Total Quality Management & Hospital management 全面质量管理与医院管理

1. Total Quality Management & Hospital management全面质量管理与医院管理 夏萍 Nancy Xia Guangdong Province Hospital of TCM

2. 案例1 • 某医院妇产科值班助产士带领护校的实习生值小夜班。22时30分，两人一起处理完两个产妇后，助产士去取夜餐。回来后，实习护士准备给婴儿配奶，并问助产士怎样配方，奶粉和水的比例怎样掌握？答：“一般配就行了”。给婴儿喂奶完后，即给上午出生的3名婴儿配葡萄糖水。 • 实习护士从壁橱最底层的3瓶粉剂中顺手拿出其中已用过的一瓶问助产士：“这是不是葡萄糖？”她连头也未抬，信口答复：“是！”实习护士便配成“糖水”喂了3名婴儿。次日凌晨1时30分，第一例婴儿出现呼吸衰竭，抢救50分钟后无效，于2时20分死亡。医务人员进行讨论，认为婴儿死得突然，诊断不清，以致抢救难以奏效。4时40分，第2例婴儿出现面部紫绀，呼吸困难；5分钟后第3例女婴也出现相同症状。立即请来儿科主治医师会诊，考虑是亚硝酸钠中毒，虽经积极抢救，终因中毒较重，两名女婴相继死亡。

3. 案例1分析 • 事后查实，此3瓶粉剂是已存放十几年的亚硝酸钠盐。由于本科老师人实习学生不需配亚硝酸钠溶液，因而未向实习护士说明此3瓶粉剂是剧毒药，不能随便动用，同时也未加锁。 • 上述案例3名婴儿死于硝酸钠中毒。此药为剧毒药品，本应由专人妥善保管，上锁存放，但竟然在新生儿配奶用的壁橱内存放此剧毒药达几十年，虽曾有数人发现，均未引起重视，足见管理上的严重失职。特别是作为带教老师的助产士，面对实习护士，明知橱内有剧毒药，本应认真负责，谨慎从事，放手不放眼，而她却不亲自查对，顺口便答“是”。以致造成3名婴儿死亡，完全丧失了一个医务人员应有责任感，是一种失职犯罪行为。助产士是本案的主要责任者，本例定为一级医疗责任事故。

4. 案例2 • 患者女性，24岁，因腰痛1年，逐渐加重住院。检查：体温37度，发育营养中等，第9、10腰椎明显凸，拾物实验（+）。脊柱X线片第9、10腰椎骨破坏、死骨形成，第9-11腰椎有椎旁脓肿。诊断为第9、10腰椎结核。某大医院骨科医师甲以个人名义被邀作主刀医师，在全麻下经胸做病灶清除加植骨手术。术中清病灶时，刮出一黄豆粒大小的白色物，助手和本院医师乙疑为脊髓，再叫甲看。但甲没有认真视物就说是“脓苔”（后经病理证实是脊髓组织）。术后患者呈弛缓性截瘫。经当地治疗和护理后，转入甲所在医院。截瘫平面不见下降，自主膀胱形成，但因善后处理了纠纷，住院2年或始出院回当地休养。

5. 案例2分析 • 此案例明显属于术者操作过失，以致刮伤脊髓。据材料称，术者是一名有相当教学和临床经验的高年资骨科医师，当助手对刮出物提出疑问时，不予重视，也不认真查看刮出组织的外观，固执己见仍继续手术，使患者永久性截瘫，造成终身残废。本例定为二级医疗责任事故。

6. 案例3 • 患者男性，52岁，患胆囊炎、胆结石住院。在连续硬膜外麻醉下行胆囊切除及胆总管取石术后。术者甲（进修医师）、第一助手（带教医师）、第二助手（实习生）、器械护士（丙）、巡回护士（丁）。缝合腹膜前，医师乙三次嘱咐护士清点纱布，丙、丁两护士均报告术者纱布数无误，可以关腹。手术结束后，把病员安全送回病房。数日后患者腹痛、呕吐，于术后第13日晚因粘连性肠梗阻再次手术探查，开腹后反县腹腔留有一条纱布，取出后清洗腹腔关腹。术后患者恢复较好，住院2个月，痊愈出院。

7. 案例3分析 • 本案例关腹前医师乙三次催促丙、丁护士清点物品，但由于二人工作态度不认真，很不负责任地报告“纱布无误”，使纱布遗留在腹腔中，致肠梗阻发生及病员二次手术之苦。丙、丁二人属失职行为，为本例事故的主要责任者，定为三级医疗责任事故。

8. Overview 介绍 Total Quality Management is a management approach that originated in the 1950's and has steadily become more popular since the early 1980's. • Total Quality Management, TQM, is a method by which management and employees can become involved in the continuous improvement of the production of goods and services. It is a combination of quality and management tools aimed at increasing business and reducing losses due to wasteful practices.

9. The TQM philosophy of management is customer-oriented. All members of a total quality management (control) organization strive to systematically manage the improvement of the organization through the ongoing participation of all employees in problem solving efforts across functional and hierarchical boundaries.

10. Some of the companies who have implemented TQM include Ford Motor Company, Phillips Semiconductor, SGL Carbon, Motorola and Toyota Motor Company.

11. Definition of TQM 全面质量管理 • TQM is a management philosophy that seeks to integrate all organizational functions (marketing, finance, design, engineering, and production, customer service, etc.) to focus on meeting customer needs and organizational objectives.

12. TQM views an organization as a collection of processes. It maintains that organizations must strive to continuously improve these processes by incorporating the knowledge and experiences of workers. • The simple objective of TQM is "Do the right things, right the first time, every time".

13. TQM is infinitely variable and adaptable. Although originally applied to manufacturing operations, and for a number of years only used in that area, TQM is now becoming recognized as a generic management tool, just as applicable in service and public sector organizations. TQM must be practiced in all activities, by all personnel, in Manufacturing, Marketing, Engineering, R&D, Sales, Purchasing, HR, etc

14. Principles of TQM The key principles of TQM are as following : Management Commitment • Plan (drive, direct) • Do (deploy, support, participate) • Check (review) • Act (recognize, communicate, revise)

15. Training Suggestion scheme Measurement and recognition Excellence teams Employee Empowerment

16. Fact Based Decision Making • SPC (statistical process control) 》12 • DOE》13, FMEA 》14 • The 7 statistical tools • TOPS (FORD 8D - Team Oriented Problem Solving)

17. Continuous Improvement • Systematic measurement and focus on CONQ • Excellence teams • Cross-functional process management • Attain, maintain, improve standards

18. Customer Focus • Supplier partnership • Service relationship with internal customers • Never compromise quality • Customer driven standards

19. Statistical process control is the application of statistical methods to identify and control the special cause of variation in a process.》9 SPC -Statistical Process Control 统计过程控制

20. DOE- Design of Experiments试验设计 • A Design of Experiment (DOE) is a structured, organized method for determining the relationship between factors (Xs) affecting a process and the output of that process (Y). • Other Definitions:1 - Conducting and analyzing controlled tests to evaluate the factors that control the value of a parameter or group of parameters. • 2- "Design of Experiments" (DoE) refers to experimental methods used to quantify indeterminate measurements of factors and interactions between factors statistically through observance of forced changes made methodically as directed by mathematically systematic tables.

21. FMEA-Failure Modes and Effects Analysis 失效模式和效果分析 A procedure and tools that help to identify every possible failure mode of a process or product, to determine its effect on other sub-items and on the required function of the product or process. The FMEA is also used to rank & prioritize the possible causes of failures as well as develop and implement preventative actions, with responsible persons assigned to carry out these actions.Failure modes and effects analysis (FMEA) is a disciplined approach used to identify possible failures of a product or service and then determine the frequency and impact of the failure.》9

22. The Concept of Continuous Improvement by TQM 持续质量改进 • TQM is mainly concerned with continuous improvement in all work, from high level strategic planning and decision-making, to detailed execution of work elements on the shop floor. It stems from the belief that mistakes can be avoided and defects can be prevented. It leads to continuously improving results, in all aspects of work, as a result of continuously improving capabilities, people, processes, technology and machine capabilities. • 从宏观的战略计划和决策到具体工作中的细节实施，全面质量管理主要与工作中的持续改进有关。这源于这样一种理念：错误和缺陷是可以避免的。由于持续改进的能力，员工，过程，技术等原因，在工作中的各个方面由此产生了了持续改进的结果

23. Continuous improvement must deal not only with improving results, but more importantly with improving capabilities to produce better results in the future. • The five major areas of focus for capability improvement are demand generation, supply generation, technology, operations and people capability. • 持续改进的目的不仅仅是提高改进的结果，更重要的是提高未来创造更好结果的改进能力。 • 能力改进的五个重要因素是：需求方，提供方，技术，运作，员工能力。

24. A central principle of TQM is that mistakes may be made by people, but most of them are caused, or at least permitted, by faulty systems and processes. This means that the root cause of such mistakes can be identified and eliminated, and repetition can be prevented by changing the process. • TQM的一个重要原则是错误可能是由人为因素造成的，但是绝大多数的错误是由于有缺陷的系统或流程所造成的，至少也是因为这样有缺陷的系统或流程而提供了错误产生的机会。这意味着这样的错误是可以被鉴别和消除的，通过改进流程可以预防错误的重复发生。

25. Preventing mistakes (defects) from occurring (Mistake - proofing or Poka-Yoke). Where mistakes can't be absolutely prevented, detecting them early to prevent them being passed down the value added chain (Inspection at source or by the next operation). Where mistakes recur, stopping production until the process can be corrected, to prevent the production of more defects. (Stop in time). 从源头阻止错误的产生 不能完全预防错误产生的环节，要早期检查以防止错误朝下一个环节发生。 重复发送错误的环节，要及时停止其运作过程以防止更多缺陷的产生，直到流程被改正。 There are three major mechanisms of prevention: 如何预防？

26. . A preliminary step in TQM implementation is to assess the organization's current reality. Relevant preconditions have to do with the organization's history, its current needs, precipitating events leading to TQM, and the existing employee quality of working life. If the current reality does not include important preconditions, TQM implementation should be delayed until the organization is in a state in which TQM is likely to succeed TQM实施的一个基本步骤是对组织目前状况的评估。组织的历史、目前需求、突发事件和现有员工的素质都是TQM实施有关的先决条件。如果组织当前的状况不包括这些重要的前提条件，TQM应该推迟实施，直到组织达到这样一种状态，既在组织内实施TQM极有可能成功的状态。 Implementation Principles and Processes 怎样实施？何时实施？

27. If an organization has a track record of effective responsiveness to the environment, and if it has been able to successfully change the way it operates when needed, TQM will be easier to implement. If an organization has been historically reactive and has no skill at improving its operating systems, there will be both employee skepticism and a lack of skilled change agents. If this condition prevails, a comprehensive program of management and leadership development may be instituted. A management audit is a good assessment tool to identify current levels of organizational functioning and areas in need of change. An organization should be basically healthy before beginning TQM. If it has significant problems such as a very unstable funding base, weak administrative systems, lack of managerial skill, or poor employee morale, TQM would not be appropriate.

28. CQI in the health care industry持续质量改进在医疗服务管理上的应用 • 80年代，CQI应用于医疗服务质量管理，取得了较好效果。1992年美国卫生组织联合评审委员会（JCAHO）通过新方案，要求全美所有院长必须经过持续质量改进的原则、方法的培训。实践证明，CQI可以减少医疗服务中的差错、并发症以及伤口感染，减少病人用药不合理现象及不按时服药现象，降低病人围手术期死亡率，从根本上提高质量，降低医疗成本于减少浪费。

29. Method and Processes 方法与步骤 CQI提出了医疗服务的9项评价指标： • 服务水平 • 适宜性 • 持续性 • 有效性 • 效果 • 效率 • 患者满意度 • 安全性 • 及时性

30. 明确推荐指标的来源和资料收集方式；设计最终资料的收集方式和其他途径收集资料明确推荐指标的来源和资料收集方式；设计最终资料的收集方式和其他途径收集资料 确定评价实绩；考虑有利于确定重点的反馈信息；确定评估的重点；着手评估 成立提供医疗服务指标的小组；选定指标 确定每一个指标标准 选择标准评价模式 评价医疗服务是否得到提高（A）；假若没有（B），采取新的行动方案，重复（A）和（B），直到提高可以实现和维持，持续监督，周期性评价监测重点 小组吧结论、结果和措施与领导、相关个人、组织和服务部门进行交流，必要时江信息广泛传播，注意收集得到的反馈信息 组织领导； 设计和发展持续提高质量的道路；选定提高和评估的重点； 明确主要功能和流程，治疗及其他组织的活动 确定关键功能 和治疗程序 明确 任务 划定 医疗 服务 范围 明确 医疗 服务 重要 方面 确定 指标 建立 评价 标准 收集 整理 资料 评价 提出建立 行动提高 医疗质量 评定效果 保证质量 提高的连 续性 与相关 个人与 集体交 流结果

31. Principle of total quality management in hospital 医院全面质量管理的原则和理念 • 顾客第一 》25 • 全员参与 》26 • 过程管理 》27 • 持续质量改进 • 数据化原则 • 系统性原则

32. 病人，病人家属 • 外部顾客 社区居民 • 与医院提供服务相关单位 • 社会公益机构 • 医院顾客 • 医院固定性人员 • 内部顾客 • 研究生 • 非固定性人员 实习生 • 进修生 • 护工》24

33. 全员参与的核心是调动人的积极性。 • 如何调动人的积极性？ • 靠教育 • 靠规范》24 Maslow's Hierarchy of Needs

34. 病人就诊过程划分 • 病人诊疗过程管理：门、急诊诊疗服务过程、住院诊疗服务过程、医技诊疗服务过程、护理服务过程等。 • 与病人诊疗直接提供服务保障过程管理：医疗器械管理、药事管理、采供血管理、卫生被服管理、营养膳食管理、医疗收费服务管理等。 • 与病人诊疗间接提供服务保障过程管理：营房设备设施管理、医院信息系统管理和运行控制、通信管理、车辆管理、环境卫生管理、治安保卫管理、院内感染管理、放射卫生防护管理等。》24

37. 医院是一个系统，医疗质量是医院系统整体功能的综合体现。质量管理就是要应用系统管理思想的整体观，对医疗质量形成的各环节，对医疗质量产生的全过程实施全面管理。医院是一个系统，医疗质量是医院系统整体功能的综合体现。质量管理就是要应用系统管理思想的整体观，对医疗质量形成的各环节，对医疗质量产生的全过程实施全面管理。