【文章內(nèi)容簡介】 cording to quality improvement principles. ? The anization’ s leaders identify key measures in the anization’ s structures, processes, and outes to be used in the anizationwide quality improvement and patient safety plan. ? Individuals with appropriate experience, knowledge, and skills systematically aggregate and analyze data in the anization. ? The anization uses an internal process to validate data. ? The anization uses a defined process for identifying and managing sentinel events Quality Improvement and Patient Safety (QPS) 質(zhì)量改進(jìn)與患者安全 ? 醫(yī)院責(zé)任人和管理者參與質(zhì)量改進(jìn)、患者安全項(xiàng)目的計(jì)劃與監(jiān)控 ? 醫(yī)院按照質(zhì)量改進(jìn)原則重新設(shè)計(jì)或修定各種體系與流程 ? 在完善醫(yī)院結(jié)構(gòu)、流程及結(jié)果中，領(lǐng)導(dǎo)制定應(yīng)用于醫(yī)院領(lǐng)域質(zhì)量改進(jìn)和患者安全計(jì)劃的關(guān)鍵措施 ? 由具有相應(yīng)經(jīng)驗(yàn)、知識及技能的人員系統(tǒng)地收集和分析醫(yī)院數(shù)據(jù) ? 醫(yī)院用內(nèi)部程序確認(rèn)數(shù)據(jù) ? 醫(yī)院制定程序，確定和管理警哨事件 Quality Improvement and Patient Safety (QPS) 質(zhì)量改進(jìn)與患者安全 ? Data are analyzed when undesirable trends and variation are evident from the data. ? The anization uses a defined process for the identification and analysis of nearmiss events. ? Improvement in quality and safety is achieved and sustained. ? Improvement and safety activities are undertaken for the priority areas identified by the anization’ s leaders. ? An ongoing program of risk management is used to identify and to reduce unanticipated adverse events and other safety risks to patients and staff. Quality Improvement and Patient Safety (QPS) 質(zhì)量改進(jìn)與患者安全 ? 數(shù)據(jù)顯示不良趨勢和變異時(shí)，分析數(shù)據(jù) ? 對臨近差錯(cuò)事件的確認(rèn)和分析，醫(yī)院按既定程序辦理 ? 質(zhì)量與安全改進(jìn)到位并維持 ? 醫(yī)院領(lǐng)導(dǎo)確定的重點(diǎn)領(lǐng)域承擔(dān)了改進(jìn)與安全活動(dòng) ? 持續(xù)的風(fēng)險(xiǎn)管理程序應(yīng)用于確認(rèn)和減少對患者及員工的意外有害事件與其他安全風(fēng)險(xiǎn) Prevention and Control of Infections (PCI) 感染預(yù)防與控制 ? One or more individuals oversee all infection prevention and control activities. This individual(s) is qualified in infection prevention and control practices through education, training, experience, or certification. ? There is a designated coordination mechanism for all infection prevention and control activities that involves physicians, nurses, and others as based on the size and plexity of the anization. ? The infection prevention and control program is based on current scientific knowledge, accepted practice guidelines, applicable laws and regulations, and standards for sanitation and cleanliness. ? The anization’ s leaders provide adequate resources to support the infection prevention and control program. ? The anization designs and implements a prehensive program to reduce the risks of health care–associated infections in patients and health care workers. ? The anization uses a riskbased approach in establishing the focus of the health care–associated infection prevention and reduction program. Prevention and Control of Infections (PCI) 感染預(yù)防與控制 ? 一個(gè)或多個(gè)員工負(fù)責(zé)所有感染預(yù)防和控制活動(dòng)。通過教育、訓(xùn)煉、實(shí)踐或認(rèn)證，這些員工在感染預(yù)防和控制活動(dòng)中具有資質(zhì)。 ? 根據(jù)醫(yī)院大小和復(fù)雜性，對所有的感染預(yù)防和控制活動(dòng)，有一個(gè)指定的，包括醫(yī)師、護(hù)士和其他員工在內(nèi)的協(xié)調(diào)機(jī)制 ? 建立在現(xiàn)代科學(xué)知識、有效實(shí)用指南之上的感染預(yù)防和控制程序符合法律、法規(guī)及衛(wèi)生與清潔標(biāo)準(zhǔn) ? 醫(yī)院領(lǐng)導(dǎo)提供足夠的資源支持感染預(yù)防和控制程序。 ? 醫(yī)院設(shè)計(jì)并實(shí)施綜合方案，減少醫(yī)療風(fēng)險(xiǎn) ——患者和衛(wèi)生保健工作者的交叉感染。 ? 在建立醫(yī)療重點(diǎn) ——感染預(yù)防和減少方案中，醫(yī)院使用以風(fēng)險(xiǎn)為基礎(chǔ)的方法 Prevention and Control of Infections (PCI) 感染預(yù)防與控制 ? The anization identifies the procedures and processes associated with the risk of infection and implements strategies to reduce infection risk. ? The anization provides barrier precautions and isolation procedures that protect patients, visitors, and staff from municable diseases and protects immunosuppressed patients from acquiring infections to which they are uniquely prone. ? Gloves, masks, eye protection, other protective equipment, soap, and disinfectants are available and used correctly when required. ? The infection prevention and control process is integrated with the anization’ s overall program for quality improvement and patient safety. ? The anization provides education on infection prevention and control practices to staff, physicians, patients, families, and other caregivers when indicated by their involvement in care. Prevention and Control of Infections (PCI) 感染預(yù)防與控制 ? 醫(yī)院確定應(yīng)對感染風(fēng)險(xiǎn)的程序和過程，并實(shí)施減少感染感染風(fēng)險(xiǎn)的策略。 ? 醫(yī)院提供防范屏障和隔離程序，保護(hù)患者、探視者及員工免得傳染病，特別要保護(hù)來自易感人群的免疫抑制患者。 ? 提供手套、口具、眼罩 ,及其他防護(hù)設(shè)備、肥皂和消液 ,在需要時(shí)能正確使用。 ? 感染預(yù)防與控制整合于醫(yī)院總體質(zhì)量改進(jìn)和患者安全程序。 ? 醫(yī)院對必須參與治療的員工、醫(yī)師、患者、家屬及其他護(hù)理人員提供感染預(yù)防與控制教育。 Governance, Leadership, and Direction (GLD) 政府、領(lǐng)導(dǎo)和指南 ? Governance responsibilities and accountabilities are described in bylaws, policies and procedures, or similar documents that guide how they are to be carried out. ? A senior manager or director is responsible for operating the anization and plying with applicable laws and regulations. ? The anization’ s leaders are identified and are collectively responsible for defining the anization’ s mission and creating the plans and policies needed to fulfill the mission. ? Medical, nursing, and other leaders of clinical services plan and implement an effective anizational structure to support their responsibilities and authority. ? One or more qualified individuals provide direction for each department or service in the anization. ? The anization establishes a framework for ethical management that ensures that patient care is provided withi