and equipment for patient care.
Data Sources. Primary observation, semistructured interviews, and surveys of hospital nurses.
Study Design. We sampled a cross-sectional group of six U.S. hospitals to examine the frequency of work system failures and their impact on nurse productivity.
Data Collection. We collected minute-by-minute data on the activities of 11 nurses. In addition, we conducted interviews with six of these nurses using questions related to obstacles to care. Finally, we created and administered two surveys in 48 nursing units, one for nurses and one for managers, asking about the frequency of specific work system failures.
Principal Findings. Nurses we observed experienced an average of 8.4 work system failures per 8-hour shift. The five most frequent types of failures, accounting for 6.4 of these obstacles, involved medications, orders, supplies, staffing, and equipment. Survey questions asking nurses how frequently they experienced these five categories of obstacles yielded similar frequencies. For an average 8-hour shift, the average task time was only 3.1 minutes, and in spite of this, nurses were interrupted mid-task an average of eight times per shift.
Conclusions. Our findings suggest that nurse effectiveness can be increased by creating improvement processes triggered by the occurrence of work system failures, with the goal of reducing future occurrences. Second, given that nursing work is fragmented and unpredictable, designing processes that are robust to interruption can help prevent errors.     

Using Public Reports of Patient Satisfaction for Hospital Quality Improvement

Objective. To explore the impact of statewide public reporting of hospital patient satisfaction on hospital quality improvement (QI), using Rhode Island (RI) as a case example.
Data Source. Primary data collected through semi-structured interviews between September 2002 and January 2003.
Study Design. The design is a retrospective study of hospital executives at all 11 general and two specialty hospitals in RI. Respondents were asked about hospital QI activities at several points throughout the public reporting process, as well as about hospital structure and processes to accomplish QI. Qualitative analysis of the interview data proceeded through an iterative process to identify themes and categories in the data.
Principal Findings. Data from the standardized statewide patient satisfaction survey process were used by hospitals to identify and target new QI initiatives, evaluate performance, and monitor progress. While all hospitals fully participated in the public reporting process, they varied in the stage of development of their QI activities and adoption of the statewide standardized survey for ongoing monitoring of their QI programs. Most hospitals placed responsibility for QI within each department, with results reported to top management, who were perceived as giving strong support for QI. The external environment facilitated QI efforts.
Conclusion. Public reporting of comparative data on patient views can enhance and reinforce QI efforts in hospitals. The participation of key stakeholders facilitated successful implementation of statewide public reporting. This experience in RI offers lessons for other states or regions as they move to public reporting of hospital quality data.     

基于DRGs的加权TOPSIS法对江西省南昌市某三甲综合医院医疗绩效评价

目的:探讨江西省南昌市某三甲医院基于DRGs指标的加权TOPSIS法对医疗服务绩效评价应用的科学性.方法:通过江西DRGs平台获取样本医院2017年病案信息,应用加权TOPSIS法进行医疗服务绩效评价.结果:样本医院科室综合排名前3为腹腔镜外科(0.478)、康复一病区(0.473)、骨三病区(0.471);综合绩效最高后3位:脑外科(0.342)、肾病风湿科(0.336)、心胸外科(0.324).结论:基于DRGs指标的加权TOPSIS法评价结果科学、客观,为医院内部绩效评价提供了一种合理可行的方法,为医院管理者全面了解各科室医疗服务能力及效率,提升整体绩效水平提供数据支撑和决策参考.     

加速实施临床路径优化医疗核心业务流程

临床路径管理的重点是优化医疗业务的核心流程和环节,实现以病人为中心、跨部门的医疗服务环节和流程的整合.我院自2005年引入临床路径管理,截止到2009年底,已有超过2万例次的临床路径管理实践,并取得较好的社会效益和经济效益.如何加速临床路径管理的推广,更好地实现预期目标,促进医疗核心业务流程优化,我们的主要经验和教训有8点:(1)建立共同需求;(2)成立强有力的领导架构;(3)制订远景规划并着力宣传;(4)消除阻力形成合力;(5)持续实施并关注细节;(6)奖励参与的员工;(7)培育医院内部实施骨干;(8)把实施的经验制度化并持续监控.推广临床路径是一项管理的变革流程,有其自身的规律,充分利用适宜的技术策略与文化策略,可提高路径实施的质量和可接受性.     

基于DRGs肿瘤专科医院精细化管理探讨

目的探讨疾病诊断相关组（Diagnosis Related Groups,DRGs）在肿瘤专科医院精细化管理中的实践经验。方法以某肿瘤专科医院为例,采用了2016年上半年（26 879例）和2017年上半年（30 155例）纳入DRGs分组的出院病例,运用DRGs评价体系,从产能、效率、安全3个维度,以医院、病组、科室、人员等不同层面对医院运行情况进行评价。结果（1）2017年上半年,全院收治患者的DRGs组数是247例,CMI指数0.94;时间消耗指数0.53,费用消耗指数0.92,低风险死亡率0.02%,中低风险死亡率0.06%;较2016年同期,全院收治患者的能力有所提升,效率更高,但安全性并未降低。（2）通过综合评分对全院科室进行排名,手术科室S1总体得分（5.61）在全院排第一,其次是非手术科室F1（得分4.72）。DRGs指标和评分的高低与科室特点有关。（3）对某科室医师a、b进行评价,医师a的CMI值（1.23）高于医师b（2.70）,综合得分差异有统计学意义（a医师7.08,b医师4.94）。DRGs评价结果公平性较强。结论DRGs评价体系是实现肿瘤专科医院精细化管理的有效途径。     

DRGs数据在医院临床输血评价中的应用分析

目的 利用DRGs数据中输血相关资料分析,以期建立有公信力的临床用血评价体系,加强对临床安全有效输血的管理.方法 采用DRGs项目组输血相关资料,用EXCEL数据库对DRGs项目组输血相关数据的输血人数、医院名称、医院类别、医院级别、DRGs编号及名称、输血人次、输血量相关数据进行分类统计.结果 统计北京市医疗机构患者用血比例、用血患者例均用量、医院用血数量分布及排序、DRGs用血分布及排序、单一DRGs在各医院间用血排序及分布、医院不同年度用血量增长及主要用血疾病组.结论 利用DRGs可有效地对临床用血指征控制效果及管理效果进行评价分析,为卫生行政部门及医院提供有公信力的管理手段,同时可为政策管理目标的制定提供数据支持.     

风险评估体系在不同科室医院感染分类管理中的运用

 目的 在新型冠状病毒肺炎疫情常态化防控的形势下,建立一套全面、科学的风险评估体系,为医院管理决策提供支持。 方法 以山东省某综合性三级甲等医院为研究对象,首先进行全院整体层面的风险评估,由医院感染管理委员会成员采用头脑风暴的方法确定风险点和风险指标,通过风险评估矩阵计算出临床科室的风险分值,使用百分位数法对其进行风险等级评定,使用单因素方差分析或非参数检验比较不同风险组的差异,根据风险点的风险分值差异对临床科室进行分层聚类分析,再由评估出的极高风险科室使用失效模型和效应分析进行内部风险评估,最终根据两轮风险评估的结果进行风险应对。 结果 共61个临床科室参与评定。临床科室通过风险评估最终评定出8个风险点,24项风险指标。风险等级评估结果显示,神经外一科、神经外二科、神经重症监护病房、呼吸重症监护病房、重症医学科属于极高风险组,占8.20%;6个风险组的管理指标、过程指标和结局指标风险分值的比较,差异均有统计学意义(均P＜0.05);层次聚类分析将临床科室分为3类,根据其特点分别定义为普通科室聚类组、重点科室聚类组和神经外科聚类组。极高风险科室通过内部风险评估评出7个高风险优先级问题,并有针对性地提出解决方案。 结论 本研究构建的风险评估体系可以对临床科室的风险等级进行有效的评定和分析,对极高风险科室的高风险优先级问题能进行有效风险应对,能明确下一步医院感染管理的重点。     

DRGs评价医院绩效的SWOT分析

目的为DRGs在湖北省以及全国的推广提供参考。方法利用DRGs绩效评价进行SWOT分析。结果从DRGs组数、CMI值、时间消耗指数、费用消耗指数、低风险组死亡率以及入组情况结合文献研究,对DRGs绩效评价进行SWOT分析。结论统一编码库,提高编码准确率,探索更科学的疾病/手术难易程度评价方式,提高病案质量,细化并公开DRGs分组方案以及专科分类将有助于DRGs应用的推广。     

四川省病案专职编码员配置现状分析

目的 通过对四川省病案专职编码员配置情况进行现状分析,以优化病案编码人才队伍建设,促病案专业高质量发展,为病案首页数据利用奠定基础。方法 对四川省二级及以上医院病案科（室）进行问卷调查,获得2019年1月1日—2019年12月31日医院病案科（室）和专职编码员基本情况等内容。结果 共调查1 279名病案专职编码员,平均每家医院配备2.14名专职编码员;其中医学相关专业占77.95%,大专及以下学历占比最高（52.39%）,人均每月负担出院患者病历数698.26份。结论 四川省目前病案专职编码员配备不足,病案专职编码员的学历偏低,不同医院间专职编码员的工作负荷差距较大,领导部门应加强对编码的重视程度,并重视人才队伍建设,逐步减轻编码员的工作量。     

Quality of Statutory Inpatient Database Before Introducing DRGs

According to the legislation of the Federal Republic of Germany (Gesundheitsstrukturgesetz 1993) defined performance figures must be listed for each case of inpatient care. As hospital morbidity data are essential for further development of the health care system and for introducing the DRGs, the corresponding statistical data of a German federal territory of the year 2000 were studied in respect of several aspects of their quality: conformity with the requirements of law, plausibility and ability to transport essential medical information. Notable variations were found between the departments and different medical disciplines without interdependence to variant hospital status. Only about 40 % of departments of surgical disciplines transferred data according to legal requirements. Some disciplines showed higher percentages of unspecific coding (e.g. traumatology). The described deficits impair data reliability. The study offers a feedback to hospital departments with regard to their formal data quality. Periodic investigation may thus help to improve data quality in future.     

A cluster randomised trial to assess the impact of clinical pathways on AMI management in rural Australian emergency departments

Background

People living in rural Australia are more likely to die in hospital following an acute myocardial infarction than those living in major cities. While several factors, including time taken to access hospital care, contribute to this risk, it is also partially attributable to the lower uptake of evidence-based guidelines for the administration of thrombolytic drugs in rural emergency departments where up to one-third of eligible patients do not receive this life-saving intervention. Clinical pathways have the potential to link evidence to practice by integrating guidelines into local systems, but their impact has been hampered by variable implementation strategies and sub-optimal research designs. The purpose of this study is to determine the impact of a five-step clinical pathways implementation process on the timely and efficient administration of thrombolytic drugs for acute myocardial infarctions managed in rural Australian emergency departments.

Methods/Design

The design is a two-arm, cluster-randomised trial with rural hospital emergency departments that treat and do not routinely transfer acute myocardial infarction patients. Six rural hospitals in the state of Victoria will participate, with three in the intervention group and three in the control group. Intervention hospitals will participate in a five-step clinical pathway implementation process: engagement of clinicians, pathway development according to local resources and systems, reminders, education, and audit and feedback. Hospitals in the control group will each receive a hard copy of Australian national guidelines for chest pain and acute myocardial infarction management. Each group will include 90 cases to give a power of 80% at 5% significance level for the two primary outcome measures: proportion of those eligible for thrombolysis receiving the drug and time to delivery of thrombolytic drug.

Discussion

Improved compliance with thrombolytic guidelines via clinical pathways will increase acute myocardial infarction survival rates in rural hospitals and thereby help to reduce rural-urban mortality inequalities. Such knowledge translation has the potential to be adapted for a range of clinical problems in a wide array of settings.

Trial registration

Australia New Zealand Clinical Trials Registry code ACTRN12608000209392.     

标准化管理在低值耗材供应关键环节的作用探讨

消毒供应中心是为临床诊疗科室提供无菌物品保障的关键部门,一次性低值耗材的供应保障是消毒供应中心的重点工作。依托医院5年的标准化主题建院活动,对一次性低值耗材进行了标准化管理,从规章制度、岗位流程、库存管理、质量控制、人员培训等各方面进行了标准化,一次性低值耗材的账务相符率由92.51%提升到99.98%,临床科室耗材请领正确率由标准化管理实施前的82.35%提高到94.78%,临床科室满意度98%以上,一次性低值耗材的管理及使用更加科学、精准、规范。     

Impact of the Medicare Short Stay Transfer Policy on Patients undergoing Major Orthopedic Surgery

Objective. To examine the impact of the Short Stay Transfer Policy (SSTP) on practice patterns.
Data Sources. This study uses data from the Centers for Medicare and Medicaid Services Medicare Provider Analysis and Review (MEDPAR) file, Home Health Standard Analytical File, 1999 Provider of Service file, and data from the 2000 United States Census.
Study Design. An interrupted time-series analysis was used to examine the length of stay (LOS) and probability of "early" discharge to post acute care (PAC).
Data Collection. Separate 100percent samples of all fee-for-service Medicare recipients undergoing either elective joint replacement (JR) surgery or surgical management of hip fracture (FX) between January 1, 1996 and December 31, 2000 were selected.
Principal Findings. Prior to implementation of the SSTP. LOS had been falling by 0.37 and 0.30 days per year for JR and FX patients respectively. After implementation of the SSTP, there was an immediate increase in LOS by 0.20 and 0.17 days, respectively. Thereafter, LOS remained flat. The proportion of patients discharged "early" to PAC had been rising by 4.4 and 2.6 percentage points per year for JR and FX patients respectively, to a peak of 28.8percent and 20.4percent early PAC utilization in September 1998. Immediately after implementation of the SSTP, there was a 4.3 and 3.0 percentage point drop in utilization of "early" PAC. Thereafter utilization of early PAC increased at a much slower rate (for JR) or remained flat (for FX). There was significant regional variation in the magnitude of response to the policy.
Conclusion. Implementation of the SSTP reduced the financial incentive to discharge patients early to PAC. This was accomplished primarily through longer LOS without meaningful change in PAC utilization. With the recent expansion of the SSTP to 29 DRGs (representing 34percent of all discharges), these findings have important implications regarding patient care.     

单病种管理研究综述

通过文献复习对病种质量管理、单病种限价、按病种收费以及临床路径研究进行了阐述,并提出行政部门之间加强协作、加大基于DRGs的病例组合付费制研究、确立单病种质量评价指标、重视单病种住院费用分析、加大单病种成本测算研究和科学推行临床路径6个方面的建议.     

Translating Research into Practice Intervention Improves Management of Acute Pain in Older Hip Fracture Patients

Objective. To test an interdisciplinary, multifaceted, translating research into practice (TRIP) intervention to (a) promote adoption, by physicians and nurses, of evidence-based (EB) acute pain management practices in hospitalized older adults, (b) decrease barriers to use of EB acute pain management practices, and (c) decrease pain intensity of older hospitalized adults.
Study Design. Experimental design with the hospital as the unit of randomization.
Study Setting. Twelve acute care hospitals in the Midwest.
Data Sources. (a) Medical records (MRs) of patients ≥65 years or older with a hip fracture admitted before and following implementation of the TRIP intervention and (b) physicians and nurses who care for those patients.
Data Collection. Data were abstracted from MRs and questions distributed to nurses and physicians.
Principal Findings. The Summative Index for Quality of Acute Pain Care (0–18 scale) was significantly higher for the experimental (10.1) than comparison group (8.4) at the end of the TRIP implementation phase. At the end of the TRIP implementation phase, patients in the experimental group had a lower mean pain intensity rating than those in the comparison group (  p <.0001).
Conclusion. The TRIP intervention improved quality of acute pain management of older adults hospitalized with a hip fracture.     

DRGs在某三甲医院外科中心绩效评价中的应用

探索疾病诊断相关组(DRGs)评价指标在某三甲医院外科中心医疗绩效评价体系中的应用。方法提取该院外科中心2018年 1月-12月出院病案首页,通过“BJ-DRGs”分组器对之自动化分组,从医疗服务的“能力”“效率”和“医疗安全”等方面进行绩效评价。结果该中心收治疾病大类（MDC）组数为18组,DRGs组数为95组,病例组合指数（CMI）为0.697,处于全院较低水平;时间消耗指数、费用消耗指数均接近1,处于全院平均水平。治疗疾病范围最广的是A病区,DRGs组数为68组;C病区技术难度最高,CMI指数为0.718;A病区住院时间消耗最短,费用消耗最低,效率分数为1.305。TOPSIS综合评价显示,A病区绩效最优,C1医师绩效最优。结论DRGs 评价指标既能够评价科室综合服务能力、服务效率和服务质量,又能够针对不同级别的医师进行综合评价。     

运用DRGs工具对老年医院诊治能力及效率进行评价的探讨

目的 应用DRGs评价系统对老年医院诊治能力及效率进行评价,提升医院的管理水平。方法 以2018年15 096份住院病案首页数据为研究对象,使用“北京版诊断相关组(BJ-DRGs)”作为风险调整工具,从病例组合指数（CMI）、时间消耗指标、费用消耗指标、住院例均费用和医疗安全等方面进行分析,探讨DRGs工具对老年医院诊治能力及效率的评价效果。结果 老年医院MDC为22个,DRGs组数为437组, CMI、时间消耗指数和费用消耗指数分别超过老年病专业和北京市医院平均水平,低风险死亡率为0,中高组和高风险组病例数占比高于全市水平,死亡率低于全市水平。结论 通过DRGs数据分析能够发现老年医院、老年医学专业与综合医院专业科室在收治常见疾病上的差异,优化老年医院资源配置,改进医疗服务质量和水平。建议在使用DRG工具评价老年医学专业时,应考虑老年患者年龄、多病共存等因素影响,完善老年医学专业的医疗效率绩效指标个性化设定。     

Effect of Critical Access Hospital Conversion on Patient Safety

Background. The Medicare Rural Hospital Flexibility Program of the 1997 Balanced Budget Act allowed hospitals meeting certain criteria to convert to critical access hospitals (CAH) and changed their Medicare reimbursement mechanism from prospective payment system (PPS) to cost-based.
Objective. To examine the impact of CAH conversion on hospital patient safety.
Data Source. Secondary data on hospital patient safety indicators (PSIs), hospital CAH status, patient case-mix, and market variables, for 89 Iowa rural hospitals during 1997–2004.
Study Design. We employed quasi-experimental designs that use both control groups and pretests. The hospital-year was the unit of analysis. We used generalized estimating equations logit and random-effects Tobit models to assess the effects of CAH conversion on hospital patient safety. The models were adjusted for patient case-mix and market variables. Sensitivity analyses, which varied by sample and statistical model, were used to examine the robustness of our findings.
Data Extraction Methods. PSIs were computed from Iowa State Inpatient Databases (SIDs) using Agency for Healthcare Research and Quality indicators software. Hospital CAH status was extracted from Iowa Hospital Association. Patient case-mix variables were extracted from Iowa SIDs. Market variables came from Area Resource File (ARF).
Principal Findings. CAH conversion in Iowa rural hospitals was associated with better performance of risk-adjusted rates of iatrogenic pneumothorax, selected infections due to medical care, accidental puncture or laceration, and composite score of four PSIs, but had no significant impact on the observed rates of death in low-mortality diagnosis-related groups (DRGs), foreign body left during procedure, risk-adjusted rate of decubitus ulcer, or composite score of six PSIs.
Conclusion. CAH conversion is associated with enhanced performance of certain PSIs.