某區域醫院自我發展品質指標初探研究

The exploratory study on quality indicators developing by a regional hospital

本初探性研究以中部某區域級教學醫院自我發展行政管理品質指標為例，遵循美國醫療機構評鑑聯合會（Joint Commission on Accreditation of Healthcare Organizations，簡稱JCAHO）指標衡量系統(Indicator Measurement System, IMSystem)架構，並根據財團法人醫院評鑑暨醫療品質策進會新制醫院評鑑需求、主管機關規定、專科醫學會評量基準以及各單位實務作業需要等構面，由單位開發多項行政管理指標定義，並採用JCAHO研發十步驟手法(Ten Step Procedure)定期進行指標數據之收集、分析和作業改善。個案醫院已有多年自行開發臨床醫護品管、醫療輔助品管與行政品質管理指標經驗，主要依循Deming P-D-C-A循環的精神，致力追求醫院全面品質管理的更高標準。希冀透過自我發展指標內容的經驗分享，作為他院執行品質指標計畫時，根據個別醫院運作之作業屬性，自行發展各項品質管理指標之參考。建議後續研究則可針對不同層級、屬性之醫院進行更深層的調查，了解個別醫院自我發展品管指標概況，並在整合各院執行模式後可進ㄧ步延伸出行政管理指標架構，在提升醫院管理品質的同時，提供民眾更安全、更具效率的醫療服務。

The exploratory research takes the administrative management indicator which is developed by a regional teaching hospital in central Taiwan as an example. Also, it follows the framework of Indicator Measurement System of American Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Besides, according to the new requirement assessment of Hospital Accreditation, the authority regulations, the basic valuation standard of the specialist medicine society and the practical operating needs in individual departments by Taiwan Joint Commission on Hospital Accreditation, they start to develop various definitions of administrative management indicators, and takes the Ten-step Procedure which is developed by JCAHO to collect the data of indicators on a regular time schedule to analyze and improve the whole operating procedure as well. There has been many experiences for years to develop the quality management of clinic medicine and nursing, supportive medication and the administrative management indicator in the case hospital. It follows the Deming P-D-C-A cycle to endeavor the higher standard of the quality management of the hospital. By sharing the experiences to develop the self-development of the content of the indicator, it could be a reference of various quality management indictors to other hospitals to operate and develop new indicators according to individual attributes. We suggest that in the following research, it might focus on the deeper investigation on different levels and attributes to understand the self- developmental condition of individual hospitals. And it could integrate various operating models to further extend the framework of administrative management indicators. By doing so, it could provide safer and more efficient medical services to the public while improve the quality of hospital management.