19
Donabedian 1. 2. 3. 1 1. a s d 2. 3. a s d f 3 1 2 2 a Avedis Donabedian, Quality Improvement through Monitoring Health Care- 1996 s 50 6 1991 458-462 20
3 JCAHO JCAHO JCAHO JCAHO a JCAHO The Joint Commission on Accreditation of Healthcare Organization JCAHO 18000 JCAHO JCAHO JCAHO500 JCAHO 25 JCAHO 4 1910 Flexner Reports Ernest Codman end result system of hospital standardization 1913 Franklin Mrtin Codman American College Surgeons -ACS 1917 1 Minimum Standard for Hospital 1926 18 1951 JCAHO JCAH The Joint Commission on Accreditation of Hospital 1953 1959 JCAH 1964 JCAH 1965 JCAH d f 1998 The Joint Commission on Accreditation of Healthcare Organization http //www.jcaho.org. 21
1966 1979 JCAH 1987 JCAH JCAHO The Joint Commission on Accreditation of Healthcare Organization 1988 Indicator Measurement System IMSystem 1989 1993 1995 1997 outcome ORXY s 1987 JCAH JCAHO 1993 1995 AMH Accreditation Manual for Hospital JCAHO HMO JCAH JCAHO 5 21 100 JCAHO KFOA Kings Fund Organization Audit HAP Hospital Accreditation Programs g -JCAHO Vol.18 No.3 58-65 22
ACHSA Australian Council on Health Services Accreditation 6 7 a 1976 1985 1987 JCAHO 1990 1991 1993 1995 7 2 1997 4 s h Ellie Scrivens, Accreditation : Protecting the Professional or the Consumer?, Open University Press,1995 j Charlotte Williamson, Whose Standards? : Consumer and professional standards in Health Care, Open University Press,1992. 23
24 A B A B A B 3 1. 2. 3. 4. 5. 6. 6 7. 7 8 k 1997 4-19
25 d 9 l 1998
Clinical Indicator Clinical Indicator 10 Clinical Indicator 11 a Decision Science Evidence-Based Medicine Decision Science Evidence-Based Medicine Sackett Evidence-Based Medicine 0 1998 1 1998 26
2 Evidence-Based Medicine Clinical Decision Science 12 medical freedom s medical malpractice defensive medicine - 2 2 Evidence-Based Medicine 1998 27
- Facilitation Openended question Direct questionssupportempathy SilenceConfrontationValidation Recapitulation 13-14 d 15 EBM evidence-based medicine f 3 Barbara Fadem, Behavioral Science 2nd edition, Williams & Wilkins 1994. 4 1995 5 1998 28
1997 12 1 4 21 50 97 21 16 1. 2. 3. 6 21 No.1959 1997 33-37 29
4. 5. 1997 98 3 1. 2. 3. 10 98 4 10 10. compliance 1. 2. 3. 4. 5. 6. 30
7. 8. 9. 10. 46-180 - a 13 13 25 1947 1964 18 1973 1981 34 1982 31
1991 1994 WHO 40 1980 1983 1984 1990 1991 1993 1995 1996 17 1997 11 11 s JCAHO Patient s Perspective JCAHO 18 1993 JCAHO 1995 Patient-Focused Functions patient Rights and Organizational Ethics Assessment of Patients Care of Patients Education Continuum of Care input input needsexpectations 7 1996 8 Joint Commission, Understanding The Patient s Perspective : A Tool for Improving Performance, Joint Commission on Accreditation of Healthcare Organizations, 1995. 32
input Focus Groups d 19 20 f 4 A,B 5.0 5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 9 1998 0 1997 56-60 33
5.1 5.2 5.3 21 3.2 3.2.1 3.2.1.1 3.2.1.2 3.2.1.1. 3.2.1.2 3.4 3.4.2 3.4.3 3.6 g 1 Ver.5.5 1998 34
1. 2. 1. Clinical indicator2. 22 2. 2 20 2 44.8 42.6 71.1 78.4 72.3 23 2 56 11 1997 998-999 3 1223 1997 35
1.1 1.2 1.3 1.4 1.5 2.1 2.2 2.3 2.4 2.5 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 3.9 3.10 3.11 4.1 4.2 4.3 4.4 4.5 5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 6.1 6.2 6.3 6.4 6.5 6.6 6.7 1.1 1.2 1.3 1.4 1.5 2.1 2.2 2.3 2.4 2.5 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 3.9 3.10 3.11 3.12 3.13 3.14 3.15 4.1 4.2 4.3 4.4 4.5 36
4.6 4.7 5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 6.1 6.2 6.3 6.4 6.5 6.6 6.7 6.8 1.1 1.2 1.3 1.4 1.5 2.1 2.2 2.3 2.4 2.5 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 3.9 3.10 3.11 3.12 3.13 3.14 3.15 4.1 4.2 4.3 4.4 4.5 4.6 4.7 5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 6.1 6.2 6.3 6.4 6.5 6.6 6.7 6.8 7.1 7.2 7.3 37
a 24 25 s 4 1997 92-97 5 1993 38
d Albert R. Jonsen, Mark Siegler, William J. Winslade - 1997 Cavin P. Leeman, John C. Fletcher, Edward M. Spencer and Sigrid Fry-Revere, Quality Control for Hospitals Clinical Ethics Services Proposed standards, Cambridge Quarterly of Healthcare Ethics Volume 6, Number 3, Winter 1997, 257-268. David C. Thomasma, Models of the Doctor-Patient Relationship and the Ethics Committee, Cambridge Quarterly of Healthcare Ethics Volume3, Number 1, Winter 1994, 10-26. Jay Katz, The Silent World of Doctor and Patient, The Free Press, 1984, 916-917. Kaplan and Sadock s Synopsis of Psychiatry - Behavioral Sciences Clinical Psychiatry, Williams & Wilkins 1994. Krakauer Henry, Evaluating the Effectiveness of Hospital Care, American Journal of Public Health, 1997 Volume 87. 39
1997 18-23 JCAHO 1998 1995 1997 141-144 21 1997 No.1888 1995 10-14 1997 129-132 NHK1997 1993 113-0033 Tel 03-5689-7256 Fax 03-5684-6083 E-mail ishinko@m.u-tokyo.ac.jp 40