疾病別認證的國際趨勢 - jct.org.tw

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疾病別認證的國際趨勢

孫茂勝副院長

2014年12月12日

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Outline

一、 JCIA及JCI-CCPC簡介

二、申請JCI-CCPC的文件準備及時程規劃

三、 JCI-CCPC條文解析

四、 JCI-CCPC進行模式及準備重點

五、彰基JCI-CCPC執行成效

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Joint Commission International Accreditation

(J.C.I.A.)

JCI屬美國醫療衛生機構認證聯合委員會(JCAHO)下設

的國際醫療品質部門

JCI總部位於美國芝加哥，是國際醫療品質評鑑最具公

信力的單位

JCI依據評鑑標準對美國以外的醫療衛生機構進行認證，

至2014年12月8日止，全球已有714家機構，遍佈63

個國家通過認證，台灣有14家醫院通過(含醫院評鑑9家、

學術性醫療中心醫院3家、非住院醫療2家)。

何謂 JCIA

Adapted from：http://www.jointcommissioninternational.org (8 Dec. 2014)

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臺灣通過JCIA認證醫院

年度受評院所（醫院）次數

2014-8 彰化基督教醫院 3rd 評鑑

2013-12 和信醫院 3rd 評鑑

2013-1 彰濱秀傳醫院 2nd 評鑑

2012-12

2012-9

2012-7

2012-7

2012-2

臺北醫學大學附設醫院

萬芳醫院

雙和醫院

臺安醫院

童綜合醫院

2nd 評鑑

3rd 評鑑

2nd 評鑑

1st 評鑑

2nd 評鑑

2011-12 義大醫院 2nd 評鑑

2009-7 敏盛醫院 (Voluntary Withdrawal)

年度受評院所（學術性醫療中心醫院）

2013-4 臺灣大學醫學院附設醫院 2nd 評鑑

2014-1 林口長庚紀念醫院 1st 評鑑

2014-9 中國醫藥大學附設醫院 2nd 評鑑

年度受評院所（非住院醫療）次數

2014-11 諾貝爾眼科診所 1st 評鑑

2013-10 大學眼科 2nd 評鑑

2011-11 维育牙醫診所及植牙中心 (Voluntary Withdrawal)

14家認證效期內


含：醫院評鑑9家、學術性醫療中心醫院3家、非住院醫療2家

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2012-12 廣州祁福醫院 4th 評鑑

2011-10 北京和睦家醫院 3rd 評鑑

2011-9 上海和睦家醫院 2nd 評鑑

2012-7 天津泰達國際心血管病醫院 2nd 評鑑

2013-8 北京燕化醫院 2nd 評鑑

2013-8 北京市健宮醫院 2nd 評鑑

2013-11 南京華世佳寶婦產醫院 2nd 評鑑

2014-3 洛陽正骨醫院 2nd 評鑑

2011-7 青海紅十字醫院

(Voluntary Withdrawal)

2011-10 深圳和美婦兒醫院 1st 評鑑

2012-1 天津寧河縣人民醫院 1st 評鑑

2012-6 成都安琪兒婦產醫院 1st 評鑑

2012-7 鄭州人民醫院 1st 評鑑

2012-10 烏海市婦幼保健院 1st 評鑑

2012-12 廣州市婦幼保健院 1st 評鑑


2013-1 南京友誼整形醫院 1st 評鑑

2013-1 湖南省兒童醫院 1st 評鑑

2013-2 浙江象山縣第一人民醫院 1st 評鑑

2013-4 江蘇鎮江市第一人民醫院 1st 評鑑

2013-5 海南現代婦嬰醫院 1st 評鑑

2013-7 深圳市蛇口人民醫院 1st 評鑑

2013-12 湖南旺旺醫院 1st 評鑑

2014-1 湖南省腫瘤醫院 1st 評鑑

2014-3 廣州復大腫瘤醫院 1st 評鑑

2014-4 北京嫣然天使兒童醫院 1st 評鑑

2014-5 蘭州市西固區人民醫院 1st 評鑑

2014-10 廣州現代醫院 1st 評鑑

2014-11 浙江蒼南縣人民醫院 1st 評鑑

2012-12 廣州市婦幼保健院 1st 評鑑

大陸通過JCIA認證醫院 (1)


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大陸通過JCIA認證醫院 (2)

年度受評院所（學術性醫療中心醫院）次數

2013-4 浙江杭州邵逸夫醫院 3rd 評鑑

2013-1 上海復旦大學附屬華山醫院 2nd 評鑑

2014-1 上海兒童醫學中心 2nd 評鑑

2013-2 浙江大學醫學院附屬第一醫院 1st 評鑑

2013-2 浙江大學醫學院附屬第二醫院 1st 評鑑

2014-9 上海復旦大學附屬兒科醫院 1st 評鑑

2014-10 新疆醫科大學第一附屬醫院 1st 評鑑

年度受評院所（非住院醫療）次數

2011-9 廣州和睦家診所 1st 評鑑


含：醫院評鑑28家、學術性醫療中心醫院7家、非住院醫療1家

36家認證效期內

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JCI評鑑服務範圍

醫院(Hospital)

教學醫院評鑑 (Academic Medical Center Hospital)

門診醫療(Ambulatory Care)

臨床實驗室(Clinical Laboratory)

居家照護 (Home Care)

長期照護 (Long Term Care)

初級照護 (Primary Care)

醫療運輸(Medical Transport )

臨床照護計畫認證(Clinical Care Program Certification)

Adapted from：http://www.jointcommissioninternational.org (9 Jan. 2014)

共計9項

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CCPC在全球醫院的發展分析

數值

洲國家總數醫院家數通過之國家

亞洲 10 20 中國、印度、約旦、卡達、新加坡、韓國、台灣、泰國、阿聯酋、菲律賓

歐洲 1 1 丹麥

非洲 0 0

中南美洲 2 8 巴西、哥倫比亞

大洋洲 0 0

合計 13 30

世界通過CCPC的國家及醫院家數

Adapted from: http://www.jointcommissioninternational.org/ 8 Dec. 2014

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國家醫院計畫名稱

台灣

(Taiwan)

( 4 )

彰化基督教醫院 Changhua Christian Hospital

1. Asthma Program

2. Chronic Kidney Disease Program

3. COPD Program

4. Diabetes Mellitus Program

5. HIV/AIDS Management Program

6. Primary Stroke Program

7. Breast Cancer Program

8. HCC Liver Cancer Program

9. Childhood Asthma Program

台北醫學大學附設醫院 Taipei Medical University Hospital


台北醫學大學--萬芳醫院 Taipei Medical University Wan Fang Medical Center

1. Acute Myocardial Infarction Program

台北醫學大學--雙和醫院 Taipei Medical University Shuang Ho Hospital


CCPC在全世界通過醫院家數統計 (1)

World’s First Place

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中國

(China)

( 1 )

TEDA International Cardiovascular Hospital

1. Heart Failure Program


約旦

(Jordan)

( 1 )

King Hussein Cancer Center 1. Cancer Program

新加坡 (Singapore )

( 1 )

Changi General Hospital 1. Acute Myocardial Infarction Program 2. Heart Failure Program

阿聯酋 (United Arab

Emirates)

( 1 )

Rashid Hospital 1. Acute Myocardial Infarction Program

印度

(India)

( 1 )

Apollo Hospital, Hyderabad 1. Primary Stroke Program


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韓國

(Korea)

( 2 )

EWHA Womans University Medical Center


Severance Hospital, Yonsei University College of Medicine


哥倫比亞

(Colombia)

( 1 )

Hospital Universitario Fundación Santa Fe de Bogotá

1. Joint Replacement Program

丹麥

(Denmark )

( 1 )

Amager Hospital 1. Asthma Program

菲律賓 (Philippines)

( 2 )

St. Luke's Medical Center - Global City


St. Luke's Medical Center - Quezon City



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泰國

(Thailand)

( 6 )

Bangkok Hospital Medical Center



3. Cancer Program



6. Pain management Program

7. Traumatic Brain Injury Program

Bumrungrad International 1. Primary Stroke Program




Kluaynamthai Home Care


Sikarin Hospital



World’s Second Place

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泰國

(Thailand)

( 6 )

Samitivej Srinakarin Hospital



3. Cancer Program

4. Asthma Program

5. Joint Replacement Program

6. Pain management Program

Vejthani Hospital 1. Joint Replacement Program



卡達

(Qatar)

( 2 )

National Centre for Cancer Care and Research, Doha (NCCCR)

1. Palliative Care Program

Hamad General Hospital 1. Primary Stoke Program


World’s Third Place

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巴西

(Brazil)

( 7 )

Associação do Sanatório Sírio - Hospital do Coração



Hospital TotalCor



Amil Total Care Cincinato Braga SP 1. Asthma Program 2. COPD Program

Hospital Israelita Albert Einstein 1. Diabetes Mellitus


Hospital Paulistano 1. Palliative Care Program


Hospital Santa Palula 1. Primary Stroke Program

Total Care Unidade Jardins 1. Heart Failure Program


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Hospital leadership

社區社區 ACC

ACC ACC ACC

ACC ACC

ACC

ACC

ACC ACC PFR AOP COP

MMU ASC PFE

IPSG

ACC

Coordination

Interaction

Communication

Integration

call center call center

FMS

PCI

QPS

MCI SQE

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Patient Care Model

全人

全社區

全程全隊

全家人

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Patient Care Model商標專利

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驗證（Certification）

對某一項產品、過程或服務能符合規定要求，由第三者出具書面保證之程序。

認證（Accreditation）

主管機關對某人或某機構給予正式認可，證明其有能力執行某特定工作之程序。

對符合標準之認可

對能力之認可

JCIA and CCPC Clarification

Joint Commission International Accreditation (J.C.I.A.)

Clinical Care Program Certification (C.C.P.C)

資料來源：財團法人全國認證基金會

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JCI-CCPC的發展歷程

First Edition:

Joint Commission International Standards for Disease or Condition- Specific Care (Effective 2005)

Second Edition:

Joint Commission International Standards for Clinical Care Program Certification (Effective 2010)

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可申請CCPC認證的計畫項目

Acute Myocardial Infarction 急性心肌梗塞

Asthma 哮喘

Cancer (all Types) 癌症(任何類型的癌症)

Chronic Kidney Disease (stage I to IV) 慢性腎病(一至四期)

Chronic Obstructive Pulmonary Disease (COPD) 慢性阻塞性肺病

Diabetes Mellitus (types 1 and 2) 糖尿病(1型/2型)

End Stage Renal Disease 晚期腎病

Heart Failure 心力衰竭

HIV/AIDS Management 愛滋病管理

Joint Replacement (all Types) 關節置換(任何類型的關節置換)

Pain Management 疼痛管理

Palliative Care (all Types) 緩和療護(任何類型的緩和療護)

Primary Stroke 初級中風

Transplantation (all Types) 移植(任何類型的移植)

Traumatic Brain Injury 創傷性腦傷害共計15項

Adapted from: http://www.jointcommissioninternational.org/

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醫院參加CCPC的優點和理由 (1)

Giving organizations a competitive advantage 提升機構的競爭力：通過認證後，可更公開的向外界證明通過認證

的醫院相較於其他同層級醫院，施行的CCPC是非常關心病人的安全，可提供更高品質的照護

Strengthening community confidence 強化民眾的信心：將病人及家屬納入照護過程中成為伙伴，尊重他

們的權利及意見，亦可提供病人及付費者有更好的選擇就醫之機會

Obtaining recognition from insurers, associations, employers, and other stakeholders 贏得相關機構認同：參加評鑑或認證以提升醫療品質已是趨勢，通

過認證可強化合作機構的信賴與認同感，以更好的照護品質要求更好的給付

Adapted from: Clinical Care Program Certification Survey Process Guide. Joint Commission International Accreditation, 2010.

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Validating high-quality care to patients 高品質照護的保證：JCI總部致力於提升病人安全與照護品質，所以

訂定高標準的認證條文，通過認證是高品質照護的保證

Helping organizations organize and strengthen their improvement efforts 持續的品質改善： JCI總部是依據目前醫療、科技的發展趨勢來訂定

認證條文，可以幫助機構持續改善，並走在時代先端

Enhancing staff education 提升員工的教育：JCI委員是受過完整的訓練，在專業領域的學經歷

都是佼佼者，在查核同時也會提供教育，協助改善機構的內部作業和流程



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Improving risk management 加強風險的管理：導入風險管理的概念，幫助機構改善或降低不良

事件、建立不良事件及安全相關議題及時通報的醫院文化，以提升病人安全，及減少醫療和財務風險

Facilitating staff recruitment 增加員工的滿意度：通過認證是高品質照護的保證，可使照護提供

者更有自信、更進步，願意共同投入工作，因此可以增加召募及留任率

Promoting team-building skills for staff 促進團隊的合作：認證條文必須靠團體運作才能達到，參加認證可

以讓團隊在以病人為中心的基礎下，強化彼此合作關係



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病人加入CCPC照護團隊的好處

以international, evidence based clinical guideline (具實證的國際級照護指引)，提供更好的照護品質

整個團隊(multi-disciplinary)積極主動的介入照護

設有監測的品質指標，如：指引遵循率(compliance rate)、病人滿意度…等，以提供高品質且一致性的照護

CCPC的照護團隊…

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什麼時候該參加CCPC

對臨床照護指引無共識

照護計畫缺乏個別化

照護計畫未整合且未詳加記錄

臨床護理人員須照護之病人數太多

缺乏明確的跨團隊合作機制

未建置成果導向之品質指標

缺乏深究問題的決心

擔心影響病人的觀感

未完全的以病人為中心

當您的照護團隊…

就是加入CCPC的時機

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醫策會疾病照護品質認證與JCI-CCPC

醫策會-DSCCP JCI-CCPC

認證名稱疾病照護品質認證 (Disease Specific Care Certification Program)

臨床照護計畫認證

(Clinical Care Program Certification)

起始年份 2008年 2005年

認證條文 3章/ 9節/ 23個基準 6章/ 48條標準/ 188個評量細項

評鑑手法 Patient-Focused Method Tracer Methodology

可認證計畫 3種，包含：冠狀動脈疾病

急性冠心症

急性心肌梗塞

15種，包含：急性心肌梗塞哮喘癌症(任何類型的癌症) 慢性腎病(一至四期) 慢性阻塞性肺病糖尿病(1型/2型) 晚期腎病心力衰竭愛滋病管理關節置換(任何類型的關節置換) 疼痛管理緩和療護(任何類型的緩和療護) 初級中風移植(任何類型的移植) 創傷性腦傷害

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Outline






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CCPC第2版共有6個章節、48個標準及188個評量細項 (Effective 1 July 2010)

CCPC第3版共有6個章節、46個標準及184個評量細項 (Effective 1 January 2015)

章節名稱 International Patient Safety Goal, IPSG

Program Leadership and Management, PLM

Delivering or Facilitating Clinical Care, DFC

Support Self-Management, SSM

Clinical Information Management, CIM

Performance Measurement and Improvement, PMI

Adapted from: http://www.jointcommissioninternational.org/

JCI-CCPC章節及標準說明 (1)

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JCI-CCPC章節及標準說明 (2)

章節標準 (STD) 評量細項 (ME)

第2版 (2010-7)

第3版 (2015-1)

第2版 (2010-7)

第3版 (2015-1)

IPSG 6 10 21 30

PLM 15 9 47 34

DFC 7 9 31 38

SSM 5 5 20 19

CIM 7 6 32 31

PMI 8 7 37 32

合計 48 46 188 184 Adapted from: http://www.jointcommissioninternational.org/

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Outline






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章節標準 (STD) 評量細項 (ME)

第2版 (2010-7)

第3版 (2015-1)

第2版 (2010-7)

第3版 (2015-1)

IPSG 6 10 21 30

PLM 15 9 47 34

DFC 7 9 31 38

SSM 5 5 20 19

CIM 7 6 32 31

PMI 8 7 37 32

合計 48 46 188 184 Adapted from: http://www.jointcommissioninternational.org/

JCI-CCPC章節及標準

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IPSG.1

Adapted from: http://www.google.com.tw (4 Feb. 2014)

Message

明訂病人辨識的政策和流程（P&P）

供相關人員遵循

Standard

Identify Patients Correctly (提昇病人辨識的正確性)

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IPSG.2

Message

處理口頭及電話醫囑之政策和流程

Write Down、Read Back、Confirm的核對機制

Standard

Improve Effective Communication (促進有效的溝通)


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IPSG.3

Message

高警訊藥品應有特殊的標示及存放

高濃度藥品，不可放置於護理站或藥局以外的單位

Standard

Improve the Safety of High-Alert Medications (促進高警訊藥品的安全性)


35

IPSG.4

Message

WHO Surgical Safety Checklist

Sign In、Time Out、Sign Out

Check該完成的檢驗/檢查

Standard

Ensure Correct-Site, Correct-Procedure, Correct-Patient Surgery

(確保手術部位、程序和病人的正確性)


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IPSG.5

Message

明訂醫院之手部衛生計畫及感染管制計畫

有監測機制，確認執行對策的有效性

Standard

Reduce the Risk of Health Care-Associated Infections (降低醫療照護相關感染之風險)


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IPSG.6

Message

建置跌倒防制計畫並主動提報相關作為

監測跌倒發生率及跌倒傷害率

嚴重事件要進行RCA

Standard

Reduce the Risk of Patient Harm Resulting from Falls (降低病人跌倒所導致傷害之風險)


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PLM-- PLM.1~.15

Leadership roles in the program are clearly defined.

(清楚定義計畫領導者的角色) PLM.1

The program is designed, implemented, and evaluated collaboratively.

(計畫的制訂、執行及評核，都是透過共同合作的機制)

PLM.2

The program is relevant and meets the needs of the target population and/or health care service area.

(計畫的設計是符合目標照護族群的需求)

PLM.3

The scope and level of care and/or services offered by the program are provided to patients and, when appropriate, families.

(計畫服務範圍和層級，要讓病人知道；需要時亦要讓家屬知道)

PLM.4

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PLM-- PLM.1~.15

The scope and level of care and/or services provided are uniform and comparable for patients with the same acuity and type of disease or condition being managed, regardless of their ability to pay or the source of payment.

(計畫提供的服務範圍和層級要具備一致性，不因病人的經濟能力而有所不同)

PLM.5

The program operates in an ethical manner.

(計畫的運作符合倫理的規範) PLM.7

Eligible patients have access to the care and/or services provided by the program.

(符合收案條件的病人，有邀請加入計畫)

PLM.6

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PLM-- PLM.1~.15

PLM.10 Facilities where patients receive care maintain and implement a program that provides a safe and secure physical environment.

(確保病人有安全及保全的就醫環境)

The program has current reference and resource materials readily available.

(計畫採用現況的參考指引和資源，並方便人員取得)

PLM.9

The program complies with applicable laws and regulations.

(計畫的運作符合法律和規範)

PLM.8

Facilities where patients receive care maintain and implement an emergency management program.

(病人照護單位訂有緊急應變計畫)

PLM.11

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PLM-- PLM.1~.15

Facilities where patients receive care maintain and implement a program for inspecting, testing, and maintaining medical equipment and documenting results.

(病人照護單位訂有醫療設備的檢測及維修計畫，並留下記錄)

PLM.13

Facilities where patients receive care maintain and implement a program to ensure that all occupants are safe from fire and smoke.

(病人照護單位訂有防火計畫，確保所有到院者避免受到火、煙的傷害)

PLM.12

42

PLM-- PLM.1~.15

PLM.15 Facilities where patients receive care maintain and implement a program to ensure that all staff members receive education and training about their roles in providing a safe and effective environment.

(病人照護單位訂有完善的教育訓練計畫，每位員工都熟知自己在提供病人安全的就醫環境上應扮演的角色)

Facilities where patients receive care maintain and implement emergency processes in the event of water, power, gas, or communication failures.

(病人照護單位訂有水、電、醫用氣體等公用系統運作失常之緊急處理流程)

PLM.14

43

All clinical staff are qualified, competent, and appropriately trained.

(所有照護團隊成員都經過適當的教育訓練，具備足夠的資格與能力)

DFC.1

All clinical and nonclinical staff are oriented to the program and to their specific job responsibilities.

(所有照護團隊成員都給予計畫相關的職前教育，使其了解自己的工作職責)

DFC.2

There are continuous, ongoing professional practice evaluations of the quality and safety of the clinical care provided by each staff member.

(所有團隊成員的專業照護品質和安全，要有持續性的評估機制)

DFC.3

DFC-- DFC.1~.7

44

The program uses a standardized process originating in clinical practice guidelines or evidence-based practice to deliver or facilitate the delivery of clinical care.

(本計畫引用具實證基礎的臨床照護指引，以提供標準化的照護)

DFC.4

All clinical staff are knowledgeable about the adapted or adopted clinical practice guidelines and implement activities that are consistent with the clinical practice guidelines.

(團隊成員都熟知本計畫之臨床照護指引，並據此提供一致性的照護)

DFC.5

DFC-- DFC.1~.7

The program tailors the standardized process to meet the patient’s needs.

(本計畫致力於導入符合病人需求之標準化的照護流程)

DFC.6

45

Concurrently occurring conditions and comorbidities are managed, or the information necessary for their management is communicated to the appropriated clinical staff.

(收案病人的共病同時要給予治療，並針對相關重要訊息與其他照護此病人的臨床人員溝通)

DFC.7

DFC-- DFC.1~.7


46

The program involves the patient and, when appropriate, the family in making decisions about managing their diseases or conditions.

(在執行疾病相關的醫療決策時，有病人及家屬的參與)

SSM.1

The program addresses the patient’s and, when appropriate, the family’s readiness, willingness, and ability to learn.

(在進行病人及家屬的教育前，有先評估其受教之接受度、意願和能力)

SSM.2

The program addresses the patient’s and, when appropriate, the family’s educational needs.

(計畫的設計有重視病人及家屬的教育需求)

SSM.3

SSM-- SSM.1~.5

47

The program materials are consistent with the clinical guidelines and relevant and appropriate to the population served.

(教育內容和資料符合臨床照護指引的規範及服務對象的需求)

SSM.4

The program addresses lifestyle changes that support self-management regimens.

(計畫提及支持病人及家屬自我照護的方案及作法)

SSM.5

SSM-- SSM.1~.5

48

The confidentiality, security, and retention of patient information are protected.

(有妥善保護病人的機密資料)

CIM.1

The program identifies those authorized to have access to and/or to make entries in the patient clinical record.

(要確認那些人員是被授權可以進入查詢或異動病人的資料)

CIM.2

The program uses standardized diagnosis codes, procedure codes, symbols, abbreviations, definitions, and methods for adding comments/addenda.

(記錄病人資料時，使用標準化的診斷碼、處置碼、代號、縮寫、定義及方法)

CIM.3

CIM-- CIM.1~.7

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Information management processes meet the program’s

internal and external information needs. (資料管理流程符合計畫內部和外部的需求)

CIM.4

CIM.5 The program gathers information about the patient’s disease or condition from clinical staff and settings across the continuum of care.

(有收集、整合臨床人員或其他機構關於病人疾病資訊的流

程，以支持連續性照護)

The program shares information about the patient’s disease or condition across the entire continuum of care to any relevant setting or clinical staff.

(有和臨床人員或其他機構分享病人疾病資訊，以支持連續

性照護)

CIM.6

CIM-- CIM.1~.7

50

The program initiates, maintains, and makes accessible a health or clinical record for every patient.

(每位收案病人的病歷資料都有進行維護及記錄)

CIM.7

CIM-- CIM.1~.7


51

The program has an organized, comprehensive approach to performance improvement.

(本計畫有建置具組織性、全方位的品質改善策略)

PMI.1

The program maintains data quality and integrity.

(維護收集之資料的品質和完整性) PMI.2

The program uses measurement data to evaluate and to improve processes and outcomes.

(運用收集之資料以評量並改善流程和執行成效)

PMI.3

PMI-- PMI.1~.8

The process for identifying, reporting, managing, and tracking sentinel events is defined and implemented.

(訂定並執行警訊事件之確認、通報、處理及追蹤流程)

PMI.4

52

The process for identifying, reporting, managing, and tracking errors and adverse events is defined and implemented.

(訂定並執行疏失或不良事件之確認、通報、處理及追蹤流程)

PMI.5

The process for identifying, reporting, managing, and tracking “near-miss” events is defined and implemented.

(訂定並執行跡近錯誤事件之確認、通報、處理及追蹤流程)

PMI.6

The program collects and analyzes data regarding variance from the clinical practice guidelines to improve the standardized process.

(收集及分析臨床照護指引執行上的差異，加以修正以標準化照護流程)

PMI.7

PMI-- PMI.1~.8

The program evaluates patient and family perceptions of the quality of care.

(針對病人及家屬進行照護品質的滿意度調查)

PMI.8

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Outline






54

CCPC評分方式

分類定義給分

Fully Met “完全符合”或“完全執行” 10分

Partially Met “部份符合” 5分

Not Met “不符合”或“未執行” 0分

Not

Applicable

對於評量細項的特定需求，若於醫院無需實

施或不適用，則被評為 “不適用”

評分等級 (Scoring Guideline)


55

CCPC認證合格之判定

須符合以下要點：

沒有任一個標準(Standard)，有一個以上的評量細項(MEs)

得分為0 1

沒有任一個國際病人安全目標(IPSG)，有一個以上的評量

細項(MEs)得分為0 2

每項標準(Standard)平均得分要≧5 3

每項國際病人安全目標(IPSG)平均得分要≧ 5 4

所有章節之標準(Standard)得分總和平均要≧ 9 5


56

認證結果

認證合格之醫院：於評鑑後10-15天內收到正式評鑑報告

（Official Survey Findings Report）

醫院須針對報告中Not Met項目，於收到報告後45天內提出策略改善計畫(Strategy Improvement Plan, SIP)

未認證合格之醫院：亦於評鑑後10-15天內收到初步評鑑報告

（Preliminary Survey Findings Report）

將進行追蹤焦點訪查（Follow-Up Focused Survey）


57

CCPC On-site Survey 以Asthma Program為例

Adapted from: http://www.google.com.tw (8 Dec. 2014)

57

58

For CCPC On-site Survey

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Day 1 (2012-11-27)

Time Topic

0800-0815 Opening Conference and Introductions, Agenda Review

0815-0900 Presentation of Overview of Clinical Care Services and PI Measures

0900-0930 Review of Performance Measure Data

0930-1000 Surveyor Document Review, as Needed

1000-1200 Unit Visits/Tracer Activity

1200-1300 Surveyor Lunch//Planning

1300-1600 Unit Visits/Tracer Activity

1600-1615 Review any issues as needed with Program Director

Survey Agenda--day 1

60

Day 2 (2012-11-28)

Time Topic

0800-0830 Daily debriefing—Review of first day survey activities

0830-0900 Further discussion of selected Four PI Measures, as needed

0900-1100 Closed Medical Record Review

1100-1200 Surveyor Interviews with Program Outpatients

1200-1300 Surveyor Lunch//Planning

1300-1430 SQE Review for Physicians, Nurses, and Other Staff

1430-1530 Surveyor Computer Integration of Report

1530-1600 Exit Conference

Survey Agenda--day 2

61

CCPC Asthma On Site Survey

62

2012-11-27迎賓

評鑑首日，委員對院長室成員前來迎接倍感溫馨

63

Opening Conference 院長室長官及委員致詞

團隊成員介紹及計畫主持人簡報

64

Orientation

Program staff introduction

Presentation of Overview of Clinical Care Services and PI Measures

65

Introduction

Presenter:

Dr. Cheng-Hsiung CHEN

66

Board certified Medical Doctor

Board certified Pulmonary Physician

Director of the ward of Chest Department

Member of Taiwan Society of Pulmonary and Critical Care Medicine

Qualifications

67

Leadership Role and Duties

Outline the objectives, missions and goals

Formulate and review the annual working plan

Manage various indices of medical service quality

Monitor patient safety and prevent on accident

event

Make preliminary decisions on the facility and

technique access and renewal

Regulation of medical care staff, adequately reply

to staff feedback and improve communication

68

Orientation

Program staff introduction

Presentation of Overview of Clinical Care Services and PI Measures

69

Orientation to the Clinical Care Program

Standards/Issues To Be Addressed

Introduction to the clinical care program

by program leaders

PLM.1 to PLM.9

DFC.4 to DFC.7

70

2012-11-27 Unit Visits/Tracer Activity

委員至各單位實地訪查環境安全、病人照護流程

71

CCPC Asthma On Site Survey

72

Daily Debriefing

早上由委員針對第一天訪查重點進行建議，由團隊成員針對委員建議進行回覆

73

Closed Medical Record Review

病歷審查是CCPC必要項目

74

STD Documentation

Requirement Measurable Elements

Medical Record

Medical Record

Medical Record

Medical Record

#_____ #_____ #_____ #_____

DX: DX: DX: DX:

Y N NA

Y N NA

Y N NA

Y N NA

CONSENTS

PLM.6 Eligible patients have access to the care and/or services provided by the program

3.Patients are given multiple opportunities to participate in the program. 給病人有多次參與該計畫的機會

PLM.7 The program operates in an ethical manner

2.The program respects the patient’s right to decline participation in the program 該計畫有尊重病人拒絕參與該計劃的權利

Medical Record Review Tool (1)

75

STD Documentation


Medical Record

Medical Record

Medical Record

Medical Record

#_____ #_____ #_____ #_____

DX: DX: DX: DX:

Y N NA

Y N NA

Y N NA

Y N NA

ASSESSMENTS

DFC.6 The program tailors the standardized process to meet the patient’s needs.

1.The program defines the patient assessment process, including family risks.

該計畫有定義病人評估的程序，包括家屬風險的評估

2. An assessment is completed for all patients within the time frame determined by the program.

病人完整的評估應在計畫訂定的時間內完成

3.The assessment is used to develop a plan of care.

依據評估的結果發展病人的照護計畫

4.The program uses a specified method for prioritizing the needs of patients.

該計畫運用特殊方式以決定病人需求之優先順序


76

STD Documentation


Medical Record

Medical Record

Medical Record

Medical Record

#_____ #_____ #_____ #_____

DX: DX: DX: DX:

Y N NA

Y N NA

Y N NA

Y N NA

CARE DELIVERY

DFC.6 The program tailors the standardized process to meet the patient’s needs.

5.The program implements interventions based on prioritization of needs and identified patient risks. 該計畫依據病人需求優先順序和已確認之病人風險介入照護

6.The prioritization method is tailored to meet the targeted population’s age and developmental needs. 優先順序的選取方式切合目標族群的年齡和發展需求

7.The program continually evaluates, revises, and implements the plan of care to meet the patient’s ongoing needs. 該計畫持續進行評估、更新和執行照護計畫，以符合病人需求


77

STD Documentation


Medical Record

Medical Record

Medical Record

Medical Record

#______ #______ #______ #______

DX: DX: DX: DX:

Y N NA

Y N NA

Y N NA

Y N NA

OTHERS

DFC.7 Concurrently occurring conditions and comorbidities are managed, or the information necessary for their management is communicated to the appropriate clinical staff

1.Care is coordinated for patients with multiple diseases and/or who are managed by multiple clinical care programs 針對多種疾病和/或多個臨床照護計畫管理之病人之照護是經過協調的

2.When concurrently occurring conditions are identified, relevant information is communicated to appropriate clinical staff treating or managing the condition(s)

當有其他共病時，病人之相關訊息有傳送給適當的治療或管理此情況之臨床工作人員


78

STD Documentation


Medical Record

Medical Record

Medical Record

Medical Record

#______ #______ #______ #______

DX: DX: DX: DX:

Y N NA

Y N NA

Y N NA

Y N NA

CIM.3 The program uses standardized diagnosis codes, procedure codes, symbols, abbreviations, definitions, and methods for adding comments/addenda.

1.Standardized diagnosis codes are used and the use monitored

使用標準化的診斷代碼並監測使用狀況

2.Standardized procedure codes are used and the use monitored.

使用標準化的處置代碼並監測使用狀況

4.Standardized symbols are used, and those not to be used are identified and monitored

使用標準化的符號，且訂定不得使用的符號清單，並監測使用狀況

5. Standardized abbreviations are used, and those not to be used are identified and monitored.

使用標準化的縮寫，且訂定不得使用的縮寫清單，並監測使用狀況


79

Staff Qualification and Education Review

人員資格審查是CCPC查核要點

80

Program Staff Qualifications Worksheet (1)

Standard Measurable Element

DFC.1 All clinical staff have educational backgrounds, experience, training, and/or certification consistent with the program’s mission, goals, and objectives. 臨床人員的教育背景、經驗、訓練和/或認證，符合計畫的任務、目標和目的。

Core criteria for hiring clinical staff in the program include, at a minimum, current licensure, relevant education, training and experience, and current competence. 該計畫聘用臨床人員的核心標準，最低限度包括，目前的證照、相關的教育、訓練和經驗，以及現況的能力。

Core criteria for evaluating clinical staff in the program include, at a minimum, current licensure and current competence. 該計畫評核臨床人員的核心標準，最低限度包括，目前的證照和現況的能力。

Professional education, advanced training, and experience are verified from primary sources. 專業教育、進階訓練和工作經驗，要經由原始機構驗證。

Current licensure and certifications are verified from primary sources 目前證照和認證要經過原始機構驗證。

DFC.2

Orientation provides information and necessary training appropriate to program responsibilities. 職前訓練應提供符合該計畫職責的資訊和必要訓練。

The competence of all clinical staff is assessed when new techniques or responsibilities are introduced and periodically within the time frames defined by the program 當新技術或職責加入時，所有臨床人員的執行能力要在該計畫訂定時限內完成評核。

81

Standard Measurable Element

DFC.2 Ongoing in-service and other education and training activities are relevant to the program’s needs. 持續進行的在職教育、其他教育以及訓練活動，要符合該計畫需求。

DFC.3 The performance of individual staff members is reviewed when indicated by findings of quality improvement activities. 透過品質改善活動之成效的呈現，檢討個人的表現。

There is an ongoing professional practice evaluation of each staff member documented in the staff member’s file that includes at least one documented evaluation each year. 團隊成員之專業能力評估資料應記錄於各自資料檔案中，並至少每年一次。

Corrective action is taken when deficiencies or substandard performance are identified. 當團隊成員之專業表現不良或不符合標準時，要採取糾正措施。

DFC.5

Clinical staff have been educated about clinical practice guidelines and their use. 臨床人員有被教育臨床照護指引的內容和使用。

Clinical staff consistently follows the 臨床人員一致遵循所選定的臨床照護指引。

Assessment activities are consistent with clinical practice guidelines. 各項評估活動應與臨床照護指引一致。

Intervention activities are consistent with clinical practice guidelines. 各項醫療處置與介入活動應與臨床照護指引一致。

Program Staff Qualifications Worksheet (2)

82

Asthma Program Exit Conference

委員授與認證初報/Asthma團隊與委員合影

83

2012-12-6 Final Survey Finding Report Letter

84

Outline






85

通過評鑑及認證之紀錄： 3次JCI醫院評鑑 9個CCPC Program

85

86

2014-12-9日止共計通過9個JCI-CCPC照護計畫 (11次的認證經驗)

美國以外世界第一

90

2011-12-28 JCI亞太地區辦公室副主任Joyce蒞院參訪

彰基CCPC成功經驗分享

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謝謝聆聽敬請指教

疾病別認證的國際趨勢 - jct.org.tw

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