Chapter 7: Overview of daily statistical evaluation: Hospital operation, medical quality and safety monitoring indicators (HMI) reflect the concepts and values of the structure, process and results of medical quality under certain time and conditions. It consists of index name and index value. Establishing scientific medical quality evaluation index is the basis of implementing scientific evaluation of medical institutions; Implementing continuous medical quality evaluation and monitoring is an important way to track and evaluate medical institutions and an important means to promote the continuous improvement of medical quality. Practice has proved that the continuous improvement of medical quality stems from the requirements and efforts of managers on the definition, measurement and evaluation of medical quality improvement. The monitoring indicators include hospital operation, medical quality and safety monitoring. Some items and data of basic monitoring indicators of hospital operation are quoted from hospital statistics and financial statements. The monitoring indicators of medical quality and safety are presented in the mode of paying equal attention to process (core) quality indicators and outcome quality indicators, which are divided into the following five aspects: 1. The key indicators of hospitalization medical quality are three outcome quality: readmission rate (readmission and reoperation), death (hospitalization death and postoperative death) and safety indicators (complications and safety). Total number of hospitalized key diseases, deaths, readmission within 2 weeks, readmission within 1 month, total number of hospitalized key operations, deaths, and unexpected return to surgery after operation. Anesthesia index postoperative complications and patient safety index II. The quality index of single disease (specific disease) focuses on the quality process (core) quality index of "acute myocardial infarction, heart disease, pneumonia, cerebral infarction, hip and knee replacement, coronary artery bypass grafting, and perioperative infection prevention", which targets tertiary hospitals and focuses on tertiary hospitals. Third, the monitoring indicators of ICU are indicators that focus on the diagnosis and treatment process and the quality of results. Four, the monitoring index of rational use of antibacterial drugs is based on the results of the use of antibacterial drugs in hospitals. Five, the monitoring indicators of hospital infection control focus on the outcome indicators of specific objects, that is, the outcome indicators of infection caused by using ventilators, catheters and catheters, and the outcome indicators of postoperative incision infection are evaluated in the scope of surgical risk assessment. Section 1 Basic Monitoring Indicators of Hospital Operation Information Department and functional departments monitor and understand the basic situation of daily operation of the hospital through basic monitoring indicators of hospital operation. II. Monitoring indicators (I) Resource allocation 1. The actual open beds, the actual open beds in the Department of Critical Care Medicine, and the actual open beds in emergency observation. -medical department two. Total number of employees and health technicians (number of doctors, number of nursing staff and number of medical technicians). -Personnel Section 3. Hospital medical building area. -Property Management Department (2) Workload-Medical Department and Clinic 1. Annual clinic, health examination, annual emergency and observation clinic. 2. The number of hospitalized and discharged cases in that year, and the total bed days actually occupied by discharge. 3. Number of inpatient and outpatient operations per year. (3) Quality of treatment-Medical Department 1. The number of cases in which cryosurgery is consistent with paraffin diagnosis. 2. The preoperative diagnosis and postoperative pathological diagnosis of malignant tumor are consistent with the number of cases. 3. The number of inpatients who died and were discharged automatically. 4. Hospitalization operations and deaths. 5. The number of hospitalized critical cases and deaths. 6. The number of emergency critical cases and deaths. 7. The newborn died in the hospital. (4) Work efficiency (items and data are quoted from hospital financial statements)-Medical Department 1. Average length of stay of discharged patients. 2. Average working days per bed. 3. Bed utilization rate (%). 4. Bed turnover times. (V) Patient burden (items and data are quoted from hospital financial statements)-Finance Department 1. Every outpatient fee (yuan), including medicine fee (yuan). 2. Every hospitalization expenses (yuan), including medicine expenses (yuan). (6) Asset operation (items and data are quoted from hospital financial statements)-Finance Department 1. Current ratio and quick ratio. 2 medical income/100 yuan of fixed assets. 3. Business expenditure/business income 100 yuan. 4. Asset-liability ratio. 5. Total value of fixed assets. 6. The proportion of drug income and medical material income in medical income. (7) Scientific research achievements (five years before evaluation)-Science and Education Section 1. Number of domestic papers ISSN, number of domestic papers and cited times (based on the information published by China Science and Technology Core Journals), and number of papers per hundred open beds. 2. Number of national and provincial scientific research projects undertaken and completed/100 open beds. 3. Obtain the amount of national and provincial scientific research funds/every hundred open beds. In the second quarter, the quality and safety monitoring indicators of inpatient medical care-Medical Department+Nursing Department+Finance Department+Information Department 1. Interpret the overall situation of medical quality and safety of inpatients, focusing on three types of outcome quality: readmission rate (readmission and reoperation), death (hospitalization death and postoperative death) and safety index (complications and safety) (1). The key diseases in hospitalization are the total number of cases and the number of deaths. (2) Main hospitalization operations: total cases, deaths, accidental reoperation after operation, average hospitalization days and average hospitalization expenses. (3) Anesthesia (4) The names of diseases and I 10 codes cited in this standard are the second edition of the tenth edition of the International Statistical Classification of Diseases and Related Health Problems (compiled by Peking Union Medical College Hospital, World Health Organization and International Classification Family Cooperation Center). The surgical name and I 9-3 code cited in this standard adopt the ninth edition of International Classification of Diseases Surgery and Surgery (Clinical Revision 2008) (edited by Liu Aimin). The following items and data indicators can be collected through the home page of inpatient medical records and briefly described respectively. Two. The monitoring index (1) is the total number of hospitalized cases of key diseases, the number of deaths, the number of readmitted cases within 2 weeks and 1 month, the average hospitalization days and the average hospitalization expenses. -Medical Department, Information Department and Financial Interpretation make statistics on the total number of cases, deaths, readmission rate within 15 days, and readmission rate within 3 1 day every year, so as to understand the overall situation of hospitalization medical quality. Denominator: The total number of cases in which all patients aged ≥ 18 were discharged from hospital due to a certain disease. Molecules (in accordance with the denominator and one of the following): ① discharged patients with "death" of a certain disease; ② Patients who are readmitted to hospital within 2 weeks 1 month after the same disease is discharged. Eighteen key diseases, I 10 code: 1. Acute myocardial infarction is mainly diagnosed as ICD 10: I2 1-I22. Patients with acute myocardial infarction who have not given birth are not included. 2. The second diagnosis of congestive heart failure ICD 10: I50 codes for patients with cardiogenic heart failure who were discharged from hospital without delivery, excluding non-cardiogenic heart failure and the terminal state of various diseases, and excluding cardiac function II. 3. The main diagnosis of cerebral hemorrhage and cerebral infarction is ICD 10: Non-pregnant women with codes of cerebral hemorrhage and cerebral infarction are discharged from hospital, and patients with codes of brain surgery/surgery are excluded. 4. Traumatic craniocerebral injury is mainly diagnosed as the unborn discharged patient with ICD 10: S06 code. 5. Gastrointestinal bleeding (without complications) was mainly diagnosed as ICD 10: K25-K28 was accompanied by .0-.2, .4-.6 subtitle codes, and K29.0 and K92.2 were discharged from hospital without complications. 6. The main diagnostic code for injuries involving multiple parts of the body is I 10: T00-T07 Non-puerperal discharged patients with injuries involving multiple parts of the body. 7. Bacterial pneumonia (adult, no complications) is mainly diagnosed as bacterial pneumonia ICD 10: J 10.0, J1.0, J 12-J 18 (excluding 8. The main diagnostic code of chronic obstructive pulmonary disease (COPD) ICD 10: J44 refers to all patients with COPD who are not pregnant and discharged from hospital without trauma. 9. Short-term and long-term complications of diabetes (1) are mainly diagnosed as I10: e10-e14 codes as short-term complications of diabetes (ketoacidosis, hyperosmotic, coma). (2) Main diagnosis I 10: All non-parturients/non-newborns with long-term complications of diabetes (kidney, eyes, nerves, circulation or other unspecified complications) were discharged. (3) The main diagnosis I10: E1E14 Any operation/operation with ICD 9-3 coding for lower limb amputation and any diagnosis coding for diabetes was discharged. (4) The main diagnosis is I 10: non-puerperal discharged diabetic patients with uncontrolled blood sugar and no short-term or long-term complications. 10. The main diagnosis of nodular goiter ICD 10: E04 All non-parturients/non-newborns with nodular goiter were discharged. 1 1. The main diagnosis of acute appendicitis complicated with diffuse peritonitis and abscess is ICD 10: K35.0, K35. 1. All non-parturients/non-newborns with acute appendicitis complicated with diffuse peritonitis and abscess have been discharged. 12. The main diagnosis of BPH ICD 10: N40 code is BPH. All puerpera/non-newborns have been discharged. 13. The main diagnosis of renal failure ICD10: n17-n19 All non-parturients/non-newborns with renal failure have been discharged. 14. Sepsis (adult) was mainly diagnosed ICD 10: A40-A4 1 non-parturient/non-neonatal septicemia (adult) was discharged. 15. The main diagnosis of hypertension (adult) is ICD 10. All non-parturient/non-neonatal hypertensive patients (adults) were discharged from the hospital, excluding heart surgery/surgery patients and patients diagnosed with stage I-IV nephropathy and prepared for hemodialysis (dialysis access operation). 16. The main diagnosis of acute pancreatitis is ICD 10: all the puerpera/non-newborns with code K85 were discharged. 17. The main diagnosis of postoperative chemotherapy for malignant tumor was ICD10: z 51.101,and he was discharged. 18. The main diagnosis of malignant tumor by maintenance chemotherapy is ICD10: Z 51.201,Z 5 1. 103. (two) the total number of hospitalized cases of key surgery, the number of deaths, the number of accidental reoperation after surgery, the average hospitalization days, and the average hospitalization expenses. —— Medical Department, Information Department and Finance Department make statistics on the total number of cases, mortality rate and accidental reoperation rate of various operations every year, and analyze the overall situation of the treatment quality of key operations in our hospital. Denominator: Number of specific surgical cases with age ≥ 18. Numerator (one of the following that satisfies denominator): ① Death toll; ② The number of accidental reoperation after operation. There are eighteen operation types and I-9-3 codes. 1. Hip-knee replacement/Operation code of all discharged patients I-9-3: 8 1.5 1-55 Hip-knee replacement. 2. The surgery/operation related to laminectomy or spinal fusion is I-9-3, and the code is 03.0 1, 02,09,80.50, 5 1, 59,81.00,01-08. 3. The discharged patients with pancreatectomy/operation code I-9-3: 52.6 or 52.7. 4.ICD 9-3 has 42.4, 42.40-42.42, 42.5, 42.5 1-42.56, 42.58-42.59 or 42.6, 42.5438+0-42.69 or main diagnostic codes. 5. Laparoscopic cholecystectomy/operation ICD 9-3 has ICD 9-3: 51.23,24, and any diagnosis of laparoscopic cholecystectomy. 6.ICD 9-3 codes 36 patients discharged from coronary artery bypass grafting (CABG)1case. 7. Patients discharged after percutaneous coronary intervention (PCI) /ICD 9-3 with codes of 0066, 36.05438+0, 36.02 or 36.05, 36.06 and 36.07. 8. Code 0 1.02-06, 02.0, 02. 1-4 for patients discharged from cranio-cerebral surgery /ICD 9-3. 9. Hysterectomy/All female discharged patients with operation code I 9-3: 68.4-68.7 Hysterectomy. 10. The code of cesarean section/operation is I 9-3: 74.0, 74. 1, 74.2, 74.4, 74.99, and it is confirmed that the patient was discharged from cesarean section. 1 1. Vaginal delivery surgery/operation codes are ICD-9-3: 72, 73.0-73.2, 73.4-73.9 (with ICD 10: Z37). 12. Breast surgery/discharged patients with operation code ICD 9-3: 85.4. 13. pneumonectomy/operation code is ICD 9-3: 32.4, 32.5 discharged patients. 14. Gastrectomy/operation code is ICD 9-3: 43.5-43.9. 15. Recurrent operation/operation code is ICD 9-3: 48.4-48.6. 16. The operation/operation codes for kidney and prostate-related operations are ICD 9-3: 55.4-6 and 60.3-5, Prostate Surgery Discharge. 17. The codes of ICD 9-3 for endovascular repair surgery/surgery include 38.34, 38.44, 38.64 or 39.7 1-74 endovascular repair effluents. 18. Malignant tumor surgery refers to the person who is mainly diagnosed as ICD 10 C00-C97, accompanied by the operation/operation ICD.9-3 "Total removal of an organ", or partial (partial) removal. 18. 1 combined radical thyroid cancer ICD 9-3: 06.2-06.5 18.2 combined radical laryngeal cancer ICD 9-3: 30.4 18.3 lobectomy ICD9- -3: 32.4 002 pneumonectomy ICD. Esophagogastrostomy ICD 9-3: 42.5 Partial esophagectomy, esophagogastrostomy ICD 9-3 Laparoscopic radical resection of colorectal cancer 18.8 whipple operation (radical pancreaticoduodenectomy) ICD9- -3: 52.7 Pancreatic body and tail resection ICD 9-3: 52.5 902 18.9 Modified radical mastectomy ICD. 03 18. 10 Radical nephrectomy ICD9- -3: 55.5 Nephron-sparing surgery ICD 9-3: 55.3 18. 1 Radical prostatectomy ICD 9-3: 60.5+08.555 3 Bilateral salpingectomy I 9-3: 65.6 65438+ 1. Total anesthesia cases/season/year (1) General anesthesia cases/season/year. Among them: cases of cardiopulmonary bypass/season/year. (2) Cases of spinal anesthesia/season/year. (3) Cases of other kinds of anesthesia/season/year. 2. The number of cases/season/year (1) treated by anesthesiologists and the number of outpatients/season/year. (2) Number of inpatients/season/year. Among them: postoperative analgesia/season/year. 3. Number of cases of cardiopulmonary resuscitation (CPR) by anesthesiologists/number of cases of successful resuscitation/season/year. 4. Number of anesthesia resuscitation cases (Steward Awakening Score)/quarter/year (1)/ quarter/year. (2) When leaving the house, the housekeeper scored ≥4 points/quarter/year. 5. Events related to accidental anesthesia/year (1) Unexpected coma events during anesthesia/season/year. (2) Cases in which the blood oxygen saturation is seriously decreased during anesthesia/season/year. (3) Cases of using awakening drugs at the end/season/year of general anesthesia. (4) Cases of respiratory tract obstruction caused by swallowing and aspiration during anesthesia/season/year. (5) Number of accidental deaths under anesthesia/season/year. (6) Cases/quarter/year of other emergencies. 6. Anesthesia classification (AS classification) cases/season/year (1) ASA-I-I cases/season/year. Number of postoperative deaths/season/year. (2) ASA- number of cases/season/year. Number of postoperative deaths/season/year. (3) ASA-Ⅲ cases/season/year. Number of postoperative deaths/season/year. (4) ASA- number of cases/season/year. Number of postoperative deaths/season/year. (5) ASA-V cases/season/year. Number of postoperative deaths/season/year. (4) Interpretation of surgical complications and patient safety indicators According to the annual statistical data, the monitoring indicators of various surgical complications and safety are analyzed, and the overall situation of surgical complications and patient safety is analyzed. 1. See Table 7- 1 for the incidence and severity of hospitalized pressure ulcers. -Table 7 of Nursing Department and Information Department-1Number name formula of incidence and severity of hospitalized pressure ulcers 1. 1 Total number of cases of pressure ulcers before admission (the main diagnosis includes I 10 code and name) and one or more cases of pressure ulcers before admission () Denominator Total number of hospitalized cases ()/KLOC Denominator of cases with one or more first-degree pressure ulcers before admission (quarterly) Number of hospitalized cases () 1. 1.2 Number of hospitalized cases with one or more second-degree pressure ulcers before admission ()1.3 Number of hospitalized cases with one or more third-degree pressure ulcers before admission. . 1.4 Number of cases with grade IV pressure ulcers before admission () Denominator Number of hospitalized cases () 1. 1.5 Number of hospitalized cases with one or more pressure ulcers in molecular acute care of pressure ulcers at home () 1. 1.6 Number of hospitalized cases with pressure ulcers at home. Number of acute nursing patients with one or more pressure sores admitted to nursing institutions denominator Number of hospitalized cases () 1. 1.7 Number of hospitalized cases with one or more pressure sores admitted to hospitals denominator () 1. 1.8 There are one or more acute nursing molecules with pressure sores admitted from other sources. Denominator of the number of patients with multiple pressure ulcers Number of hospitalized cases () 1.2 Molecules with pressure ulcers are sent to acute care Denominator of the number of patients with one or more pressure ulcers-1 Denominator of the number of patients assessed as high-risk at admission -2 Number of hospitalized cases ()