提升出院準備服務通報率之改善專案

A Project to Improve the Referral of Discharge Planning

本專案目的為提升本院內外科病房出院準備服務通報率。經現況分析發現，內外科病房護理人員24小時出院準備服務通報率僅31.9%.經由個別訪談及問卷調查分析通報率偏低的主因包括：篩選表單標準不一致、缺乏在職教育訓練、人員對出院準備服務認知不足、通報流程不便。經由專案小組討論及文獻查證後，修訂出院準備服務篩選表單與作業手冊，並取得院方同意將通報流程電腦化，經舉辦在職教育及宣導後，該單位同仁對出服的認知自35.7%提高為95.7%.通報率逐月上升，推動三個月後平均達84.7%。值得一提的是專案實施後，本院與安養機構建立了雙向溝通的管道，主動提供出院後定期追蹤、照護指導與諾詢服務，獲得機構極大的回應與肯定，此乃非預期的重大收穫，讓本院發揮更大社區醫療的功能。

This study aims to improve the referral rate for patient discharge planning in both medical and surgical wards. The current referral rate of patient discharge planning within 24 hours is only 31.9%. The four main causes of low referral rate based on interview and survey showed inconsistence in screen standards, lack of on-job training, lack of related knowledge on discharge service, and inconvenience in the referral process. Through literature review and the project team's discussion, the screening protocol and the operational manual for referral were revised. The referral process was updated and computerized. After staff on-job training and reinforcement of the process of discharge planning, the monthly referral rate improved. Staff awareness of discharge planning increased from 35.7% to 95.7%. The referral rate increased to 84.7% within three months since the project started. In addition, an established communication channel between extended nursing facilities and the hospital, proactive and periodic follow-up after patient discharge, care guidance, and counsel service were highly recognized by partner organizations. These achievements showing the hospital's further functions in community services were unexpected.