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JCI评审中感染控制质量持续改进的实践

Continuous quality improvement of infection control in JCI accreditation

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目的 JCI认证的核心是医疗质量和医疗安全,引入JCI评审标准,创造有利于患者安全的文化,降低患者和员工医院感染的风险,持续改进医院感染控制质量,使感染控制工作更加标准化、规范化和国际化.方法 引用JCI评审标准感染预防与控制(PCI)章节和相关章节中的标准、衡量要素,制定医院感染控制文件和所有工作流程,医院形成了质量体系定期自我评估的模式,采取多种形式培训JCI标准内涵,运用PDCA循环模式对感染控制优先监测项目进行持续改进,以先进的感染控制理念指导临床实践.结果 一次通过JCI评审,医院医疗服务和医院管理品质得以提高,员工感染控制意识得到增强;通过不断地信息收集、数据分析,医院感染风险因素得到有效控制,手卫生依从率得到提升;感染控制质量持续改进、螺旋式提高;完善的质量持续改进框架引导流程的改进,对持续降低存在于临床过程和医疗环境中感染的风险因素起到了积极的作用.结论 JCI标准是一套结构完整且科学的医疗质量评价体系,使每例患者获得最清洁、最安全、受关注、受尊重和感到满意的服务,使就医群体和社会公众对医院关心患者安全和医疗质量的信任大幅提升,已成为世界各国医疗机构走向国际市场、参与国际竞争的通行证.
OBJECTIVE The core value of JCI accreditation is health care quality and safety.By introduction of JCI accreditation standards,a culture of patient safety can be established to reduce the risk of nosocomial infection in the staff so as to continuously improve the control of nosocomial infections and to achieve the standardized and internationalized control procedure of nosocomial infections.METHODS By referring to the JCI accreditation standards and measurements listed in the chapter of prevention and control of infection (PCI),the hospital took efforts to perform the self-evaluation mechanism of quality system at regular intervals.A vast amount of JCI standards training activity was carried out in various forms,and the hospital infection control regulations were developed with advanced concept of infection control in clinical practice to guide the use of PDCA cycle of infection control monitoring project priorities for continuous improvement.RESULTS The hospital was approved of JCI accreditation at the initial on-site survey.The quality of health care service and hospital management have been intensified,and all the staff members' awareness of infection control was enhanced.As a result of collection and analysis of the relevant data,the risk factors of the nosocomial infections were effectively under control.The nosocomial infection control quality was improved continuously and spirally,which led to the perfection of practical procedures,and which played an active role in reducing the risk of infections in clinical practice and hospital environment.CONCLUSION JCI is an universally accepted standard of integrity and scientific method in the field of medical treatment and services evaluation,which may ensure the most hygienic,safe and satisfactory service with proper attention and respect.Focusing on JCI standard reflects the stress and attention placed by hospital on the patients' safety and health care service quality,which makes the JCI standard the bridge to the international market for the health care institutions from all around the world.

JCI accreditationInfection controlQualityContinuous improvementPractice CLC number:Document codeA Article IC

李运萍、潘丽杰、肖红、周文莉、董颖、王俐、于国平

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青海红十字医院院感科,青海西宁810000

广州复大天河医院院感科,广东广州510300

JCI评审 感染控制 质量 持续改进 实践

2013

中华医院感染学杂志
中华预防医学会 中国人民解放军总医院

中华医院感染学杂志

CSTPCDCSCD北大核心
影响因子:1.885
ISSN:1005-4529
年,卷(期):2013.23(15)
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