全面质量管理与医院管理

1TotalQualityManagement&Hospitalmanagement全面质量管理与医院管理夏萍NancyXiaGuangdongProvinceHospitalofTCM2案例1某医院妇产科值班助产士带领护校的实习生值小夜班。22时30分，两人一起处理完两个产妇后，助产士去取夜餐。回来后，实习护士准备给婴儿配奶，并问助产士怎样配方，奶粉和水的比例怎样掌握？答：“一般配就行了”。给婴儿喂奶完后，即给上午出生的3名婴儿配葡萄糖水。实习护士从壁橱最底层的3瓶粉剂中顺手拿出其中已用过的一瓶问助产士：“这是不是葡萄糖？”她连头也未抬，信口答复：“是！”实习护士便配成“糖水”喂了3名婴儿。次日凌晨1时30分，第一例婴儿出现呼吸衰竭，抢救50分钟后无效，于2时20分死亡。医务人员进行讨论，认为婴儿死得突然，诊断不清，以致抢救难以奏效。4时40分，第2例婴儿出现面部紫绀，呼吸困难；5分钟后第3例女婴也出现相同症状。立即请来儿科主治医师会诊，考虑是亚硝酸钠中毒，虽经积极抢救，终因中毒较重，两名女婴相继死亡。3案例1分析事后查实，此3瓶粉剂是已存放十几年的亚硝酸钠盐。由于本科老师人实习学生不需配亚硝酸钠溶液，因而未向实习护士说明此3瓶粉剂是剧毒药，不能随便动用，同时也未加锁。上述案例3名婴儿死于硝酸钠中毒。此药为剧毒药品，本应由专人妥善保管，上锁存放，但竟然在新生儿配奶用的壁橱内存放此剧毒药达几十年，虽曾有数人发现，均未引起重视，足见管理上的严重失职。特别是作为带教老师的助产士，面对实习护士，明知橱内有剧毒药，本应认真负责，谨慎从事，放手不放眼，而她却不亲自查对，顺口便答“是”。以致造成3名婴儿死亡，完全丧失了一个医务人员应有责任感，是一种失职犯罪行为。助产士是本案的主要责任者，本例定为一级医疗责任事故。4案例2患者女性，24岁，因腰痛1年，逐渐加重住院。检查：体温37度，发育营养中等，第9、10腰椎明显凸，拾物实验（+）。脊柱X线片第9、10腰椎骨破坏、死骨形成，第9-11腰椎有椎旁脓肿。诊断为第9、10腰椎结核。某大医院骨科医师甲以个人名义被邀作主刀医师，在全麻下经胸做病灶清除加植骨手术。术中清病灶时，刮出一黄豆粒大小的白色物，助手和本院医师乙疑为脊髓，再叫甲看。但甲没有认真视物就说是“脓苔”（后经病理证实是脊髓组织）。术后患者呈弛缓性截瘫。经当地治疗和护理后，转入甲所在医院。截瘫平面不见下降，自主膀胱形成，但因善后处理了纠纷，住院2年或始出院回当地休养。5案例2分析此案例明显属于术者操作过失，以致刮伤脊髓。据材料称，术者是一名有相当教学和临床经验的高年资骨科医师，当助手对刮出物提出疑问时，不予重视，也不认真查看刮出组织的外观，固执己见仍继续手术，使患者永久性截瘫，造成终身残废。本例定为二级医疗责任事故。6案例3患者男性，52岁，患胆囊炎、胆结石住院。在连续硬膜外麻醉下行胆囊切除及胆总管取石术后。术者甲（进修医师）、第一助手（带教医师）、第二助手（实习生）、器械护士（丙）、巡回护士（丁）。缝合腹膜前，医师乙三次嘱咐护士清点纱布，丙、丁两护士均报告术者纱布数无误，可以关腹。手术结束后，把病员安全送回病房。数日后患者腹痛、呕吐，于术后第13日晚因粘连性肠梗阻再次手术探查，开腹后反县腹腔留有一条纱布，取出后清洗腹腔关腹。术后患者恢复较好，住院2个月，痊愈出院。7案例3分析本案例关腹前医师乙三次催促丙、丁护士清点物品，但由于二人工作态度不认真，很不负责任地报告“纱布无误”，使纱布遗留在腹腔中，致肠梗阻发生及病员二次手术之苦。丙、丁二人属失职行为，为本例事故的主要责任者，定为三级医疗责任事故。8Overview介绍TotalQualityManagementisamanagementapproachthatoriginatedinthe1950'sandhassteadilybecomemorepopularsincetheearly1980's.TotalQualityManagement,TQM,isamethodbywhichmanagementandemployeescanbecomeinvolvedinthecontinuousimprovementoftheproductionofgoodsandservices.Itisacombinationofqualityandmanagementtoolsaimedatincreasingbusinessandreducinglossesduetowastefulpractices.9TheTQMphilosophyofmanagementiscustomer-oriented.Allmembersofatotalqualitymanagement(control)organizationstrivetosystematicallymanagetheimprovementoftheorganizationthroughtheongoingparticipationofallemployeesinproblemsolvingeffortsacrossfunctionalandhierarchicalboundaries.10SomeofthecompanieswhohaveimplementedTQMincludeFordMotorCompany,PhillipsSemiconductor,SGLCarbon,MotorolaandToyotaMotorCompany.11DefinitionofTQM全面质量管理TQMisamanagementphilosophythatseekstointegrateallorganizationalfunctions(marketing,finance,design,engineering,andproduction,customerservice,etc.)tofocusonmeetingcustomerneedsandorganizationalobjectives.12TQMviewsanorganizationasacollectionofprocesses.Itmaintainsthatorganizationsmuststrivetocontinuouslyimprovetheseprocessesbyincorporatingtheknowledgeandexperiencesofworkers.ThesimpleobjectiveofTQMisDotherightthings,rightthefirsttime,everytime.13TQMisinfinitelyvariableandadaptable.Althoughoriginallyappliedtomanufacturingoperations,andforanumberofyearsonlyusedinthatarea,TQMisnowbecomingrecognizedasagenericmanagementtool,justasapplicableinserviceandpublicsectororganizations.TQMmustbepracticedinallactivities,byallpersonnel,inManufacturing,Marketing,Engineering,R&D,Sales,Purchasing,HR,etc14PrinciplesofTQMThekeyprinciplesofTQMareasfollowing:ManagementCommitmentPlan(drive,direct)Do(deploy,support,participate)Check(review)Act(recognize,communicate,revise)15EmployeeEmpowermentTrainingSuggestionschemeMeasurementandrecognitionExcellenceteams16FactBasedDecisionMakingSPC(statisticalprocesscontrol)》12DOE》13,FMEA》14The7statisticaltoolsTOPS(FORD8D-TeamOrientedProblemSolving)17ContinuousImprovementSystematicmeasurementandfocusonCONQExcellenceteamsCross-functionalprocessmanagementAttain,maintain,improvestandards18CustomerFocusSupplierpartnershipServicerelationshipwithinternalcustomersNevercompromisequalityCustomerdrivenstandards19SPC-StatisticalProcessControl统计过程控制Statisticalprocesscontrolistheapplicationofstatisticalmethodstoidentifyandcontrolthespecialcauseofvariationinaprocess.》920DOE-DesignofExperiments试验设计ADesignofExperiment(DOE)isastructured,organizedmethodfordeterminingtherelationshipbetweenfactors(Xs)affectingaprocessandtheoutputofthatprocess(Y).OtherDefinitions:1-Conductingandanalyzingcontrolledteststoevaluatethefactorsthatcontrolthevalueofaparameterorgroupofparameters.2-DesignofExperiments(DoE)referstoexperimentalmethodsusedtoquantifyindeterminatemeasurementsoffactorsandinteractionsbetweenfactorsstatisticallythroughobservanceofforcedchangesmademethodicallyasdirectedbymathematicallysystematictables.21FMEA-FailureModesandEffectsAnalysis失效模式和效果分析Aprocedureandtoolsthathelptoidentifyeverypossiblefailuremodeofaprocessorproduct,todetermineitseffectonothersub-itemsandontherequiredfunctionoftheproductorprocess.TheFMEAisalsousedtorank&prioritizethepossiblecausesoffailuresaswellasdevelopandimplementpreventativeactions,withresponsiblepersonsassignedtocarryouttheseactions.Failuremodesandeffectsanalysis(FMEA)isadisciplinedapproachusedtoidentifypossiblefailuresofaproductorserviceandthendeterminethefrequencyandimpacto