Moll Marie Christine, Decavel Frédérique, Merlet Christine
CHU d'Angers.
Rech Soins Infirm. 2009 Sep(98):19-27.
For a few years, health institutions have had to comply with the certification and the need to establish the new governance. Thanks to the accreditation version 2 (obtained in 2005), the elaboration of the hospital project (adopted in October, 2006) and the organization in poles since 2006, the quality oriented management became a priority axis at the University Hospital of Angers. The strategic adaptation to quality requirements leads to develop the hospital management, more especially at the level of the clinical, medico technical and administrative poles. The elements of the hospital project including the part about the quality, risk and evaluation aim at being adapted by every pole according to the level of its project. This adaptation which is imposed to each pole manager requires a practical and educational accompaniment allowing at the same time to realize a diagnosis of the progress of the quality approach, a measure of the impact of the global impregnation within the institution and a comparison between pole. A eight axis dashboard with criteria and a user guide were developed from certification ISO 9001, the EFQM manual and the certification manual version 2 of the Healthcare High Authorities. The criteria are transcribed in an EXCEL grid ready to use. Succeeding in estimating your own quality system means that you demonstrate the maturity of the quality approach. The results of this evaluation confirmed those of the certification. The dashboard is a management structuring tool at the service of the multidisciplinary team. Two considerations emerge from these results: First of all, for the hospital top management, the axes to be improved emerge as a priority to determine and target the next annual action plans. The results also allow to support the auto evaluation for the certification version 2010 planned in January of the same year. It is a pragmatic tool which allows auto evaluation and comparison to estimate the pole performances. It is a strategic driving tool for the hospital, for the quality department and for the pole. The pole quality system evaluation dashboard for Healthcare institutions is a simple tool which allies strategy and performance for a better efficiency of the actions to be taken to improve the quality, the risk management and the evaluation of the poles for a better service to the hospital users.
几年来，卫生机构必须遵守认证要求并建立新的管理模式。得益于2005年获得的二级认证、2006年10月通过的医院项目以及自2006年起按科室进行的组织架构调整，以质量为导向的管理成为昂热大学医院的优先发展方向。对质量要求的战略调整促使医院管理不断发展，尤其是在临床、医疗技术和行政科室层面。医院项目中的各项内容，包括质量、风险和评估部分，旨在由各科室根据自身项目水平进行调整。这种对各科室负责人的强制调整需要实际的指导和培训，以便同时对质量改进方法的进展进行诊断、衡量整体渗透在机构内的影响以及科室之间的比较。根据ISO 9001认证、欧洲质量管理基金会（EFQM）手册以及医疗卫生高级管理部门的二级认证手册，开发了一个包含八个轴的仪表盘及标准和用户指南。这些标准被转录到一个随时可用的EXCEL表格中。成功评估自身质量体系意味着展示质量改进方法的成熟度。此次评估结果与认证结果相符。该仪表盘是为多学科团队服务的管理结构化工具。从这些结果中可以得出两点思考：首先，对于医院高层管理人员来说，需要改进的方面成为确定和制定下一年度行动计划的优先目标。这些结果还为同年1月计划进行的2010版认证的自我评估提供了支持。这是一个实用工具，可用于自我评估和比较，以评估科室绩效。它是医院、质量部门和科室的战略驱动工具。医疗卫生机构的科室质量体系评估仪表盘是一个简单工具，它将战略与绩效相结合，以便更高效地采取行动来提高质量、风险管理和科室评估，从而更好地为医院用户服务。
