發(fā)布時(shí)間：2018-05-14 15:48

  本文選題：Donabedian質(zhì)量理論 + 即時(shí)檢驗(yàn)��； 參考：《南方醫(yī)科大學(xué)》2017年碩士論文

【摘要】：研究背景POCT(Point of Care Testing)作為臨床檢驗(yàn)領(lǐng)域新出現(xiàn)的一種檢驗(yàn)手段,正日益受到人們的重視。美國(guó)國(guó)家臨床生化科學(xué)院(NACB)在其制定的“POCT詢證文件”草案中,將POCT定義為“在接近病人治療處,由未接受臨床實(shí)驗(yàn)室學(xué)科訓(xùn)練的臨床人員或病人(自我檢測(cè))進(jìn)行的臨床檢驗(yàn),POCT是在傳統(tǒng)、核心或中心實(shí)驗(yàn)室以外進(jìn)行的一切檢驗(yàn)”。POCT是一類極具潛力的檢測(cè)技術(shù),因其快捷方便的特點(diǎn),已被臨床醫(yī)務(wù)工作者、患者廣泛接受,在很大程度上縮短了患者檢查診療時(shí)間。與西方發(fā)達(dá)國(guó)家相比,我國(guó)應(yīng)用POCT的時(shí)間不長(zhǎng),缺乏相應(yīng)的管理經(jīng)驗(yàn),且POCT檢測(cè)易受到儀器性能、操作熟練程度等諸多因素的影響,POCT的質(zhì)量管理顯得越來(lái)越重要。目前,POCT被廣泛運(yùn)用于臨床血糖檢測(cè),各臨床科室每天都要進(jìn)行大量的血糖檢測(cè)操作,而血糖檢測(cè)結(jié)果也將影響醫(yī)生的診療結(jié)果,若處理不當(dāng),甚至?xí)＜安∪说慕】�。然�?臨床POCT血糖檢測(cè)質(zhì)量管理仍存在較多問(wèn)題。如:臨床操作人員缺乏相關(guān)檢驗(yàn)知識(shí)培訓(xùn)、血糖檢測(cè)過(guò)程缺乏標(biāo)準(zhǔn)的操作規(guī)程、未重視臨床操作人員回顧性考核與評(píng)價(jià)、臨床操作人員持續(xù)改進(jìn)意識(shí)欠缺等。因此,研究POCT血糖檢測(cè)質(zhì)量管理現(xiàn)狀,探討管理策略,對(duì)保障臨床血糖檢測(cè)質(zhì)量,減少臨床診療誤診率,保證醫(yī)療質(zhì)量安全具有重要意義。研究目的本研究旨在構(gòu)建一套符合臨床實(shí)際需求,科學(xué)、可行、目的性強(qiáng)的,并能在各級(jí)醫(yī)院參考應(yīng)用乃至為衛(wèi)生行政部門制定政策管理文件提供借鑒的院內(nèi)POCT血糖檢測(cè)質(zhì)量管理指標(biāo)體系,并探討其管理策略。研究方法1、文獻(xiàn)研究法本研究主要集中在以下兩個(gè)方面進(jìn)行文獻(xiàn)檢索:一是相關(guān)的POCT血糖檢測(cè)管理政策法規(guī),收集相關(guān)指標(biāo);二是通過(guò)中國(guó)知網(wǎng)、萬(wàn)方等多種數(shù)據(jù)庫(kù)廣泛檢索,了解POCT血糖檢測(cè)國(guó)內(nèi)外現(xiàn)狀,并將相關(guān)內(nèi)容轉(zhuǎn)換為指標(biāo)條目。2、德爾菲專家咨詢法本研究采用德爾菲專家咨詢法,制定專家咨詢問(wèn)卷,并選擇20名專家進(jìn)行評(píng)定,通過(guò)兩輪正式調(diào)查,確定各級(jí)指標(biāo)的權(quán)重值。為保證指標(biāo)體系的科學(xué)性和可靠性,在本次研究中以專家的積極系數(shù)、權(quán)威系數(shù)和專家意見的協(xié)調(diào)程度等來(lái)衡量專家咨詢結(jié)果的可靠程度。3、統(tǒng)計(jì)分析法(1)描述性統(tǒng)計(jì)描述咨詢專家的年齡結(jié)構(gòu)、技術(shù)職稱、學(xué)歷結(jié)構(gòu)、工作年限、管理職務(wù)等基本情況。(2)專家積極系數(shù)專家積極系數(shù)表示咨詢專家對(duì)本研究的關(guān)注與重視程度,一般用咨詢問(wèn)卷的回收率來(lái)反映,問(wèn)卷回收率越高,說(shuō)明專家積極系數(shù)越高。其計(jì)算公式為:Cj=mj/m;式中,Cj為專家積極系數(shù),mj為參與評(píng)價(jià)的專家,m為專家總?cè)藬?shù)。(3)專家權(quán)威程度專家權(quán)威程度,一般由專家對(duì)評(píng)價(jià)指標(biāo)作出判斷的依據(jù)和專家對(duì)該指標(biāo)的熟悉程度兩方面進(jìn)行衡量,其計(jì)算公式為:Cr=(Ca+Cs)/2(Cr為專家的權(quán)威程度系數(shù),Ca為專家判斷系數(shù),Cs為專家熟悉程度系數(shù))。(4)專家意見的協(xié)調(diào)系數(shù)專家意見的一致性用Kendall's協(xié)調(diào)系數(shù)反映。用W表示Kendall's協(xié)調(diào)系數(shù),W值在0～1之間,越接近1,表示所有專家對(duì)全部指標(biāo)評(píng)分的協(xié)調(diào)程度越好。(5)變異系數(shù)變異系數(shù)為方差與均值的比,一般情況下,變異系數(shù)小于0.25,說(shuō)明專家的意見相對(duì)集中。在本研究中,對(duì)于三級(jí)指標(biāo)的篩選,變異系數(shù)取0.25為標(biāo)準(zhǔn),大于0.25的指標(biāo)予以刪除。結(jié)果1、第一輪和第二輪的專家積極系數(shù)均為100%,有效率均為100%。2、專家權(quán)威系數(shù)在0.883～0.940之間,均值為0.911。3、第一輪專家咨詢中專家對(duì)一、二級(jí)指標(biāo)的總協(xié)調(diào)系數(shù)分別為0.466和0.561,第二輪專家咨詢中專家對(duì)一、二級(jí)指標(biāo)的總協(xié)調(diào)系數(shù)分別為0.684和0.636,經(jīng)卡方檢驗(yàn),P0.000。4、第一輪專家咨詢中,一級(jí)指標(biāo)權(quán)重賦值的變異系數(shù)在0.1662～0.2359之間波動(dòng);二級(jí)指標(biāo)權(quán)重賦值的變異系數(shù)在0.1932～0.4668之間波動(dòng),權(quán)重變異系數(shù)只有“患者滿意”變異系數(shù)大于0.4,其余均小于0.4;三級(jí)指標(biāo)權(quán)重賦值的變異系數(shù)在0.0567～0.2606之間波動(dòng),滿分率分布在0.40～0.95之間,根據(jù)指標(biāo)篩選原則,刪除1條三級(jí)指標(biāo)。5、第二輪專家咨詢中,一級(jí)指標(biāo)權(quán)重賦值的變異系數(shù)在0.0759～0.1497之間波動(dòng);二級(jí)指標(biāo)權(quán)重賦值的變異系數(shù)在0.1776～0.4174之間波動(dòng);三級(jí)指標(biāo)權(quán)重賦值變異系數(shù)在0.0789～0.2427之間波動(dòng),滿分率分布在0.20～0.90之間,根據(jù)指標(biāo)篩選原則,刪除2條三級(jí)指標(biāo)。第二輪專家咨詢的變異系數(shù)總體上小于第一輪,說(shuō)明專家意見趨于一致。本研究通過(guò)文獻(xiàn)分析和征求專家意見,草擬出院內(nèi)POCT血糖檢測(cè)質(zhì)量管理體系指標(biāo)池,并通過(guò)兩輪專家咨詢,分別確定了各級(jí)指標(biāo)的權(quán)重。最終,確定了 3個(gè)一級(jí)指標(biāo):組織管理(0.29)、檢測(cè)過(guò)程(0.41)和監(jiān)督監(jiān)測(cè)(0.30),11個(gè)二級(jí)指標(biāo):組織結(jié)構(gòu)(0.25)、人員培訓(xùn)(0.37)、質(zhì)控管理(0.38)、儀器試紙(0.21)、操作人員(0.20)、患者準(zhǔn)備(0.15)、標(biāo)本采集(0.23)、結(jié)果報(bào)告(0.21)、醫(yī)患滿意(0.29)、檔案管理(0.33)、持續(xù)改進(jìn)(0.38)和37項(xiàng)三級(jí)指標(biāo)。結(jié)論本研究圍繞醫(yī)院臨床POCT血糖檢測(cè)現(xiàn)實(shí)需要構(gòu)建了院內(nèi)POCT血糖檢測(cè)質(zhì)量管理指標(biāo)體系,并提出一系列改進(jìn)措施,具有較好的完整性、科學(xué)性和實(shí)用性,不僅能提高臨床POCT血糖檢測(cè)質(zhì)量管理的能力與水平,同時(shí)能夠?yàn)榕R床其它POCT檢測(cè)項(xiàng)目的管理提供新的思路與借鑒,從而促進(jìn)醫(yī)院管理質(zhì)量和醫(yī)療服務(wù)水平的提升,具有良好的經(jīng)濟(jì)效益與社會(huì)效益。
[Abstract]:The research background POCT (Point of Care Testing) is becoming more and more important as a new test in the field of clinical testing. The National Academy of clinical and Biochemical Sciences (NACB), in the draft of the "POCT certificate document", defines POCT as "near the sick person treatment place, trained by the unaccepted clinical laboratory subject." Clinical examination of clinical personnel or patients (self testing), POCT is all tests carried out in the traditional, core or central laboratory. ".POCT is a kind of highly potential testing technology. Because of its fast and convenient characteristics, it has been widely accepted by clinical medical workers and patients, and to a great extent shortens the patient's inspection and treatment time. Compared with the developed countries in the west, the application of POCT in China is not long, the management experience is lacking, and the POCT detection is easily affected by many factors such as instrument performance and operation proficiency. The quality management of POCT is becoming more and more important. At present, POCT is widely used in clinical blood glucose testing, and every clinical department should carry out a large number of clinical departments every day. The results of blood sugar detection will also affect the results of the doctor's diagnosis and treatment. If it is not handled properly, it will even jeopardize the patient's health. However, there are still many problems in the quality management of clinical POCT blood glucose detection. For example, the clinical operators lack the training of related knowledge, the lack of standard procedures for blood glucose detection and the lack of clinical practice. It is of great significance to study the current situation of the quality management of POCT blood glucose detection and explore the management strategy, which is of great significance to ensure the quality of clinical blood glucose detection, reduce the misdiagnosis rate of clinical diagnosis and treatment, and ensure the safety of medical quality. In order to meet the needs of clinical practice, scientific, feasible and purposeful, the quality management index system of POCT blood glucose detection can be provided for reference in hospitals at all levels and even for the health administration department to formulate policy management documents. And its management strategy is discussed. Research methods 1. The research method of literature research is mainly focused on the following two aspects Document retrieval: first, related POCT blood glucose monitoring and management policies and regulations, collect relevant indicators; two, through a wide range of databases, such as China know net, Wan Fang and other databases, to understand the status of POCT blood glucose testing at home and abroad, and convert the related content to the index item.2, and the Delphy expert consultation method is made by Delphy expert consultation method. The expert consultation questionnaire, and selected 20 experts to assess, through two rounds of formal investigation, determine the weight of the indicators at all levels to ensure the scientific and reliability of the index system. In this study, the reliability of the expert consultation results is measured by the positive coefficient of experts, the authority coefficient and the coordination degree of expert opinion in this study, and the statistical analysis is.3. Method (1) descriptive statistics describe the age structure of experts, technical titles, academic structure, work years, management posts and other basic conditions. (2) the positive coefficient of expert positive coefficient experts expressed the attention and importance of the experts to this study, generally reflected by the recovery rate of the questionnaire, the higher the recovery rate of the questionnaire, the experts were positive. The higher the coefficient is, the formula is as follows: Cj=mj/m; in the formula, Cj is the positive factor of expert, MJ is the expert to participate in the evaluation, and M is the total number of experts. (3) the expert authority degree of expert authority is generally measured by the experts' basis for judging the evaluation index and the familiarity of the experts on the index. The formula is Cr= (Ca+Cs) /2. Cr is the authority degree coefficient of the expert, Ca is the expert judgment coefficient, Cs is the expert familiar with the degree coefficient. (4) the consistency of expert opinion coordination coefficient expert opinion is reflected by the Kendall's coordination coefficient. The Kendall's coordination coefficient is expressed with W, the W value is between the 1, the better the coordination degree of all the experts to all the indexes is shown. (5) The coefficient of variation coefficient of variation is the ratio of variance to mean value. In general, the coefficient of variation is less than 0.25, indicating that the expert's opinion is relatively concentrated. In this study, the coefficient of variation is 0.25 is the standard for the selection of three level indicators and the index greater than 0.25 is deleted. Results 1, the positive coefficient of the first and second rounds is 100%, and the efficiency is effective. 100%.2, the expert authority coefficient between 0.883 and 0.940, the average value of 0.911.3, the first round of expert consultation experts to one, two level index of the total coordination coefficient of 0.466 and 0.561, second expert consultation experts to one, two level index of the total coordination coefficient of 0.684 and 0.636, through the chi square test, P0.000.4, first round of expert consultation The variation coefficients of the weight assignment of the first grade index fluctuate between 0.1662 and 0.2359, and the coefficient of variation of the weight assignment of the two level index fluctuates between 0.1932 and 0.4668. The coefficient of variation of the weight variation is only more than 0.4 and the rest is less than 0.4, and the coefficient of variation of the weight assignment of the three level index fluctuates between 0.0567 and 0.2606. The rate of full score is between 0.40 and 0.95. According to the principle of index selection, 1 three grade index.5 is deleted. In the second round of expert consultation, the coefficient of variation of the weight assignment of the first class index fluctuates between 0.0759 to 0.1497, the coefficient of variation of the weight assignment of the two level index fluctuates between 0.1776 and 0.4174, and the coefficient of variation of the weights of the three index is in 0.0789. 0.2427 fluctuation, the full score rate is between 0.20 and 0.90, according to the index screening principle, delete 2 three grade index. The variation coefficient of the second round expert consultation is less than the first round, indicating that the expert opinion tends to be consistent. This study drafts the index of the quality management system of POCT blood glucose detection in discharge through literature analysis and consultation. The pool, and through two rounds of expert consultation, identified the weights of the indicators at all levels. Finally, 3 first level indicators were identified: Organization Management (0.29), detection process (0.41) and supervision and monitoring (0.30), 11 two level indicators: organization structure (0.25), personnel training (0.37), quality control management (0.38), instrument test paper (0.21), operator (0.20), patient preparation (0.15), standard The results report (0.23), the results report (0.21), medical and patient satisfaction (0.29), file management (0.33), continuous improvement (0.38) and 37 three level indicators. Conclusion this study around the hospital clinical POCT blood glucose testing reality needs to build a hospital POCT blood glucose monitoring quality management index system, and put forward a series of improvement measures, with good integrity, scientific and Practicality can not only improve the ability and level of the quality management of clinical POCT blood glucose detection, but also provide new ideas and reference for the management of other clinical POCT detection projects, thus promoting the improvement of hospital management quality and the level of medical service, with good economic and social benefits.

【學(xué)位授予單位】：南方醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R446

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