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易利华：医院JCI基线评估的思与行

2017-11-10 易利华 健康界

JCI基线评估
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时间过得很快，距离2015年8月医院通过JCI正式评审，成为中国大陆地区第48家通过JCI认证的医院之后！已经又两年多了，我们即将迎来明年的第二周期正式评审！为了将JCI第二周期正式评审工作做好，根据医院的安排，我们将在下一周迎来JCI总部从美国派来的五位专家，对医院进行的JCI第二周期创建工作的基线评估检查。这是对我们医院近年来医院管理内涵建设进行检验检测的一个重要阶段！所谓基线评估就是指对医院

时间过得很快，距离2015年8月医院通过JCI正式评审，成为中国大陆地区第48家通过JCI认证的医院之后！已经又两年多了，我们即将迎来明年的第二周期正式评审！为了将JCI第二周期正式评审工作做好，根据医院的安排，我们将在下一周迎来JCI总部从美国派来的五位专家，对医院进行的JCI第二周期创建工作的基线评估检查。这是对我们医院近年来医院管理内涵建设进行检验检测的一个重要阶段！

所谓基线评估就是指对医院管理真实情况的一个评价。他不需要医院做过多的准备，而是按照医院正常的运转来进行检查和评估。当然他的评价标准依然是按照JCI第六版的标准来进行的！而这种检测和评估对于一个医院进行接下来的JCI正式评审，是具有借鉴、比较和推进意义的！我们围绕基线评估，主要做了以下工作：

第一，是对全员进行了JCI五十问的系统培训和手卫生、CPR的人人过关考核。强调患者安全六大目标的执行，做好迎检工作。

既是一个学习过程，也是一个执行过程，更是一个持续改进的过程。按照JCI认证的要求与内容清单，我们医院做好了两个执行力的工作！一是管理层面的执行力。主要完善各科室的管理制度和SOP工作流程，做好各种数据处理和医疗质量的持续改进案例的整理工作。二是规范医务人员的临床工作执行力。从患者入院身份的识别，病情评估到安全核查！以及出院宣教等各方面入手，加强JCI所要求的医院各项管理制度的落实。

第二，医院各个部门要突出重点，抓好JCI对医院管理的重点要求。

我们要特别注意要做好对警讯药品的管理，对全院124种高危警讯药品做好重点监控和管理。特别是在临床的整个医疗过程中，都要按照JCI的要求进行闭环管理。临床各科要做好各临床路径的SOP！我们要按照危急值的闭环要求做好细节的落实！在手术部门要重点做好安全核查，这也是一个关键。

医院各部门都要严格按照JCI标准来开展医疗护理工作，严格执行各项规章制度，诊疗规范及操作常规。落实患者身份识别、危急值报告处理、手术安全核查、手卫生、高危药品管理、患者跌倒预防等国际患者安全目标！要按照病历书写规范的要求认真书写病历，尤其是在医患沟通、知情同意、手术记录、危机值处理记录和病历打印，上级医生及时审签等方面都要落实到位。

第三，要重视医院薄弱环节的整改！

针对上一轮JCI评审中，我们医院在药品闭环管理上存在的问题，要重点进行持续改进！特别是对潜在用药安全风险的环节，要借助PDCA等管理工具开展提高用药安全的质量持续改进工作。在过去的三年中，我们医院药剂部门开展了14项质量持续改进项目。如：静配中心开展降低静配药物配制差错的品管圈活动，有效地提高了临床医疗的用药安全。

医院还根据药品说明书的相关要求，重新修订了我院的遮光药品目录，加强全院抢救车及病区的备药管理。对于药品的有效期、摆放位置、储存条件等进行规范管理！还将重点放到对于抢救室、胃镜室、ICU、麻醉科进行特殊药品的督查。完成对药品不良事件与用药错误的年度分析报告，针对存在的问题提出有效的整改措施！注重医院药品管理的持续改进！

除此以外，医院在消防安全管理、后勤食堂管理，以及消毒供应和其他安全管理方面也有许多观察项亟待改进！

总之，JCI的基线评估是一次严苛的医院管理评价！也是一个持续改进的重要过程！我们将通过基线评估的检查，让自己的医院管理更加卓越！让自己医院的医疗服务更加优良！让自己医院的管理更加持续改进！下周的五天值得期待！

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    2018-03-01 caobinglei8079

    #JCI#

    0

  2. [GetPortalCommentsPageByObjectIdResponse(id=1982091, encodeId=e96a1982091bb, content=<a href='/topic/show?id=12c010266f0' target=_blank style='color:#2F92EE;'>#JCI#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=25, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=10266, encryptionId=12c010266f0, topicName=JCI)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=5e30378, createdName=caobinglei8079, createdTime=Thu Mar 01 00:43:00 CST 2018, time=2018-03-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=265142, encodeId=266426514229, content=学了......., beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4Neru1qt53a14aACuSzg3TZhkTcsPYVibyHibhTZ5L4k9qIBWiaej4lgomIsGptf8N16E4mTuIq2DVdJXjPjmwZKrLib/0, createdBy=5a0f2055853, createdName=135****7952平儿, createdTime=Tue Nov 28 22:49:13 CST 2017, time=2017-11-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=264867, encodeId=973e26486e28, content=学了........, beContent=null, objectType=article, channel=null, level=null, likeNumber=34, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4Neru1qt53a14aACuSzg3TZhkTcsPYVibyHibhTZ5L4k9qIBWiaej4lgomIsGptf8N16E4mTuIq2DVdJXjPjmwZKrLib/0, createdBy=5a0f2055853, createdName=135****7952平儿, createdTime=Mon Nov 27 22:19:00 CST 2017, time=2017-11-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=262936, encodeId=5187262936e1, content=学了........, beContent=null, objectType=article, channel=null, level=null, likeNumber=43, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4Neru1qt53a14aACuSzg3TZhkTcsPYVibyHibhTZ5L4k9qIBWiaej4lgomIsGptf8N16E4mTuIq2DVdJXjPjmwZKrLib/0, createdBy=5a0f2055853, createdName=135****7952平儿, createdTime=Mon Nov 20 22:57:55 CST 2017, time=2017-11-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=260300, encodeId=fbb0260300e6, content=时间过得很快.距离2015年8月医院通过JCI正式评审.成为中国大陆地区第48家通过JCI认证***之后!, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo7cJ6ejWUr2nIia8qOvAKNdLHr32Df6G8iaoaOx6pHaoiacwp26DaslxZHCGbibZhhCGven4rvmWP60GahtzgFjgCjR/0, createdBy=6b111703011, createdName=有备才能无患, createdTime=Fri Nov 10 16:39:34 CST 2017, time=2017-11-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=260286, encodeId=c2dd2602867d, content=希望能够学习到更好的医学, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160718/IMG578C993D395567540.jpg, createdBy=59b81918946, createdName=flysky120, createdTime=Fri Nov 10 14:50:24 CST 2017, time=2017-11-10, status=1, ipAttribution=)]
    2017-11-28 135****7952平儿

    学了.......

    0

  3. [GetPortalCommentsPageByObjectIdResponse(id=1982091, encodeId=e96a1982091bb, content=<a href='/topic/show?id=12c010266f0' target=_blank style='color:#2F92EE;'>#JCI#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=25, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=10266, encryptionId=12c010266f0, topicName=JCI)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=5e30378, createdName=caobinglei8079, createdTime=Thu Mar 01 00:43:00 CST 2018, time=2018-03-01, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=265142, encodeId=266426514229, content=学了......., beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4Neru1qt53a14aACuSzg3TZhkTcsPYVibyHibhTZ5L4k9qIBWiaej4lgomIsGptf8N16E4mTuIq2DVdJXjPjmwZKrLib/0, createdBy=5a0f2055853, createdName=135****7952平儿, createdTime=Tue Nov 28 22:49:13 CST 2017, time=2017-11-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=264867, encodeId=973e26486e28, content=学了........, beContent=null, objectType=article, channel=null, level=null, likeNumber=34, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4Neru1qt53a14aACuSzg3TZhkTcsPYVibyHibhTZ5L4k9qIBWiaej4lgomIsGptf8N16E4mTuIq2DVdJXjPjmwZKrLib/0, createdBy=5a0f2055853, createdName=135****7952平儿, createdTime=Mon Nov 27 22:19:00 CST 2017, time=2017-11-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=262936, encodeId=5187262936e1, content=学了........, beContent=null, objectType=article, channel=null, level=null, likeNumber=43, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4Neru1qt53a14aACuSzg3TZhkTcsPYVibyHibhTZ5L4k9qIBWiaej4lgomIsGptf8N16E4mTuIq2DVdJXjPjmwZKrLib/0, createdBy=5a0f2055853, createdName=135****7952平儿, createdTime=Mon Nov 20 22:57:55 CST 2017, time=2017-11-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=260300, encodeId=fbb0260300e6, content=时间过得很快.距离2015年8月医院通过JCI正式评审.成为中国大陆地区第48家通过JCI认证***之后!, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo7cJ6ejWUr2nIia8qOvAKNdLHr32Df6G8iaoaOx6pHaoiacwp26DaslxZHCGbibZhhCGven4rvmWP60GahtzgFjgCjR/0, createdBy=6b111703011, createdName=有备才能无患, createdTime=Fri Nov 10 16:39:34 CST 2017, time=2017-11-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=260286, encodeId=c2dd2602867d, content=希望能够学习到更好的医学, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160718/IMG578C993D395567540.jpg, createdBy=59b81918946, createdName=flysky120, createdTime=Fri Nov 10 14:50:24 CST 2017, time=2017-11-10, status=1, ipAttribution=)]
    2017-11-27 135****7952平儿

    学了........

    0

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    2017-11-20 135****7952平儿

    学了........

    0

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    2017-11-10 有备才能无患

    时间过得很快.距离2015年8月医院通过JCI正式评审.成为中国大陆地区第48家通过JCI认证***之后!

    0

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    2017-11-10 flysky120

    希望能够学习到更好的医学

    0