Weinberg N S, Stason W B
Patient Care Improvement Council, Partners Community Health Care, Inc., Boston, MA, USA.
Int J Qual Health Care. 1998 Aug;10(4):295-302. doi: 10.1093/intqhc/10.4.295.
While routine clinical decision-making has a substantial effect on quality, most practising physicians do not routinely examine their outcomes.
To set up a practical process for identifying problems in hospital practices of primary care physicians, examine their causes, and develop a quality improvement process that intimately involves practising physicians in problem-solving.
All hospital admissions to the Primary Care Service were screened over a 14-month period using simple pre-specified criteria. Quality problems were verified by medical record reviews carried out by two physicians. These problems were discussed at monthly meetings of physicians to characterize the problems fully, identify their causes, and document adverse effects on patient outcomes.
One community hospital.
Primary care physicians from three group practices and four solo practices who admit patients to the Primary Care Service.
Monthly group discussions plus discussions with individual physicians when time did not permit all quality problems to be discussed at group meetings. Certain issues of high sensitivity were also discussed with the individuals rather than in an open forum.
Missed or delayed diagnoses, inappropriate treatments, and complications and their root causes.
Quality problems were identified in 6% of all admissions. Of these, 60% were missed or delayed diagnoses, 22% were iatrogenic complications and 18% were inappropriate treatments. Root cause analysis suggested that physician behaviors led to 75% of problems; systems problems to 20% and inadequate knowledge to 5%. Process improvements included development of a call-in system to reduce delays in obtaining X-ray reports; implementation of an anticoagulation monitoring system in one group practice; and a protocol of regular feedback of errors in diagnosis to emergency room physicians. Participating physicians reported increased awareness of common errors and greater attention to detail in patient evaluations.
Knowledge of root causes of quality problems is essential for improving quality of care. A simple routine approach to examining adverse outcomes and how care might be improved in the future was set up. Active participation of practising physicians is essential. Other organizations could use this process for routinely reviewing and improving quality.
虽然常规临床决策对医疗质量有重大影响，但大多数执业医师并不经常审视其诊疗结果。
建立一个实用流程，以识别基层医疗医师医院诊疗中的问题，探究其原因，并制定一个让执业医师密切参与解决问题的质量改进流程。
在14个月期间，使用预先设定的简单标准对基层医疗服务的所有住院病例进行筛查。由两名医师通过病历审查来核实质量问题。在医师月度会议上讨论这些问题，以全面描述问题、找出原因并记录对患者诊疗结果的不良影响。
一家社区医院。
来自三个联合诊所和四个单人诊所、将患者收治到基层医疗服务的基层医疗医师。
每月进行小组讨论，在时间不允许在小组会议上讨论所有质量问题时，与个别医师进行讨论。某些高度敏感的问题也与个人讨论，而非在公开论坛上讨论。
漏诊或延误诊断、不恰当治疗、并发症及其根本原因。
在所有住院病例中，6%发现了质量问题。其中，60%是漏诊或延误诊断，22%是医源性并发症，18%是不恰当治疗。根本原因分析表明，75%的问题是由医师行为导致的；20%是系统问题，5%是知识不足。流程改进包括建立一个电话系统以减少获取X光报告的延误；在一个联合诊所实施抗凝监测系统；以及制定向急诊室医师定期反馈诊断错误的方案。参与的医师报告称，对常见错误的认识有所提高，在患者评估中对细节的关注也更多。
了解质量问题的根本原因对于提高医疗质量至关重要。建立了一种简单的常规方法来检查不良结果以及未来如何改进医疗服务。执业医师的积极参与至关重要。其他机构可以使用这个流程来定期审查和提高质量。
