In July 2009, the Notice of the General Office of the State Council on Printing and Distributing the Work Arrangements for Five Key Reforms of the Medical and Health System in 2009 (Guo Ban Han [2009] No.75) clearly required "promoting the clinical pathway of common diseases" in the work deployment of "promoting the pilot reform of public hospitals". Subsequently, the Department of Medical Administration of the Ministry of Health set up an expert committee for technical evaluation of clinical pathway, and organized and formulated 22 specialties of 165438. On the basis of designation by the Ministry of Health and recommendation by provinces (cities), 1 10 hospitals in 23 provinces (cities) were selected as pilot units of clinical pathway management in the Ministry of Health.
From June 5438 to February 2009, the pilot project of clinical pathway management was carried out nationwide. In order to ensure the smooth implementation of the clinical pathway pilot project and achieve the expected results, according to the relevant requirements of the Notice of the Medical Administration Department of the Ministry of Health on the Supervision and Baseline Investigation at the Start-up Stage of the Clinical Pathway Management Pilot Project (No.49 of the Ministry of Health [2010]), since March 2065 438+00, under the unified arrangement of the Medical Administration Department of the Ministry of Health, Six supervision teams composed of relevant personnel from the Medical Administration Department of the Ministry of Health, members of the Clinical Pathway Management Pilot Office of the Ministry of Health, experts from the Clinical Pathway Management Technical Review Committee of the Ministry of Health and relevant personnel from the Hospital Management Research Institute of the Ministry of Health were formed to supervise the national clinical management pilot hospitals. As of August 27th, 20 10, the supervision team * * completed the supervision and inspection and baseline survey of 86 pilot hospitals in 16 province. Now some of the contents are analyzed as follows. 1. 1 data source
Summarize the work of clinical pathway management pilot hospitals and record the discussion between hospital managers and medical staff in pilot departments; Check and collect the specific implementation plan, relevant management system, establishment document of leading group, clinical pathway text, training records, etc. ; Baseline questionnaire of clinical pathway management pilot work and evaluation form of non-specific indicators related to single disease submitted by pilot hospitals to the steering group.
1.2 method
In this paper, the supervision team talked with hospital managers, heads of pilot departments and relevant medical staff in the pilot departments to understand the overall situation, difficulties and doubts faced by the pilot work of clinical pathway, as well as the understanding and attitude of relevant personnel to the development of clinical pathway. By summarizing and analyzing the relevant materials and texts provided by the pilot hospitals, we can understand the situation of clinical pathway management in the pilot hospitals.
2 Results and analysis
According to the supervision, clinical pathway management has been carried out in most pilot hospitals in 16 pilot provinces, but the pilot work of clinical pathway management in some pilot hospitals is still in its infancy, and the number of cases entering clinical pathway management is small, and the data lacks statistical significance.
According to preliminary statistics, as of June 30th, 20 10, 22 specialties such as cardiology, general surgery and orthopedics have been selected in pilot hospitals designated by the Ministry of Health in Beijing and Shanxi respectively, and 1 12 diseases have carried out clinical pathway pilot work, and * *1243 patients have entered the clinic.
By May 3rd, 2065438, 6 pilot hospitals of clinical pathway of Ministry of Health in Henan Province had selected 12 specialties, covering 53 diseases such as acute non-ST-segment elevation myocardial infarction, chronic suppurative otitis media, thyroid cancer and cerebral hemorrhage in the clinical pathway of Ministry of Health12. * * * 2009 patients entered the clinical pathway management process, of which 1289 patients completed the clinical pathway, and 71/kloc-0 patients showed variation, accounting for 35.39%.
By the end of July, 20 10, Shanghai * * * Ministry of Health 1 1 Clinical Pathway Management Pilot Hospital has carried out clinical pathways for 54 diseases in 13 specialties, with a total of 6,587 people entering the pathway and 6,338 people completing the pathway.
Most provincial (municipal) health bureaus have set up leading groups and expert working groups to guide the pilot work of clinical pathway management in pilot hospitals in their respective jurisdictions. Combined with the actual situation of the province, the pilot provinces have formulated and issued a provincial-level clinical pathway management pilot work plan. Each pilot hospital set up a pilot work leading group and issued an implementation plan for clinical pathway management. Most pilot hospitals can guide the pilot departments to formulate versions of medical treatment, nursing and patient clinical pathway for related diseases according to the actual situation of their own hospitals. Various pilot hospitals have carried out different forms of clinical pathway pilot training. According to the supervision, the specific contents of clinical pathway management are as follows:
2. 1 Establish an organization and clarify responsibilities.
The results of discussion and data consultation show that the provincial (municipal) health bureaus have set up leading groups and expert working groups for clinical pathway management pilot work in accordance with the unified deployment of the Department of Medical Administration of the Ministry of Health. The director of the provincial health department is the leader of the leading group, and the heads of the medical administration department and related departments and the dean of the pilot hospital are the deputy heads and members of the leading group. The Health Department of Jiangxi Province regards clinical pathway management as the core content of the reform of public hospitals in the whole province, and lists it as the focus of health work and medical administration in 20 10. Some pilot hospitals in Beijing, Guangdong, Liaoning, Jilin, Shandong, Henan and Xinjiang. Taking the lead, the hospital clinical pathway management pilot work leading group was established, with the president as the leader, the vice president in charge as the deputy leader, and the heads of various pilot professional departments, medical management, nursing management, pharmaceutical affairs management, information statistics, medical record management, economic management and other departments as members, and the work responsibilities were clarified.
2.2 Software development services clinical
According to the supervision, we found that since the pilot work of clinical pathway management was carried out, the pilot hospitals generally realized the important role of information system support in clinical application, real-time monitoring of clinical pathway and statistical analysis of information, and actively tried to develop applications. After attending the training course of clinical pathway, the Information Department of Deyang People's Hospital of Sichuan Province digitized the tables and information of clinical pathway in a short time, and the clinical orders of the pilot departments were electronic, which reduced the workload of clinicians. In the next step, the hospital will also prepare to input the implementation data, baseline survey, evaluation and other data into the HIS system. The hospital also plans to search and establish an effective multidimensional data model in software development, monitor the implementation of clinical pathway in real time, read the quality and cost indicators of related diseases, and analyze the effect of clinical pathway implementation, which not only avoids the problem of unreliable manual writing, but also reduces the workload of doctors and achieves the purpose of ensuring efficiency and quality.
Shanghai Sixth People's Hospital believes that it is an important direction of hospital clinical information system to integrate clinical pathway and electronic medical record to form a complete electronic record of patients' diagnosis and treatment process. The clinical pathway software in our hospital is divided into five parts: patient management, doctor's advice management, pathway management, variation management and statistical analysis, and it is integrated with other related systems to achieve the effects of process optimization, time-saving and labor-saving, and convenient management and data statistics.
In order to cooperate with the development of clinical pathway, Zhejiang Greentown Hospital Information Center cooperated with a company in Zhejiang to develop a "process-based three-dimensional model", which takes time (hospitalization days) as the vertical axis and daily events (doctor's advice, nursing plan, mutation treatment, payment fee, index evaluation form, patient evaluation, etc.) as the vertical axis. ) are two-dimensional planes, which integrate the functions of electronic medical record system. Pilot operations have been carried out for some diseases. It can automatically collect the index value of each medical record (associated with HIS, EMR, medical record statistics and other systems), and then summarize it to become a statistical table of a certain disease in the hospital at a certain time.
2.3 Expand the scope and make plans.
Some clinical pathway management pilot provincial health departments have added provincial pilot hospitals on the basis of the pilot hospitals stipulated by the Ministry of Health; Some pilot provinces of clinical pathway management have increased the pilot specialties and diseases of hospitals on the basis of the pilot specialties stipulated by the Ministry of Health. On the basis of eight clinical pathway management pilot hospitals designated by the Ministry of Health, 56 hospitals were selected as clinical pathway management pilot hospitals in Guangdong Province, covering 2 1 city. On the basis of three clinical pathway management pilot hospitals of the Ministry of Health, Shanxi Province selected 27 city and county hospitals as provincial clinical pathway management pilot hospitals to guide the hospitals to reasonably determine the pilot specialties and diseases according to their own reality.
On the basis of the pilot specialties stipulated by the Ministry of Health, some pilot hospitals have added pilot specialties according to the specific conditions of this province. On the basis of five pilot specialties designated by the Ministry of Health, Jiangxi Provincial Health Department identified 22 pilot specialties and 56 pilot diseases in 46 pilot hospitals for clinical pathway management. The Health Department of Gansu Province firmly grasped the opportunity of the pilot project of clinical pathway management of the Ministry of Health, and combined with the specific situation of the province, expanded the pilot specialties and diseases.
For example, Gansu Provincial People's Hospital has expanded from 2 diseases to 6 diseases; Tianshui First People's Hospital increased from 2 pilot departments to 5 departments. In order to ensure the smooth progress of the clinical pathway pilot work, the pilot hospitals have strengthened the construction of the clinical pathway organization system. Gansu Provincial People's Hospital has improved the relevant supporting working mechanism for the implementation of clinical pathway management and the reward and punishment methods for single-disease clinical pathway management. Nanshan Hospital in Shenzhen, Guangdong Province directly linked the evaluation results of single-disease clinical pathway with the evaluation and appointment of responsible departments, the title of responsible person, the promotion before evaluation and the distribution of labor. Appropriate introduction of incentive mechanism has a positive role in promoting the smooth development of clinical pathway management pilot work.
2.4 Refine the path and strengthen training.
According to the supervision, after the Ministry of Health publishes the clinical pathway text, the pilot provinces and hospitals can refine the clinical pathway text according to the local actual situation to adapt it to the local actual situation.
In order to promote the development of clinical pathway management in the pilot and promote the pilot work of clinical pathway management, the Department of Medical Administration of the Ministry of Health began to hold four training courses on the pilot work of clinical pathway management of the Ministry of Health on 20 10. After the training course, some provincial and municipal health bureaus held meetings or training courses to mobilize and retrain the local clinical pathway work. Pilot hospitals also actively carry out various forms of retraining, including hospital-wide training and pilot department training, and make full use of weekly hospital meetings, regular medical meetings, department directors' meetings, special conferences and other forms for training, which gradually improves the knowledge and understanding of the majority of managers and medical staff on the pilot work of clinical pathway management and stimulates the enthusiasm of the pilot work of clinical pathway management. Southern Hospital of Guangdong Province also issued a special issue of clinical pathway management, which included clinical pathway management in the annual pre-job training and assessment of quality control personnel and resident chief physicians.
2.5 Improve the system and make continuous improvement.
Liaoning pilot hospital has set up a quality control management team and a department implementation team. The First Hospital of Peking University held a meeting of clinical pathway management guidance and evaluation group. The affiliated hospital of Jining Medical College insisted on solving the problem of management variation in the implementation of clinical pathway for many years, and the dean organized research to solve the key problems affecting the smooth implementation of clinical pathway every month. The Health Department of Henan Province requires the health administrative departments at all levels in the pilot areas and hospitals to be responsible for grading and establishing assessment indicators. Shengjing Hospital affiliated to China Medical University established a reward and punishment mechanism, signed a letter of commitment with pilot departments and doctors, and linked it to performance appraisal. The First Affiliated Hospital of Sun Yat-sen University of Medical Sciences strengthens the cooperation of relevant auxiliary departments to reduce the prolonged hospitalization days caused by untimely appointment, payment and report. It is proposed to improve doctors' diagnosis and treatment level and reduce the variation caused by non-first-visit and non-clinical pathway diseases. Southern Hospital of Southern Medical University organized several seminars on the implementation of clinical pathway management to study and solve the possible bottlenecks in the trial implementation of clinical pathway management, and introduced the management measures for holiday surgery.
3 discussion and suggestions
3. 1 Problems in clinical pathway management in pilot hospitals
According to the supervision, we think that the pilot hospital has done a lot of work in the early stage of the pilot work and achieved certain results. However, because the pilot work has just started, many hospitals are still in the exploratory stage of clinical pathway implementation, and there are still some limitations in understanding, so some problems will inevitably occur during the pilot process. The specific analysis is as follows:
3. 1. 1 Not enough attention was paid to the pilot work.
During the supervision, it was found that there were great differences in the importance of clinical pathway management and the understanding of pilot work among pilot hospitals. Some pilot hospitals have some misunderstandings about the purpose and significance of the clinical pathway text and even the clinical pathway itself, which is quite different from the original intention of the Ministry of Health to implement the clinical pathway. Individual pilot hospitals did not set up relevant organizations headed by the president according to the unified deployment of the Ministry of Health, and some of the leaders of the leading group were vice presidents or even medical section chiefs. The main leaders of some provincial health departments and some pilot hospitals are not enthusiastic about the pilot work of clinical pathway management. Medical staff in some pilot hospitals believe that the main purpose of clinical pathway management is to reduce medical expenses, which will affect their income. Therefore, there is some resistance in the pilot work of hospital clinical pathway management, which leads to a series of problems raised by pilot hospitals, pilot clinical departments and relevant functional departments not being studied and solved in time, which affects the smooth implementation of the pilot work to some extent.
3. There are defects in the implementation of1.2 pilot project.
Due to objective reasons such as serious extra beds and shortage of medical staff, the management department further lowered the average reimbursement standard, which led to the decline of hospital efficiency and the legal status of clinical pathway, and the lack of motivation to participate in the pilot work of clinical pathway, which affected the implementation of the pilot work to some extent. At the same time, the management level of some pilot hospitals has the phenomenon that the support and coordination between functional departments are not in place, and there are management bottlenecks such as the operation can not be arranged on schedule and the drugs are out of stock, which hinders the smooth implementation of the clinical pathway pilot work. The progress of work among pilot departments in some pilot hospitals is uneven, the number of cases in some pilot departments entering the clinical pathway management pilot does not meet the relevant requirements, and the pilot work in some pilot departments lags behind and the pilot work is not in place.
3. 1.3 pilot retraining is not in place.
The main leaders of some provincial health departments and pilot hospitals were unable to participate in the training organized by the Ministry of Health for some reason, which led to a poor understanding of the pilot work of clinical pathway. Due to the interference of various socio-economic factors, some pilot hospitals did not carry out the pilot training of clinical pathway management. In some pilot hospitals, leaders and medical staff do not understand the clinical pathway management in place, and there are even some misunderstandings. Some hospitals and departments still have concerns that the implementation of clinical pathway management will affect the income of hospitals and departments and reduce the treatment of medical staff, which is extremely unfavorable for the smooth progress of clinical pathway management pilot work as scheduled.
3. 1.4 The degree of informatization lags behind clinical pathway management.
According to the supervision, the information system support of most clinical pathway management pilot hospitals is not enough, which leads to a large workload of data collation and analysis. If the hospital develops itself, it will lead to repeated investment and serious waste. However, most hospitals have limited R&D capacity and the country has no unified construction standards and requirements.
Due to the relatively backward economy in some pilot provinces, most of the pilot hospitals have a low degree of informatization, and the pilot work of clinical pathway management is still in the manual operation stage, with different storage forms. Some hospitals are kept in medical records, and some are kept in the pilot departments themselves. Because clinical pathway management pays attention to the concept of evidence-based medicine, the confusion of storage mode restricts the progress of clinical pathway management pilot work to some extent from efficiency and effect, affects the enthusiasm of medical staff to participate in the pilot work, and is not conducive to the collection and utilization of relevant information in the later stage of the pilot work [1-2]. During the supervision, it was found that individual pilot hospitals neglected the establishment and accumulation of clinical pathway management pilot working documents. The records of clinical pathway implementation, clinical pathway table filling and patient exit from clinical pathway are incomplete. How to deploy and mobilize the pilot work, other relevant meeting minutes are either absent or simple; The records of pilot training in individual hospitals, including training time, place, teachers, teaching content and training objects, are basically lacking. The incompleteness of the pilot work document is not conducive to accumulating experience and further promotion through the pilot work.
3.2 Suggestions
3.2. 1 Further strengthen the training of clinical pathway management. Clinical Pathway Pilot Each major urgently requires the Ministry of Health to start clinical pathway management training for single diseases classified by major as soon as possible. We suggest that "China Clinical Pathway Network" can be used as soon as possible to build a platform that is helpful for clinical pathway makers to communicate with specific practitioners, help to understand the clinical pathway text and related policy information promulgated by the Ministry of Health, help to refine clinical pathways, and help pilot departments to formulate clinical pathways that are more in line with local hospital management processes and actual diagnosis and treatment level. Root cause analysis of medical quality monitoring indicators, disease classification ICD- 10 and surgical classification ICD-9-CM-3 codes, and related data on the first page of inpatient medical records in some pilot hospitals; I don't know much about how to use the monitoring tool of inpatients' experience and satisfaction, and I am confused in using it. Therefore, it is necessary to carry out special training in these areas.
3.2.2 Strengthen the exchange of experience in the pilot work of clinical pathway management. At present, Germany, Taiwan Province Province and other developed countries and regions at home and abroad have accumulated some successful experiences in clinical pathway management [3-4]. During the supervision, it was also learned that some areas, health authorities at all levels and clinical pathway management pilot hospitals lacked opportunities to visit and study in developed countries and regions, and they urgently hoped to have the opportunity to go out to visit and inspect, so as to enhance their perceptual understanding of clinical pathway management and better grasp the key points and important links in the pilot process of clinical pathway management.
3.2.3 Accelerate the development of clinical pathway management software and website platform. The informatization degree of clinical pathway management pilot work is an important factor affecting whether the pilot work can be carried out smoothly as scheduled [5-6]. Therefore, it is urgent for each pilot hospital to provide relevant software for dynamic monitoring and automatic tabulation of the pilot work, and to make uniform provisions on the preservation of relevant data and documents of clinical pathway pilot hospitals, so as to facilitate the evaluation of the pilot work in the future. At the same time, it is necessary to establish a regular notification system for the pilot work, so that the Ministry of Health can keep abreast of the pilot work of clinical pathway management in pilot provinces and cities, including the content, form, progress, existing problems and the gap with the expected goal, so as to ensure the smooth progress of the pilot work of clinical pathway management and accumulate experience for gradually expanding the pilot scope and even comprehensively popularizing clinical pathway management.