持续改进护理文书书写质量控制管理方法的体会

目的：提高护理文件书写质量控制效力,使护理文件书写质量持续改进与提高。方法：规范护理管理,加大对护理人员的培训力度;加强护理文件书写质控环节的管理;不断完善系统的病历质控管理组织。结果：提高了护理人员对护理文件书写重要性的认识,重视护理文件环节、终末质量控制,使护理文件书写质量得到了持续改进和提高。结论：持续改进护理文件书写质控管理方法,能提高护理文书书写质量控制效力,确保护理文件书写质量持续改进和提高。     

电子护理文书的质量管理探讨

目的 规范电子病历护理文书书写,提高护理文书质量.方法 根据护理文书质量标准,对电子病历护理文书进行缺陷控制并完善电子护理文书书写程序.结果 电子病历护理文书实现标准化、规范化、信息化管理,书写效率提高.结论 必须树立逐级、层层负责的指导思想,不断完善电子护理文书系统功能,才能提高护理文书质量.     

护理文书环节质量控制的探讨

目的通过护理文书环节质量检查提高护理文书书写质量。方法由质控处、护理部组织专职护理组长进行护理病案质量随机抽查,每月平均抽查病历200份,对发现的质量问题,在护士长例会上进行反馈,评出前3名及后3名,并按规定给予相应奖励或处分。结果书写质量较《医疗事故处理条例》实施前有了大幅度提高。结论注重环节质量控制,加强护理人员法律意识和业务技能培训,制定相应的奖罚制度并健全病历书写管理制度是提高护理文书书写质量的重要措施。     

护理记录的质量控制

目的 实施护理记录质量控制,提高护理记录书写质量.方法 组成科研项目课题小组,运用ISO9001标准管理体系建立的文件化质量管理体系,按照<广东省病历书写规范>的要求,对我院外五区护理记录书写质量进行控制,并对其实施控制前后的护理记录书写质量进行比较.结果 实施控制后护理记录的书写质量明显提高.结论 为了保障医疗安全,要重视护理记录质量.     

5636份外科系统终末质控病案的缺陷分析与对策

目的通过分析5636份外科系统病案中存在的缺陷,探讨病案缺陷的成因,提出对策,减少病案缺陷的产生。方法根据《广东省病历书写与管理规范》和我院《终末病历评分表》,对5636份外科系统病案进行终末质控。结果发现病案单项否决缺陷11项,普通缺陷10项。单项否决中缺陷最多的是缺血液制品知情同意书,共86次,占单项否决总数25．59％,普通缺陷最多的是医嘱,共1343次,占普通缺陷总数38．69％。结论提高医务人员对病案的重视程度,加强临床医师规范化的学习,加强病案环节质量控制,保证病案书写质量。     

医疗护理文书质量规范管理的比较研究

目的针对护理文书缺陷,进行质量规范管理,提高护理文件书写质量.方法规范管理前抽查护理书写病历600份,对存在的缺陷采取设立护理书写抽查登记本、成立质控小组、制订扣分标准等措施,规范管理后抽查护理书写病历600份,对缺陷进行比较,且进行统计学分析.结果规范管理后护理文书质量显著提高(P＜0.05),前后比较差异有统计学意义.结论加强护理质量规范管理是保证护理文书质量的关键.     

过程管理理论与护理病历质量控制

目的规范护理病历质控方法,提高护理病历书写质量。方法通过制定护理病历过程质控流程、培训和监督实施,加强护理病历质量控制效果的持续改进。结果护理病历存在的问题减少,终未护理病历合格率明显提高。结论系统的过程管理是提高护理病历书写质量的一种有效的方法。     

提高护理记录书写质量的体会

目的:为了完善护理记录,提高护理记录的书写质量.方法:随机抽取2004年5月至2005年5月病历600份,其中培训前、后各300份,检查分析病历存在的问题.培训学习内容为有关卫生的法律法规,护理常规、病历书写规范.结果:检查培训后护理记录书写质量明显提高.存在的问题明显低于培训学习前(P＜0.05.结论:通过培训学习,增强了护理人员的法律意识,提高护理人员专业技能和循证护理的能力.规范护理记录的书写,严格质量控制,护理记录书写质量明显提高.     

单项否决病案分析与改进

目的通过分析2016年单项否决病案产生的原因,提出应对措施,以提高病案书写质量。方法采取普查法,并对质控结果进行统计学分析。结果单项否决病案中“缺整页病历记录造成病案不完整”占比最高（62.80%）,医嘱单和体温单缺失最严重,手术科室缺陷明显多于非手术科室。结论单项否决病案缺陷项目原因有多环节病案质控把关不严,病例重点内容监控不到位,医护工作流程衔接不流畅,特殊区域监管存在缺陷等。建议加强环节指控,发挥指控员作用;提高认识,严格落实奖惩措施;改善工作流程,加强医护间协作;应用质量管理工具,促进病案质量持续     

以环节病历质控为突破口提高病案管理质量

目的探讨环节病历质控在提高病案书写质量上的作用及效果。方法通过对环节病历质控,对笔者所在医院2007—2009年环节病历进行质量检查,对缺陷病历进行分析。结果笔者所在医院2007—2009年住院运行病历中缺陷病历数明显下降,归档病案甲级率逐年上升,病案书写质量和内涵质量有了很大提高。结论加强环节病历质控是提高病案质量的突破口。     

Assessing the quality of quality indicators

Quality in healthcare is not directly observable and measurable. Quality indicators serve as a tool for operationalizing quality of care. Different quality measures are required depending on the purpose, context, and audience concerned. The methodological quality of the indicators themselves has to be critically assessed. Various quality requirements for indicators have been published and can be described based on the steps of the developmental process. Importance, scientific acceptability, usability, and feasibility are reported as basic criteria for assessment. The QUALIFY instrument offers a standardized approach for assessing quality indicators and reflects best current practice. Measuring quality through indicators is no end in itself. The effect of measurement on motivating quality improvement must be evaluated in future studies.     

Improving the quality of quality improvement projects

As the stakes grow for evaluating the quality of health care delivery, so too should greater attention be paid to the integrity of the design, conduct, and inferences made from QI projects. QI projects that seek to make inferences, especially public inferences, about the impact of an intervention to improve quality of care should be rigorously designed and evaluated, and limitations and potential biases transparently reported to understand how they may affect the conclusions suggested by the project. Our patients deserve nothing less.     

医疗质量与质量成本关系探讨

医疗质量是病人选择医院最直接、最主要的标准,也是医院在激烈的医疗市场竞争中取胜的关键.为此,如何在保证医疗服务质量的前提下,对质量成本进行有效控制,以实现质量最优、成本最低,获取最大的质量效益,这是医院管理中迫切需要解决的问题。     

Using the AHRQ quality indicators to improve health care quality

In summary, the AHRQ QIs are a set of readily available programs that can be downloaded without charge from the AHRQ Web site. The methodology is completely open and accessible to all users. The QI software can be applied to hospital administrative data that is available within individual institutions or from state data organizations and hospital associations and can provide valuable insights into health care quality at extremely low cost. The QIs have been incorporated into numerous quality assessment reports, including hospital-specific reports, with the aim of improving health care quality at a reasonable cost. With enhancements currently underway, the QIs will be an even more valuable part of the toolkit to improve health care quality in the United States.     

Using decision analysis to assess the quality of quality assurance

Quality assurance is rapidly encroaching on the fields of epidemiology and infection control. If we are to lead this most recent revolution in medical care, we must ensure that our approach is structured, that we reassess our goals and methods regularly and that we achieve the maximal benefit from the resources we consume. According to Colloton, "Unless refined or replaced, the unsophisticated methodologies now emerging on several fronts will be used, with or without our endorsement, to assess the quality of care rendered within all of medical practice."