Quyết định 7051/QĐ-BYT 2016 thí điểm chỉ số cơ bản đo lường chất lượng bệnh viện

Property

Indicator

Component

Professional capacity
(2 indicators)

1.Rate of application of therapeutic technique according to healthcare levels

Process

2.Rate of surgery of level II or higher level

Process

Safety
(4 indicators)

3.Rate of wound infection

Outcomes

4.Rate of hospital-acquired infection (pneumonia)

Outcomes

5.Number of serious medical accidents

Outcomes

6. Number of seriousnon-medical accidents

Outcomes

Efficiency
(4 indicators)

7.Average duration of medical examination

Process

8.Average duration of hospitalization (applicable to all types of diseases)

Process

9.Actual usage of patient beds

Outcomes

10.Efficiency of use ofoperating rooms

Process

Effectiveness
(2 indicators)

11.Mortality rate and rate of poor prognosis (applicable to all types of diseases)

Outcomes

12.Rate of referral to higher-level healthcare facilities (applicable to all types of diseases)

Outcomes

Staff-centered indicators
(2 indicators)

13.Rate of injuries caused by sharp objects

Process

14.Rate of HBV inoculation in health workers

Process

Patient-centered indicators
(2 indicators)

15.Rate of patients satisfaction of healthcare services

Outcomes

16.Rate of health workers’ satisfaction

Outcomes

IndicatorNo. 1

Rate of application oftherapeutictechnique according to healthcare levels

Applicableareas

The whole hospital

Quality property

Professional capacity

Qualitycomponent

Process

Reasons

The application of therapeutic technique is an indicator used for assessing the professional capacity of the hospital, a basis for assessing the ability to meet the healthcare demand of citizens of an area as well as a basis for investment in the development of the hospital.

Calculation method

Numerator

Total number of therapeutic techniques being applied

Denominator

Total number of therapeutictechniquesaccording to healthcare levels

Inclusion criteria

Techniques specified in Circular No.43/2013/TT-BYT

Exclusion criteria

Therapeutic techniques only available in higher level

Data sources

Medical records, surgery monitoring books

Data collection and consolidation

Such data are currently collected and consolidated by hospitals. The measurement of such data does not increase burden on the hospitals.

Data value

High accuracy and reliability

Reporting frequency

Annually or biannually

Indicator No. 2

Rate of surgery of level II or higher level

Applicable areas

Surgery

Quality property

Professional capacity

Quality component

Process

Reasons

Surgeries of level II or higher level are performed at hospitals of districts. However, very few district-level hospitals can perform level-II surgeries. Such type of surgeries is often performed at central and provincial hospitals. The rate of level-II surgeries facilitates the assessment of professionalconformityand classification so that suitable measures are taken to enhance the capacity of the lower-level hospitals and reduce the load of the higher-level hospitals.

Calculation method

Numerator

Total number ofsurgeries of level II or higher levelbeingperformed

Denominator

Total surgeries being performed

Data sources

Surgery monitoring books, hospitals’statistical reports, hospitals’ inspection records.

Data collection and consolidation

Such data arecurrentlycollected and consolidated. The measurement of such data does not increase burden on the hospitals.

Data value

High accuracy and reliabilitybecause:

-Surgeries are classified clearly in a list issued bythe Ministry of Health

-Information is collected carefully by departments of the hospitals

- Allowancesare verified by hospitals and insurance offices before being paid

Reporting frequency

Annually or biannually

Indicator No. 3

Rate of hospital-acquired infection (wound infection)

Applicable areas

Surgery

Quality property

Safety

Quality component

Outcomes

Reasons

Wound infection is a common post-surgery complication. Wound infection affects the patient s health, lengthens the hospitalization period and increases the treatment cost.The Ministry of Healthshall specify the hospitals subject to investigation, take records of and supervise the hospital-acquired infection, including wound infection

Calculation method

Numerator

Total number of patients suffering wound infection in thereporting period

Denominator

Total number of patients undergoing surgeries in the reporting period

Data sources

Medical records, investigations into wound infection

Data collection and consolidation

Data about wound infection shall be collected depending on regular investigation by infection-controlling staff of the hospitals. Several central hospitals have carried out hospital-acquired infection control. Regarding hospitals which have not conducted hospital-acquired infection surveillance, the collection and consolidation of data shall be carried out by qualified employees and the installed surveillance system.

Data value

Averageaccuracy and reliability

Reporting frequency

Quarterly, biannually, every 9 months or annually

Indicator No. 4

Rate of hospital-acquired infection (pneumonia)

Applicable areas

Surgery

Quality property

Safety

Quality component

Outcomes

Reasons

Pneumoniacaused by hospital-acquired infection is a common complication on patients who receive long-term treatment and/or medical ventilation.Pneumoniacaused by hospital-acquired infection affects the patients’ health, lengthens the hospitalization period and increases the treatment cost.The Ministry of Health shall specify the hospitals subject to investigation, take records of and supervise the hospital-acquired infection, including pneumonia.

Calculation method

Numerator

Total number of patients suffering pneumoniacaused by hospital-acquired infectionin the reporting period

Denominator

Total number of patients receiving medical ventilation or treatment at hospitals for at least 1 month in thereporting period

Data sources

Medical records, investigations into the hospital-acquired infection (pneumonia)

Data collection and consolidation

Data abouthospital-acquired infection (pneumonia)shall be collected depending on regular investigation by infection-controlling staff of the hospitals. Hospital-acquired infectioncontrol has been carried out by central hospitals.Regarding hospitals which have not conducted hospital-acquired infection surveillance, the collection and consolidation of data shall be carried out by qualified employees and the installed surveillance system.

Data value

Average accuracy and reliability

Reporting frequency

Quarterly, biannually, every 9 months or annually

Indicator No. 5

Number of serious medical accidents

Applicable areas

The whole hospital

Quality property

Safety

Quality component

Outcomes

Reasons

Serious medical accidents are accidents due to professional mistakes or the side effects of the drugs that lead to serious consequence for patients’ health and life (lifelong sequel or death). Though the number of serious accidents is not remarkable, it requestshandlingand preventive measures as soon as possible.

Calculation method

Number of serious medical accidents

-Serious medical accidents due to the use of drugs

+Serious medical accidentsdue to side effects of drugs

+Serious medical accidentsdue to surgical operations

+ Serious medical accidentsdue to medical procedures

+ Serious medical accidents due to blood transfusion

+ Otherserious medical accidents

Data sources

Medical records, professional accidents records, medical accident reporting system,minute books of criticism about deaths, discipline-exercising monitoring book.

Data collection and consolidation

Hospital are collecting and consolidating data aboutaccidents (caused by the use of drugs, side effects of drugs, surgical operations, medical procedures, blood transfusion, etc.).The measurement of such data does not increase burden ondata collection and consolidation.

Data value

Low accuracy because health workers and the hospitals do not often make records of and reports on medical accidents. However, data in reports on serious medical accidents are highly reliable.

Reporting frequency

Annually or biannually

Indicator No. 6

Number of serious non-medical accidents

Applicable areas

The whole hospital

Quality property

Safety

Quality component

Outcomes

Reasons

Seriousnon-medical accidents are accidentsnot caused by professional mistakes nor the side effects of drugs thatlead to serious consequence for health and lifeof patients, health workers and the community(lifelong sequel or death). Though the number of serious accidents is not remarkable, it requests handling and preventive measures as soon as possible.

Calculation method

Number of seriousnon-medical accidents

+ Suicide

+ Falling from heights

+ Kidnapping

+ Assault, rape, murder

+ Fire

+ Leak or loss of materials or highly hazardous waste

+ Other accidents

Data sources

Monitoring books, handover books, discipline-exercising monitoring books, inspection dossiers, etc.

Data collection and consolidation

Though such contents are not included in regular reporting system, data are collected and consolidated because of their seriousness and relevance to regulatory authorities. The measurement of such indicator does not place a remarkable burden on the collection and consolidation of data in the hospitals.

Data value

Average accuracy, because hospitalsrarely make reports on the accidents no matter how serious they are.However, data on reported accidents have high reliability.

Reporting frequency

Biannually or annually

Indicator No. 7

Average duration of medical examination

Applicable areas

Consulting room

Quality property

Efficiency

Quality component

Process

Reasons

Patients often complaint about the long duration of medical examinations, especially those conducted at provincial and central hospitals. The duration of medical examination reflects the patient overload as well as the healthcare organization of the hospitals. The measurement of duration of medical examination contributes in the improvement in the patients’ satisfaction and the efficiency of theconsulting room

Calculation method

Duration of medical examination is the period of time when the patients complete the medical examination procedures from the time of registration of medical examination to the time they receive the diagnoses, prescriptions or instructions from doctors at theconsulting rooms

Numerator

Totalduration of medical examinationof all patients

Denominator

Total number of patients receiving medical examination

Inclusion criteria

Total number of patients registering the medical examination

Exclusion criteria

Patients failing to comply with the medical examination procedures

Data sources

Measuring such indicator, it is required that hospitals will collect and consolidate data about time of medical examination Regarding hospitals applyinginformation technologyin the management of outpatient, the time of registration and the finish time of the examination are displayed on computers. For hospitals not recording the time of registration and the finish time of the examination, such information shall be added to the examination registration books or the examination books.

Data collection and consolidation

If the registration time and finish time of examination are recorded, the burden on the collection and consolidation of data is minor.

Data value

High accuracy and reliability

Reporting frequency

Quarterly, biannually, every 9 months or annually

Indicator No. 8

Average duration of hospitalization (applicable to all types of diseases)

Applicable areas

The whole hospital

Quality property

Efficiency

Quality component

Process

Reasons

The increase in the length of hospitalization increases the seriousness of the overload and the treatment cost the patients must pay. The length of hospitalization reflects the efficiency and the suitability of the treatment and healthcare provided by hospitals.

Calculation method

Numerator

Total number of days of inpatient treatment in thereporting period

Denominator

Total number ofpersons receivinginpatient treatment in the reporting period

Inclusion criteria

All of patients having the inpatient treatmentrecords

Exclusion criteria

Patients referred from other hospitals where they have received inpatient treatment; Patients referred to other hospitals where they continue receiving inpatient treatment

Data sources

Medical records, hospital admission - discharge - referral books, hospitalstatistic reports

Data collection and consolidation

Such data are currently collected and consolidatedby hospitals. The measurement of such data does not increase burden on the hospitals.

Data value

High accuracy and reliability

Reporting frequency

Quarterly, biannually, every 9 months or annually

Indicator No. 9

Actual usage of patient beds

Applicable areas

The whole hospital

Quality property

Efficiency

Quality component

Outcomes

Reasons

The overload of hospitals, especially of central levels, is an imperative issue. Although the actual number of patient beds is higher than the planned one, most hospitals use the planned number to calculate the usage of patient beds. The usage of patient beds calculated according to the actual number of patient beds reflects more accurately the rate of overload and assist the supervision of changes in the operation of a hospital.

Calculation method

Numerator

Total number of days of inpatient treatment in the reporting period

Denominator

Actual number of patient beds in total multiplying the number of days in thereporting period

Data sources

Medical records, hospital admission - discharge -referralbooks

Data collection and consolidation

Such data are currently collected and consolidated by hospitals. The measurement of such data does not increase burden on the hospitals.

Data value

High accuracy and reliability

Reporting frequency

Biannually or annually

Indicator No. 10

Efficiency of use of operating rooms

Applicable areas

Surgery

Quality property

Efficiency

Quality component

Process

Reasons

Operating rooms receive the most investment of the hospitals. In several hospitals, the unreasonable organization of operating rooms leads to the overload and the extension of surgery-pending period while in other hospitalsoperating rooms are rarely used. The measurement and improvement of the usage ofoperating rooms contributes in the reduction of load of the hospital and the efficient use of current resources.

Calculation method

Numerator

Total amount of using time ofoperating rooms (depending on the entering and leaving time) in a quarter

Denominator

The number ofoperating rooms * 8 hours * 5 days/week

Inclusion criteria

Elective and urgent surgeries

Exclusion criteria

-

Data sources

Currently,dataabout using time of operating roomsarenotcollected and consolidated by hospitals.The measurement of such indicator requires the recording of the time the patients enter or leave the operating rooms to the monitoring books or handover books of the operating rooms or the operating monitoring books

Data collection and consolidation

Ifsuch dataare recorded, the burden on the collection and consolidation of data is minor.

Data value

High accuracy and reliability

Reporting frequency

Quarterly, biannually, every 9 months or annually

Indicator No. 11

Mortality rate and rate of poor prognosis (applicable to all types of diseases)

Applicable areas

The whole hospital

Quality property

Effectiveness

Quality component

Outcomes

Reasons

Mortality rate is a common treatment quality indicator. In Vietnam, for most complex cases where patients are predicted to die, their families apply for discharge for resting at home. Nowadays, since the patients may be admitted after receiving inpatient treatment from other hospitals, the comparison of the efficiency and safety in treatment using hospitals’ mortality rate is not very suitable

Calculation method

Numerator

Total number of patients died at the hospital and predicted to die and discharged on request in thereporting period

Denominator

Total number of persons receiving inpatient treatment in the reporting period

Inclusion criteria

Allpersons receiving inpatient treatment

Exclusion criteria

Patientsreferredfrom other hospitals where they have received inpatient treatment;

Data sources

Medical records, hospital admission - discharge -referralbooks

Data collection and consolidation

Dataabout mortality and poor prognosisare currently collected and consolidated by hospitals.However, such data includes patients referred from other hospitals.The measurement of such data does not increase burden on data collectionbut requires a minor change in data collection

Data value

High accuracy and reliability

Reporting frequency

Quarterly, biannually, every 9 months or annually

Indicator No. 12

Rate ofreferral tohigher-level healthcare facilities (applicable to all types of diseases)

Applicable areas

The whole hospital

Quality property

Effectiveness

Quality component

Outcomes

Reasons

Referral rate is a common treatment quality indicator. In Vietnam, most complex cases are referred to higher-level hospitals because lower-level hospitals do not have sufficient conditions and capacity to apply the required therapeutic techniques andtreatment regimens, etc.Nowadays, since the patientsor their familiesmayapply for discharge to finish the current treatment and receive treatment from higher-level hospitals without decisions of current hospitals, the comparison of the efficiency and safety in treatment usingthe referralrate is not very suitable

Calculation method

Numerator

Total number of patients referred to higher-level hospitals under decisions of current hospital in thereporting period

Denominator

Total number of persons receiving inpatient treatment in the reporting period

Inclusion criteria

-

Exclusion criteria

Patients applying for discharge from hospitals to finish the current treatment and referral to higher-level hospitals without decisions of current hospitals; patients referred to higher-level hospitals for emergency under decisions of current hospitals

Data sources

Medical records, hospital admission - discharge - referal books

Data collection and consolidation

Such data are currently collected and consolidated by hospitals. The measurement of such data does not increase burden on data collection

Accuracy and reliability

Average accuracy and reliability

Reporting frequency

Quarterly, biannually, every 9 months or annually

Indicator No. 13

Ratioof injuries caused by sharp objectsto 1000 persons

Applicable areas

The whole hospital

Quality property

Staff’s orientation

Quality component

Process

Reasons

Injuries caused by sharp objects is a main reasons ofoccupational diseasestransmitted through bloodstream which is popular in health workers.

Calculation method

Numerator

Total number of health workers suffering injuries caused by sharp objects in thereporting period* 1000

Denominator

Total number of health workers

Data sources

Such data are currently collected and consolidated by hospitals.However, such accidents are often not reported and recorded by health workers.

Data sources should be health workers’ occupational health dossiers and medical interview results (made and recorded in periodiccheck-ups which are held every 6 months according to regulations)

Data collection and consolidation

The collection and consolidation of information about injuries caused by sharp objects will not cause any noticeable burden on hospitals which seriously comply with regulations oncheck-upandoccupational diseasemanagement for employees.

Accuracy and reliability

Average accuracy and reliability

Reporting frequency

Biannually or annually

Indicator No. 14

Rate of HBV inoculation in health workers

Applicable areas

The whole hospital

Quality property

Stafforientation

Quality component

Process

Reasons

The Ministry of Healthprescribes that health workers shall have HBV inoculation. However, hospitals do not highly comply with such regulation.

Calculation method

Numerator

Total number of health worker having 3 doses ofHBV inoculation* 100%

Denominator

Total number of health workers requested to have HBV inoculation

Data sources

Health workers’ occupational health dossier

Results of medical interview of health workers in each periodic check-ups

Data collection and consolidation

The measurement of such indicator shall depend on the occupational health survey conducted in the periodic check-ups provided for health workers according to regulations.The collection and consolidation of information about injuries caused by sharp objects will not cause any noticeable burden on hospitalswhichseriously comply with regulations on check-up and occupational disease management for employees.

Data value

Average accuracy and reliability

Reporting frequency

Biannually or annually

Indicator No. 15

Rate of patients satisfaction of healthcare services

Applicable areas

The whole hospital

Quality property

Patients’ satisfaction

Quality component

Outcomes

Reasons

Patients’ satisfaction is an important outcome of hospitals. Patients satisfaction is also relevant to the total number of patients coming to hospitals to receive examination and the future usage of patient beds. As prescribed bythe Ministry of Health, hospitals shall regularly conduct the assessment of patients’ satisfaction. Nowadays, many complaints about the behavior of hospitals staff have been received.

Calculation method

Numerator

Total number of patients satisfied with the behavior of health workers * 100

Denominator

Total number of patientsinterviewed

Inclusion criteria

Patients was and beingdischargedfrom the hospital

Exclusion criteria

Patients receiving inpatient treatment

Data sources

Surveys on patients satisfaction

Data collection and consolidation

The measurement of such indicator does not cause any noticeable burden on hospitals which seriously comply with regulations on assessment of patients’ satisfaction

Data value

Changeable accuracy and reliability, depending on types of samples and questions and the processing of data.

The Ministry of Healthshall issue a consistent questionnaire used for all hospitals to reduce the variance in data

Reporting frequency

Quarterly, biannually, every 9 months or annually

Indicator No. 16

Rate of health workers’ satisfaction

Applicable areas

The whole hospital

Quality property

Stafforientation

Quality component

Outcomes

Reasons

Health workers’ satisfaction is an important outcome of hospitals.Health workers’ satisfaction is also related to their behavior during the provision of healthcare services.As prescribed by the Ministry of Health, hospitals shall regularly conduct the assessment ofhealth workers’ satisfaction. Nowadays, many complaints about the behavior ofhealth workershave been received.

Calculation method

Numerator

Total number of health workers satisfied with their hospitals’ management * 100

Denominator

Total number of health workersin the hospital

Inclusion criteria

All thehealth workers in the hospital

Data sources

Surveys onhealth workers’ satisfaction

Data collection and consolidation

The measurement of such indicator does not cause any noticeable burden on hospitals which seriously comply with regulations on assessment ofhealth workers’ satisfaction

Data value

Changeable accuracy and reliability, depending on types of questions and the processing of data.

The Ministry of Health shall issue a consistent questionnaire used for all hospitals to reduce the variance in data

Reporting frequency

Quarterly, biannually, every 9 months or annually