江苏省三级医院评审标准感染管理实施细则解读  

Interpretation of detailed rules for contents of infection management of Jiangsu provincial tertiary hospital evaluation standards

作　　者：李阳[1] 刘波 张卫红 LI Yang;LIU Bo;ZHANG Wei-hong(Nanjing Drum Tower Hospital,The Affiliated Hospital of Nanjing University Medical School,Nanjing,Jiangsu 210008,China;不详)

机构地区：[1]南京大学医学院附属鼓楼医院感染管理办公室,江苏南京210008 [2]南京医科大学第一附属医院(江苏省人民医院)感染管理处,江苏南京210029

出　　处：《中华医院感染学杂志》2023年第10期1444-1448,共5页Chinese Journal of Nosocomiology

基　　金：江苏省医院协会医院管理创新研究课题(JSYGY-3-2021-511)。

摘　　要：目的依据国家《三级医院评审标准(2022年版)》,结合江苏省医院感染管理工作现状,制定江苏省三级医院评审标准感染管理实施细则。方法江苏省感染管理专家组依据当前感染管理工作重点和本地特点,对新标准感染管理内容中的监测数据和现场评审部分制定实施细则。创新性引入病例组合指数(CMI)值对监测数据进行校正,有利于各三级医院数据能客观、公正地进行比较。结果结合院感发展新趋势和工作难点等,专家组对监测数据、现场评审等关键内容和评审方法进行优化,使评审结果能更加全面、真实地反映医院实际感染管理状况。结论江苏省三级医院新评审标准实施细则探索能够真实反映医院实际感染管理状况,具有一定的参考价值。OBJECTIVE To formulate the detailed rules for contents of infection management of Jiangsu provincial tertiary hospital evaluation standards based on the Evaluation Standards for Tertiary Hospital(2022 Edition)and the current situation of infection management in Jiangsu Province.METHODS The detailed enforcement rules were formulated for surveillance data and on-site assessment parts from infection management contents of the new standard based on the current priorities of infection management and local characteristics by Jiangsu provincial infection management expert group.An innovative case-mix index(CMI)was introduced to revise the surveillance data,which may facilitate the objective and fair comparison of data among the tertiary hospitals.RESULTS The expert group optimized the key contents such as surveillance data and onsite review as well as the review methods based on the new trends of development of infection management and work difficulties,which may help to achieve a more comprehensive review result and reflect the actual situation of the infection management.CONCLUSION The exploration of the detailed enforcement rules for the new evaluation standards of tertiary hospital in Jiangsu Province can truly reflect the actual situation of infection management,and it has certain reference value.

关 键 词：等级医院评审 新标准 感染管理 病例组合指数 现场评审 

分 类 号：R197.323[医药卫生—卫生事业管理]