The Rationale for Applying a Single Health Care Quality Indicator Threshold in Different Sections of the Hospital-Falls Incidence for Example

[[abstract]]目的：跌倒事件占醫院住院病人意外事件的比率最高，跌倒發生率亦是醫院評鑑的指標之一，因此醫院會訂定跌倒發生率作為各科病房臨床醫療品質控管及防範跌倒成效指標。然專科間存在疾病和人口特質的差異，訂定全院單一閾值來控管是否合宜？為本研究欲探討之議題。方法：本研究採回溯性調查，針對北部某醫學中心96至99年跌倒異常事件月報表，計算各年度各科跌倒發生率；以四分法把基期（96）年各科跌倒發生率，分為低、中、高風險三組，採用線性迴歸及廣義估計方程式（Generalized EstimatingEquation，GEE）重複量數複迴歸，檢定跌倒發生率改善情形是否與各科發生風險有關。結果：96年不同科別間跌倒發生率有極大差異，最高為精神科千分之2.02，最低為婦產科千分之0.33，差異達6.09倍；96至99三年間改善情形各科有明顯不同，精神科改善最多，婦產科及安寧病房不減反增。以重複量數複迴歸分析，發現96年屬低度跌倒風險之科別，三年間跌倒發生率有增加，中度跌倒風險之科別未有明顯改變，高風險科別跌倒發生率有改善。結論：各科病人特性不同，全院單一閾值之管理，僅能對超過閾值之專科產生壓力；有關醫療品質指標閾值之訂立，建議醫院採用各科改善百分比作為品質管控之標準，將有助於全院朝向全面品質管理（Total Quality Management，TQM），亦即以品質為核心的全面管理，追求卓越的績效努力，讓立意極佳的指標閾值更具臨床運用的意義。 Objective: Falls make up the highest proportion of abnormal events in the hospital; therefore, every hospital sets a threshold for the incidence of falls as part of quality control and the hospital accreditation process. Few studies have discussed the rationale for using a common threshold for falls in different sections of the hospital. The aim of this study was to explore the rationale for applying such a common threshold for the incidence of falls in different sections as an administrative reference.Methods: In this retrospective study, the number of falls and the total hospital days in different sections of the study medical center were collected for 2007-2010. The data were divided into high, middle and low incidence groups. Correlations between the incidence of falls and improvements in that incidence were analyzed by linear regression and generalized estimating equations (GEE).Results: There was a great difference in the incidence of falls in different sections of the hospital. The difference between the highest (psychiatric 2.02 per mille) and the lowest (gynaecologic 0.33 per mille) was 6.09 times higher. We found an apparent improvement in the incidence of falls in the Psychiatric section, but falls increased in the gynaecologic and hospice sections from 2007 to 2010. By using GEE analysis, we found that those sections which had a low incidence of falls in 2007, showed an increase over the three years. Those sections with a medium incidence of falls showed no apparent differences, but the sections with a high incidence improved.Conclusions: It is inappropriate to apply the same health care indicator threshold to different sections of the hospital without considering their different patient characteristics. This only puts pressure on those sections which have a high incidence of falls. In order to establish appropriate thresholds for quality health care, we suggest that hospitals adopt a percentage of improvement for each section as the quality control standard. This would enable the hospital to move forward to a better level of Total Quality Management, and make the quality indicator threshold more meaningful