布里斯托尔,船长和临床治理:谢沃哈特遗忘的教训
M A Mohammed1, K K Cheng, A Rouse
1Department of Surgery, University of Birmingham, Edgbaston, UK.
Lancet (London, England)
|March 29, 2001
概括
沃尔特·谢沃特 (Walter Shewhart) 的控制图,一种用于经济控制变化的方法,区分了常见和特殊的原因. 这种方法对于改善质量和临床治理至关重要,正如六个案例研究所示.
科学领域:
- 质量管理质量管理.
- 统计过程控制 统计过程控制
- 改善医疗保健 改善医疗保健
背景情况:
- 在过去的一个世纪里,制造业显著提高了产品质量.
- 沃尔特·A·谢沃特 (Walter A. Shewhart) 对变化的经济控制的研究对这一成功至关重要.
- 谢沃特的控制图表提供了一个图形方法来区分常见的和特殊的变化原因.
研究的目的:
- 为了证明Shewhart的控制图方法在实现临床治理中的核心作用.
- 为了说明统计过程控制在现实场景中的实际应用.
- 突出如何理解变化可以带来质量和安全的有形改善.
主要方法:
- 应用Shewhart的控制图表方法.
- 分析了六个不同的案例研究.
- 检查变异分类 (常见与特殊原因).
主要成果:
- 控制图有效地指导用户通过识别变化源来采取适当的改进行动.
- 案例研究,包括像布里斯托尔过度儿科心脏手术死亡和哈罗德·希普曼的行动等备受目的事件,说明了该方法的实用性.
- 该方法在将临床治理原则转化为实际现实方面发挥了重要作用.
结论:
- 谢沃哈特的控制图表方法是各种部门 (包括医疗保健) 质量改善的强大工具.
- 区分常见原因变异和特殊原因变异对于有效解决问题和改进过程至关重要.
- 统计过程控制原则的应用可以为实现强大的临床治理和患者安全做出重大贡献.
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