運用臨床稽核落實評鑑日常化

Implementing Clinical Audits to Institutionalize Accreditation as Routine Practice

臨床稽核是在結構、過程與成果面進行系統性的檢視，達到以病人為中心之醫療照護的目標，能夠幫助醫療機構減少「想像中的工作」和「實際執行的工作」之間差距的方法，強化同仁平日的病人安全意識，減少醫療作業的不穩定性，符合最佳實證流程，並且提升醫院內部自我查核與持續改善的動力。臨床稽核的執行，需要成立臨床稽核團隊並培訓稽核員，根據醫療照護準則制定評核標準並建置稽核相關表單，訂定稽核主題與時程安排，實際稽核的執行，並對稽核結果的檢討改善與追蹤，才能確保臨床實務遵從標準流程，落實評鑑以病人為中心的精神。

 

Clinical audits systematically review structures, processes, and outcomes to achieve patient- centered health care. They help health-care institutions bridge the gap between "work as imagined" and "work as done," reinforcing staff’s awareness of patient safety, reducing operational instability, adhering to best evidence-based practices, and enhancing the hospital’s internal self-assessment and continuous improvement efforts. Implementing clinical audits involves establishing a clinical audit team, training auditors, developing assessment criteria based on health-care standards, creating audit-related forms, setting audit themes and schedules, conducting audits, reviewing results for improvement opportunities, and tracking progress. These steps ensure that clinical practice follows standard processes and implements the patient-centered health care emphasized in medical center accreditation.