助产专科质量信息化管理系统的建设与运行成效  

The establishment and management of midwifery quality evaluation system

作　　者：潘继红[1] 姚瑛[1] 周立平[2] 邹文霞[2] 李兵 胡海滨[2] 胡品佳[2] 黄发原 郑丽娟[2] 

机构地区：[1]广东省妇幼保健院护理部,广州市510442 [2]广东省妇幼保健院产科,广州市510442 [3]广东省妇幼保健科,广州市510442 [4]广东省妇幼保健院信息科,广州市510442

出　　处：《中国护理管理》2016年第11期1544-1547,共4页Chinese Nursing Management

基　　金：2014年度广东省医学科研基金指令性课题(C2014012)

摘　　要：目的 :建立一套基于结构化电子病历,科学、信息化的助产专科质量管理体系,并探讨其对助产专科质量的监测和持续改进价值。方法 :结构化产科护理文书,确定质量评价指标的数据来源,建立信息化的助产专科质量管理体系;并对比分析实施信息化管理前后其助产专科质量关键指标的变化趋势。结果 :建立和运行了包含三级质量指标的助产专科质量管理系统,并运用该系统的实时监测和分析功能确定了过程质量指标"产程中促自然分娩合格率"和"阴道试产转剖宫产率"作为重点改进主题,通过质量改进活动,其过程质量指标"产程中促自然分娩合格率""阴道试产转剖宫产率"显著改善,其终末指标"阴道分娩率""VBAC成功率"和"会阴侧切率"等显著改善,差异均有统计学意义(P<0.01)。结论 :建立了科学的、可靠的助产专科质量信息化管理系统模块,可有效监测和指导助产专科质量的持续改进。Objective： To develop a scientific and systemic indicators to evaluate midwifery safety and quality in obstetrical department. Methods： The indicators were built on data obtained from standardized obstetric nursing documents, and were employed to evaluate and improve quality of care by providing research-based comparative data on nursing care and the relationship to patient outcomes. Results： According to the indicators, two process indicators, qualified rate of promoting natural labor and the rate of cesarean delivery were focused on improvement.Three outcome indicators, vaginal delivery rate, VBAC success rate and episiotomy rate were improved significantly（P〈0.01）. Conclusion： The midwifery quality management module is reliable which can be used to provide real-time evaluation of midwifery safety and quality in obstetrical department.

关 键 词：助产专科 质量评价指标 信息化 管理 

分 类 号：R47[医药卫生—护理学]