医疗质量实时控制临床路径的应用研究
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摘要
我国加入WTO后医疗市场竞争日趋激烈的新形势，使医院建设面临着巨大的挑战。医院只有通过提高医疗质量，减低医疗成本，利用有限的医疗资源，提供最佳医疗服务才能将这种挑战变成发展的机遇。
医疗质量实时控制旨在医院全面质量管理基础上，强化医疗质量的过程管理，通过医院信息化建设，实现有效地、不间断地医疗质量监控，最终实现医院管理“优质、高效、低耗”的目的。而临床路径作为一种诊疗过程标准化管理的质量控制工具，为住院诊疗质量实时控制提供较为理想的条件。本研究就是在医疗质量实时控制的总体框架下，引用临床路径、时间管理等国内外先进管理经验，结合国内医院管理现状，建立符合实际、方便可行的住院诊疗标准化和过程管理方法，实现对住院诊疗质量的实时控制，最终达到提高医疗质量，降低医疗成本，增加患者满意程度的目的。
本研究基于持续质量改进思想，强调“保证高质量住院诊疗服务过程的管理过程”和“质量改进程序或过程”，确立了住院诊疗质量实时控制临床路径过程改进、持续改进和预防性改进的管理理念。采用前馈控制、反馈控制和现场控制的方法建立住院诊疗实时控制临床路径管理模式。
本研究建立了临床路径的一些具体方法。在确定临床路径开发对象
住院诊疗质量实时控制临床路径的应用研究 颀士学位论文
时，提出通过对病种的手术方式进行分组，比较各组病例住院天数的变异
系数，确定诊疗过程标准化的难易。在制定临床路径标准住院时间时，引
入欧洲 商业项目时间管理的理论与方法，将住院诊疗过程内容进行分
解，找出关键路径，最终制定出最佳诊疗时间标准。在临床路径管理方法
上，依据我国医院实际运行模式，与医院现有制度紧密结合，建立临床路
径管理组织体系并制定管理规范。在变异的管理中提出将不可控变异发生
的比例作为评价路径制定是否合理的标准，将造成住院天数延长的变异与
发生较多的可控变异作为管理的重点，进行持续质量改进。
本研究在医疗质量实时控制中首次将临床路径应用于住院诊疗过程
的管理中，并取得了显著的效果。尤其是通过对膝骨性关节炎、陈旧性半
月板损伤和半月板撕裂伤病例进行临床路径管理，结果显示实验组与对照
组相比总体平均住院天数减少了3．17天，平均总医疗费用降低1191元，
对医疗服务满意程度显著增加。
With our country's entry into WTO, increasing competition exists in our medical market, and hospitals face tremendous challenges. Only through improving medical quality, reducing medical cost and offering optimal service with the limited medical resources, can hospitals turn the challenges into opportunities for development.
Real-time control of medical quality aims at enhancing process management of medical quality on the basis of hospital total quality management, making the monitoring and control of medical quality more effective and continuous by the building of hospital information systems, and achieving the purpose of 'high-quality, high-efficiency and low-cost' management. Clinical pathways can offer perfect conditions to real-time control of medical quality as a means to control quality through process standardization. Within the overall frame of real-time control of medical quality, this research designs effective, convenient, practicable ways of the standardization and management of the hospitalization diagnosis and treatment process by referring to advanced domestic and overseas management experiences such as clinical pathways and time management, and associating the reality of domestic hospital management, in order to realize
real-time control of the quality of hospitalization diagnosis and treatment, and to gain the aims of improving medical quality, reducing medical cost and increasing inpatient satisfaction level.
Based on the idea of continuous quality improvement, the research focuses on 'the management process ensuring high-quality service process of hospitalization diagnosis and treatment' and 'the procedure and process of improving quality', establish the conception of real-time control of the quality of hospitalization diagnosis and treatment which consists of process improving, continuous improving and preventive improving. A model of clinical pathways in real-time control of the quality of hospitalization diagnosis and treatment has been set up.
The research has designed some methods for clinical pathways. In selecting objects for exploitation, we suggest grouping disease entities by surgical operation techniques, comparing the coefficient variances of the average hospitalized days of each grouping, and then evaluating the ease or difficulty of standardization. In planning the standard hospitalized days of clinical pathways, we have refered to the theory and method of project time management of business administration in Europe. This method sets the optimal standard time by woke breakdown analyzing, and then find out the critical path of the process of hospitalization diagnosis and treatment. On the method of clinical pathways management, we suggest establishing the organization system and criterion of clinical pathways management on the
basis of hospital existing management institution. On the method of variance management, we suggest using the proportion of controllable variance to evaluate the rationality of clinical pathways, and regarding the variances that delay hospitalized days or the controllable variances that happen frequently as the management emphases.
The research used clinical pathways in real-time control of medical quality for the first time and has gained remarkable effect. Particularly. With inpatients of osteoarthritis of knee joint, obsolete meniscus injury and tears wound of meniscus, those who were on clinical pathways had a low average length of stay by 3.17 days (9.85 vs. 6.68 days), a low average total charge by 1,191 Yuan (4,490 vs. 5,681 Yuan) and a high satisfaction level, in comparison to the control patients.
医疗质量实时控制旨在医院全面质量管理基础上，强化医疗质量的过程管理，通过医院信息化建设，实现有效地、不间断地医疗质量监控，最终实现医院管理“优质、高效、低耗”的目的。而临床路径作为一种诊疗过程标准化管理的质量控制工具，为住院诊疗质量实时控制提供较为理想的条件。本研究就是在医疗质量实时控制的总体框架下，引用临床路径、时间管理等国内外先进管理经验，结合国内医院管理现状，建立符合实际、方便可行的住院诊疗标准化和过程管理方法，实现对住院诊疗质量的实时控制，最终达到提高医疗质量，降低医疗成本，增加患者满意程度的目的。
本研究基于持续质量改进思想，强调“保证高质量住院诊疗服务过程的管理过程”和“质量改进程序或过程”，确立了住院诊疗质量实时控制临床路径过程改进、持续改进和预防性改进的管理理念。采用前馈控制、反馈控制和现场控制的方法建立住院诊疗实时控制临床路径管理模式。
本研究建立了临床路径的一些具体方法。在确定临床路径开发对象
住院诊疗质量实时控制临床路径的应用研究 颀士学位论文
时，提出通过对病种的手术方式进行分组，比较各组病例住院天数的变异
系数，确定诊疗过程标准化的难易。在制定临床路径标准住院时间时，引
入欧洲 商业项目时间管理的理论与方法，将住院诊疗过程内容进行分
解，找出关键路径，最终制定出最佳诊疗时间标准。在临床路径管理方法
上，依据我国医院实际运行模式，与医院现有制度紧密结合，建立临床路
径管理组织体系并制定管理规范。在变异的管理中提出将不可控变异发生
的比例作为评价路径制定是否合理的标准，将造成住院天数延长的变异与
发生较多的可控变异作为管理的重点，进行持续质量改进。
本研究在医疗质量实时控制中首次将临床路径应用于住院诊疗过程
的管理中，并取得了显著的效果。尤其是通过对膝骨性关节炎、陈旧性半
月板损伤和半月板撕裂伤病例进行临床路径管理，结果显示实验组与对照
组相比总体平均住院天数减少了3．17天，平均总医疗费用降低1191元，
对医疗服务满意程度显著增加。
With our country's entry into WTO, increasing competition exists in our medical market, and hospitals face tremendous challenges. Only through improving medical quality, reducing medical cost and offering optimal service with the limited medical resources, can hospitals turn the challenges into opportunities for development.
Real-time control of medical quality aims at enhancing process management of medical quality on the basis of hospital total quality management, making the monitoring and control of medical quality more effective and continuous by the building of hospital information systems, and achieving the purpose of 'high-quality, high-efficiency and low-cost' management. Clinical pathways can offer perfect conditions to real-time control of medical quality as a means to control quality through process standardization. Within the overall frame of real-time control of medical quality, this research designs effective, convenient, practicable ways of the standardization and management of the hospitalization diagnosis and treatment process by referring to advanced domestic and overseas management experiences such as clinical pathways and time management, and associating the reality of domestic hospital management, in order to realize
real-time control of the quality of hospitalization diagnosis and treatment, and to gain the aims of improving medical quality, reducing medical cost and increasing inpatient satisfaction level.
Based on the idea of continuous quality improvement, the research focuses on 'the management process ensuring high-quality service process of hospitalization diagnosis and treatment' and 'the procedure and process of improving quality', establish the conception of real-time control of the quality of hospitalization diagnosis and treatment which consists of process improving, continuous improving and preventive improving. A model of clinical pathways in real-time control of the quality of hospitalization diagnosis and treatment has been set up.
The research has designed some methods for clinical pathways. In selecting objects for exploitation, we suggest grouping disease entities by surgical operation techniques, comparing the coefficient variances of the average hospitalized days of each grouping, and then evaluating the ease or difficulty of standardization. In planning the standard hospitalized days of clinical pathways, we have refered to the theory and method of project time management of business administration in Europe. This method sets the optimal standard time by woke breakdown analyzing, and then find out the critical path of the process of hospitalization diagnosis and treatment. On the method of clinical pathways management, we suggest establishing the organization system and criterion of clinical pathways management on the
basis of hospital existing management institution. On the method of variance management, we suggest using the proportion of controllable variance to evaluate the rationality of clinical pathways, and regarding the variances that delay hospitalized days or the controllable variances that happen frequently as the management emphases.
The research used clinical pathways in real-time control of medical quality for the first time and has gained remarkable effect. Particularly. With inpatients of osteoarthritis of knee joint, obsolete meniscus injury and tears wound of meniscus, those who were on clinical pathways had a low average length of stay by 3.17 days (9.85 vs. 6.68 days), a low average total charge by 1,191 Yuan (4,490 vs. 5,681 Yuan) and a high satisfaction level, in comparison to the control patients.
引文
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[2] 董军，朱士俊，曹秀堂，等． 医疗质量实时控制的基础条件与实施．中华医院管理杂志，2002，18：333-335．
[3] 朱士俊，董军，曹秀堂等．医疗质量实时控制研究概述．中华医院管理杂志，2002，18：331-333．
[4] 张正华，刘援增，肖先福，等．加入世界贸易规则 参与国际竞争．中华医院管理杂志，2002，18：12-15．
[5] 黄伟灿，陈剑伟，朱晓军．中国加入WTO后医院的基本应对策略．中华医院管理杂志，2002，18：15-17．
[6] 马俊，刘兵，主编．实用医院质量管理学，天津：天津社会科学院出版社，1999．10-12．
[7] 张立平，主编．军队医院管理学．北京：人民军医出版社，1997．373-382．
[8] 王太和，陶树清，等，我院实施ISO9000族标准的探讨．中华医院管理杂志，2000，16：601-603．
[9] 杨建国，主编．护理行业实施ISO9000实践与指南．广州：广东科技出版社，2001，16：601-603．
[10] 黄惠英．医疗质量保证的国际趋势．国外医学·医院管理分册；1999(1)：1-5．
[11] Greenfield, -E. Critical pathways: what they are and what they are not, J-Burn-Care-Rehabil 1995 Mar-Apr; 16(2 Pt 2): 196-7.
[12] Buffa ES. Modern Production Management. 3rd ed. New York. NY: John Wiley & Sons; 1969.
[13] Wahner HM. Principles of Operations Research. 2nd ed. Englewood Cliffs, NJ: Prentice-Hall; 1975.
[14] Christopher P. Cannon, Patrick T.O'Gara. Critical Pathways in Cardiology. Lippincott Williams & Wilkins. 2001: 3-5.
[15] 王冬，董军，朱士俊．临床路径——临床医疗的标准化管理模式．医院管理论坛，2003(1)：38-42．
[16] 张斌，吴立武，等．从相关主题词发展状况对比国内外医院管理研究的差异．中国医院管理，2002(5)：7-9．
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