建立以病人為焦點的內部稽核運作模式

Establish a Patient Focused Audit Model in Hospital Care

所謂的「以病人為焦點查證方式(Patient-Focused Methodology, PFM)」係以醫院內某特定病人或照護相關議題為重點，透過系統性規劃查證路線，來檢視受評醫院在評鑑基準的執行過程與成效，讓評鑑委員能做更貼近照護事實的查證，藉以瞭解醫院是如何執行日常照護作業，也就是還原病人所接受到的醫療照護，故特別重視作業標準與規範的一致性與落實度，以及跨單位間縱向與橫向的溝通及醫療照護的銜接。本專案目的在建立以病人為焦點的稽核運作模式，期望藉由系統性的查證方式，透過稽核地圖與稽核表交叉合併運用方式，檢視院內同仁對於醫療品質與病人安全政策的遵從性，落實以病人為中心的照護，並確保本院各項標準作業流程均能有效滿足。
結果：1.個案醫院成立了內部稽核小組，共培育了42名內部稽核種子成員，並擬定醫院內部評鑑稽核辦法。2.實施期間共執行38梯次PFM查核，共發現287項執行層面的脆弱點，且經由追蹤改善機制於110年12月底均全數完成改善。3.專案執行期間個案醫院接受外部稽核，通過了國健署癌症診療品質認證及醫策會七項疾病照護品質認證。
本專案發現以病人為焦點的查證方式能有效地檢視院內同仁對於醫療品質與病人安全政策的遵從性，並能同步檢視縱向與橫向醫療照護提供之品質，進一步進行系統性問題的改善，提升整體醫療照護品質。

The patient-focused methodology (PFM) focuses on a particular patient or health-care problem in a hospital and creates a systematic plan to assess the implementation and effectiveness of that hospital’s practices against existing evaluation standards. The goals of this approach are for the evaluation committee to gain a closer understanding of the hospital’s day-to-day nursing operations and to assess the quality of the medical care received by patients. The PFM involves both vertical and horizontal communication within the health-care system.
This study established a patient-focused audit approach. Through a systematic verification method that combines audit maps and sheets, we aimed to ensure compliance with existing medical quality and patient safety standards and to provide patient-centered care in the case hospital.
The case hospital formed an internal audit team, trained 42 internal audit members, and developed internal evaluation and audit methods. During the implementation period, 38 PFM inspection rounds were conducted, and 287 weaknesses at the implementation level were identified and resolved by the end of December 2021 through a monitoring improvement mechanism. In addition, the case hospitals received external audits and were certified for the cancer diagnosis and treatment quality and seven disease care quality certifications from the Joint Commission of Taiwan.
This study found that the PFM can effectively assess compliance with medical quality and patient safety policies and evaluate the quality of both vertical and horizontal medical care. In addition, this approach can identify systemic issues, leading to both individual improvements and an overall improvement in the quality of medical care.