TRIN KHAI

CI TIN CHT LNG

Bnh vin Hon M Si Gn

2015

BS. Nguyn Hu Trm Em

G. BVHMSG

 NGHA CA VIC THC HIN 83 TIU CH

CHT LNG BNH VIN
To c vn ho an ton ngi bnh v t bnh
nhn l trung tm, m bo quyn ngi bnh.
Ci thin s hi lng ca ngi bnh qua cc dch
v khm cha bnh.
Chun ho qui trnh chuyn mn, nng cao c
cht lng chuyn mn, k thut
Ngn nga ri ro trong y khoa.
Qun l tt hn ngun nhn lc, xy dng i ng
k tha

L TRNH THC HIN

Nm u tin (2013) thit lp c cu t chc t chc h thng qun
l cht lng tch hp vi ISO.

Nm th 2 (2014) Hon thin c cu t chc h thng QLCL v

xy dng cc quy trnh hot ng, hng dn cng vic.
Nm th 3 (2015) Hon thin cc quy trnh, hng dn, thc
hin cc hot ng ci ci tin v o lng cc ch s hot ng.
Nm th 4 (2016) Tip tc ci tin, nh gi hiu qu v chun ha
theo Tiu ch nh gi BYT .
Nm th 5 (2017) thc hin ci thin cht lng theo BYT v nh
hng JCI.

HOT NG C TH
1.
2.
3.
4.
5.
6.
7.
8.

Qui trnh v phc

Kim nh lm sng
Thc hin 6 mc tiu An ton Bnh Nhn
Rt ngn thi gian ch i
Sp xp khoa phng 5S
Code blue- Hi sc tim phi.
Thi tay ngh iu dng
Hun luyn giao tip v tm l tip xc.

CC BC NH GI CHT LNG BNH VIN

1 QU TRNH T KIM TRA

2 HOT
NG CI TIN CHT LNG
2

3 NH GI KT QU

CC HOT NG CI TIN CHT LNG

1. S T CHC QUN L CHT LNG
DCH T BPTNMT

01~30/10
LX/BPTNMT

Tomorrows Healthcare Today!

PHN CNG TRCH NHIM NH GI

M s

Tn tiu ch nh gi

A.1

Ch dn, n tip, hng dn, cp cu ngi bnh

A2.

iu kin c s vt cht phc v ngi bnh

A3.

Mi trng chm sc ngi bnh

A4.

Quyn v li ch ca ngi bnh

B1.

S lng v c cu nhn lc bnh vin

B2.

Cht lng ngun nhn lc

B3.

Ch i ng v K, mi trng lm vic
Lnh o bnh vin

B4.

Ph trch
BS. Bi Quang i
BS. Phan Thanh Ton
B. Mai Th Kim Phng
B. Mai Th Kim Phng
D. Cao Th Kim Lin
ng. Nguyn c Bnh
B. Nguyn Trn Qunh Nh
B. Phm Th Long
BS. Nguyn Hu Trm Em
Anh. Nguyn Hu Kim
B. Mai Th Kim Phng
ng. Trn Vn Li
B. V Th Kim Anh

C1.

An ninh, trt t v an ton chy n

C2.
C3.

Qun l h s bnh n
ng dng cng ngh thng tin

C4.

Phng nga v kim sot nhim khun

C5.
C6.

Nng lc thc hin KT chuyn mn

Hot ng D v chm sc ngi bnh

ng. on Ngc Dng

BS. Phan Hong Nguyn
B. Ng Nht Nguyt T
BS. Nguyn Ngc Bo Long
D. Cao Th Kim Lin

C7.

Nng lc thc hin chm sc DD v tit ch

BS. H Th Kim Anh

C8.

Cht lng xt nghim

BS. L Th Kim Dung

C9.

Qun l cung ng v s dng thuc

DS. Trn Minh Nht

C10.

Nghin cu khoa hc

BS. Nguyn Ngc Bo Long

D1.

Thit lp h thng v xy dng, trin khai k hoch ci tin cht lng

BS. Nguyn Th Thanh T

D2.

Phng nga sai st, s c,cch khc phc

ng. Nguyn Trc Cng

D3.

nh gi, o lng, hp tc v ci tin CL

ng. Nguyn Trc Cng

E1.

Tiu ch sn khoa, nhi khoa

BS. L Th Kim Ngn

2. XY DNG B QUY TRNH V PHC IU TR

Cc khoa phng xy dng trn 240 quy trnh hot

ng quy trnh dch v h tr.

xy dng c b phc iu tr nht c tp

on v cc quy trnh k thut chm sc ca iu
dng.

Tomorrows Healthcare Today!

3. THC HIN KIM NH LM SNG

Ch ng:
1. Kim nh lm sng nh k
2. Ln theo du vt lm sng
Th ng:
1. Bnh bnh n
2. Rt kinh nghim chuyn mn.
3. Kim tho t vong.
T chc thc hin:
1. Thc hin hot ng kim nh lm sng pht hin nhng im
cha tt trong cng tc chm sc v iu tr s iu chnh ngay.
2. nh k vo th 3 hng tun Ban QTLS chm im h s bnh
n v th 5 thc hin bnh bnh n. Khi pht hin c sai st
chn chnh ngay. => Kt qu trong nm 2015 bnh vin khng
xy ra s c nghim trng v khng c ca khiu kin, i bi
thng Gim sai st y khoa
Tomorrows Healthcare Today!

3. THC HIN SU MC TIU AN TON BNH NHN

1. NHN DIN CHNH XC NGI BNH NM 2012

1 Tng quan n
2 Mc ti d n
3
Gi mc
Tt mc
1
bc trin khai
4 Cc 60
BN

Tomorrows Healthcare Today!

10

3. THC HIN SU MC TIU AN TON BNH NHN (tt)

2. GIAO TIP HIU QU

i vi iu dng v bnh nhn: IDET

i vi iu dng v bc s:
SBAR
Trong tnh hung cp cu:
VERBAL ORDER-Y lnh ming

3. THC HIN SU MC TIU AN TON BNH NHN (tt)

3. AN TON DNG THUC C NGUY C CAO

Gim qu ti

2 Mc ti d n

Tng CLDV

2
3 ch CP
Khng
4
BN

Tomorrows Healthcare Today!

12

3. THC HIN SU MC TIU AN TON BNH NHN (tt)

4. AN TON TRONG PHU THUT

Tomorrows Healthcare Today!

13

3. THC HIN SU MC TIU AN TON BNH NHN (tt)

5. PHNG NGA LY NHIM- RA TAY

2
2
3
T l tun th ra tay ca nhn vin y t trong nm 2015
Tt mc
1

Tomorrows Healthcare Today!

3. THC HIN SU MC TIU AN TON BNH NHN (tt)

6. PHNG NGA T NG

Gim qu ti

2
2
3 ch CP
Khng
Tt mc
1

4
BN

Tomorrows Healthcare Today!

15

4. RT NGN THI GIAN CH I BNG CNG NGH - HIS

Qun l bnh vin

1
2

2
3
T 01.06.2014 4a HIS vo hot ng
ng dng cng ngh thng tin gim st k n, qun l h s bnh n
Gim thi gian ch i ca ngi bnh
Qun l tt c s d liu v thng tin y t
Trin khai cc gii php ng dng CNTT trong qun l v hot ng chuyn mn
Tip tc hon thin theo khuyn co ca phng CNTT, S Y t
Tomorrows Healthcare Today!

16

5. CI TIN SP XP CC KHOA PHNG (5S)

Qun l bnh vin

1 Tng quan n
Gim qu ti

Tng CLDV

2
BanCPiu hnh d n
3 ch
Khng
4

Gi mc
Cc 60
bc trin khai
BN

Kho vt t

T ng trang thit b y t
Tomorrows Healthcare Today!

5. CI TIN SP XP CC KHOA PHNG (5S) tt

Ni vt t y t tiu hao

Tomorrows Healthcare Today!

Xe thuc cp cu

18

6. TP HUN HI SC TIM PHI-CODE BLUE

1
2

Tng CLDV

2
BanCPiu hnh d n
3 ch
Khng
Gi mc
60

4
BN

Tomorrows Healthcare Today!

19

7. THI NH GI TAY NGH CA IU DNG, NH GI BC S

1
Gim qu ti

2
2
3 ch CP
Khng
4

Gi mc
Cc 60
bc trin khai

Tomorrows Healthcare Today!

20

8.

HUN LUYN NHN VIN Y T V GIAO TIP, TM L TIP XC VI

TRNG DOANH NHN PACE

1
Gim qu ti

2
2
3 ch CP
Khng
4

Gi mc
Cc 60
bc trin khai

Tomorrows Healthcare Today!

21

KT QU KIM TRA BNH VIN

1. HNG N NGI BNH

2014

BPTNMT

Qui trnh khm bnh

Thiu hng dn

LX/BPTNMT

2015

22

2. HNG DN N TIP

2014

2015

23

3. NGUN LC

2014

2015

4. CHUYN MN

2014

2015

5. CI TIN CHT LNG

2014

2015

TM TT KT QU NH GI CHT
LNG BNH VIN

THNH TCH T C
KT QU KIN TRA BNH VIN

2013

2014

2015

PHN A. Hng n ngi bnh

2.83

3.28

4.61

PHN B. Pht trin ngun nhn lc bnh

vin
PHN C. Hot ng chuyn mn

3.0

3.83

4.14

2.51

3.2

4.00

PHN D. Hot ng ci tin cht lng

2.82

3.73

4.45

PHN E. Tiu ch c th chuyn khoa

IM TRUNG BNH CC TIU CH

2.71

4.00
3.42

4.22

28

KHC PHC CC VN TN TI TRONG T KIM TRA

2014

1. thc hin b khuyn co ca S Y T (Khuyn co an ton

Ngi bnh, an ton Thuc, an ton Sn khoa, an ton Xt
nghim, Phc , trin khai gim bc xc ca ngi bnh.).
2. Ban hnh b quy ch bnh vin, hng dn tng quy ch c th
c th n cc khoa.
3. trin khai thc hin hn 15 ti nghin cu khoa hc v trin
khai p dng vo thc t nng cao cht lng khm, cha
bnh. T chc Hi Ngh Khoa Hc Hon M 12/2015.
4. trin khai c mt s k thut mi nhm nng cao cng tc
khm cha bnh.
K thut lm sng mi c 6 k thut.
K thut cn lm sang mi c 5 k thut
K thut cao thc hin c 6 k thut
Chuyn giao tuyn di trong h thng 5 k thun lm sng

KHC PHC CC VN TN TI TRONG

T KIM TRA 2014 (tt)
5. xy dng quy trnh xc nhn ng v tr phu thut v trin
khai bng kim.
6. lm mi tt c bng ch dn khu khm bnh ngi bnh
d dng tip cn n cc khoa/phng
7. Xy dng li quy trnh khm bnh (c BHYT, khng BHYT)
8. Sp xp khu khm tim mch v thc hin cn lm sng nm
gn nhau to thun li cho ngi bnh.
9. Tng cng nhn vin CSKH h tr ngi bnh.
10. B tr thm 1 phng siu m tim, 1 phng o in tim, 1
phng siu m tng qut.
11. Hon thin h thng IT b sung mt s phn mm: bo co
trc tip, qun l Nhn s, phn tch d liu, thng k thi gian
ch, qun l thuc

KHC PHC CC VN TN TI TRONG

T KIM TRA 2014 (tt)

12. Ci tin cht lng xt nghim: c cp chng

nhn an ton sinh hc cp II, thc hin hiu
chun cc trang thit b xt nghim, phn tch
thng k lch chun, thc hin ni kim v
ngoi kim..

ch li ca vic nng cao cht lng bnh vin

1. Rt ngn thi gian ch i, gia tng hiu qu lao ng
ca nhn vin.
2. Gia tng s hi lng ngi bnh- Kho st nh gi s hi
lng gia tng (hng thng 4,54,72)
2. Ngi bnh c an ton hn, gim sai st v khng
khiu kin nghim trng trong 2015.
3. c s tn nhim ca cng ng.
4. Gia tng s lng bnh nhn chn khm v iu tr ti
bnh vin ( tng doanh thu, ngha v thu, BHYT, ng
gp t thin)
5. To c nim tin nhn vin, to mi trng tt nhn
vin lm vic, k nng qun l bnh vin c nng cao.

XIN CHN THNH CM N S QUAN TM CA QU V

THANK YOU