构建动态绩效考核指标体系持续提升医院感染管理水平

Establishment of dynamic performance evaluation indicator system to continuously improve level of management of healthcare-associated infection

目的建立科学的绩效考核指标体系,持续提升医院感染管理水平。方法通过对文献及北京市医管局绩效考核与评价说明书的研读,结合本院情况,自2012年始从四个维度,围绕四个目标,不断对感染控制绩效考核指标进行评价与筛选,至2016年动态筛选出绩效考核一级指标19个,二级指标97个,三级指标141个,建立了医院感染管理绩效考核指标体系。结果 2012-2014年,医院感染管理工作在北京市医管局绩效考核中均获得满分;2015年医院感染专项得分率为95.65%,高于全院94.54%的总得分率;2012-2015年医院感染发病率均<2.0%。手卫生正确率、依从率分别从2012年的45.3%和26.9%提高到2015年的93.5%和67.6%。结论医院感染管理绩效考核指标体系构建取得初步成效。

OBJECTIVE To establish the scientific performance evaluation indicator system so as to continuously improve the level of management of healthcare-associated infection.METHODS Since 2012,starting from four dimensionalities and embracing four goals,the performance evaluation indicators for control of healthcare-associated infection were evaluated and screened through review of literatures and performance assessment and evaluation specifications from Beijing Municipal Administration of Hospitals（BMAH）in combination with the status of the hospital;totally 19first-grade performance evaluation indicators,97second-grade indicators,and 141third-grade indicators have been dynamically screened out by 2016,and the performance evaluation indicator system for management of healthcare-associated infection has been established.RESULTS The management of healthcare-associated infection got full marks for the performance evaluation of BMAH in 2012-2014;the scoring rate of hospital infection control was 95.65%in 2015,higher than 94.54% of the total scoring rate in the whole hospital.The incidence of healthcare-associated infection was less than 2.0%in 2012-2015.The rate of accurate hand hygiene was increased from 45.3%in 2012 to 93.5%in 2015;the rate of hand hygiene compliance was increased from 26.9%in 2012 to 67.6%in 2015.CONCLUSIONThe establishment of the performance evaluation indicator system has achieved initial effect.