临床路径的应用研究
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摘要
随着医疗卫生体制改革的逐步深入，医疗市场的竞争日趋激烈，医院只有进一步加强医疗质量管理、在维持或提高医疗服务质量的前提下降低住院费用、减少住院时间、节约卫生资源、提高医疗效益/成本比，才能为人民群众提供价廉、质优、高效的医疗卫生服务，并且在激烈的医疗市场竞争中处于优势地位。
本课题借鉴国外研究和应用临床路径(Clinical pathway,CP)所取得的先进经验，对临床路径的流程设计、组织实施、过程管理、应用效果等作了系统的研究，目的是通过研究，探索临床路径应用的内在规律，寻找符合我国国情的临床路径实施办法。
课题首先采用历史回顾的方法,借助于医院信息系统(Hospital information system,HIS),检索某医院2002年1月1日至6月30日各临床科室主要的病种信息，根据临床路径病种选择原则，确定了拟试点临床路径的病种，然后，根据循证医学(Evidence-based medicine,EBM)、帕雷托(Vilfredo Pareto)原理等理念和方法，对临床路径诊疗流程的住院时间、实施范围、项目内容等进行了设计，并将设计的临床路径诊疗流程于2002年10月运用到临床科室。经过一定周期(5个月)的临床应用后，对其实施的效果进行了分析和评价。
研究结果表明，临床路径作为一种先进的质量效益型医疗质量管理模式，对于降低平均住院日、增加床位周转次数、减少平均住院费用、提高医院经济效益和社会效益、贯彻整体护理理念、规范诊疗行为、增进病人满意等有着明显的效果，符合我国“低成本、广覆盖”的卫生改革政策；同时，临床路径的实施，也对医院运行体制、传统习惯、服务理念等提出了全新的要求，因此，医院管理者在推行临床路径时要勇于创新、充分论证、系统培训、合理安排，才能充分发挥临床路径在医院管理中的积极作用。
本研究从流程设计到效果评价、从基本理论到组织实施，对临床路径的实际应用作了有益的探索，对临床路径在医院的应用和推广有一定的借鉴意义。
With the deep reform of medical health care system and the pregressively sharp competition of medical market, hospitals can provide people with medical health services with low-price, good quality and high efficiency and survive prominently in the competitive medical market by the enhancement of control of medical quality, decreases in hospitalization cost and hopitalization time, saving of hygiene resources, improvement of the ratio of medical efficiency to cost.
The author of this research project, based on the advanced experiences of foreign hospitals in the studies and application of clinical pathway, has conducted a systematic study of the flow design, organization and practice,process control,effects of application for the purpose of the exploration of the internal laws of clinical pathway so as to find the practical and feasible methods for the practice of clinical pathway in China.
In this research project, retrospective method was adopted. With the aid of hospital information system(HIS), we retrieved the information on main disease classifications in each clinical department in a hospital from January 1st to June 30th, 2002. According to the principles of disease classification in clinical pathway, the disease classification in clinical pathway for trial was decided. Then, according to theories and methods such as Evidence-based Medicine(EBM), Business Process Reengineering(BPR), weighted and moved average method and Vilfredo Pareto chart method, we performed the design of hospitalization time, practice range, contents and items in medicne and treatment flow of clinical pathway, which was put into practice in clinical departments in October, 2002. Systematic analysis and evaluation of the results were conducted after a period of practice(5 months).
The results of the study revealed that clinical pathway, an advanced mode for the control of medical quality, was of significant effects on the decreases in average lengh of days and average hospitalization cost, increase in turnover times of beds, improvement of economic returns and social returns of hospital, practice of holistic nursing idea, standardization of diagnosis and treatment behaviors and promotion of the satisfaction of patients. Clinical pathway was coincident with the policies of medical health of "low cost and wide coverage". In addition, the practice of clinical pathway also revealed that the current running system, traditional habits and service idea were not able to meet the
requirements of the complete practice of clinical pathway. Therefore, it requires that hospital administrators should conduct innovation, adequate demonstration, systematic training and reasonable arrangement so that the effects of clinical pathway could be brought into full play.
Clinical pathway, originated from America, is gradually adopted in many advanced countries in the world. It was introduced into Chinese Mainland in 1998 and attracted the attention of some hospital administrator thereafter. The study of the flow design, evaluation of the efficency, basic theories and organization and practice of clinical pathway in the control of medical quality may be helpful to the wider application in our country.
本课题借鉴国外研究和应用临床路径(Clinical pathway,CP)所取得的先进经验，对临床路径的流程设计、组织实施、过程管理、应用效果等作了系统的研究，目的是通过研究，探索临床路径应用的内在规律，寻找符合我国国情的临床路径实施办法。
课题首先采用历史回顾的方法,借助于医院信息系统(Hospital information system,HIS),检索某医院2002年1月1日至6月30日各临床科室主要的病种信息，根据临床路径病种选择原则，确定了拟试点临床路径的病种，然后，根据循证医学(Evidence-based medicine,EBM)、帕雷托(Vilfredo Pareto)原理等理念和方法，对临床路径诊疗流程的住院时间、实施范围、项目内容等进行了设计，并将设计的临床路径诊疗流程于2002年10月运用到临床科室。经过一定周期(5个月)的临床应用后，对其实施的效果进行了分析和评价。
研究结果表明，临床路径作为一种先进的质量效益型医疗质量管理模式，对于降低平均住院日、增加床位周转次数、减少平均住院费用、提高医院经济效益和社会效益、贯彻整体护理理念、规范诊疗行为、增进病人满意等有着明显的效果，符合我国“低成本、广覆盖”的卫生改革政策；同时，临床路径的实施，也对医院运行体制、传统习惯、服务理念等提出了全新的要求，因此，医院管理者在推行临床路径时要勇于创新、充分论证、系统培训、合理安排，才能充分发挥临床路径在医院管理中的积极作用。
本研究从流程设计到效果评价、从基本理论到组织实施，对临床路径的实际应用作了有益的探索，对临床路径在医院的应用和推广有一定的借鉴意义。
With the deep reform of medical health care system and the pregressively sharp competition of medical market, hospitals can provide people with medical health services with low-price, good quality and high efficiency and survive prominently in the competitive medical market by the enhancement of control of medical quality, decreases in hospitalization cost and hopitalization time, saving of hygiene resources, improvement of the ratio of medical efficiency to cost.
The author of this research project, based on the advanced experiences of foreign hospitals in the studies and application of clinical pathway, has conducted a systematic study of the flow design, organization and practice,process control,effects of application for the purpose of the exploration of the internal laws of clinical pathway so as to find the practical and feasible methods for the practice of clinical pathway in China.
In this research project, retrospective method was adopted. With the aid of hospital information system(HIS), we retrieved the information on main disease classifications in each clinical department in a hospital from January 1st to June 30th, 2002. According to the principles of disease classification in clinical pathway, the disease classification in clinical pathway for trial was decided. Then, according to theories and methods such as Evidence-based Medicine(EBM), Business Process Reengineering(BPR), weighted and moved average method and Vilfredo Pareto chart method, we performed the design of hospitalization time, practice range, contents and items in medicne and treatment flow of clinical pathway, which was put into practice in clinical departments in October, 2002. Systematic analysis and evaluation of the results were conducted after a period of practice(5 months).
The results of the study revealed that clinical pathway, an advanced mode for the control of medical quality, was of significant effects on the decreases in average lengh of days and average hospitalization cost, increase in turnover times of beds, improvement of economic returns and social returns of hospital, practice of holistic nursing idea, standardization of diagnosis and treatment behaviors and promotion of the satisfaction of patients. Clinical pathway was coincident with the policies of medical health of "low cost and wide coverage". In addition, the practice of clinical pathway also revealed that the current running system, traditional habits and service idea were not able to meet the
requirements of the complete practice of clinical pathway. Therefore, it requires that hospital administrators should conduct innovation, adequate demonstration, systematic training and reasonable arrangement so that the effects of clinical pathway could be brought into full play.
Clinical pathway, originated from America, is gradually adopted in many advanced countries in the world. It was introduced into Chinese Mainland in 1998 and attracted the attention of some hospital administrator thereafter. The study of the flow design, evaluation of the efficency, basic theories and organization and practice of clinical pathway in the control of medical quality may be helpful to the wider application in our country.
引文
1. 郭永松，试论过度医疗服务及其管理对策 中国卫生质量管理，1999(1):31-32
2. 王龙兴，曹俊山，传统医疗服务行为面临的挑战及其对策 中国卫生经济，1998，17(12):16-17
3. 陈志东，沈炜明，药学监护的发展概况 上海医学，1998,19（10）：21-22
4. 赵郁馨，1992年全国卫生费用调查分析报告 中国卫生经济，1994,13(7):21
5. 胡德奎等，病人住院时间分布规律对住院日影响的研究 中华医院管理杂志，2000,16(6):362-363
6. 张文康，在2000年全国卫生工作会议上的讲话
7. 齐德广，秦银河等，临床路径在医疗质量管理中的应用 中国医院管理，2002(10):11-12
8. 吴袁剑云，英立平，《临床路径实施手册》，北京医科大学出版社
9. 方立珍等，《临床路径－全新的临床服务模式》，湖南科学技术出版社
10. 齐德广 秦银河等，临床路径的应用及其相关问题与对策初探，解放军医院管理杂志，2003Feb;10(1):037-039
11. 鱼 敏，关键路径法在美国医院中的应用[J].国外医学·医院管理分册，1996,13(2):61-63
12. 张宏雁等，临床路径在医院管理中的应用 国外医学·医院管理分册，2001,18(3):98-101
13. 齐德广，秦银河，临床路径在医疗质量管理中的应用研究 中国医院，2002(11):36-38
14. 黄惠英，医疗质量保证的国际趋势，国外医学·医院管理分册，1999,16(1):1-5
15. Dennis E，Weiland MD．Why Use Clinical Pathways Rather than Practice Guidelines AmJ Surg 1997,174:592-594
16. 杨天桂，临床路径－一种单病种质量管理的现代新模式．中华医院管理学会全国医院医疗质量管理与控制高级研修班会议资料，2001.11
17. 马旭升．病种医疗质量管理及相关研究进展．解放军医院管理杂志，2000,7(3):237-239
18. 齐德广，秦银河等，腰椎间盘突出手术患者临床路径实施范围和设计住院时间界定方法初探，中国医院管理，2002(12):19-22
19. 朱士俊等，《医院管理与信息利用》，人民军医出版社，116-118
20. 《管理会计》中国人民大学出版社
21. 马谢民，英立平等，常见手术病种住院流程重组与缩短平均住院日的研究，1999, 15(10):603-604
22. Peppard J, Rowland P. The essence of Business Process Re-enginecr ing. Prentice Hall Europe, 1995:20-196.
23. Restuccia JD, Paync SMC, Lenhart G, et al. Assessing the app ropriateness of hospital utilization to improve efficiency and compctitive posit ion. Health Care Management Review, 1987,12,17-27.
24. 《医疗护理技术操作常规》（第四版），人民军医出版社
25. 屈会起，张金钟等，如何在我国发展循征医学 中华医院管理杂志，2000，16(6)：325-327
26. 屈会起，张金钟等，循证医学是临床医学发展的必然 中华医院管理杂志，2000，16(6):330-332
27. 沈钰如，标准化诊疗模式的制定 国外医学·医院管理分册，1998；(4)：160-161
28. 任真年，《现代医院医疗质量管理》，人民军医出版社，1999.8
29. 齐德广 秦银河等,胆囊结石伴慢性胆囊炎腹腔镜胆囊切除术临床路径实施效果分析第三军医大学学报 2003年第9期
30. 朱亚芹，宋金林等，TOPSIS法在公共场所卫生工作质量评价中的应用，中国卫生统计，2002,19(1):37-38
31. 王应明，徐南荣等，用TOPSIS法综合评价工业经济效益，数理统计与管理，1992,11(4):17
32. 刘玉秀，徐少青，TOPSIS法用于医院工作质量的多指标综合评价，中国卫生统计，1993,10(2):12-14
33. 易发超等，TOPSIS法在综合评价计划免疫工作中的应用，中国卫生统计，1995，12(2):45-48
34. 杨益国，宋金林，应用密切值法评价公共场所卫生工作质量，实用预防医学，2001,8(1):70-71
35. 潘志敏，用TOPSIS法对我院各病区工作进行综合评价，中国卫生统计，2001，18(4):232-233
36. 李菲菲等，慢性胆囊炎伴胆石症腹腔镜胆囊切除术的住院流程重组，中华医院管理杂志，1999,15（10）
37. Restuccia JD, Paync SMC, Lenhart G, et al. Assessing the app ropriateness of hospital utilization to improve efficiency and compctitive posit ion. Health Care Management Review, 1987,12,17-27
38. 王燕庆，腰椎间盘突出手术合理住院流程与平均住院日探讨．中国病案，2000，1(2):41-45
39. 张丹，陈剑铭等，结节性甲状腺肿手术住院流程分析与重组，中华医院管理杂志，1999,15(10):605-606
40. 郑建萍，英立平等，子宫平滑肌瘤手术合理住院流程与平均住院日，中华医院管理杂志，1999,15(10):606-607
41. 陈伟菊，临床路径在新加坡樟宜综合医院的应用，实用护理杂志，2001,18(3):141
42. Clinical pathways--can they be used in trauma care. An analysis of their ability to fit the patient...... Wilson,-S; Bin,-J; Sesperez,-J; Seger,-M; Sugrue,-M , Injury. 2001 Sep; 32(7): 525-32
43. Impact of a pediatric asthma clinical pathway on hospital cost and length of stay...... Wazeka,-A; Valacer,-D-J; Cooper,-M; Caplan,-D-W; DiMaio,-M , Pediatr-Pulmonol. 2001 Sep; 32(3): 211-6
44. Judging the effectiveness of clinical pathways for pneumonia: the role of risk adjustment...... Estrada,-C-A; Unterborn,-J-N; Price,-J; Thompson,-D; Gibson,-L , Eff-Clin-Pract. 2000 Sep-Oct; 3(5): 221-8
45. Chest pain rule-out MI clinical pathway saves $183,000...... Kight,-L , Hosp-Case-Manag. 1999 Dec; 7(12)
46. Development and implementation of a clinical pathway for severe traumatic brain injury. Vitaz,-T-W; McIlvoy,-L; Raque,-G-H; Spain,-D; Shields,-C-B, J-Trauma. 2001 Aug; 51(2): 369-75
47. Successful incorporation of the Severe Head Injury Guidelines into a phased- outcome clinical pathway. Mcilvoy,-L; Spain,-D-A; Raque,-G; Vitaz,-T; Boaz,-P; Meyer,-K, J-Neurosci-Nurs. 2001 Apr; 33(2): 72-8, 82
48. Mining time dependency patterns in clinical pathways....... Lin,-F; Chou,-S; Pan,-S; Chen,-Y,Int-J-Med-Inf. 2001 Jun; 62(1): 11-25
49. Development and implementation of a clinical pathway for spinal cord injuries,Vitaz,-T-W; McIlvoy,-L; Raque,-G-H; Spain,-D-A; Shields,-C-B, J-Spinal-Disord. 2001 Jun; 14(3): 271-276
50. A clinical pathway for outpatient cancer pain management,Georgesen,-J,Oncology- (Huntingt), 2000. Suppl Pt 1: 13-6
The impact of a clinical pathway for gastric bypass surgery on resource utilization Cooney, Bryant,-P; Haluck,-R; Rodgers,-M; Lowery,-M,J-Surg-Res. 2001 Jun 15;
51. 98(2): 97-101
52. Clinical Pathways for general surgeons: partial or total thyroidectomy,Am-Surg. 1998 Nov; 64(11): 1118-20
53. 《医院全面品质管理实施手册》 王复苏主编 北京．民主与建设出版社．2002．94-100
2. 王龙兴，曹俊山，传统医疗服务行为面临的挑战及其对策 中国卫生经济，1998，17(12):16-17
3. 陈志东，沈炜明，药学监护的发展概况 上海医学，1998,19（10）：21-22
4. 赵郁馨，1992年全国卫生费用调查分析报告 中国卫生经济，1994,13(7):21
5. 胡德奎等，病人住院时间分布规律对住院日影响的研究 中华医院管理杂志，2000,16(6):362-363
6. 张文康，在2000年全国卫生工作会议上的讲话
7. 齐德广，秦银河等，临床路径在医疗质量管理中的应用 中国医院管理，2002(10):11-12
8. 吴袁剑云，英立平，《临床路径实施手册》，北京医科大学出版社
9. 方立珍等，《临床路径－全新的临床服务模式》，湖南科学技术出版社
10. 齐德广 秦银河等，临床路径的应用及其相关问题与对策初探，解放军医院管理杂志，2003Feb;10(1):037-039
11. 鱼 敏，关键路径法在美国医院中的应用[J].国外医学·医院管理分册，1996,13(2):61-63
12. 张宏雁等，临床路径在医院管理中的应用 国外医学·医院管理分册，2001,18(3):98-101
13. 齐德广，秦银河，临床路径在医疗质量管理中的应用研究 中国医院，2002(11):36-38
14. 黄惠英，医疗质量保证的国际趋势，国外医学·医院管理分册，1999,16(1):1-5
15. Dennis E，Weiland MD．Why Use Clinical Pathways Rather than Practice Guidelines AmJ Surg 1997,174:592-594
16. 杨天桂，临床路径－一种单病种质量管理的现代新模式．中华医院管理学会全国医院医疗质量管理与控制高级研修班会议资料，2001.11
17. 马旭升．病种医疗质量管理及相关研究进展．解放军医院管理杂志，2000,7(3):237-239
18. 齐德广，秦银河等，腰椎间盘突出手术患者临床路径实施范围和设计住院时间界定方法初探，中国医院管理，2002(12):19-22
19. 朱士俊等，《医院管理与信息利用》，人民军医出版社，116-118
20. 《管理会计》中国人民大学出版社
21. 马谢民，英立平等，常见手术病种住院流程重组与缩短平均住院日的研究，1999, 15(10):603-604
22. Peppard J, Rowland P. The essence of Business Process Re-enginecr ing. Prentice Hall Europe, 1995:20-196.
23. Restuccia JD, Paync SMC, Lenhart G, et al. Assessing the app ropriateness of hospital utilization to improve efficiency and compctitive posit ion. Health Care Management Review, 1987,12,17-27.
24. 《医疗护理技术操作常规》（第四版），人民军医出版社
25. 屈会起，张金钟等，如何在我国发展循征医学 中华医院管理杂志，2000，16(6)：325-327
26. 屈会起，张金钟等，循证医学是临床医学发展的必然 中华医院管理杂志，2000，16(6):330-332
27. 沈钰如，标准化诊疗模式的制定 国外医学·医院管理分册，1998；(4)：160-161
28. 任真年，《现代医院医疗质量管理》，人民军医出版社，1999.8
29. 齐德广 秦银河等,胆囊结石伴慢性胆囊炎腹腔镜胆囊切除术临床路径实施效果分析第三军医大学学报 2003年第9期
30. 朱亚芹，宋金林等，TOPSIS法在公共场所卫生工作质量评价中的应用，中国卫生统计，2002,19(1):37-38
31. 王应明，徐南荣等，用TOPSIS法综合评价工业经济效益，数理统计与管理，1992,11(4):17
32. 刘玉秀，徐少青，TOPSIS法用于医院工作质量的多指标综合评价，中国卫生统计，1993,10(2):12-14
33. 易发超等，TOPSIS法在综合评价计划免疫工作中的应用，中国卫生统计，1995，12(2):45-48
34. 杨益国，宋金林，应用密切值法评价公共场所卫生工作质量，实用预防医学，2001,8(1):70-71
35. 潘志敏，用TOPSIS法对我院各病区工作进行综合评价，中国卫生统计，2001，18(4):232-233
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