变异管理对临床路径不断优化的作用分析

分析了临床路径在病种诊疗流程管理中产生的变异因素,并针对变异因素进行分类,针对不同变异类型采取有效的控制措施,为临床路径的持续改进提供保障。     

基于休哈特控制图的临床路径指标预警管理实践

目的 运用休哈特控制图对科室临床路径运行指标（完成比例、变异率）实施预警控制管理。方法 选择某科室2016年1—12月份临床路径运行数据,绘制该科室临床路径完成比例、变异率休哈特控制图（P控制图）,结合临床诊疗特点自设预警控制指标及控制点。结果 利用休哈特控制图（P控制图）,实时对该科室临床路径完成比例、变异率预警控制,分别针对该二项指标给予2次预警控制,督促分析整改。结论 休哈特控制图可以全面展现科室临床路径运行趋势、增加不同科室间临床路径运行的可比性、实时预警纠偏科室临床路径的不良运行,降低运行惯性;作为一项精细化管理的重要工具,要求实施者具有统计、临床、管理等相关知识储备。     

基于临床路径的“3+3”信息系统初探

医院信息化管理已成为当代医院管理的重要手段,信息化平台也成为临床运作的重要工具。临床路径信息化管理是医院发展的主要趋势。上海交通大学附属第六人民医院作为卫生部试行临床路径管理的试点医院,在临床路径实施过程中,创新管理运作模式,提出了基于临床路径的“3+3”信息系统。介绍了该系统的架构、设计理念及其应用成效。该系统是临床路径实施信息化管理的实践应用。实践证明,使用信息化手段推动临床路径的试点实施,达到了强化医院精细化管理的目的。     

临床路径管理实践中若干问题探讨

临床路径是一种质量效益型医疗管理模式,在现代医院管理中广泛应用。通过实施临床路径,可以规范诊疗行为、提高医疗质量、保障医疗安全、促进医疗费用合理化、提高患者满意度。对临床路径管理实践中的常见问题进行了分析,并对相关问题提出了若干针对性的解决措施,包括加强临床路径知识再教育和再培训,强调多学科、多部门共同参与以及通过信息化建设提高变异管理效能等。     

DRGs付费试点与临床路径实施情况初步观察

疾病诊断相关组付费试点是继临床路径管理试点之后的又一项医药卫生体制改革内容。通过对北京地区某三级甲等医院开展DRGs付费试点工作前后的临床路径相关指标进行统计分析,得到结论为DRGs付费制度对临床路径在医院管理方面的应用起到有效的推动作用,有利于进一步提高医疗效率、保障医疗安全。     

电子病历系统对临床路径管理的影响研究

目的 探讨电子病历系统对临床路径管理的影响。方法 入选河北北方学院附属第一医院2014年1月—2014年6月进入临床路径管理的512例患者（包括胆囊结石腹腔镜胆囊切除术、慢性鼻-鼻窦炎、2型糖尿病3个病种）作为观察对象,其中258例患者采用电子病历系统进行临床路径管理,254例患者采用纸质病历系统进行临床路径管理,比较两组病历质量、路径变异率、病种治疗费用及患者满意度。结果 观察组甲级率明显高于对照组、乙级率明显低于对照组,差异均具有统计学意义（均P<0.05）;观察组路径变异率为7.8%（20/258）,显著低于对照组15.0%（38/254）,差异具有统计学意义（P＜0.05）;观察组3个病种的治疗费用均显著低于对照组,差异均具有统计学意义（均P＜0.05）;观察组患者满意度为95.3%（246/258）,显著高于对照组的77.2%（196/254）,差异具有统计学意义（P＜0.05）。结论 电子病历系统与临床路径管理结合有助于降低路径变异率,提高医护人员工作效率,降低医疗费用,提高患者满意度。     

急性缺血性脑卒中临床路径管理模式的优化及实践

目的 评价优化后急性缺血性脑卒中临床路径管理模式的优越性。方法 随机选取医院实施急性缺血性脑卒中治疗临床路径管理优化前后收治的急性脑梗死患者各200例,采用回顾性分析比较各组患者的相关指标。结果 路径优化管理后,患者诊疗等待时间缩短,疾病规范诊疗比率进一步提高,医护工作量大大减少,患者满意度进一步提高。结论 实施临床路径能够改善医疗质量,更好地利用医疗资源。临床路径优化后医疗质量进一步提高。     

临床路径过程质量的分层管理

目的 临床路径实施中的持续改进。方法 采用专家咨询法和文献查阅设定临床路径过程质量的评价指标及权重系数;对每项指标与医院3年平均值或医保规定标准值比较的差值设定4个等级分数,再将各指标的评分求和即得出被评价病种的最终量化的评价结果。以此标准计算每季度入径病种总得分及各指标得分。结果 根据病种总得分与路径文本应得总分按百分比进行符合度比较,符合度低的病种优先干预;病种中影响总得分程度最大的评价指标（即得分最低的）作为下一季度优先干预的环节。结论 建立临床路径过程质量的评价体系,有利于临床路径过程质量的分层管理,是促进临床路径实施过程持续改进的一种管理模式。     

我院优化临床路径环节质控的策略和实践

临床路径作为一项有效的管理方法,在保障医疗安全和提高医疗效率中发挥了重要作用。以医院开展临床路径工作的实践经验为基础,从组织管理和执行实施两个方面,介绍了以加强环节质量控制及提高执行效率为目的的临床路径建设及持续优化策略,探讨完善临床路径管理的有效方法。     

实施临床路径的医院概况及其成因分析

目的 通过对我国实施临床路径的医院的情况进行描述、分析,发现其中存在的问题,提出建议。方法 文献研究法,即分析以“临床路径”为关键词,在维普中文科技期刊数据库中搜索到的1 051篇相关文献,同时结合查阅互联网上的相关信息以及电话回访核对信息的方法。结果 我国实施临床路径的医院有162家,占全国医院总数的0.82%;162家医院在全国的分布情况为：华东、华中、华北、华南、东北、西南和西北分别占37.7%、17.9%、14.8%、13.0%、7.4%、4.9%和4.3%;实施临床路径的医院在级别和隶属关系上存在不同,三级医院实施的数量要多于其他级别的医院;82.7%的医院实施临床路径的病种数量少于10个,4.8%的医院实施的病种数量在50个以上;临床路径实施的持续时间平均为2.02年。结论 我国实施临床路径的医院数量少,区域分布不平衡,进入临床路径的病种数量相对较少,病种较单一;临床路径实施的持续时间较短。我国临床路径的实施与推广,需要政府政策、医院、患者多方面的努力,为临床路径的实施与推广奠定更好的基础。     

Analysis of macrophyte indicator variation as a function of sampling,temporal, and stressor effects

Biological indicators that signal changes in lake condition are essential tools for guiding resource management decisions. Macrophyte-based indicators have traditionally been selected and evaluated in the context of nutrient-based stressors, although the need to evaluate indicators that are sensitive to climate stressors has been increasingly relevant. Moreover, indicators should ideally exhibit minimal sampling variation and have low natural temporal variation so there is high power to detect changes in the mean value over time. Eight macrophyte indicators were estimated in 23 Minnesota (USA) lakes using four years of repeated surveys to estimate sampling and temporal variation, response to development (phosphorus concentration) and climate stress (annual growing degree days), and power to detect significant change at various annual sampling intervals. Indicators included a macrophyte index of biotic integrity, floristic quality index, maximum depth of growth, total species richness, common species richness, mean richness, and frequency occurrence of rooted species and Chara sp. Overall, regression and smoothed additive models indicated significant relationships of indicators to total lake phosphorus and mean annual growing degree days. The macrophyte index of biotic integrity, floristic quality index, and the frequency rooted species had minimal sampling variation in this study, were responsive to development or climate stress, and had low annual variation (coefficients of variation 0.08, 0.10, and 0.19, respectively) resulting in high to moderate power (>50%) for detecting significant change over a 20 year period. Results from these analyses will facilitate the use of precise and powerful indicators that respond to stressors that are of concern for the management of freshwater glacial lakes.     

Quantifying Patterns of Change in Marine Ecosystem Response to Multiple Pressures

The ability to understand and ultimately predict ecosystem response to multiple pressures is paramount to successfully implement ecosystem-based management. Thresholds shifts and nonlinear patterns in ecosystem responses can be used to determine reference points that identify levels of a pressure that may drastically alter ecosystem status, which can inform management action. However, quantifying ecosystem reference points has proven elusive due in large part to the multi-dimensional nature of both ecosystem pressures and ecosystem responses. We used ecological indicators, synthetic measures of ecosystem status and functioning, to enumerate important ecosystem attributes and to reduce the complexity of the Northeast Shelf Large Marine Ecosystem (NES LME). Random forests were used to quantify the importance of four environmental and four anthropogenic pressure variables to the value of ecological indicators, and to quantify shifts in aggregate ecological indicator response along pressure gradients. Anthropogenic pressure variables were critical defining features and were able to predict an average of 8-13% (up to 25-66% for individual ecological indicators) of the variation in ecological indicator values, whereas environmental pressures were able to predict an average of 1-5 % (up to 9-26% for individual ecological indicators) of ecological indicator variation. Each pressure variable predicted a different suite of ecological indicator’s variation and the shapes of ecological indicator responses along pressure gradients were generally nonlinear. Threshold shifts in ecosystem response to exploitation, the most important pressure variable, occurred when commercial landings were 20 and 60% of total surveyed biomass. Although present, threshold shifts in ecosystem response to environmental pressures were much less important, which suggests that anthropogenic pressures have significantly altered the ecosystem structure and functioning of the NES LME. Gradient response curves provide ecologically informed transformations of pressure variables to explain patterns of ecosystem structure and functioning. By concurrently identifying thresholds for a suite of ecological indicator responses to multiple pressures, we demonstrate that ecosystem reference points can be evaluated and used to support ecosystem-based management.     

Eastern spread of the invasive <Emphasis Type="Italic">Artemia franciscana</Emphasis> in the Mediterranean Basin,with the first record from the Balkan Peninsula

Long-term (1987–2015) monitoring data from Lake Lugano (Switzerland/Italy) were used to examine the effects of winter weather, solar radiation and mixing regime on the recovery of the trophic state of a lake undergoing nutrient management. Main hypotheses were that (H1) trends in trophic state were influenced not only by nutrient management, but also by winter weather and solar radiation, and (H2) the effects of management were more pronounced in the holomictic South basin than in the meromictic North basin of the lake. External loadings of phosphorus were strongly reduced during the study period, but key indicators of trophic state, including phosphorous concentration, primary production, chlorophyll a and deep-water oxygenation, showed inconsistent responses. Supporting H1, winter weather (parameterized using an index of the East Atlantic pattern) influenced temporal variation in phosphorus concentration and primary production in the North basin. Supporting H2, the effects of management on trophic state were clearer in the South basin, where most trophic-state indicators declined. Meromixis affected the restoration of the North basin lake by transmitting effects of climatic variation on trophic state. The added variability obscured the effects of restoration and caused sudden deteriorations in water quality, indicating that the restoration of meromictic lakes presents unique challenges.     

Quality Indicators for Continuous Monitoring to Improve Maternal and Infant Health in Maternity Departments: A Modified Delphi Survey of an International Multidisciplinary Panel

Objective

Measuring the quality of inpatient obstetrical care using quality indicators is becoming increasingly important for both patients and healthcare providers. However, there is no consensus about which measures are optimal. We describe a modified Delphi method to identify a set of indicators for continuously monitoring the quality of maternity care by healthcare professionals.

Methodology and Main Findings

An international French-speaking multidisciplinary panel comprising 22 obstetricians-gynaecologists, 12 midwives, and 1 paediatrician assessed potential indicators extracted from a medical literature search, using a two-round Delphi procedure followed by a physical meeting. Each panellist rated each indicator based on validity and feasibility. In the first round, 35 panellists from 5 countries and 20 maternity units evaluated 26 indicators including 15 related to the management of the overall population of pregnant women, 3 to the management of women followed from the first trimester of pregnancy, 2 to the management of low-risk pregnant women, and 6 to the management of neonates. 25 quality indicators were kept for next step. In the second round, 27 (27/35: 77%) panellists selected 17 indicators; the remaining 8 indicators were discussed during a physical meeting. The final set comprised 18 indicators.

Conclusion

A multidisciplinary panel selected indicators that reflect the quality of obstetrical care. This set of indicators could be used to assess and monitor obstetrical care, with the goal of improving the quality of care in maternity units.     

Quality Indicators for Safe Medication Preparation and Administration: A Systematic Review

Background

One-third of all medication errors causing harm to hospitalized patients occur in the medication preparation and administration phase, which is predominantly a nursing activity. To monitor, evaluate and improve the quality and safety of this process, evidence-based quality indicators can be used.

Objectives

The aim of study was to identify evidence-based quality indicators (structure, process and outcome) for safe in-hospital medication preparation and administration.

Methods

MEDLINE, EMBASE and CINAHL were searched for relevant studies published up to January 2015. Additionally, nine databases were searched to identify relevant grey literature. Two reviewers independently selected studies if (1) the method for quality indicator development combined a literature search with expert panel opinion, (2) the study contained quality indicators on medication safety, and (3) any of the quality indicators were applicable to hospital medication preparation and administration. A multidisciplinary team appraised the studies independently using the AIRE instrument, which contains four domains and 20 items. Quality indicators applicable to in-hospital medication preparation and administration were extracted using a structured form.

Results

The search identified 1683 studies, of which 64 were reviewed in detail and five met the inclusion criteria. Overall, according to the AIRE domains, all studies were clear on purpose; most of them applied stakeholder involvement and used evidence reasonably; usage of the indicator in practice was scarcely described. A total of 21 quality indicators were identified: 5 structure indicators (e.g. safety management and high alert medication), 11 process indicators (e.g. verification and protocols) and 5 outcome indicators (e.g. harm and death). These quality indicators partially cover the 7 rights.

Conclusion

Despite the relatively small number of included studies, the identified quality indicators can serve as an excellent starting point for further development of nursing specific quality indicators for medication safety. Especially on the right patient, right route, right time and right documentation there is room future development of quality indicators.     

Effective Coverage and Systems Effectiveness for Malaria Case Management in Sub-Saharan African Countries

Scale-up of malaria preventive and control interventions over the last decade resulted in substantial declines in mortality and morbidity from the disease in sub-Saharan Africa and many other parts of the world. Sustaining these gains will depend on the health system performance. Treatment provides individual benefits by curing infection and preventing progression to severe disease as well as community-level benefits by reducing the infectious reservoir and averting emergence and spread of drug resistance. However many patients with malaria do not access care, providers do not comply with treatment guidelines, and hence, patients do not necessarily receive the correct regimen. Even when the correct regimen is administered some patients will not adhere and others will be treated with counterfeit or substandard medication leading to treatment failures and spread of drug resistance. We apply systems effectiveness concepts that explicitly consider implications of health system factors such as treatment seeking, provider compliance, adherence, and quality of medication to estimate treatment outcomes for malaria case management. We compile data for these indicators to derive estimates of effective coverage for 43 high-burden Sub-Saharan African countries. Parameters are populated from the Demographic and Health Surveys and other published sources. We assess the relative importance of these factors on the level of effective coverage and consider variation in these health systems indicators across countries. Our findings suggest that effective coverage for malaria case management ranges from 8% to 72% in the region. Different factors account for health system inefficiencies in different countries. Significant losses in effectiveness of treatment are estimated in all countries. The patterns of inter-country variation suggest that these are system failures that are amenable to change. Identifying the reasons for the poor health system performance and intervening to tackle them become key priority areas for malaria control and elimination policies in the region.     

Implications of Liebig's law of the minimum for the use of ecological indicators based on abundance

Many ecological responses to environmental variables or anthropogenic agents are difficult and expensive to measure. Therefore it is attractive to describe such responses in terms of indicators that are easier to measure. In ecosystem management, indicators can be used to monitor spatial and temporal changes in an environmental feature. The aim of this paper is to show that it is important to take Liebig's law of the minimum into consideration to understand when it is appropriate or inappropriate to use ecological indicators based on abundance. When developing indicators that relate the abundance of an organism to an environmental factor, it is likely that this relationship will be polygonal rather than a simple linear relationship. The upper boundary of the distribution describes how abundance is limited by this factor, while the variation below the upper boundary is explained by situations when factors other than the factor of interest limit abundance. The variation below the upper boundary of the distribution means that the use of indicators to examine spatial patterns in the response of abundance to an environmental factor can be problematic. Thus, while abundance-based indicators can identify sites that are in a good condition, they are less useful to detect those affected by environmental degradation. In contrast, abundance-based ecological indicators may enable temporal monitoring of the impact of environmental factors, as it is expected that limiting factors are less variable in time than in space. In conclusion, when multiple factors are limiting, a significant correlation between an indicator and a variable is not enough to validate the status of a factor as an indicator.     

Selecting indicators of soil, microbial, and plant conditions to understand ecological changes in Georgia pine forests

Characterizing how resource use and management activities affect ecological conditions is necessary to document and understand anthropogenic changes in ecological systems. Resource managers on military installations have the delicate task of balancing the training needs of soldiers effectively with the need to maintain a high quality of ecological conditions. This study considers ways that ecological indicators can provide information on impacts that training has on environmental characteristics that occur at different scales and in different sectors of the environment. The characteristics examined include soil chemistry, soil microbes, and vegetation. A discriminant function analysis was conducted to determine whether ecological indicators could differentiate among different levels of military use. A combination of 10 indicators explained 90% of the variation among plots from five different military use levels. Results indicated that an appropriate suite of ecological indicators for military resource managers includes soil, microbial, and vegetation characteristics. Since many of these indicators are related, managers at this location potentially have freedom to choose indicators that are relatively easy to measure, without sacrificing information.