· 유영진 인제대학교부속상계백병원 ... 의정부성모병원 pr35 산부인과...
TRANSCRIPT
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CCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCooooooooooooooooooooooooooooooooooooonnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnttttttttttttttttttttttttttttttttttttteeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeennnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnntttttttttttttttttttttttttttttttttttttsssssssssssssssssssssssssssssssssssss
>>> 325 B
| PR1~PR7 | 1 11 29() 14:0015:30
PR1 3
PR2 6 CHA
PR3 Simulation 8
PR4 10
PR5 13
PR6 T-cannula occlusion 16
PR7 18
| PR8~PR14 | 2 11 29() 16:3018:00
PR8 21
2012
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PR9 Non value added activity 24
PR10 27
PR11 30
PR12 33
PR13 36
PR14 Protocol 39
>>> 324
| PR15~PR21 | 1 11 29() 16:3018:00
PR15 45
PR16 49
PR17 SMS 51
PR18 MRI 53
PR19 56
PR20 Communication 59
PR21 (2010-2011, CQI) 62
| PR22~PR28 | 2 11 30() 08:3010:00
PR22 64
PR23 67
PR24 69
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iii
PR25 72
PR26 QI 74
PR27 77
PR28 Project 3S 81
| PR29~PR35 | 3 11 30() 11:0012:30
PR29 84
PR30 (TAT) 87
PR31 ! (Everyday is Cheer-up day) 89
PR32 () 92
PR33 3 STEPS 95
PR34 (CRE : Customer Relationship Experience) 97
PR35 (6 ) 100 CHA
>>> 325 B
| PR36~PR42 | 1 11 30() 08:3010:00
PR36 105
PR37 107
PR38 110
PR39 TURN OVER TIME 113
PR40 115
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iv
PR41 117
PR42 120
| PR43~PR49 | 2 11 30() 11:0012:30
PR43 123
PR44 125
PR45 128 CHA
PR46 130
PR47 6 133
PR48 135
PR49 137
>>> 323
| PR50~PR56 | 11 29() 14:0015:30
PR50 141
PR51 143
PR52 145
PR53 147
PR54 150
PR55 153
PR56 156
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>>> 325 A
| PR57 | 11 29() 14:0015:30
PR57 Abdomen, Hip, Pelvis, L-spine, T-spine AP Low Dose Technique 161
| PR58 | 11 29() 14:0015:30
PR58 163
| PR59~PR60 | 11 29() 14:0015:30
PR59 (NST) 168
PR60 171 CHA
| PR61 | 11 29() 14:0015:30
PR61 173
| PR62 | 11 29() 14:0015:30
PR62 175
| PR63 | 11 29() 14:0015:30
PR63 AGS(Asan Global Standard) 178
>>> 324
| PR64~PR70 | 11 29() 14:0015:30
PR64 183 CHA
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PR65 186
PR66 (CQI) 188
PR67 191
PR68 196
PR69 199
PR70 3 20% 202
>>> 322
| PR71~PR77 | 1 11 29() 14:0015:30
PR71 CP 207
PR72 209
PR73 CP 212
PR74 CPR guideline 215
PR75 CP 218
PR76 Arterial catheter management 221
PR77 CP 223
| PR78~PR84 | 2 11 29() 16:3018:00
PR78 226
PR79 regimen 228
PR80 PRN 231
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vii
PR81 235
PR82 Check Sheet 237
PR83 239
PR84 one stop 241
>>> 323
| PR85~PR91 | 1 11 29() 16:3018:00
PR85 247
PR86 249
PR87 253
PR88 Dysphagia CP 256
PR89 259 CHA
PR90 262
PR91 264
| PR92~PR98 | 2 11 30() 08:3010:00
PR92 267
PR93 270
PR94 Implant - - 272
PR95 Cardiac CT 275
PR96 - Push 278 CHA
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PR97 281
PR98 Critical Value 285
| PR99~PR105 | 3 11 30() 11:0012:30
PR99 287
PR100 Process 289
PR101 291
PR102 293
PR103 Peak Time 295
PR104 (6 ) 298 CHA
PR105 301
>>> 322
| PR106~PR112 | 1 11 30() 08:3010:00
PR106 305
PR107 308
PR108 310
PR109 312
PR110 318
PR111 320
PR112 323
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| PR113~PR119 | 2 11 30() 11:0012:30
PR113 325
PR114 Pneumatic instrument Process 327
PR115 330
PR116 333
PR117 336
PR118 340
PR119 () 343
>>> 306
| PR120~PR126 | 1 11 29() 14:0015:30
PR120 349
PR121 351
PR122 354
PR123 357
PR124 / 359
PR125 361
PR126 364
| PR127~PR133 | 2 11 30() 08:3010:00
PR127 366
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x
PR128 / 369
PR129 371
PR130 373
PR131 376
PR132 378
PR133 , 382 CHA
>>> 325 A
| PR134~PR140 | 1 11 29() 16:3018:00
PR134 1Kg 1 387
PR135 ( ) 389
PR136 393
PR137 Burn 395
PR138 397
PR139 400
PR140 Screening 403
| PR141~PR147 | 2 11 30() 08:3010:00
PR141 406
PR142 408
PR143 411
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xi
PR144 413
PR145 (VRE) 6-sigma 416
PR146 IPSG ( ) 418
PR147 Medication Errors 420
| PR148~PR154 | 3 11 30() 11:0012:30
PR148 422
PR149 424
PR150 426
PR151 , 428
PR152 ( ) 431
PR153 , 434
PR154 438
>>> 306
| PR155~PR163 | 1 11 29() 16:3018:00
PR155 443
PR156 MAKING 445
PR157 447
PR158 DRG 7 450
PR159 EMRESD CP 452
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PR160 QI 454
PR161 456
PR162 458
PR163 scope 460
| PR164~PR172 | 2 11 30() 11:0012:30
PR164 463
PR165 466
PR166 468
PR167 470
PR168 473
PR169 476
PR170 479
PR171 482
PR172 484
>>> 322
| PR173~PR177 | 11 29() 15:3016:30
PR173 489
PR174 491
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PR175 Project. ( !!) 493
PR176 496
PR177 504
>>> 322
| PR178~PR180 | 11 30() 10:0011:00
PR178 509
PR179 511
PR180 513
P1 519
P2 522
P3 525
P4 527
P5 529
P6 531
P7 533
P8 536
P9 538
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xiv
P10 540
P11 542
P12 544
P13 546
P14 548
P15 (PCVC) 551
P16 553
P17 KCL 555
P18 558
P19 complication 560
P20 562
P21 565
P22 567
P23 569
P24 572
P25 575
P26 578
P27 System & Culture 580
P28 583
P29 586
P30 589
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xv
P31 591
P32 593
P33 () 595
P34 CP 599
P35 601
P36 process 603
P37 606
P38 609
P39 611
P40 613
P41 Portable 615
P42 617
P43 619
P44 622
P45 624
P46 628
P47 , , 630
P48 632
P49 634
P50 636
P51 Linac-gram Film & Simulation Film Scan PACS UP-load 638
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xvi
P52 Error Zero 640
P53 642
P54 645
P55 647
P56 () 649 CHA
P57 AMA discharge 651
P58 CT 655
P59 657
P60 659
P61 661
P62 663
P63 665
P64 TAT 667
P65 670
P66 672
P67 () / 674
P68 676
P69 hand book 678
P70 680
P71 682
P72 684
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xvii
P73 686
P74 688
P75 (Lending) 691
P76 693
P77 695
P78 697
P79 699
P80 702
P81 CP 704
P82 707
P83 709
P84 712
P85 714
P86 718
P87 ( ) 720
P88 723
P89 725
P90 CP 728
P91 731
P92 733 UNIT
P93 735
-
xviii
P94 738
P95 740
P96 744
P97 Process Blood culture 746
P98 748
P99 750
P100 752
P101 755
P102 , 758
P103 761
P104 763
P105 765
P106 767
P107 769
P108 772
P109 776
P110 778
P111 783
P112 786
P113 788
P114 Flow 790
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xix
P115 , CP 792
P116 EMR 794
P117 796
P118 799
P119 801
P120 804
P121 806
P122 808
P123 810
P124 812
P125 816
P126 818
P127 820
P128 823
P129 826
P130 829
P131 833
P132 (activity conference) 835
P133 837
P134 840
P135 842
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xx
P136 844
P137 846
P138 848
P139 851
P140 (PEAK) 853
P141 856
P142 Process 858
P143 860
P144 862
P145 865
P146 868
P147 871
P148 Checklist 873 CHA
P149 875
P150 877
P151 880
P152 883
P153 885
P154 887
P155 889
P156 892
-
xxi
P157 895
P158 (VAP) 897
P159 901
P160 904
P161 906
P162 908 CHA
P163 910
P164 912 CHA
P165 915
P166 917
P167 920
P168 922
P169 925
P170 928
P171 930
P172 932
P173 934 CHA
P174 937 CHA
P175 VOC(Voice Of Customer) 939
P176 943
P177 946
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xxii
P178 948
P179 Upgrade 950
P180 954
P181 956
P182 958
P183 960
P184 963
P185 965
P186 967
P187 969
P188 971
P189 973
P190 (() ) 976
P191 978
P192 980
P193 process 982
P194 985
P195 987
P196 989
P197 991
P198 993
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xxiii
P199 FUN 995
P200 SMS 998
P201 1000
P202 1004
P203 1006
P204 1008
P205 1011
P206 1014
P207 CP 1016
P208 CP 1018
P209 ESR 1020
P210 MRI 1022
P211 NICU 1025
P212 PEAK 1028
P213 Postpartum bleeding 1030
P214 QI 1032
P215 RCT CP 1034
P216 SICU 1036
P217 TAT 1038
P218 Timeout 1040
P219 VCUG , , 1042
-
325B
11 29() 14:0015:30PR1PR7 1
11 29() 16:3018:00PR8PR14 2
-
2012 3
, , , ,
14W
1
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, .
.
,
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.
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-
4 2012
5
1)
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form notify .
.
. : SR form
.
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.
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2)
. , . . ,
test .
3)
. sedative .
. .
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.
5)
( : ) .
7
- 20
(6.58 (QI ) -> 3.05 (2011)-> 2.46 (2012)
1)
.
-
2012 5
.
. notify .
. Notification .
- 20
: (60% (QI ) -> 100% (2011)-> 90% (2012) notification form : (40% (QI ) -> 92.9% (2011)-> 100% (2012)
2)
.
: test
3)
.
.
. confirm .
> - seizure f/u
(20% (QI ) -> 64.3% (2011) -> 67.9% (2012)
* 100% lorazepam 2mg
4)
.
. O2 inhalation brain damage
>
: 100%
5)
. focus
. event
focus
- seizure f/u
(25% (QI ) -> 72.7% (2011) -> 84.8% (2012)
8
1)
flow 2
(6.58 (QI ) -> 3.05 (2011)-> 2.46 (2012) .
2)
. flow update
( manage F/U - )
. flow SBAR notication form
manage .
. QI
data .
-
6 2012
CHA 81
1
80%
, (, , , , )
.
.
2
, , ,
.
.
3
4
1) - :
( ), ,
(1) : (3/1~3/31) 250
(2) : (6/1~6/30) 243
2) : 81 13, 81
3) : 18 5
-
2012 7
5
1) : 3.45(69%)
2) : total 250 31 12.4%
) , : 12
) , , : 5
) , , , : 1
) , : 13
6
1)
) :
) :
2)
) : ,
) :
.
3) : 18
7
1) : 3.45
(69%) 4.1 (82%) 13% .
2) : : 3/1~3/31 total 250 31
12.4% , : 6/1~6/30 total 243 16
6.5% 5.9%
.
8
, .
.
.
-
8 2012
Simulation
1
. ,
.
.
.
, ,
simulation
.
2
, ,
.
.
Simulation
.
3
, , Simulation ,
.
-
2012 9
4
,
, .
5
,
. , 1 3 .
.
6
, , Simulation
.
Simulation setting . Simulation
. CPR
CPR
.
7
610 .
, Simulation .
8
.
,
.
-
10 2012
141
1
,
. 141 ,
, ,
.
,
.
2
3 '15 ' 56.7%, '
' 12.6% 15 69.3%
. 31.5% ,
.
3
( / *100), (
/ *100), ( /
*100), .
4
141 : 2012 3~4 D-duty, E-duty
(1. , 2. ,
, 3. , 4. , 5.
, 6., 7. , 8. , 9., 10. , 11.)
-
2012 11
.
2012 4 . 2012 3
.
5
1) 31.5%, (36.9%), (10.7%),
(12.3%), , (9.1%),
(8%), (6.4%)
.
2)
,
, ,
.
3) 10.7%
33.3% .
.
4) ,
.
6
1)
: ,
,
2)
PI 2~3/
3) ,
, PI
-
12 2012
7
34.1% 68.6%
, 33.3% 25% ,
80.4% 94.4%
.
31.5% 59.3% .
8
,
,
.
,
. 6
, .
-
2012 13
93
1
.
, NCCN(National Comprehensive Cancer Network)
.
(2006) 10.6% .
WHO 3
,
.
.
2
3 15.8% ,
30~35% .
, ,
, .
, ,
,
,
. , , ,
.
3
, 7 , ,
, .
-
14 2012
4
7 2011 4 1
~30 20 , 2011 71~8 31
15 19 .
2011 5 20~27 , 2011 6 16~20 .
2011 4 14~16 , 2011 8 18~20
.
5
,
, ,
, ,
.
6
1) 7 , ,
.
2) ,
NRS .
3)
.
4) ,
, ,
,
.
5) , 7
,
.
7
. , 7 50.0 73.3
46.9% , 55.1 80.1 45.4% ,
61.6 83.7 35.9% , 44.7
90.0 102.9% .
-
2012 15
8
,
, 7
. ,
, .
,
.
.
-
16 2012
T-cannula occlusion
1
trachostomy
CPCR . tracheostomy
T-cannula occlusion .
2
,
tracheostomy
T-cannula .
T-cannula ,
T-cannula . T-cannula occlusion T-cannula
.
3
T-cannula , T-cannula occlusion
nebulizer .
4
T-cannula occlusion ,
T-cannula , nebulizer
.
-
2012 17
5
fishbone diagram
T-cannula , ,
nebulizer .
6
T-cannula 2, 2
T-cannula orientation
2 . 1 2000cc
, nebulizer
feedback . T-cannula occlusion
T-cannula occlusion
emergency kit .
7
T-cannula 16.2%, 3.4% nebulizer
4.8% .
8
T-cannula occlusion
,
. T-cannula occlusion
, T-cannula .
-
18 2012
, , , , , ,
1
, ,
, allergy reaction, speed shock fluid overload, , catheter
embolism ,
.
.
, ,
, ,
.
,
QI .
2
, .
, , ,
.
,
.
, .
,
.
-
2012 19
3
QI
,
.
4
170
.
5
, 60%,
38.4%, Regurgitation 17.3%, 4.7% .
, .
6
1) ,
2)
3) ,
4)
5) ,
7
IV start
.
.
.
, .
-
20 2012
8
QI .
,
.
-
2012 21
, , , , , , , , , , , , , , ,
1
,
.
.
.
.
2
,
, 30% .
3
.
: / : ([ - ]/
)*100
4
,
2 .
2 .
-
22 2012
5
.
,
. ,
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. ,
,
.
6
3 , 9 1 .
.
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.
,
.
. , , ( , ,
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.
7
2
Microsoft Excel program . 2.4
1.6, 33.3% .
, , , ,
2.9, 1.8 37.9% .
, , 1.4
1.1, 0.9 23.0% .
-
2012 23
8
30%
.
.
,
.
-
24 2012
Non value added activity
, , , , , , , , , , , , , ,
1
1 ,
.
2
, ,
,
.
3
Non value added activity ,
20% 5
4 .
.
4
2011 2 9 ~ 2 15 9
130 non value added activities , QI
50 80
, , 22 .
, ,
.
-
2012 25
5
22 Non value added activity , , ,
.
6
.
.
,
.
, , , ,
.
,
.
7
12.0
9 , 4.45,
4.36 .
4.64 .
, .
. 9
331 221 37% ,
41.6 21.5 53% .
4.77. 211 167 21% .
9
.
. Non value added activity QI ,
4 ,
. 2011
, 2012
-
26 2012
.
.
8
1)
, .
.
2) Non value added activity ,
,
.
-
2012 27
, , , 12
1
3
, , 30 1
. ,
.
,
.
.
2
10 ~ 1 40.4
, (8
) 1 20 ~ 3 20 2 30 ,
.
,
,
QI .
3
10% .
1 .
-
28 2012
4
7 1
. Duty
.
5
(work sheet) ()
, , , ,
, , .
/ , ,
. Duty 9 25,
9 9, 11 9
.
6
1. method(2 or 3 ) .
: 2, 3 .
:
2. , , LIST
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3. .
4. . (
, BST Check, check, B/W Check, , work sheet )
5. 8 .
6. , , .
7.
.
8. .
9.
.
10. 30 Campaign ( : 30 , : 30 , : 30 )
.
11. .
( : , : EMR , : EMR
)
-
2012 29
7
2011 40 1 32 8
, 2 23 1 2 17 . ,
9 25 1 9 6, 2 9 7 18 ,
9 9 1 9 5, 2 8 58 11 , 11
9 1 10 36, 2 9 16 1 20 9 54
1 2 9 7 47 . 1
20
.
8
15 . method
functional 39 24 15 , Team 41
19 22 Team
. method 6.7( ) 4, 8, 9(
) team method . 9 54
9 7 47
. 17
8 55 , 28 9
13 .
2013 7 DRG . DRG
.
. Team method
.
-
30 2012
24
1
2012
79% . benzodiazepine
Midazolam , ,
.
.
2
20
flumazenil 0.25mg . flumazenil
. ,
, 20
flumazenil ,
. ,
event, midazolam ,
.
.
.
3
,
(5 )
.
-
2012 31
4
2011 ,
. 2012 14
4 2012 7 23 9 19
Flumazenil
.
5
2011 217
46.54% . 4 40
10% . 126
21.1%, 3.9% 32.54%
1 .
6
. Flumazenil
20
flumazenil . ,
. Richmond Agitation-Sedation Scale
,
Modified Aldrete score (, , , , ) 9 , 9
, , 2 .
,
.
7
1) 1.04% 0.42%
46.54% 40% .
2) 10% 0% .
3) 21.1% 22.3%, 42.2% 43.8%
, 31.3% 30.8%, 3.9% 3.1% .
4) 1 32.54% 36.2%, 4
45.24% 56.9%, 8 18.25% 6.2%, 8~12 1.59%
-
32 2012
0%, 12 2.38% 0.8% . 77.78%
4 93.1% 4
.
5) 34.56 26.73 7.83 .
.
8
. Flumazenil ,
.
.
.
-
2012 33
1,
1,
1,
2,
2,
2,
2
1,
2
1
,
. (2007, )
(2008, ).
.
, .
2
,
, .
, ,
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, .
, , .
3
20% ,
90% , 5 .
4
2012 4 1 8 31
, , .
-
34 2012
5
1)
3 ,
. 5 , 5
. 5
4 .2)
(1) 5 3.28, 5 1.78. 5 4.67, 4.77.
(2)
4.79 .
6
, ' PI .
.
7
1) 3.28 1.78 2.62 .
2) 4.67
.
3) 4.77 ,
4 .
4)
4.79 95.8% .
-
2012 35
8
(2011, e daily).
, ,
.
.
-
36 2012
1
24 3
. 3 --
7.5-7.5-9, 8-8-8 . -
- 8-8-8 . 8-8-8
,
. 2010
. ,
.
2
, ,
, , overtime
. ,
.
.
.
3
.
4
, 6 .
-
2012 37
5
. -- 8-8-8
() 21.8%, 7.5-7.5-9(1) 47.7%, 7.5-7-9.5(2) 17.8%
1 , 30 1
.
overtime 1~1 30 . 39.4% , ,
. overtime , , ,
, .
52.6%, 44.4%, 3% .
.
6
TFT 8 ,
. -- 7.5-7.5-9
, (3 ), , , 5
1 .
.
7Am~8Am 30
. 30
.
,
--, 8-7.5-8.5 10 1
, 20 1 . 55.1%
10 (, , ) 3
. 52.6%
7 .
, .
7
50.5
57.1 . 8-8-8 8-7.5-8.5
. 9.6, 6.2,
9.9, 4.8, 1.3 . 14.1 .
-
38 2012
8
2011 . 3 , . 6.6
. , . QI
,
.
. overtime ,
.
2011
-
Protocol
18
1
.
24G, 18G Medicut
, . ,
. QI
Protocol
.
2
.
.
.
3
1) Protocol .
2) Check List 90%
.
3) 10% .
-
40 2012
4
1)
- :
- : 57, 75
2)
- : 2012 4 16 ~ 5 30
- : 2012 8 18 ~ 9 21
- : Check List
( Check List, )
5
1)
.
2)
.
3)
.
4)
.
6
1) Protocol
.
2) check list
.
3) Check List :
72 96 .
.
4) .
5) .
6) ()
.
-
2012 41
7
1) .
2) 4.32(86.4%)
4.82(96.4%) .
3) (Grade 1 ) 12% 5.9%
.
4) 3(72~96)
14(20%) 38(55.9%)
.
8
. 2
.
.
.
-
324
11 29() 16:3018:00PR15PR21 1
11 30() 08:3010:00PR22PR28 2
11 30() 11:0012:30PR29PR35 3
-
2012 45
, , , , , , , , , ,
( )
1
, . , ,
. 3 .
.
.
. QA
,
,
.
2
.
, , ,
. , , ,
VIP . ,
.
.
.
3
1) ( SMS )
2)
-
46 2012
3)
4)
5)
6)
7) 15
4
1) 2009 2011 3
2)
3)
4) 2012
5)
6)
7) 10
8) SMS
9)
10) 15
11) 2012
5
2012 1 8 2011
. 2011
. 2012
2011 0.4
. 10
.
10 95%
10 .
.
6
1)
- 30 SMS SMS
- 1
-
2012 47
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- , , ,
2)
3)
4)
-
-
-
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1) .
30 SMS
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.
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.
.
2) , , , .
, ,
. QA
24 .
3) .
2011 2012 10% ,
.
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5
, ,
.
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-
.
-
48 2012
- , .
- .
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.
8
2012 66.5 81.5 QA 73.5, 86.1
. 86.1 91.7
.
.
.
.
-
2012 49
1
, .
2
2011
85%
.
3
1) : 4 ( , , , )
60 .
2) : 2011 1~ 8, 2012 1~ 8 .
4
1) : 1 2011 51~630(60)
( )2 2012 701~730(60)
2) : 3) : , , FAX
-
50 2012
5
1) : .( ), . .( )
2) : . .
6
1)
. (URC) . .
2) :
1, 2 . 2 1 . , e-mail , . .
7
2012 , ,
, FAX . 2011 85% 2012 2
90% 2011 2012 8% .
8
.
. .
-
2012 51
SMS
, , , , ,
1
.
.
, QI .
2
3( 1 , 1 , 2 ) ,
.
SMS
. SMS
.
3
SMS , QI
, , .
4
200 , SMS
, , , Likert 5 .
-
52 2012
5
SMS 1 ,
200 98 49%
, SMS (52)53% SMS .
6
SMS ,
,
.
, .
7
, 35.5% ,
SMS 1 29 3
. , GS
17 5 .
3.54 4.51 ,
2.9 4.24 .
.
8
SMS
.
,
. ,
20% ,
.
-
2012 53
MRI
, , , , , ,
1
MRI 110db ,
. 30 .
MRI
, .
2
MRI 2 2006 85
, 340 MRI . MRI
, , , .
2011 4900 MRI ,
107 100
16% . MRI MRI
.
3
1) ,
2)
3) MRI (, , )
-
54 2012
4
1) : 2012 3 2 ~ 4 30 2 MRI
400 ( ) .
2) : 2012 5 1 ~9 30 5 MRI
800 .
3) : 2012 3 2 ~ 9 30 7
1200 .
5
MRI (12%), (11.5%), (7.5%), (6.5%)
, 17.5%, 0.5% . ? 97% , 7080 (27%), (15.5%), (5%), (3.3%), (2%)
.
6
1) ( , , )
(, ) .
2) ( , ,
) ,
.
3) MRI
.
4) MRI (, , )
.
7
1) :
95% 3% MRI
96% .
99% .
2) :
.
3) :
-
2012 55
17.5% 8.8% .
0.5% 0.6% ,
.
4) N- : MRI N
6 35 , MRI
.
8
,
.
.
, ,
.
-
56 2012
1
.
(, , , ) .
2
, , .
1) ( , , )2) ( , , )
3) ( , )
4) ( , , )
:
3
1)
2)
3)
4)
4
1) QA 1
(39, 2, 100 )2) ( 9 : 00~11 : 00 , 3~8)
3) (3~8)
4) (3~8)
-
2012 57
5
1) - , , 2) - ,
3) -
4) - , , CS
6
1)
- ( ) (2013.5 )
- 2 2
-
2)
- ,
- ,
- (vein viewer vision)
3)
- (24 , , )
- capillary (skin puncture)
4)
- ( 7 : 30 7 : 00 30 )- ( 7 : 00~9 : 00 2 1 )
- CS
7
QA 3 9 5.6%
. 2.1%, 10.9%, 20%, 7.5% .
90% ,
.
.
-
58 2012
8
. QA
. , .
,
( ), .
-
2012 59
Communication
1
.
, .
?
?
? ?
.
2
.
, ,
.
()
.
.
-
60 2012
3
, .
.
.
4
. .
5
80%
, 31% . 78%
.
6
() ,
() . ,
.
7
83% ,
5% ,
72% .
.
-
2012 61
8
.
. ,
.
-
62 2012
(2010-2011, CQI)
1
.
.
, 2010 QI .
CQI
.
2
.
.
.
3
. , (TAT) ,
,
. , , .
-
2012 63
4
, 48 .
3 .
.
5
2011 1 2010 .
.
6
2010
.
Q&A .
.
7
.
. 2010 QI 2011
.
1 3 .
8
.
. ,
.
-
64 2012
, , , , , , , , ,
1
. 2011 7 15 ,
80.2% 15 62% . 2011
30%
60% .
2
(
180)
, .
, ( 180) 80%
, 80% .
3
( 180) .
4
1) : 2011 7
, ,
2) ( 180)
2011 1~7, 2011 8~12
3) ( 180)
-
2012 65
2011 7 12( )
4)
2011 4~7, 8~12
5)
2011 726~81, 2012 13~114
5
, , (
, ), , ,
, , ( , CT. MRI ),
(), , .
( 180)
.
6
1) ( ) 2) :
: : : 1
3) :
20
1
7
=> ( 180) 68% 72.5%
=> 48 16
=> ( , )
1) : : 10.5(9.5 ), : 10(15 ), : 21.5(48.5 )
2) : 10(39 )
=> 70% 96%
-
66 2012
8
( ) , (, )
. QI
( 450)
.
-
2012 67
1
.
. ,
( ) .
, ,
.
.
2
2 94% . 2011.12.01~2012.2.29
56.1%. VOC
: , .
: .
: . ,
( ) .
3
2 6
.
-
68 2012
4
2011.3.1 ~2012.2.29 CT, MRI, , , , ,
6 2
.
5
94% ,
71.9% .
,
.
6
6 2
.
,
,
- () . ,
7
2 120
29 .
,
. 2
.
8
.
.
. ,
.
-
2012 69
, , , ,
11 Unit
1
, ,
, .
, .
2
,
, ,
.
.
3
, ,
.
4
C 41,
50 91. SPSS ver 12.0
, ,
t-test.
-
70 2012
5
- 4.6 4.14 13%
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- 61.3 71.2 10% .
6
1)
, ,
2)
, ,
3) ,
, , ,
4)
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7
1)
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-
2)
- ,
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3)
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-
-
8
, ,
-
2012 71
. QI
.
.
-
72 2012
, , , , , , , , , , , , ,
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1
2008 7 5822 1
7730 .
2 .
. , . ,
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.
2
.
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.
3
6 5 5 , 1
.
-
2012 73
4
2012 2~9 10 20
.
5
60%, 45%, 60%, 90%, 45% 60% 90% . 70% ,
.
6
() , , , ,
.
7
5 17% 79% 63% , 0% 75% .
100% 75% .
8
,
. , ,
.
.
-
74 2012
QI
, , , , , , , ,
1
10.8% ,
.
.
2
1 45% . care
(needs) , , ,
.
3
1) 1 : 4.42/5
- (12) : 4.27/5
- : 4.27/5
- , : 4.47/5
- : 4.41/5
- : 4.68/5
2) 1 ,
- : 51.6/100
- : 52.5/100
-
2012 75
4
1)
- : 65
- : 2011 4 1 ~ 20
2011 99 ~ 23
- : 60, 57
- :
2)
- : 12, 13, 14, 15
- : 2011 4 1 ~ 20
2011 9 9 ~ 23
- : , 63
- :
5
1)
5 4.42 .
, . 25%
4.5 12 (4.27) .
2)
51.6 (, 2004) , 52.5
57.5 . 10% .
6
1)
- : (, , )
-
2) .
3)
- 1
-
-
76 2012
7
1)
.
2)
.
3) , , ,
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.
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.
3) , , ,
.
-
2012 77
1
, , , ,
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.
.
.
.
2
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10X10
, .
.
(2)
.
.
3
-
78 2012
.
1) .
2) .
3) .
4) .
4
1) : 2011 3 27 6 30 2011 7 1 9 10
2) : 91
3) :
4) :
.
5
1)
43(47%), 48(53%) 31(34%) 60
(66%). 10 1(1%), 20 3(3%), 30 2(2%), 40 24(26%),
50 61(65%).
78(86%) 13(14%) .
52(57%) .
.
69(76%) (2) .
2)
.
72(79%) 13(14%) .
11(12%) .
-
2012 79
.
71(78%) .
.
6
1) 22
2)
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(3) 5-6 :
(4) 6-9 : 2
3)
(1)
.
.
(2)
.
.
.
7
.
, .
.
.
.
-
80 2012
8
( )
.
.
.
-
2012 81
Project 3S
, ,
1
. 2011 CS
.
2012 QA .
2
Service, System, Space
, .
3
QA .
: / *100 -
- Service, System, Space
4
, , QA
/ 2 .
1) : 1 2012 3, 2 2012 10
2) : ,
-
82 2012
5
- 1
1) Service /
2) System /
3) Space ,
6
1) Service
" " (leaflet)
2) System
( )
() - 12 : 00, - 12 : 0012 : 30
3) Space
=>
7
, Service
"" .
System ,
. , Space
, .
,
.
-
2012 83
8
.
.
-
84 2012
1
.
,
.
,
. 2010 18,521
38.5%(7,123) 61.5%(11,398)
, ,
.
.
2
,
. ,
. ,
, .
3
-
2012 85
4
2011.4.11-4.22 10
359 . ,
.
5
13% , 70% .
70% ,
. 1
60% .
6
7 : 30-9 : 10 10 : 00-11 : 00
,
,
. , ,
, , ,
. .
7
4 10 7 522 4 2
10 5.35 4.57 . 77% ,
70% ,
.
(92%), 8% .
293(56%), 137(26%), 132(25%) 50%
, , .
-
86 2012
8
QI 10 : 00-11 : 30
, 50%
.
.
. Happy call
.
-
2012 87
(TAT)
1
TAT(Turnaround time) .
.
2
,
.
.
3
1)
2) OCS
3) TAT
4
1) 2012 4 100
.
2) 100 2012 3 6 2
OCS , .
-
88 2012
5
1) ,
2) (2012 4~5)
2012 4~5 4560
OCS .
2
3) (2012 6~7)
2012 6~7 4584
OCS .
2
6
1) 2) 2 2
.
3) .
7
1) ,
2) , ,
3)
8
( )
~ . 30
( 70m) . 15
20~30 .
TAT .
-
2012 89
! (Everyday is Cheer-up day)
, , , , ,
1
QI ,
.
.
2
, , , ,
. , .
.
3
.
4
1) 2012 3 12-21, 1 3-4
4 Focus Group Interview . Focus Group Interview ,
8 ( , , ,
, , , , ) .
8 83
.
2) , 2012 4 5-9
-
90 2012
.
92.5% , 91.4%
.
5
, 5 2.44 3.64
. , , , ,
.
,
, . ,
.
6
1)
(1) (CDP : Continuous Dialogue Program)
( ) .
, ,
.
, , , .
(2)
, ,
,
, .
2)
(1)
,
, , .
3)
(1) OMEGA
OMEGA nurse
. OMEGA nurse
.
-
2012 91
- OMEGA nurse
Opening() --- ,
Moving() ------ ,
Emotioning() ---- ,
Giving( ) ----- ,
Amaging( ) ---- ,
7
.
8
, .
,
. .
OMEGA nurse
.
.
-
92 2012
()
( TFTeam)
1
, .
,
. (JCI)
.
2
1) :
2) : Open
3) :
4)
3
1) 2)
4
1) (2011. 4. 15~4. 20) - : 290(, )
- : , , , ,
-
2012 93
, , ,
8(Likert 5 )
2) (2010. 12~2011. 10, 11) :
5
, ,
, ,
. can , open .
6
1)
- - : - : , Can
, Betadine ball
2)
- Can
- Betadine ball Betadine Ball
3)
4) , Feedback
7
1) ,
2) : (5) 2.53.8 (2.33.7), (3.13.3), (2.63.8), (2.23.9), (2.43.7)
3)
- () : 4.9 3.3
- () : 13.4 7, 150 60
4) : Betadine Solutin ball 198,572 ( 3,761,952 3,563,380)
-
94 2012
8
( )
. ,
. , Feedback ,
, .
-
2012 95
3 STEPS
121
1
.
, ,
. ,
, ,
`3 STEPS
.
2
, , , , , .
, ,
.
`3 STEPS ` ,
.
3
3 STEPS `- call. call. call -
.
4
`3 STEPS ,
, , .
-
96 2012
5
, 1-2, , ,
, ,
.
6
, , , , 3 STEPS ` 3 STEPS .
7
3 STEPS ` 80
96.9 16.9 .
8
/ ,
'3 STEPS '
80 5 96.9 16.9
.
.
-
2012 97
(CRE : Customer
Relationship Experience)
1
.
QI .
7000 . 3 2
5000 Follow-Up .
1 : 1 (CRE : Customer Relationship Experience)
. (contact)
(CRE)
.
2
. 80%
, .
. ,
.
,
.
.
3
1) (nmCRE : nuclear medicine Customer Relationship Experience))
-
98 2012
2) (nmCRE MOT)
3)
4
2011, 2012 .
1) Follow-Up
2)
3) 1 : 1 (nmCRE)
5
(CRM) (CRE) .
2009 2011 12 , 90
.
.
6
1) (nmCRE)
1 : 1 CRE ,
(nmCRE) .
2) (nmCRE MOT)
(nmCRE)
3)
5
7
2011 5 2012 8 5365 .
.
MOT , ,
, , .
2011 78, 2011 80.5, 2012 80.6
. 2012 .
-
2012 99
8
? . 1 : 1 .
,
.
.
-
100 2012
(6 )
, , , , , , , , , ,
CHA
1
2009 2010 29% , 2010 25%
.
2
2
. 2011.8.8 ~
2011.8.13 358 13 .
13 30%
.
3
1) : 13
2) ( ~ 7 )
4
1)
2011.01.03~2011.06.30 20, 277
13
2)
2011.8.8~2011.8.13 358
-
2012 101
5
1) .
2) .
3) (, , ).
4) 1 / 20 3 .
5) .
6) .
6
1) , (Quick Fix)
- 2011 9 5
- , 4 5
- ,
8 ( )
2) (Quick Fix)
.
.
3)
, ,
.
4) 5) SMS
SMS
6)
- 8 30 12
- 11 40 , 10
10~11
7) One-Stop Card
- ,
- , , X-
8) SMS
10 SMS ,
9) 10)
-
102 2012
7
1)
2011.08.29~11.30 12,699
13 . 22.1% 41%,
0.732 1.72 .
2)
2011.11.16~2011.11.22 210
. 76.5 80,
2.57 2.81 .
8
SMS
40% , , ,
.
1) ,
OCS
2) i-PAD
-
325B
11 30() 08:3010:00PR36PR42 1
11 30() 11:0012:30PR43PR49 2
-
2012 105
1
2010 7 FDI
( )
14 cycle50
. ()
.
2
1. 3~4 .
2.
3.
4.
3
1.
2. strip stick
3. culture
4
2010 7 2011 12
, .
-
106 2012
5
1. , .
2. 14, 10
.
3. (bedside ) .
6
1. .
2. strip stick - 10 7 .
3. () , ,
7
1. 3 6~7 .
3. .
4. .
5. .
6. .
8
.
50%
.
()
.
-
2012 107
,
1
.
,
. Pouch
.
.
QI .
2
.
, , , , ,
.
50% .
3
1)
2) ()
4
1) : 2012.04 ~ 2012.09
2)
-
108 2012
3)
5
.
,
, 6 . ,
, ,
.
6
,
, 2 .
1) : , , (72), (62)
2) : , ,
3) : 2
6, 3 , 18
4) : 2 6
7
1) : 3, 3 72
2 12 .
2) : 3 30 QI
12 , 1/3
.
8
4 6 75
.
.
1) 30 12
.
-
2012 109
2) 30 12 60%
.
.
-
110 2012
,
92
1
40~50%
.
. EMR
.
()
.
.
.
2
EMR
. (OCS+Written Chart)
OCS confirm
.
.
. 1 , ,
1
.
.
-
2012 111
3
1) 100%
2) ()
4
1) 2012 2 1 2 29 92 81
OCS Review . 92
.
2)
. 3, 4
8 .
5
1) 2012 2 92 81 .
18 78%
.
2) .
72%
1 .
6
1)
EMR / .
. 1
1 Y 1 . .
2) .
6 48%
.3)
.
-
112 2012
7
23% 88% 65%P
.
.
72% 82%
.
8
.
50%
.
.
-
2012 113
TURN OVER TIME
, , , ,
Unit
1
.
Turn Over Time
2 . Turn Over
Time
.
2
2011 4 turn over time
, , ,
. Brain storming Endoscope
, , EMR , Process
, Communication
, , .
-
Turn over time AM 8 : 00 ~ PM 4 : 30
.
3
Turn Ove Time 20 16 20% .
-
114 2012
4
2011. 8. 8. 2011. 10. 21. Turn over time Monitoring sheet AM 8 : 00
~ PM 4 : 30 Turn over time 16 720
.
5
720 Turn over time 16 226 16 494
20 , ,
, , .
6
1) Package
, .
2) , ,
Package .
3) , , Process .
4)
- .
7
1) Turn over time 20 15 5 .
2) Endoscope Pack .3) Setting .
4) EMR , .
8
QI Turn over time 20 15 5 .
Endoscope , Package
,
Setting , EMR
, .
.
1) .
2) Package .
-
2012 115
, , , ,
9B
1
,
.
.
2
, ,
, .
, ,
gauze(4*5 gauze & burn gauze) 40%
.
3
, .
4
dressing room 20
.
5
(32.5%), (32.5%),
(20.0%), (15.0%) .
-
116 2012
6
1)
-
2)
- dressing room
3)
- 5 .
4) D-set 4*5 gauze 2 , burn gauze 300 gauze .
7
6.75%, 4*5 gauze 1 17.53%, burn gauze 1
12.34% .
8
dressing room
. 95.0% 8.395
. gauze dressing
gauze gauze .
,
, .
.
part 1
.
-
2012 117
1
45%~65% .
.
.
2
,
,
.
.
3
, ,
, .
4
, , ,
Room, ,
.
(967) 2011 3
. 2010 9 ~ 2011 2 6 .
-
118 2012
5
1- , 2-
, 3-, 4- 7 3.0 .
3 194,475,523,
350.
.
6
1) .
, code
.
2) ( 7Room ) .
,
Room .
3) .
4) sign .
.
5) (4 ) .
.
6) . 10
.
7
2011 919~20 7 39
,
3.4 3.6 ,
, Room ,
,
, QI
. 4
4 25 2
8% 4 12 11 92%
84% . room, OCS
-
2012 119
3 194,475,523, 10
152,669,604 41,805,919 21% .
350 377 27 8%
5% .
8
1)
8% 15% QI
.
2) : , Room OCS
QI
Room .
-
120 2012
,
1
,
2011 QI .
2
(25) ,
, 2011 QI
80% (80%) .
3
. (%) : 80%
- (%, 2009, 2011 ) = {(2011/2011)-(09/09
)}100. (80%)
4
. - 1/
. - 2009 2011
(SAP) ()
.
-
2012 121
5
.
. 1 . ,
.
6
. Supply
. Supply
. ,
.
. 1/
Feedback
7
.
: 2011 1~9 9, 011, 036 .
. 2009, 2011 1~8
80% (93%).
: 2009 27,521,442
. 2009
2011 ,
.
. Supply 89%
94%.
-
Supply
.
. Supply 25 22 .
-
-
122 2012
8
(SAP)
(9, 011, 036) .
72% 93% (2009 27,521,442 )
89% 2011 QI .
,
.
-
2012 123
, , , , , , , ,
, ,
1
, ,
. ,
(Time-related shelf-life) (Event-related shelf-life)
.
,
2 . 2000 QI 7,
4, Set 2 , 2010
,
.
2
1)
2011 8 10 2011 9 21(3, 4, 6) 162
9 , 8 31, 9 7, 9 21
7 .
(1)
: . : 1 .
(2)
, , 2 : , Dressing car : , Dressing car : , Dressing car : ,
2)
(1)
-
124 2012
(Biological
indicator) BI
, (
, , ) .
(2)
: Thioglycollate Broth . 10ml Thioglycollate broth
Forceps .
35 7 .(3) 9
9, 2 .
3
24.5 AAMI(1984) 18~24 8
, 62.5% AAMI(1998) 35~70% .
9 , 162 42 7
4
, .
2000
.
. 2000 2010 QI
4 , 2011 CQI
.
(2004) 744 154
~423 , (2003) 208
245 . 2
, CQI
4 , 2011 446
2012 140 306(68.6%) .
. ,
, .
,
.
-
2012 125
, , , ,
1
.
, , . , ,
. ,
.
.
2
.
,
. ,
. ,
.
.
.
3
1)
2)
3)
-
126 2012
4
1) Check list 3.12~4.10
2)
3)
4)
5
2X2
gauze 220, 3X3 gauze 120, Saliln 150, S-cotton 45, L- cotton 25,
510 34%, 37%, 30Kg .
6
1) 2 x 2 gauze 60 50, 3X3 gauze 70 50,
Saline 200 160, S-cotton 2/3 1/3
2) Potadin, Alcohol, H2O2
, ,
3) (60), (30), (10)
7
1) : 2X2 gauze 220 78 65%, 33 gauze 120 46 62%, Saline 150 62 59%, S-cotton 45 40
11%, 535 226 58%
2) : 6.08kg 1.36kg 5kg ,
6.5kg 1.56kg 5kg, 10.22kg 2.64kg 8kg, H2O2
7.46kg 1.94kg 6kg, 30kg 8kg 22kg .
3) : 510 78 85%
4) : 4X8 gauze 1 35 1 7 21 ,
2X2 gauze 15 8 45 , 3X3 gauze 20 4 22 , Saline
12 8 37 , 2 5 .
5) 79% .
-
2012 127
8
, , , , ,
, . .
.
-
128 2012
CHA
1
Set
List, Single ,
,
.
2
, Set
.
,
.
3
,
4
1)
(1) : 2012 326 ~ 42
(2) : 2012 626 ~ 82
2) : ,
3) :
4) : PASW Ver.19
-
2012 129
5
66% Set
Single 55% 57% .
Set ,
. 40%, 25%
.
6
1)
(1)
(2)
2) :
(1)
(2) :
3)
(1) Set
(2) Single
7
5%, 48%, 47%
.
40% 90% , 57 16
31 15 261 , 25% 90%
.
8
Set Tape
, . ( : )
Set Tape . Set Single Tape
.
-
130 2012
, , , , , ,
1
,
. ,
.
. ,
,
.
2
.
.
.
3
2011~2012 9 .
4
, casecart bag
.
-
2012 131
5
2011 4.7%, 3.5%.
231, 64. ,
trocar 148
.
6
1) 2 -
2) -
3) ,
4)
5) casecart bag - 174, 379
7
4.2%, 3.5% .
210, 30 .
4.8% 9.0%
. 7.6% 53.0%
.
, 80(28.3%) ,
105(37.2%) .
( )
.
1)
2011 2012
(%) 4.7 4.2
() 231 210
(%) 3.5 3.5
() 64 30
-
132 2012
2)
2011(%) 2012(%)
1.79 1.38
0 0
1.43 1.3
0.10 0.06
1.52 1.44
1.14 0.44
0 0
1.06 1.43
0.07 0
1.14 1.65
8
.
.
.
-
2012 133
6
1
(, ,
) 2011 2 8
21,675,940, 32,401,642 . ,
20112 8 64,400,000 44,862,935
.(17,065 )
.
2
->->->Calibration->QC->Test-> -> 8.
Map 22
82.8% 6 .
1)
2)
3) Clot
4)
5)
6)
, ,
.
1) : (Interface)
, .
2) : .
3) : , .
.
-
134 2012
1) : Pay-off matrix, (, ,
) . (
, )
2) : Box plot 750t->400t .
750t
.
3) : .
3
3,078,264 .
1,004(1,064 60 ) x 3,066
4
, , 3 ,
, ,
, .
, .
-
2012 135
1
2006
.
, 2010 ,
.
2
,
,
. ,
, .
2010 EO GAS , 6,
3, 3, STEAM 2
EO GAS . EO GAS
,
, 2011 EO GAS, STERRAD, STEAM
.
3
, , 2 EO GAS , STERRAD
, STEAM 27, 15, 6 .
, , .
-
136 2012
4
3 959 2010 1 10
, 2011
6 , , , 2
STEAM 2 2 8
.
, . 2010
.
5
1) 2010 STEAM 10 27, 15, 2
6 100% .
2) 2011 EO GAS, STERRAD, STEAM 6 27,
15, 15, 2 6 .
3) , ,
.
4) ,
. 24, 70% .
6
2010 STEAM , 2011
STEAM EO GAS, STERRAD 6, 3,
3, 2 1 .
, , .
7
, .
.
QI ,
.
-
2012 137
1
, ,
, , (, ), ,
.
.
2
.
3
4
1)
(1) : 2012 3 1 ~ 2012 4 30
(2) :
.
2)
(1) : 2012 8 1 ~ 2012 8 31
(2) : .
-
138 2012
5
1) 1 , ,
" " 54%, " " 38%, "
" 48%, " " 32% .
53.9%
90.3% 5.9%
.
2)
6% , 3.9% .
6
1)
2)
3)
7
1) 6%
4.2% 6.9% 5.3% .
3.9% 0.5% , 4.3%
1.0% .
2) .
8
QI
. QI
80%
.
, (, , , )
1% .
-
323
11 29() 14:0015:30PR50PR56
-
2012 141
()
1
.
.
. , sonographer ,
,
, sonographer .
, , .
2
(Turn Around Time, TAT :
)
, ,
.
.
, TAT
.
.
3
(TAT)
.
-
142 2012
4
(TAT) ( , , ) (, CT, )
5
97 set code program ,
.
6
4 (Normal, Concentric LVH, Nonvalvular A.fib, Heart transplantation)
set code 26 ,
set code sonographer senior sonographer
. set code
.
7
set code 62.5% 77.7%
64.8 50.8 14 . (TAT) 15.44 5.13
.
8
(TAT) 15.44 5.13 ,
set code 64.8 set code 50.8 21.6%
. set code 78% set code
62% , set code
.
, set code
1~2 TAT
. set code sonographer set
code
.
-
2012 143
1
EMR
.
. , ,
.
2
, . care plan
care plan
.
.
3
care plan , ,
.
4
2 (HD#3)
care plan . ,
, , 2 .
-
144 2012
5
Care plan 0%
.
37.5%, 23.3%, 26.6%
care plan .
6
Focus-DAR SOAP
. care
plan , .
7
Care plan 0%
100% .
37.5% 87.5% 133%, 23.3% 87.5% 275%
, 26.6% 89.1% 234% .
8
care plan , ,
, ,
.
.
.
-
2012 145
1
.
.
2
full term
.
3
KCD-6 KCD-6 () .
4
KCD-6 , DB
. 2012 1~3
, 7~8
.
-
146 2012
5
EMR DB
KCD-6 ,
.
,
.
6
1. KCD 6
2.
3.
4.
5.
7
.
8
.
-
2012 147
1
2011 3 2011 9 30 ,
, ,
,
.
2
,
.
,
, .
3
1) 30
.
2) , ,
.
3) OCS PW() .
-
148 2012
4
3
30 , , ,
PW 6 12
PW .
5
30 16 53.3%
PW PW 6 12 5.6%
, 3 PW OCS
.
6
1)
Policy - ()
- , ,
:
2)
safety box , CCTV ,
4)
: 1 ( , e-campus ), , ,
7
1) 30 16 53.3% ,
30 29 96.7% .
.
2) ()
85%
, 96.3% ,
safety box
-
2012 149
96.6% 47.4%
, . 3) PW()
PW 6 12
5.6% 82.5% .
OCS Log in PW
.
8
/
.
. ,
, , , ,
, .
-
150 2012
,
1
.
.
,
QI .
2
.
1) : JCI (EMR)
2) : ( )
3) :
3
1) :
2) () :
4
1(2010. 12. 20 ~ 22), 2(2011. 1. 3 ~ 5)
(Admission note)
.
-
2012 151
5
1) 1 : 77.1%, : 42.5%
2 : 86.3%, : 45.5%
2)
(, , , Brief op note ) 95% ,
90%
3)
2011. 2 ~ 2011. 6
6
JCI EMROCS ( )
7
1)
, 100% . , 95.7% .
(Pre op. note, Brief op. note, , ) QI Pre op. note 92.8%94.8%, Brief op. note 85%
96.2%, 91.7% 97%, 52.7% 97.8% QI
.
2) 44.1% 81.7%, 82.1% 96.3%, 44%
82.7% QI .
3) 96.1% 98.5%, 92.3% 95.5%,
93.1% 98% QI .
8
100%
, 95% .
, .
96.3%, 80% .
-
152 2012
, .
20 ,
98% .
QI ,
( ) .
95%
, feedback
.
-
2012 153
1
.
, , .
.
2
.
,
.
.
3
: 24 = 24 / 100
: daily = daily / 100
: 48 = 48 / 100
-
154 2012
4
2011.08.01 ~ 08.31 , ,
.
5
6
: .
: , , . ,
.
- 2012 1 1
- 2012 7 2 ,
(2418) : 18 24
.
-
.
- .
- 3 , 1
- , .
: .
- Plan Plan - -
-
2012 155
SMS : Staff .
: ( )
- Finding
7
: 84.8%(22.7%), 68.0%(37.9%), 56.9%(13.3%)
: 99.7%(0.3%), 89.1%(28.8%), 97.6%(27.6%)
- ,
.
8
24
18.8 1.8 , ,
, .
,
. 2012 10
QI
. .
-
156 2012
, , , ,
1
. .
,
,
QI .
2
, ,
.
.
.
3
1) : 10%
2) : = /
4
1) :
2) : 2011 3~5
3) : , , , ,
4)
:
-
2012 157
: : + : +[ : ] : + () +
5
1)
,
2)
: (40%) : (100%) : + (60%) : + [ : ](100%) : + () + (100%)
6
"" ,
.
1)
1 (20113~5) .
. 2) "INHIS LIVE"
: PLIF 8 (2011.6.14 ) : 2011.4.8 : + 5 (2011.6.14) : + [ : ] 4 (2011.6.13) : + + 7 (2011.6.17)
3) INHIS LIVE
: (20117~9)
4)
,
-
158 2012
7
1) 8.7% : 8/92()() / () : 8/26() (30.7%) : 0/13() (0%) : 0/7() (0%) : 0/40() (0%) : 0/6() (0%)
2) : 8, 2, 2(2011.11.7 )
8
QI 67.6% 8.7%
QI
.
1)
2)
.
-
325A
11 29() 14:0015:30PR57PR63
-
2012 161
Abdomen, Hip, Pelvis, L-spine, T-spine AP
Low Dose Technique
, , , , , ,
1
.
2
, . DR system , F/S, CR system
3
Abdomen, Hip, Pelvis, L-spine, T-spine AP
4
(2011 4~12), (2012 4~12) Abdomen, Hip, Pelvis, L-spine, T-spine AP
5
1) DR F/S, CR system , ,
.
2) (accuracy) (reproducibility) .
-
162 2012
6
1) DR system kVp 15%
2) QA/QC
7
kVp 15% Abdomen 22%, Pelvis 28%, L-spine 21%, T-spine
23%
8
, QA/QC
QA/QC .
-
2012 163
, 6
1
,
.
,
2011
QI . ,
,
,
, 2012 QI
CQI .
CQI .
2
.
,
.
1)
2) CP(Clinical Pathway) ,
3)
4)
5)
6) .
-
164 2012
,
.
,
QI
.
3
1)
2)
4
. : 2011. 1 ~ 2012. 9
.
(1)
.
(2) .
(3) , ,
.
(4)
5
.
(1) () - ,
- ,
-
-
()
(2)
-
-
2012 165
-
(3) ATC()
- ATC() ,
.
-
-
-, (4) -
- ,
QI 1 3
,
.
(1)
-
2012 15%
- ,
(2)
-
2012 50%
-
-
(3) Call
- ,
Call
.
(1)
- .
-
(2)
-
166 2012
-
-
(3)
- CP (Clinical Pathway) ,
CP .
-
.
(1)
- 2011 20%
. ,
-
(2)
-
(3)
- ,
-
6
QI 2011 14,566,492
( 1,213,874), CQI 2012 1 9
4,788,662( 532,073) 60% .
,
2012 3 1
.
7
2012 CQI
50%, 7% 3% 60%
. 40%
-
2012 167
7%, e-kit
3%, 16%,
14%
.
, ,
.
-
168 2012
(NST)
, , , , , , *
, *
1
, 40% , 75%
. ,
. ,
, (KSPEN) (, NST) NST .
NST program , NST ,
.
2
NST NST program ,
, . NST
NST program ,
.
3
1) NST
2) NST
3) NST
4
1) NST
2) NST
-
2012 169
3) ASPEN, ESPEN
4) 2011 12011 9 NST program
5
NST program , , .
NST NST , ,
NST NST
.
6
1) NST NST .
2) NST ASPEN, ESPEN ,
NST , , NST
.
3) NST program (NST
) , .
- Nutrition Score
-
-
- NST
- NST
4) NST NST NST ,
. .
7
1) NST
(NST) , , ,
9 point
.
2) NST ,
(1) NST
NST 1 2
. , ICU NST
.
(2) NST
-
170 2012
(day) NST .
(3) NST NST
(day) 1, 2
, 2 1
.
(4) NST NST
1 91.7% 2 100%
.
3)
2 , 2, 7
. 7 .
8
(NST)
NST .
40 (KSPEN) NST
NST . ,
NST NST
.
-
2012 171
CHA
1
.
40% ,
75% .
.
2
48 ,
. %IBW(ideal body weight), serum albumin, total lymphocyte
count 3 2 .
, . ,
. ,
, , , . ,
,
, , .
,
.
3
-
172 2012
4
.
5
34,
16(47%), 18(53%),
16(88%) 1 .
,
, .
6
TFT ,
, , , . ,
, ,
. ,
, .
7
47.0% 73.0%, 26.0% ,
(x=6.489, p=0.011).
8
.
, , .
-
2012 173
1
1~5 % .
.
.
.
.
2
2008
3 , 2009
2011 5 % .
, .
3
72 , .
1) 72
.
2) , 72
.
4
2011 11 1231 72
. 82 %
.
-
174 2012
5
2011 1 72
, . 2011 6 KCD
400 .
(A09), (J18),
(J06), (L50), (R50)
2~7 % .
, , , , , , , , TOP 10
57 % .
, .
6
, 4
case .
, , set .
,
. .
7
2011 0.67 %, , 2.07 % .
, ,
.
8
.
, .
.
.
-
2012 175
, , , , , ,
1
, , , ,
, , ,
, .
.
2
,
, .
,
, , . QA
.
3
1) , , , 90%
2) ( )
3) (2010 1.5kg 2011 1.5kg )
4) /
5)
6) (Post conceptual age)
-
176 2012
4
, 2010 5-9, 2011
5-9 EMR .
1)
- ,
- ,
- ,
- / , ,
2)
- setting , , , ,
3)
- , , ,
5
2010 5 1 9 30 1.5kg
29, 385 68 .
27
19 9(47.4%) .
19 6(31.6%) .
. 34
36 2 .
.
,
, .
.
6
8 ,
, 17 . ,
. minimal handling
, sucking
34 , ,
-
2012 177
NIDCAP .
,
NICU NICU
, ,
. , ,
, , ,
.
7
27 16 47.4% 46.4%
. 31.6% 78.6% ,
. , 36 2 35 4 4
, 2.18kg 2.256g 76g , 68 60
8 . ,
, 70.6 78.18 .
41.2, 86.8, 6 87.2 ,
69 98 29 . 82.5%
99.1%.
8
2010 5 9 5
, , , , ,
,
, 27 16
11 47.4% 46.4% .
362 354 4 ,
68 60 8 .
,
.
-
178 2012
AGS(Asan Global Standard)
*,
*,
*,
**,
**,
**,
**,
**,
**
*(8 ), 1