医院感染风险分层评估体系的建立与应用

Establishment and application of hospital infection risk stratification assessment system

目的建立医院-临床科室2个层面、高风险科室-高风险指标2个维度的医院感染风险分层评估体系并应用.方法首先采用文献调研法、头脑风暴法、风险图分析法(鱼骨图)从整体层面对临床科室进行风险识别,确定风险点、风险指标及其权重系数.根据风险的发生可能性、后果严重程度、不易探测度和当前管理体系完整性4个维度建立矩阵,进行风险分析.计算风险分值,采用百分位数法,根据不同风险分值分别从临床科室和风险指标2个维度划分不同风险组.针对风险分值最高的临床科室,由科室医院感染管理小组采用失效模式与效应分析(FMEA)开展科室的风险评估,列出高风险失效原因并制定改进方案.针对风险分值最高的风险指标,构建基于企业风险管理-整合框架(COSO-ERM)的风险管理体系.结果32个临床科室纳入风险评估范围,列出7项风险点和21项风险指标;将临床科室划分为6个风险组,ICU的风险分值最高,采用FMEA管理工具ICU共列出5个高风险失效原因,制定22个对策.将风险指标划分为4个风险组,医院感染发病率的风险分值最高,基于COSO-ERM框架构建的三级风险管理体系包括一级指标3个,二级指标16个,三级指标39个.结论本研究建立的风险分层评估体系,能科学明确和有效管理医院高风险科室、高风险指标,从而前移感染控制关口,做到精准感控.

OBJECTIVE To establish and apply a hierarchical risk assessment system for hospital infection with two levels of hospital-clinical departments and two dimensions of high-risk department and indicators.METHODS Firstly,literature research method,brainstorming method and risk map analysis method(fishbone diagram)were used to identify the risks of the clinical department from the overall level,and the risk points,risk indicators and their weighting coefficients were determined.According to four dimensions,the possibility of risk occurrence,the severity of the consequences,the difficulty of detection and the integrity of the current management system,a ma-trix was established for risk analysis.Risk scores was calculated,and the percentile method was used to divide dif-ferent risk groups from two dimensions,clinical departments and risk indicators,respectively,according to differ-ent risk scores.For the clinical departments with the highest risk scores,the hospital infection management team of the department adopted FMEA(failure mode and effect analysis)to carry out the risk assessment of the under-graduate department,and proposed an improvement plan for the causes of high-risk failure.For the risk indicators with the highest risk scores,a risk management system based on the enterprise risk management-integrated(CO-SO-ERM)was constructed.RESULTS Totally 32 clinical departments were included in the scope of risk assess-ment,and 7 risk points and 21 risk indicators were listed.The clinical departments were divided into 6 risk groups,and the ICU had the highest risk score.A total of 5 high-risk failure causes were listed and 22 counter-measures were formulated using FMEA management tool in the ICU.The risk indicators were divided into 4 risk groups,and the incidence of hospital infections had the highest risk score.The three-level risk management system based on COSO-ERM framework included 3 first-level indicators,16 second-level indicators and 39 third-level in-dicators.CONCLUSION The risk stratification assessment system established in this study can scientifically and ef-fectively manage high-risk departments and high-risk indicators in hospitals,so as to move forward the infection control threshold and achieve precise infection control.