JCI医院评审标准(第四版).ppt

1、JOINTCOMMISSIONINTERNATIONALACCREDITATIONSTANDARDSFORHOSPITALS,4THEDITION,美国医疗机构评审国际联合委员会 国际医院管理标准 （第四版） （2011年1月1日起执行）,SectionI: Patient-CenteredStandards 患者中心标准,InternationalPatientSafetyGoals(IPSG) 国际患者安全目标 AccesstoCareandContinuityofCare(ACC) 医疗护理途径及连续性 PatientandFamilyRights(PFR) 患者及其家属权益 Asses

2、smentofPatients(AOP) 患者评估 CareofPatients(COP) 患者的医疗护理 AnesthesiaandSurgicalCare(ASC) 麻醉及外科医疗护理 MedicationManagementandUse(MMU) 药品管理和使用 PatientandFamilyEducation(PFE) 患者及其家属教育,InternationalPatientSafetyGoals(IPSG)国际患者安全目标,IPSG.1IdentifyPatientsCorrectly IPSG.2ImproveEffectiveCommunication IPSG.3Impro

3、vetheSafetyofHigh-AlertMedications IPSG.4EnsureCorrect-Site,Correct-Procedure,Correct-PatientSurgery IPSG.5ReducetheRiskofHealthCareAssociatedInfections IPSG.6ReducetheRiskofPatientHarmResultingfromFalls,InternationalPatientSafetyGoals(IPSG)国际患者安全目标,IPSG.1正确辨认患者 IPSG.2有效地改进沟通 IPSG.3改进高敏感性疗程的安全性 IPSG

4、.4保证正确部位，正确做法，正确患者手术 IPSG.5减少相关医疗风险 IPSG.6减少患者摔倒发生伤害的风险,AccesstoCareandContinuityofCare(ACC)医疗护理途径及连续性,ACC.1Patientsareadmittedtoreceiveinpatientcareorregisteredforoutpatientservicesbasedontheir identifiedhealthcare needs andtheorganizationsmissionandresources. ACC.2Theorganizationdesignsandcarrieso

5、utprocessestoprovidecontinuityofpatientcareservicesin theorganizationandcoordinationamonghealthcarepractitioners. ACC.3Thereisapolicyguidingthereferralordischargeofpatients. ACC.4Patientsaretransferredtootherorganizationsbasedonstatusandtheneedtomeettheircontinuing careneeds. ACC.5Theprocessforrefer

6、ring,transferring,ordischargingpatients,bothinpatientsandoutpatients, includesplanningtomeetthepatientstransportationneeds.,AccesstoCareandContinuityofCare(ACC)医疗护理途径及连续性,ACC.1根据患者治疗需求和医院使命及资源，决定患者住院治疗或门诊治疗 ACC.2在医院科室和医护人员间制定并实施相互协调的程序，为患者提供连续的医疗服务 ACC.3指导患者转诊或出院的制度明确 ACC.4根据病情和需要，为让患者得到持续治疗，有患者转院制度

7、 ACC.5住院和门诊患者的转诊、转院，或出院程序含有患者运送需求的计划,PatientandFamilyRights(PFR)患者及其家属权益,PFR.1Theorganizationisresponsibleforprovidingprocessesthatsupportpatientsandfamiliesrights duringcare. PFR.2Theorganizationsupportspatientsandfamiliesrightstoparticipateinthecareprocess. PFR.3Theorganizationinformspatientsandfa

8、miliesaboutitsprocesstoreceiveandtoactoncomplaints,conflicts,anddifferencesofopinionaboutpatientcareandthepatientsrighttoparticipateinthese processes. PFR.4Staffmembersareeducatedabouttheirrolesinidentifyingpatientsvaluesandbeliefsandprotectingpatientsrights. PFR.5Allpatientsareinformedabouttheirrig

9、htsandresponsibilitiesinamannerandlanguagetheycan understand. PFR.6Patientinformedconsentisobtainedthroughaprocessdefinedbytheorganizationandcarriedoutbytrainedstaffinalanguagethepatientcanunderstand.,PatientandFamilyRights(PFR)患者及其家属权益,PFR.1医院负责提供支持患者及其家属在治疗期间权益的程序 PFR.2医院支持患者及其家属参与治疗过程的权益 PFR.3医院告

10、知患者及其家属有关受理投诉、纠风和不同治疗意见的程序，及参与这些程序的权益 PFR.4教育员工正确对待不同价值观和信仰的患者，并维护其权益 PFR.5以患者能理解的方式和语言告知其权益和责任 PFR.6用患者能理解的语言训炼员工，并由其通过医院制定的程序获得患者知情同意,PatientandFamilyRights(PFR)患者及其家属权益,PFR.7Theorganizationinformspatientsandfamiliesabouthowtogainaccesstoclinicalresearch,clinicalinvestigation,orclinicaltrialsinvol

11、vinghumansubjects. PFR.8Informedconsentisobtainedbeforeapatientparticipatesinclinicalresearch,clinicalinvestigation, andclinicaltrials. PFR.9Theorganizationhasacommitteeoranotherwaytooverseeallresearchintheorganizationinvolvinghumansubjects. PFR.10Theorganizationinformspatientsandfamiliesabouthowtoc

12、hoosetodonateorgansandothertissues. PFR.11Theorganizationprovidesoversightoftheharvestingandtransplantationoforgansandtissues.,PatientandFamilyRights(PFR)患者及其家属权益,PFR.7医院告知患者及其家属有关如何获得以人体为对象的临床研究、监床调查和临床试验的途经 PFR.8在患者参与临床研究、临床调查和临床试验前，获得患者知情同意 PFR.9医院有一个委员会或其他方式监督院内所有以人体为对象的研究 PFR.10医院告知患者及其家属有关如何选择

13、捐献人体器官和其他人体组织 PFR.11医院监督获取和移植人体器官或组织,AssessmentofPatients(AOP)患者评估,AOP.1Allpatientscaredforbytheorganizationhavetheirhealthcareneedsidentifiedthroughanestablishedassessmentprocess. AOP.2Allpatientsarereassessedatintervalsbasedontheirconditionandtreatmenttodeterminetheirresponsetotreatmentandtoplanfo

14、rcontinuedtreatmentordischarge. AOP.3Qualifiedindividualsconducttheassessmentsandreassessments. AOP.4Physicians,nurses,andotherindividualsandservicesresponsibleforpatientcarecollaboratetoanalyzeandtointegratepatientassessments. AOP.5Laboratoryservicesareavailabletomeetpatientneeds,andallsuchservices

15、meetapplicablelocalandnationalstandards,laws,andregulations. AOP.6Radiologyanddiagnosticimagingservicesareavailabletomeetpatientneeds,andallsuchservicesmeetapplicablelocalandnationalstandards,laws,andregulations.,AssessmentofPatients(AOP)患者评估,AOP.1通过已建立的评估程序，医院确定了所有患者的医疗需求 AOP.2根据情况和治疗需要，在一定间隔时间内对所有

16、患者进行再评估，观察他们对治疗的反应，制定持续治疗或出院计划 AOP.3由有资质的人员指挥评估和再评估 AOP.4医师、护士和其他负责患者治疗的人员及科室共同分析和归纳患者评估 AOP.5所有实验室服务能有效地满足患者需要，并符合当地和国家标准、法律及法规 AOP.6所有放射和影像服务能有效地满足患者需要，并符合当地和国家标准、法律及法规,CareofPatients(COP)患者的医疗护理,COP.1Policiesandproceduresandapplicablelawsandregulationsguidetheuniformcareofallpatients. COP.2Therei

17、saprocesstointegrateandtocoordinatethecareprovidedtoeachpatient. COP.3Policiesandproceduresguidethecareofhighriskpatientsandtheprovisionofhigh-riskservices. COP.4Avarietyoffoodchoices,appropriateforthepatientsnutritionalstatusandconsistentwithhisorherclinicalcare,isregularlyavailable. COP.5Patientsa

18、tnutritionriskreceivenutritiontherapy. COP.6Patientsaresupportedinmanagingpaineffectively. COP.7Theorganizationaddressesend-of-lifecare.,CareofPatients(COP)患者的医疗护理,COP.1治疗规范，并符合政策、程序及有关法律和法规 COP.2对每位患者提供的治疗有一个集成和协调的程序 COP.3高危患者的治疗与高危服务的提供符合政策、程序 COP.4各种各样的食物选择规范有效，符合患者营养状况，并与临床治疗一致 COP.5有营养风险的患者接受营养

19、治疗 COP.6支持患者有效地管理疼通 COP.7医院提供临终关怀治疗,Anesthesia and Surgical Care (ASC)麻醉和外科治疗,ASC.1 Anesthesia services (including moderate and deep sedation) are available to meet patient needs, and all such services meet applicable local and national standards, laws, and regulations and professional standards. AS

20、C.2 A qualified individual(s) is responsible for managing the anesthesia services (including moderate and deep sedation). ASC.3 Policies and procedures guide the care of patients undergoing moderate and deep sedation. ASC.4 A qualified individual conducts a preanesthesia assessment and preinduction

21、assessment.,Anesthesia and Surgical Care (ASC)麻醉和外科治疗,ASC.1 所有麻醉服务（包括中度和深度镇静）满足患者需求，并符合当地和国家标准、法律、法规和专业标准 ASC.2 由有资质的人员负责管理麻醉服务（包括中度和深度镇静） ASC.3 政策和程序指导患者接受中度及深度镇静治疗 ASC.4 由有资质的人员指导麻醉前评估和正式手术前评估,Anesthesia and Surgical Care (ASC)麻醉和外科治疗,ASC.5 Each patients anesthesia care is planned and documented i

22、n the patients record. ASC.6 Each patients postanesthesia status is monitored and documented, and the patient is discharged from the recovery area by a qualified individual or by using established criteria. ASC.7 Each patients surgical care is planned and documented based on the results of the asses

23、sment.,Anesthesia and Surgical Care (ASC)麻醉和外科治疗,ASC.5 在患者病历中，有每位患者的麻醉治疗计划和纪录 ASC.6 监测和纪录每位患者麻醉的状态，由有资质的人员，或按已建立的标准批准患者离开恢复区 ASC.7 根据评估结果制定每位患者的外科治疗计划，并纪录在案,Medication Management and Use (MMU)药品管理和使用,MMU.1 Medication use in the organization complies with applicable laws and regulations and is organi

24、zed to meet patient needs. MMU.2 An appropriate selection of medications for prescribing or ordering is stocked or readily available. MMU.3 Medications are properly and safely stored. MMU.4 Prescribing, ordering, and transcribing are guided by policies and procedures. MMU.5 Medications are prepared

25、and dispensed in a safe and clean environment. MMU.6 The organization identifies those qualified individuals permitted to administer medications. MMU.7 Medication effects on patients are monitored.,Medication Management and Use (MMU)药品管理和使用,MMU.1 医院用药符合法律法规，并有效地满足患者需求 MMU.2 规定或医嘱药品的选择库存可用 MMU.3 正确、安

26、全贮存药品 MMU.4 按政策和程序开处方、下医嘱和抄录用药 MMU.5 在安全和清洁环境下准备、分发药品 MMU.6 医院只允许有资质的人员执行用药 MMU.7 监控患者用药疗效,Patient and Family Education (PFE) 患者和家属教育,PFE.1 The organization provides education that supports patient and family participation in care decisions and care processes. PFE.2 Each patients educational needs a

27、re assessed and recorded in his or her record. PFE.3 Education and training help meet patients ongoing health needs. PFE.4 Patient and family education includes the following topics, related to the patients care: the safe use of medications, the safe use of medical equipment, potential interactions

28、between medications and food, nutritional guidance, pain management, and rehabilitation techniques. PFE.5 Education methods include the patients and familys values and preferences and allow sufficient interaction among the patient, family, and staff for learning to occur. PFE.6 Health professionals

29、caring for the patient collaborate to provide education.,Patient and Family Education (PFE) 患者和家属教育,PFE.1 医院提供教育支持患者和家属参与治疗决策及治疗过程 PFE.2 评估每位患者的教育需求，并记入病历 PFE.3 教育与训炼有助于满足患者持续健康需求 PFE.4 患者和家属教育包括下列患者治疗的相关题目：安全用药、安全使用医疗设备、药品与食物间的潜在相互作用、营养指导、疼通管理，及康复技术 PFE.5 教育方法包括患者和家属的价值观和特选需求，并允许患者、家属和员工在学习上充足地交流 P

30、FE.6 为患者治疗的医护人员配合提供教育,Section II: Health Care Organization Management Standards医疗机构管理标准,Quality Improvement and Patient Safety (QPS) 质量改进与患者安全 Prevention and Control of Infections (PCI) 感染预防与控制 Governance, Leadership, and Direction (GLD) 政府、领导和向导 Facility Management and Safety (FMS) 设施管理和安全 Staff Qu

31、alifications and Education (SQE) 员工资格与教育 Management of Communication and Information (MCI) 沟通与情报管理,Quality Improvement and Patient Safety (QPS)质量改进与患者安全,QPS.1 Those responsible for governing and managing the organization participate in planning and measuring a quality improvement and patient safety

32、program. QPS.2 The organization designs new and modified systems and processes according to quality improvement principles. QPS.3 The organizations leaders identify key measures in the organizations structures, processes, and outcomes to be used in the organizationwide quality improvement and patien

33、t safety plan. QPS.4 Individuals with appropriate experience, knowledge, and skills systematically aggregate and analyze data in the organization. QPS.5 The organization uses an internal process to validate data. QPS.6 The organization uses a defined process for identifying and managing sentinel eve

34、nts,Quality Improvement and Patient Safety (QPS)质量改进与患者安全,QPS.1 医院责任人和管理者参与质量改进、患者安全项目的计划与监控 QPS.2 医院按照质量改进原则重新设计或修定各种体系与流程 QPS.3 在完善医院结构、流程及结果中，领导制定应用于医院领域质量改进和患者安全计划的关键措施 QPS.4 由具有相应经验、知识及技能的人员系统地收集和分析医院数据 QPS.5 医院用内部程序确认数据 QPS.6 医院制定程序，确定和管理警哨事件,Quality Improvement and Patient Safety (QPS)质量改进与患者

35、安全,QPS.7 Data are analyzed when undesirable trends and variation are evident from the data. QPS.8 The organization uses a defined process for the identification and analysis of near-miss events. QPS.9 Improvement in quality and safety is achieved and sustained. QPS.10 Improvement and safety activiti

36、es are undertaken for the priority areas identified by the organizations leaders. QPS.11 An ongoing program of risk management is used to identify and to reduce unanticipated adverse events and other safety risks to patients and staff.,Quality Improvement and Patient Safety (QPS)质量改进与患者安全,QPS.7 数据显示

37、不良趋势和变异时，分析数据 QPS.8 对临近差错事件的确认和分析，医院按既定程序办理 QPS.9 质量与安全改进到位并维持 QPS.10 医院领导确定的重点领域承担了改进与安全活动 QPS.11 持续的风险管理程序应用于确认和减少对患者及员工的意外有害事件与其他安全风险,Prevention and Control of Infections (PCI)感染预防与控制,PCI.1 One or more individuals oversee all infection prevention and control activities. This individual(s) is qual

38、ified in infection prevention and control practices through education, training, experience, or certification. PCI.2 There is a designated coordination mechanism for all infection prevention and control activities that involves physicians, nurses, and others as based on the size and complexity of th

39、e organization. PCI.3 The infection prevention and control program is based on current scientific knowledge, accepted practice guidelines, applicable laws and regulations, and standards for sanitation and cleanliness. PCI.4 The organizations leaders provide adequate resources to support the infectio

40、n prevention and control program. PCI.5 The organization designs and implements a comprehensive program to reduce the risks of health careassociated infections in patients and health care workers. PCI.6 The organization uses a risk-based approach in establishing the focus of the health careassociate

41、d infection prevention and reduction program.,Prevention and Control of Infections (PCI)感染预防与控制,PCI.1 一个或多个员工负责所有感染预防和控制活动。通过教育、训炼、实践或认证，这些员工在感染预防和控制活动中具有资质。 PCI.2 根据医院大小和复杂性，对所有的感染预防和控制活动，有一个指定的，包括医师、护士和其他员工在内的协调机制 PCI.3 建立在现代科学知识、有效实用指南之上的感染预防和控制程序符合法律、法规及卫生与清洁标准 PCI.4 医院领导提供足够的资源支持感染预防和控制程序。 PCI.

42、5 医院设计并实施综合方案，减少医疗风险患者和卫生保健工作者的交叉感染。 PCI.6 在建立医疗重点感染预防和减少方案中，医院使用以风险为基础的方法,Prevention and Control of Infections (PCI)感染预防与控制,PCI.7 The organization identifies the procedures and processes associated with the risk of infection and implements strategies to reduce infection risk. PCI.8 The organization

43、 provides barrier precautions and isolation procedures that protect patients, visitors, and staff from communicable diseases and protects immunosuppressed patients from acquiring infections to which they are uniquely prone. PCI.9 Gloves, masks, eye protection, other protective equipment, soap, and d

44、isinfectants are available and used correctly when required. PCI.10 The infection prevention and control process is integrated with the organizations overall program for quality improvement and patient safety. PCI.11 The organization provides education on infection prevention and control practices t

45、o staff, physicians, patients, families, and other caregivers when indicated by their involvement in care.,Prevention and Control of Infections (PCI)感染预防与控制,PCI.7 医院确定应对感染风险的程序和过程，并实施减少感染感染风险的策略。 PCI.8 医院提供防范屏障和隔离程序，保护患者、探视者及员工免得传染病，特别要保护来自易感人群的免疫抑制患者。 PCI.9 提供手套、口具、眼罩,及其他防护设备、肥皂和消液,在需要时能正确使用。 PCI.1

46、0 感染预防与控制整合于医院总体质量改进和患者安全程序。 PCI.11 医院对必须参与治疗的员工、医师、患者、家属及其他护理人员提供感染预防与控制教育。,Governance, Leadership, and Direction (GLD)政府、领导和指南,GLD.1 Governance responsibilities and accountabilities are described in bylaws, policies and procedures, or similar documents that guide how they are to be carried out. GL

47、D.2 A senior manager or director is responsible for operating the organization and complying with applicable laws and regulations. GLD.3 The organizations leaders are identified and are collectively responsible for defining the organizations mission and creating the plans and policies needed to fulf

48、ill the mission. GLD.4 Medical, nursing, and other leaders of clinical services plan and implement an effective organizational structure to support their responsibilities and authority. GLD.5 One or more qualified individuals provide direction for each department or service in the organization. GLD.

49、6 The organization establishes a framework for ethical management that ensures that patient care is provided within business, financial, ethical, and legal norms and that protects patients and their rights.,Governance, Leadership, and Direction (GLD)政府、领导和指南,GLD.1 政府责任与职责表述为制度、政策和程序，或明确如何贯彻实施类似文件。 G

50、LD.2 高管或主管对医院运行负责，并遵守适用法律和法规。 GLD.3 医院领导人确定，并集体负责制定医院使命,创建实现使命所需要的规划和政策。 GLD.4 医疗、护理及其他临床服务的领导者计划并执行有效的组织结构，支持其责任和权威。 GLD.5 一个或多个有资质的人员对医院的每个科室或服务提供指导。 GLD.6 保证为患者提供的治疗符合商业、金融、伦理、法律规范，并保护患者和他们的权利。,Facility Management and Safety (FMS)设施管理和安全,FMS.1 The organization complies with relevant laws, regulat

51、ions, and facility inspection requirements. FMS.2 The organization develops and maintains a written plan(s) describing the processes to manage risks to patients, families, visitors, and staff. FMS.3 One or more qualified individuals oversee the planning and implementation of the program to manage th

52、e risks in the care environment. FMS.4 The organization plans and implements a program to provide a safe and secure physical environment. FMS.5 The organization has a plan for the inventory, handling, storage, and use of hazardous materials and the control and disposal of hazardous materials and was

53、te. FMS.6 The organization develops and maintains an emergency management plan and program to respond to likely community emergencies, epidemics, and natural or other disasters.,Facility Management and Safety (FMS)设施管理和安全,FMS.1 医院遵守有关法律、法规和设备检查要求。 FMS.2 医院编写和维护了描写管理患者、家属、探访者和工作人员风险过程的书面方案。 FMS.3 一个或

54、多个有资格的人员监督管理治疗环境风险程序的计划和实施。 FMS.4 医院计划和实施了提供安全可靠的硬件环境的程序 FMS.5 医院有危险物品的清点、处理、贮存、使用及危险品与废物的控制和清理计划。 FMS.6 医院编写和维护应对可能的社区紧急事件、流行病、自然或其他灾害的紧急管理方案与程序,Facility Management and Safety (FMS)设施管理和安全,FMS.7 The organization plans and implements a program to ensure that all occupants are safe from fire, smoke,

55、or other emergencies in the facility. FMS.8 The organization plans and implements a program for inspecting, testing, and maintaining medical equipment and documenting the results. FMS.9 Potable water and electrical power are available 24 hours a day, seven days a week, through regular or alternate s

56、ources, to meet essential patient care needs. FMS.10 Electrical, water, waste, ventilation, medical gas, and other key systems are regularly inspected, maintained, and, when appropriate, improved. FMS.11 The organization educates and trains all staff members about their roles in providing a safe and

57、 effective patient care facility.,Facility Management and Safety (FMS)设施管理和安全,FMS.7 医院制定和实施了一个程序,确保所有住户是远离设备意外发生的火灾、烟雾、或其他突发事件。 FMS.8 医院制定和实施一个检查、测试、维护医疗设备的程序，并记录结果。 通过常规或备用源，饮用水和电力一周7天、一天24小时可用，以满足基本患者的治疗需求。 FMS.10 定期检查和维护电气、水、废弃物、通风、医用气体和其它关键系统，并在适当的时候予以改进 FMS.11 医院教育和培训全体员工在为患者提供安全、有效的治疗设施时所应扮演的角

58、色。,Staff Qualifications and Education (SQE)员工资格与教育,SQE.1 Organization leaders define the desired education, skills, knowledge, and other requirements of all staff members. SQE.2 Organization leaders develop and implement processes for recruiting, evaluating, and appointing staff as well as other rel

59、ated procedures identified by the organization. SQE.3 The organization uses a defined process to ensure that clinical staff knowledge and skills are consistent with patient needs. SQE.4 The organization uses a defined process to ensure that nonclinical staff knowledge and skills are consistent with

60、organization needs and the requirements of the position. SQE.5 There is documented personnel information for each staff member. SQE.6 A staffing plan for the organization, developed collaboratively by the leaders, identifies the number, types, and desired qualifications of staff.,Staff Qualification