항균제 관리 필요성

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2 (IOM, 1990) The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.

3 Classification of Quality Problems Overuse Underuse Misuse From JAMA 1998;280:

6 Some Examples from Medical Literatures - Overuse & Underuse - Unnecessary surgery: 8-86%(Leape, 1992) No regular HbA 1 c & retinal exam. for many D.M. patients(weiner et al., 1995) Only14% of pt. with CV Ds. achieved recommended lipid level(mcbride et al., 1998). Failure to treat effectively AMI leads to 18,000 preventable deaths/yr(chassin & Galvin, 1998).

7 Some Examples from Medical Literatures - Misuse - In US 180,000 deaths/yr partly as a result of iatrogenic injuries(leape, 1994) In US 106,000 deaths/yr by fatal ADR among inpatietns(lazarou et al., 1998) Fatal medication errors in US doubled among outpatients btw & 1993(Phillips et al, 1998). Lower quality of care within hospitals for black & the uninsured(kahn et al., 1994; Burstin et al, 1992)

8 QI Implicit case review Medical audit Problem-oriented studies Ongoing monitoring of departmental indicators Systems thinking Practice guidelines Outcomes management TQM/CQI Organization-wide continuous improvement in performance

9 Performance What How well Results Health outcomes Costs Satisfaction Judgment Quality Value

10 (JCAHO) What is done (efficacy) (appropriateness) How it is done (availability) (timeliness) (effectiveness) (continuity) (safety) (efficiency) (respect and caring)

13 (customer focus) (understanding work as processes and systems) (testing changes) (emphasizing the use of data) (teamwork)

14 (external customer) (internal customer)

15 (root cause analysis) bad apple syndrome (medication error) Inputs Processes Outputs/Outcomes

16 : 6. 3 vincristine 5mg IV order ( ). order...

17 ..,. order., ( ).,. 5 45

20 : : I II

22 You can t manage what you can t measure. PDCA Cycle: Plan-Do-Check-Act

24 (Individual Problem Solving) (Rapid Team Problem Solving) (Systematic Team Problem Solving) (Process Improvement)

25 Q1 : Process Improvement : Q2 Q2 Individual Problem Solving : Q3 Q3 Systematic Team Problem Solving Rapid Team Problem Solving

26 When to use When you know the problem is dependent on only one person Teams Data Unnecessary Almost none Time Little

27 When to use When the team needs quick results and has a lot of intuitive ideas Teams Data Ad hoc Can succeed with little data Time Little

28 When to use When the problem is complex or recurring, requiring analysis Teams Data Ad hoc Need data to understand the causes of the problem Time Limited to the time necessary

29 When to use When a key process or system requires ongoing monitoring or continual improvement Teams Data Permanent Data from continuous monitoring; may need to collect more Time Continuous

30 QI FOCUS-PDCA FOCUS Find a process improvement opportunity Organize a team that knows a process Clarify the current knowledge of the process Understand causes of process variation Select the process improvement PDCA Plan - Do - Check - Act

31 QI FOCUS-PDCA FOCUS Find, Organize, Clarify, Understand, Select PDCA Plan the process improvement Do the improvement, data collection & analysis Check the results and lessons learned Act by adopting, adjusting, or abandoning the change

32 QI Assessment QI: FOCUS Improvement :, QI: PDCA

34 1

35 1

36 1?????

37 1 Brainstorming Data Collection The 7 Management Tools Affinity Diagrams Interrelationship Diagrams Tree Diagrams Matrix Diagrams Prioritization Matrices Process Decision Program Chart Activity Network Diagrams

38 2 (Internal customers) (External customers) / : Brainstorming

39 3???? /? /? :,

40 4 /?? : What..Who..Where..When..How? (Common cause variation) (Special cause variation)?

41 4 Brainstorming Cause and Effect Diagram Inverse Tree Diagram Multi-Voting Scatter Diagrams Run and Control Charts Histograms

42 Q1 vs. Q2:? : ( ), Q3 : ( ), Q4 Q3:? : Do Nothing, : Q4:?

44 5????

46 6,,,,?? Brainstorming Process Decision Program Charts

47 7

48 8????

49 8 Data Collection Scatter Diagrams Run and Control Charts Histograms Customer Surveys

50 9 (Hold the gain) (Adopt the change) (Adjust the change) (Abandon the change)

51 9,, orientation, feedback,, /, feedback,,,, /,,,

52 9?????

53 Four Steps to Quality Improvement Step 1: Identify Determine what to improves Step 2: Analyze Understand what must be known or understood about the problem in order to make improvement Step 3: Develop Hypothesize about what changes will yield improvement Step 4: Test & Implement Test the hypothesized solution to see if it yields improvement; based on the results, decide whether to abandon, modify, or implement the solution

54 Identify Individual decision making for a small problem that is not interdependent on others Analyze Relies on individual analysis, using existing data, observation, and intuition Develop The change is usually minor and not interdependent on others Test & Implement Trial and error approach to testing

55 Identify An ad hoc team identifies an intuited or obvious problem based on intuition, observation, and existing data Analyze Generally requires minimal analysis using mainly existing data and group intuition Develop A series of small changes Test & Implement Many small to medium tests in similar systems

56 Identify An ad hoc team addresses a complex, recurring problem Analyze The team examines the problem to try to identify its root causes; existing data and/or data collection is used Develop Generally large change that addresses the root cause of the problem Test & Implement Generally requires extensive testing before implementation.

57 Identify A permanent team addresses a core process or issue in a large process or system Analyze Requires detailed process knowledge from on-going data collection and monitoring Develop A change in a key process Test & Implement Depends on the approach used and magnitude of the change; permanent teams continue to monitor and improve the process

58 : Find, Organize Clarify : 11.8 ( 9.1 ) Understand (+) Select

59 : Plan Do (2nd) : 120 ml/day 3ml/Kg/day 4 Check : : 0/19 0/18 : Act

60 Make a new organizational culture Consider cost of poor quality Focus on System/Process Do the right thing right the first time Communicate success stories Use positive enforcements Encourage team approach & integration

항균제 관리 필요성

항균제 관리 필요성 6. 3 vincristine 5mg IV order ( ). order... ..,. order.,. 5 20 1. ( 110 74 ).,. 5 45 : Quality of care is the degree to which health services for individuals and populations increase the likelihood of