ISO 9001 n ISO 14001 n ISO 22000

標準化平台建構 流程平台ISO 9001 n 環保平台ISO 14001 n 飲食平台ISO 22000 HACCP n 資訊平台ISO 27000 n 檢驗標準平台ISO 15490 n 職安平台OHSAS 18001 n 品質策略平台QM 9004 n 10/25/2021 42

TQM 地圖 設計 計畫 評估 監測 同意 輸入 QS QA QAs 指標 具 QC QS Quality standards 研究範疇，指標擬定 QA Quality assurance 了解如何確保品質 QAs Quality assessment QC Quality control QI 10/25/2021 追蹤 QI 了解如何監控，評估及結果 了解如何控制過程及結果 利用QC結果，進一步對於 Quality improvement 未來活動計畫QA From: Haglund , B. J. A. , Jansson , B. , Pettersson , B. & Tillgren , P. (1998). A quality assurance instrument for practioners. An example from Sweden. In Davies, J. K. & Macdonald, G. Quality, Evidence and Effectiveness in Health Promotion. Striving for Certainties. London and New York: Routledge. Pp. 93 -116. 44

W. Edward Deming Out of the crisis n n n 可以預防的 1900, Born @ Iowa 1921, BS of Electric Engineering@ U. Wyoming 1925, MS of mathematics and physics@ U. Colorado 1928, Ph. D of M&P @ U. Yale & Bell Telephone with Walter A. Shewhart (control chart & SPC) 1940, WWII for American War Standards 1951, Rebuilt postwar Japan's economy (Deming Prize): improving quality will reduce expenses while increasing productivity and market share. The Lady Tasting Tea by David Salsburg n In 1981, help Ford jump-start its quality movement. From Ford Embraces Six-Sigma Quality Goals, SME 2000 10/25/2021 45

Deming Wheel Plan Act Do Check 10/25/2021 From The Hospital Research and Education Trust, 1989 46

Joseph M. Juran 品質＝適合使用（fitness to use） n n n 1904, Born @ Romania 1924, BS of Electrical Engineering @ U. Minnesota & Western Electric 1941, Pareto principle : 80% of a problem is caused by 20% of the causes 1954, Japan JUSE for Quality Management 1966, QCC 1979, Juran Institute 10/25/2021 47

Joseph M. Juran 品質＝適合使用（fitness to use） n TQM 的提倡者 n n Resistance to change (cultural resistance) n n 1985年美國國防部創立 The root cause of quality issues. ”使用期間能夠滿足使用者的需求” n n 提供與需求一致的產品(或服務) 醫療的活動與結果能夠符合病人的需求 10/25/2021 48

Avedis Donabedian, MD, MPH father of quality assurance and poet n n n Born in Beirut, Lebanon on 7 Jan. 1919 1944, American University of Beirut as MD 1955, Harvard School of Public Health as MPH 1957, New York Medical College 1961, University of Michigan n 28 years 結構，過程，結果 9 Nov. 2000 die of Prostate cancer 10/25/2021 51

Avedis Donabedian, MD, MPH n 醫療品質評估指標 structure indicators n 過程面指標 process indicators n 結果面指標 outcome indicators n 結構面指標 10/25/2021 53

過程面指標 What is done? What happens in the medical interaction health care services- Avedis Donabedian n 就是生產作業管理的Process n n n Input, Process and Output 診療行為標準化，ISO 9002 診斷結果異常的追蹤比率 n 檢查排程的時間 n 緊急手術等候時間 n 10/25/2021 55

過程面指標 What is done? n n n n DM: % with a Hb. A 1 c check at least once a year DM: % with a retinal exam in a year CHF: % patients having LVEF OB: % of pregnant women receiving prenatal care in first trimester Pneumonia: % of patients have blood culture before antibiotics administration URI: % of antibiotics prescribed TB: % of patients complete a curative course of treatment within 12 months of initiation of treatment 10/25/2021 56

結果面指標 What happens? End results of health care practices and interventions- Avedis Donabedian n 預期性或非預期性 n 感染率 n 死亡率 n 合併症比率 n 醫療適當性的評估 n 10/25/2021 57

結果面指標 What happens? n n n Hemodialysis: % of patients with Hct=33% DM: % of Hb. A 1 c>9. 5%; <9%; <7% DM: admission for amputations Asthma: hospital admissions for pediatric asthma per 10, 000 population HTN: % of patients BP under control Cancer, AIDS: mortality rate 10/25/2021 58

“病人為中心”─常見指標 n 病人就醫經驗 n n n % of patients who report that doctor listens carefully, adults and parents of children % of patients who report that doctor spent enough time with them 就醫等候時間: n n % ED patients waiting for admission Waiting list Waiting for transplantation 排程等候時間 10/25/2021 59

醫療品質指標 Continuous Quality Improvement n 醫療品質指標效益 n 院外購買指標 n n TQIP (Taiwan Quality Indicator Project) THIS (Taiwan Healthcare Indicator Series) 院內自創指標： 6 sigma and DMAIC 系統化並長期監測 n n n 建立常模及參考點 品質趨勢及客觀測量 品質篩選 具及標竿學習 10/25/2021 62

醫療品質的國際發展趨勢 過去 現在 未來 Quality Control Quality Management Innovation Incremental Improvement Continuous Improvement Breakthrough Improvement Cost Down Cost Management Value Creation Use of Data Use of Information Use of Knowledge 10/25/2021 67

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