以病人為焦點的查證模式（Patient Focus Method, PFM）之評鑑準備──以臺中榮民總醫院經驗為例

Prepare for hospital accreditation with patient-focus method:the experience of Taichung Veterans General Hospital

財團法人醫院評鑑暨醫療品質策進會推廣以病人為焦點的查證模式（Patient Focus Method,PFM）。臺中榮民總醫院有鑑於此臺灣醫院評鑑發展之方向，為讓醫院同仁能瞭解及熟悉PFM評鑑驗證模式，自2013年建置醫院內部的評鑑稽核團隊與機制，定期執行院內實地查證，並制訂稽核題庫及稽核表，導入稽核地圖（Tracer map）繪製，至今共培訓了88名院內稽核委員，辦理122場之實地稽核查證。稽核過程中，所發現的建議或缺失事項均回饋相關單位進行改善；如為重大缺失事項則須安排進行複查。未來將持續整合醫院內部評鑑稽核與ISO 9001品質管理系統內部稽核，並將內部稽核機制標準化及常規化，落實評鑑基準融入日常工作之中。臺中榮總順利在2017年6月完成醫學中心與教學醫院評鑑作業，且醫院評鑑基準達優良比例高達96.3％。本文綜整臺中榮總建置醫院內部評鑑稽核過程之寶貴經驗，提供各方醫院因應與準備評鑑參考。 The Joint Commission of Taiwan has advocated and dedicated Patient Focus Method (PFM) into the Taiwan Hospital Accreditation System. Taichung Veterans General Hospital followed the trend of Taiwan hospital evaluation. We established the internal audit system of PFM, which allows hospital colleagues to understand and familiar with the PFM evaluation model since 2013. We implemented the site verification regularly and designed the audit check-up table and the tracer map. A total of 88 auditors completed the training courses and finished 122 field audits. All the findings, which did not meet the standards, were sent back to the responsible units for continuous improvement. The major system defects were rechecked by the auditors. In June 2017, we received an external audit from Joint Commission of Taiwan and our overall performance was appreciated, and get a excellent grade of up to 96.3%. We´ll integrate the internal audit of hospital accreditation and ISO 9001 quality management system into daily practice and integrated into our core culture of providing high-quality patients care.