Continuous Quality Improvement of Nursing Care: Case Study of a Clinical Pathway Revision for Cardiac Catheterization

護理照護之持續性醫療品質改善－以Tw-DRGs125之臨床路徑為例

10.1097/JNR.0b013e318228cf46

嚴玉華(Yu-Hua Yan)；陳怡(Yi Chen)；龔志銘(Chih-Ming Kung)；彭麗蓉(Li-Jung Peng)

臨床路徑修正 ； 診斷關聯群 ； 持續性醫療品質改善 ； clinical pathway revision ； Taiwan diagnosis related groups Tw-DRGs ； continuous quality improvement

The Journal of Nursing Research

19卷3期（2011 / 09 / 01）

181 - 189

英文

Background: Taiwan's Bureau of National Health Insurance (BNHI) has been gradually introducing Taiwan diagnosis related groups (Tw-DRGs) for inpatient cases since 2010. Challenged to adapt to payment system changes, hospitals must implement necessary management control systems or measures to maintain both fiscal soundness and medical care quality.Purpose: This study investigated the outcome of management participation in work to revise cardiac catheterization clinical pathway operating procedures.Methods: BNHI-qualified cases for Tw-DRGs 125 payment principles were recruited as study subjects to revise the cardiac catheterization clinical pathway. Researchers compared pre-and postrevision values in terms of mean medical care fees, patient volumes, healthcare quality, and length of hospital stay, as well as financial risk.Results: Significant differences were observed in precardiac catheterization nursing care completion rates, mean lengths of hospital stay, diagnosis numbers, surgical treatment numbers, and numbers of complications or comorbidities. Medical utilization was also significantly lower (p＜.05) after revision implementation.Conclusions: Clinical pathway revision involves organization, procedural flows, and performance management. The revision successfully improved hospital finances and promoted medical care quality.

Background: Taiwan's Bureau of National Health Insurance (BNHI) has been gradually introducing Taiwan diagnosis related groups (Tw-DRGs) for inpatient cases since 2010. Challenged to adapt to payment system changes, hospitals must implement necessary management control systems or measures to maintain both fiscal soundness and medical care quality.Purpose: This study investigated the outcome of management participation in work to revise cardiac catheterization clinical pathway operating procedures.Methods: BNHI-qualified cases for Tw-DRGs 125 payment principles were recruited as study subjects to revise the cardiac catheterization clinical pathway. Researchers compared pre-and postrevision values in terms of mean medical care fees, patient volumes, healthcare quality, and length of hospital stay, as well as financial risk.Results: Significant differences were observed in precardiac catheterization nursing care completion rates, mean lengths of hospital stay, diagnosis numbers, surgical treatment numbers, and numbers of complications or comorbidities. Medical utilization was also significantly lower (p＜.05) after revision implementation.Conclusions: Clinical pathway revision involves organization, procedural flows, and performance management. The revision successfully improved hospital finances and promoted medical care quality.

1. Chen, W. M.、Chu, H. F.、Chien, C. W.、Su, S.、Wu, S. C.(2006)。The reaction of hospitals for the coming DRGs payment system。Journal of Healthcare Management，7(2)，193-205。
   連結：
2. Huang, L. J.、Hsu, M. H.、Huang, S. H.(2007)。Continuous quality improvement in a regional hospital- An evaluation of a clinical pathway of laparoscopic surgery for ectopic pregnancy。Journal of Healthcare Management，8(1)，39-50。
   連結：
3. Kuo, S. E.、Wang, L. F.、Lin, I. C.(2007)。Research on unexpected readmissions within 15 days of inpatient discharge-application of six sigma and FMEA。Quality Magazine，43(12)，64-66。
   連結：
4. Lin, L. C.、Chu, C. I.(2008)。Impact of DRGs weighting announcement on hospital coding-comparison of the respiratory system disease coding change among hospitals in eastern Taiwan。The Journal of Health Science，10(2)，133-143。
   連結：
5. Tsai, W. C.、Kung, P. T.、Yang, C. L.、Chiang, Y. J.(2005)。The trend of utilizations of high-tech medical instruments in Taiwan, 1998-2001。Journal of Healthcare Management，6(4)，446-460。
   連結：
6. Bureau of National Health Insurance. (2010). DRGs payment system.Retrieved October 4, 2010, from http://www.nhi.gov.tw (in Chinese)
7. Department of Health, Executive Yuan, Taiwan, ROC. (2010). 2009 cause of death statistics. Retrieved October 4, 2010, from http://www.doh.gov.tw (in Chinese)
8. Berta, P.,Callea, G.,Martini, G.,Vittadini, G.(2010).The effects of upcoding, cream skimming and readmissions on the Italian hospitals efficiency: A population-based investigation.Economic Modelling,27(4),812-821.
9. Blumenthal, D.,Kilos, S. M.(1998).A report card on continuous quality improvement.Milbank Quarterly,76(4),625-648.
10. Boling, P. A.(2009).Care transitions and home health care.Clinics in Geriatric Medicine,25(1),135-148.
11. Chan, Y. L.,Ho, S. K.(1997).Continuous quality improvement: A survey of American and Canadian healthcare executives.Hospital & Health Services Administration,42(4),525-544.
12. Chang, L. C.(2005)。Tainan County,Taiwan, ROC，Chang Jung Christian University。
13. Chang, M. L.(2009)。New beginning for nursing care management under Tw-DRGs。The National Union of Nurses' Associations，70，10-11。
14. Chen,M.C.、Chang, H. Y.、Huang, C. C.、Shi, W. M.、Li, M. Y.、Ho,L. H.(2008)。The project of utilizing clinical pathway to assist fracture patients recovering after surgical operation。Chang Gung Nursing，19(1)，87-98。
15. Chow, S. K.,Wong, F. K.,Chan, T. M.,Chung, L. Y.,Chang, K. K.,Lee, R. P.(2008).Community nursing services for postdischarge chronically ill patients.Journal of Clinical Nursing,17(7B),260-271.
16. DesHarnais, S.,Chesney, J.,Fleming, S.(1988).Trends and regional variations in hospital utilization and quality during the first two years of the prospective payment system.Inquiry,25(3),374-382.
17. Ellis, R. P.,McGuire, T. G.(1993).Supply-side and demand-side cost sharing in health care.Journal of Economic Perspectives,7(4),135-151.
18. Gau, J. Y.、Ting, C. T.、Yeh, M. C.、Chang, T. H.(2008)。The effectiveness of comprehensive care programs at improving selfcare and quality of life and reducing rehospitalization in patients with congestive heart failure。Journal of Evidence-Based Nursing，4(3)，233-242。
19. Gurzick, M.,Kesten, K. S.(2010).The impact of clinical nurse specialists on clinical pathways in the application of evidencebased practice.Journal of Professional Nursing,26(1),42-48.
20. Guterman, S.,Dobson, A.(1986).Impact of the medicare prospective payment system for hospitals.Health Care Financing Review,7(2),97-114.
21. Hsu, N. L.、Lai, C. F.、Hsieh, M. L.、Liao, W. A.、Lin, P. C.(2002)。Comparison the quality of nursing care between pre and post implementing clinical path。Tzu Chi Nursing Journal，1(20)，77-87。
22. Hunter, B.,Segrott, J.(2008).Re-mapping client journeys and professional identities: A review of the literature on clinical pathways.International Journal of Nursing Studies,45(4),608-625.
23. Kahn, K. L.,Rogers, W. H.,Rubenstein, L. V.,Sherwood, M. J.,Reinisch, E. J.,Keeler, E. B.(1990).Measuring quality of care with explicit process criteria before and after implementation of the DRG-based prospective payment system.The Journal of the American Medical Association,264(15),1969-1973.
24. Lee, C. F.、Lu, Z. Y.、Liao, Y. C.、Li, T. J.(2006)。Analyze and evaluate the clinical pathway of cardiac catheterization with concepts of case management。Journal of Oriental Institute of Technology，26，225-230。
25. Lezzoni, L. I.,Restuccia, J. D.,Shwartz, M.,Schaumburg, D.,Coffman, G. A.,Kreger, B. E.(1992).The utility of severity of illness information in assessing the quality of hospital care. The role of the clinical trajectory.Medical Care,30(5),428-444.
26. Lin, S. C.、Tsai, K. W.、Chiang, J. K.、Koo, M.(2010)。The factors associated with hospital readmissions of elderly residents in long-term care facilities。Tzu Chi Nursing Journal，9(3)，92-100。
27. Miura, L.,Dipiero, A.,Homer, L.(2009).Effects of a geriatricianled hip fracture program: Improvements in clinical and economic outcomes.Journal of the American Geriatrics Society,57(1),159-167.
28. Ponte, R.,Higgins, J.,James, J.,Fay, M.,Madden, M.(1993).Development needs of advance practice nurses in a managed care environment.The Journal of Nursing Administration,23(11),13-19.
29. Yan, Y. H.、Wu, C. C.、Chou, S. R.、Mo, L. R.(2008)。Influence of DRGs on hospital finance of inpatient services: An analysis on the diseases of the digestive system at a regional hospital in south Taiwan。Show Chwan Medical Journal，8(1-2)，1-8。
30. Zhu, D. S.(2004)。A study on the effects of the practice of clinical pathway in hospitals on length of stay, medical expenses, and medical quality-total hip replacement as an example。Journal of Health Management，2(1)，21-36。

1. 楊銘欽、黃昱瞳、黃光華、陳珮青、郭年真、李玉春(2016)。實施全民健康保險住院診斷關聯群支付制度對醫療機構之影響。臺灣公共衛生雜誌，35(3)，268-280。