Establishment and application of hospital infection risk stratification assessment system
OBJECTIVE To establish and apply a hierarchical risk assessment system for hospital infection with two levels of hospital-clinical departments and two dimensions of high-risk department and indicators.METHODS Firstly,literature research method,brainstorming method and risk map analysis method(fishbone diagram)were used to identify the risks of the clinical department from the overall level,and the risk points,risk indicators and their weighting coefficients were determined.According to four dimensions,the possibility of risk occurrence,the severity of the consequences,the difficulty of detection and the integrity of the current management system,a ma-trix was established for risk analysis.Risk scores was calculated,and the percentile method was used to divide dif-ferent risk groups from two dimensions,clinical departments and risk indicators,respectively,according to differ-ent risk scores.For the clinical departments with the highest risk scores,the hospital infection management team of the department adopted FMEA(failure mode and effect analysis)to carry out the risk assessment of the under-graduate department,and proposed an improvement plan for the causes of high-risk failure.For the risk indicators with the highest risk scores,a risk management system based on the enterprise risk management-integrated(CO-SO-ERM)was constructed.RESULTS Totally 32 clinical departments were included in the scope of risk assess-ment,and 7 risk points and 21 risk indicators were listed.The clinical departments were divided into 6 risk groups,and the ICU had the highest risk score.A total of 5 high-risk failure causes were listed and 22 counter-measures were formulated using FMEA management tool in the ICU.The risk indicators were divided into 4 risk groups,and the incidence of hospital infections had the highest risk score.The three-level risk management system based on COSO-ERM framework included 3 first-level indicators,16 second-level indicators and 39 third-level in-dicators.CONCLUSION The risk stratification assessment system established in this study can scientifically and ef-fectively manage high-risk departments and high-risk indicators in hospitals,so as to move forward the infection control threshold and achieve precise infection control.
Hospital infectionRisk assessmentMatrixFailure mode and effect analysisEnterprise risk man-agement-integrated framework
NETL
NSTL
万方数据
