Quality Improvement & Patient Safety

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1 진료지침과진료계획표 - CP 개발및적용을통한질향상활동 이화여자대학교목동병원

2 Safety & Quality "Aims for Improvement." health care should be safe effective patient-centered timely efficient equitable Institute of Medicine, Crossing the Quality Chasm: A New Health System for the 21 st Century, 2001

3 For Improvement 1. Standardizing care to remove unnecessary steps 2. Utilizing checklists to plan, operate, and manage daily activities 3. Learning from defect

4 Standardization Variation is a critical element in health care systems standardization of care processes Clinical Practice Guidelines CP(clinical pathways)

5 CP 의시작 목표 자원사용에있어서효율성향상 정해진시간내에업무종료 adaptation of the documents used in industrial quality management, the Standard Operating Procedures (SOPs) New England Medical Center (1985)

6 Clinical pathways clinical pathways integrated care pathways critical pathways care plans care paths care maps... 진료지침, 진료계획표

7 Standard definition of CPGs "Clinical practice guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances." 특정한임상적상황에서제공되는의료서비스에대해의료진과환자의적절한의사결정에도움을주기위하여체계적으로개발된진술 Field MJ, Lohr KN. Guidelines for clinical practice: from development to use. Institute of Medicine, Washington, D.C: National Academy Press Field MJ, Lohr KN. Clinical Practice Guidelines: Directions for a New Program, Institute of Medicine, Washington, DC: National Academy Press. 1990

8 Clinical Pathways structured, multidisciplinary plans of care designed to support the implementation of clinical guidelines and protocols provide detailed guidance for each stage in the management of a patient treatments, interventions etc.... with a specific condition over a given time period, and include progress and outcomes details.

9 Clinical Pathways 진료계획표 환자진료목표를설정하고이를효율적으로달성하기위하여진료활동의순서와시점을제시한환자관리계획 시간과업무의교차표 Time-task matrix

10 Clinical guidelines/clinical pathways Clinical (practice) guidelines provide generic recommendations Clinical pathways detail the local structure, systems and time-frames to address these recommendations

11 진료지침 & 진료계획표 Steven D. Pearson, Dorothy Goulart-Fisher, Thomas H. Lee, Critical Pathways as a Strategy for Improving Care: Problems and Potential, Ann Intern Med. 1995;123(12):

12 차이점 진료지침 진료계획표 진료의적절성에대한의사결정에초점 진료의질적수준유지효율성에초점 주된개발자의사 환자진료관련여러분야의의료제공자 시간개념없음 시간개념포함 의무기록과무관 의무기록일부이용

13 Examples: Clinical guidelines Australian and New Zealand Society of Blood Transfusion Ltd(2011) 질병관리본부 (2013) WHO(2002)

transfusion Blood Sampling Storage & Transport Administration

14 Examples: Clinical guidelines Indication for transfusion Consent For Blood Products Prescription Of Blood Products Requests & Pre transfusion Blood Sampling Storage & Transport Administration Special Transfusion Circumstances Management & Reporting Of Adverse Events

15 Examples: Clinical guidelines 뇌졸중임상연구센터 (2013)

16 Examples: Clinical Pathways DAY 1 => DAY 5

17 Examples: Clinical Pathways

18 Clinical pathways Multidisciplinary management tool based on evidence-based practice

19 CP 의기대효과 위험감소 진료과정 주요의사결정단계관련절차 양질의진료제공 근거기반의료활용 일관적절차 의료의질향상 의료서비스누락과중복방지 진료지원체계개선 진료효율성제고 환자만족도향상 환자이해도증가 교육효과증가 직원만족도향상 임상진료절차표준화 업무간소화 효율적의사소통

20 Clinical pathways: effects on. professional practice e.g. quality of documentation patient outcomes e.g. mortality, complications length of hospital stay hospital costs The Cochrane Collaboration. Clinical pathways: effects on professional practice, patient outcomes, length of stay and hospital costs (Review) (2010)

21 Critical Pathway( 인증기준 ) Ref> JCI Standards/ 의료기관인증기준

22 진료지침개발 목적 진료지침을개발하고표준화하여진료과정에서의위험을감소하고, 근거기반의료를활용한양질의진료를제공하기위해 규정 임상진료를가이드하기위한진료지침을선정, 개발, 수행, 평가.

23 진료지침개발 진료지침관리를위한리더의역할 진료지침을집중적으로적용할우선순위영역을매년선정 우선순위영역선택 진료지침을적용함으로써환자진료의질과안전이개선 바람직하지않은편차가감소 Select the area of practice diagnoses, higher costs, higher volumes, higher mortality, higher length of stay, greater number of outcome variations. 환자집단 (Patient Group) 질병 (Disease) 진단 (Diagnosis) 관련성평가 시술 (Procedure) 수술 (Surgery)

24 진료지침개발 리더의역할 진료지침개발및수행격려 진료지침의권위있는출처에의한과학적근거를평가 진료지침을공식승인 : 위원회 진료지침수행모니터 진료지침수행하기위해관련직원을훈련하도록지원

25 진료지침개발 부서의역할 적합한진료지침제안 개발하여표준화된업무가이루어지도록할책임 직원이정해진진료지침에따라업무를수행하도록교육 모니터링하여경영진에보고 편차가감소했음을입증 주기적으로갱신 근거자료의변경이나절차, 성과의평가를기반으로

26 진료지침개발 개발및지원체계 주제제안 QPS 센터검토논의 QPS 위원회 팀구성절차검토문헌고찰 CP / CPG 개발변이분석 적용 필요시, CP / CPG 변경 모니터링

27 진료지침개발 진료지침선정과정 다빈도발생 가능성 재원일수 단축가능성 고위험진료 여부 진료지침우선순위표 적용 / 실행 용이성 변이발생 가능성

28 진료지침개발 진료지침의개발과정 팀구성 현재진료 과정평가 문헌고찰 진료지침 개발 환자교육 자료개발 직원교육 변이분석

29 < 진료지침개발과정 Flow map> CP 의경우, 환자교육까지개발 변이계획에서미리결정되어진내용이이루어지지않았거나기대되어진결과가이루어지지않은상태 국내외문헌검토승인된임상지침참고 적용대상환자군의의무기록검토 ( 재원일수, 처방내역등 ) 의사, 간호사, 약사, 영양사, 검사실, 행정부문등

30 진료지침개발 다학제팀구성 부서를대표할수있는자가참여 각각의역할을분담 의사, 간호사, 약사, 영양사, 검사실, 행정부문등다양한분야의실무자포함

31 < 팀구성 > 구성원역할공통역할 의사간호사약사영양사사회사업사원무팀 진료과정결정, 의사교육수행과정의전반적관리와조정임상결과중심의평가틀개발및평가수행 간호과정결정, 간호수행전체적인진료수행과정의관리와조정간호사교육환자용교육자료준비및상담 교육 투약업무개발 영양, 식이개발 사회상담부분개발 입 퇴원시점의업무수행개발 1. 적용및효과분석 2. 목표에대한평가 3. 진료의질관리와모니터

32 진료지침개발 현재진료과정평가 객관적자료 적용대상환자군의의무기록검토 예시 : 재원일수, 처방내역, 비용분석등 환자치료과정의중간결과 절차의중요한단계 고가의의료비가필요한부분등

33 진료지침개발 문헌고찰 효율성을높이고불필요한일을방지하기위해서국내외문헌검토 현행되는과학적근거기반 전문협회또는위원회, 국제기구에의해승인된임상지침참고

34 진료지침개발 진료지침개발 수집된자료를바탕으로진료지침개발 Elements of care for each professional Evaluation of patients multidimensional needs Education of patients and families Planning of patients pathway Planning and execution of diagnostic exams Execution of interventions or procedures Activation of specialty consultancies Management of pharmacological therapy Management of nutrition Management of activities and patients safety

35 진료지침개발 고려할점 the Right Care for the Right Person at the Right Time in the Right Way Potential~ Overuse Misuse Underuse

36 진료지침개발 환자교육자료개발 시간 - 업무 (Time-Task) 형식 예 > 백내장, 제왕절개술, 자궁절제술, 뇌졸중

37 < 시간 - 업무 (Time-Task) 형식 >

38 진료지침개발 변이분석 변이 계획에서미리결정되어진내용이이루어지지않았거나기대되어진결과가이루어지지않은상태 변이발생시고려사항 변이를어떻게알수있는지 어떻게분류해야하는지 언제기록해야하는지 변이발생시누가시정해야하는지

39 진료지침개발 진료지침게시 원내게시판에공지 새로운진료지침 개정된진료지침등 처방전달시스템 (OCS ; Order Communication System) 내 [ 표준진료지침 ] 활용 관련부서직원이공유할수있도록 To understand To apply To ensure effective integration & coordination

40 진료지침개발 직원교육 직원이진료지침을수행할수있도록 대상 : 진료지침관련직원 교육 / 훈련

41 진료지침개발 지표관리 모니터링 잘수행되고효과적인지 분기별모니터링 Indicator

42 진료지침개발 지표관리 모니터링항목 적용률, 탈락률 변이발생률, 추가처방 (order) 발생률 between the one in practice and the recommended CP 재원일수 총진료비용 환자, 보호자, 직원만족도 patients outcomes

43 Examples: before & after the implementation of the clinical pathway Panella, M(2003). "Reducing clinical variations with clinical pathways: do pathways work?". Int J Qual Health Care 15 (6):

44 진료지침개발 진료지침갱신 모니터결과 절차, 성과의평가를기반으로 근거자료의변경 주기적으로검토 매년 / 2 년마다

45 진료지침개발 예시 임상경로 (CP) 수정체대절개수술 편도및아데노이드절제술 충수절제술 제왕절개분만등 임상실무지침 (CPG) 일혈환자관리 수술전항혈전제및항혈소판제제사용 Fast Track: Stroke, AMI, Postpartum bleeding 등

46 진료지침개발 개발및적용과정에서어려운점 경영진의지 직원참여유도 효율성검토 지속적인관리

47 경청해주셔서감사합니다

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untitled . Clancy CM et al Evidence based decision making:global evidence local decision Health affairs Clancy CM et al, Evidence-based decision making:global evidence, local decision. Health affairs. 2005;24:151