Upload
francine-richard
View
123
Download
0
Embed Size (px)
DESCRIPTION
103 年度 癌症診療品質認證 醫院說明會. 主辦機構:國民健康署 承辦機構: 國家衛生研究院 癌症研究所 TCOG 簡報日期: 102 年 11 月 01 日. 大綱. 申請資格 申請程序 認證方式 實地認證程序 認證作業流程 認證基準評量項目. 認證任務分組 認證等級評定 認證資格效期 資料審閱區間 重要宣導事項. 103 年認證作業程序重點說明. 103 年認證基準評分重點說明 問題與討論. 103 年 認證作業程序重點說明. 申請資格. 至少需同時符合下列第一、二點條件: - PowerPoint PPT Presentation
Citation preview
103 TCOG102 11 01
*103
103
103 *
99 500
*
103 3 1 103 3 31
https://pfp.hpa.gov.tw 4 8 *
*
10356610
*
900 2 50% *
*
30 5 5 30 5 12301320300 40 20
*
*
4 (1 )1 6 1 17 6 6 1 2 1 1 36 10 2
*2.24.4
1.11.21.31.42.12.22.32.42.52.63.13.23.3.13.3.23.3.33.3.43.43.53.6.13.6.23.7.13.7.23.83.93.6.33.6.43.104.14.24.34.44.54.65.15.26.1
*
Rating A 10 Rating A + Rating B 26 Rating D + Rating E 0 10 Rating B 5 Rating A Rating A + Rating B > 10 Rating D 3 Rating E 0 Rating A + Rating B 10 Rating D 4 Rating E 1
B
1.22.43.23.3.33.53.6.23.6.33.104.15.1*
*
4 991001110312311031 102 103111031231103 2 101102103
*
102 1 102 12 101 1 102 12 102 1 103 2 103 2
-1 2
(*
-2
*
103*
*
*
1.1Rating ERating DRating C50%
*
1.1Rating B C Rating A B 1.2 75 %
*
1.1
*
1.1
*
*
*
1.2 1234
*
1.2 Rating ERating D Rating C Rating CRating B C
*
1.2 Rating A B 14
*
1.2
)*
*
-1
*3.13.23.6.13.7.23.83.91.1
-2
*
1.3 Rating ERating D Rating C Rating CRating B CPDCARating A BPDCA
*
1.312
*
99
125 *
*
1.4 1AJCC 23
4
*
1.4 1AJCC23
*
1.4
*
*
*
9811 6 2.1 D
22.1 D*
*
2.1Rating E Rating D Rating DRating CRating B C
*
2.1Rating A B 3,000 1 3,000 2 102 1
*
2.120
*
2.1103100
*
*
2.2Rating E Rating D Rating D95%98%90%95%Rating C98%95%98%Rating B98%98%95%Rating A98%
*
2.299101101101(1) ( A / B ) 100%101A99 B99 + 99
*
2.2(2) ( E+F ) / D 100% (101)D99E9999F9999
*
2.2(3) ( G / H ) 100% (101)G99H99
2.
*
2.3Rating ERating D Rating C Rating CRating B C Rating A B
*
2.3
*
2.3Rating A 3 123
*
1.3 2.3
*
*
2.4 Rating ERating D Rating C Rating CRating B CRating A B
*
2.4 1 2 3 4Class1~2 5
*
2.4 2.5
*
*
2.5Class1~2Rating E
Rating D Rating C
Rating C 80%
*
2.5Rating B C 80 ~ 95%
Rating A B 95%
*
2.5Class 1~ 2Stage
*
2.5123 Class 1~245
*
2.5K / L 100 % K L
10% Class 1~2
*
96 2.13Tumor Size96983.4 T Clinical T1151172.14Regional Lymph Nodes Examined991003.5 N Clinical N1181192.15Regional Lymph Nodes Positive1011023.6 M Clinical M1201213.7Clinical Stage Group122124
*
3.10 T Pathologic T127129Other Staging System FIGO3.11 N Pathologic N130131Other Staging SystemBCLC1013.12 M Pathologic M1321333.13Pathologic Stage Group134136Other Staging Systemhistology101
2.4
*
-1 1.5
coding*
-2 99 1 1 AJCC 7 AJCC 7
103102101 *
*
2.6 Class 03Rating ERating DRating CRating B CRating A B
*
2.61 Class 0~32 Class 1~2 2 5 Class 0 3 3456
*
2*
*
*
3.1Rating ERating D Rating C Rating CRating B C
*
3.1Rating A B /
*
3.11 peer review article234
*
3.1Rating A Hodgkin lymphomaBDiffuse large B cell lymphoma Follicular lymphoma
*
-11. work-up 2. 90R/T C/T3. *
-2 6 1~3 10 3*
4123
*
3.2 Rating ERating D Rating C Rating C70 %Rating B C50%
*
3.2 Rating A BClass 1~2
*
3.2 Class 1~21 2 2
3
1,000 61,001~2,00092,001 12
*
3.2 123minimum requirement12345comorbidity6regimensdose
*
3.2 C B summary note
*regimenR/Tdose
-1
*
-2 toxicity *
-3
*
*
3.3 3.3.1 Rating E 20 %Rating D20 % 40 %Rating C40 % 60 %Rating B60 % 80 %Rating A 80 %
*
3.3.112TNM AJCC
*
3.3.1
12 7 2 4 1 1 [ ( 27 + 14 + 01 ) / ( 212 ) ] 100 %18 / 24 100 %75 %Rating B3.2
*
TNM
Initial staging*
*
3.3.2 Rating E 20 %Rating D20 % 40 %Rating C40 % 60 %Rating B60 % 80 %Rating A 80 %
*
3.3.2123
*
3.3.2
12 8 3 3 2 1 1 [ ( 38 + 23 + 11 ) / ( 312 ) ] 100 %31 / 36 100 %86 %Rating A3.2
*
Toxicity survey sheet
*
*
3.3.3 Rating E 20 %Rating D20 % 40 %Rating C40 % 60 %Rating B60 % 80 %Rating A 80 %
*
3.3.3 123Neoadjuvant
*
3.3.3
9 4 3 2 2 2 1 1 [ ( 34 + 22 + 12 + 01 ) / ( 39 ) ] 100 %18 / 27 100 %67 % Rating B 3.2
*1.
*
*
3.3.4Rating E 20 %Rating D20 % 40 %Rating C40 % 60 %Rating B60 % 80 %Rating A 80 % curative intent
*
3.3.4curative intent123 1 13 C
*
3.3.4
9 2 3 3 2 3 1 1 [ ( 32 + 23 + 13 + 01 ) / ( 39 ) ] 100 %15 / 27 100 %56 % Rating C3.2
*
progress note
*
*
3.4Rating ERating D Rating C Rating CRating B C70 %
*
3.4Rating A B
*
3.4
*
3.424 B1502
*
1. 2. 3. 4. 5. 6. ()
*
7. 8. 9. 10. 11. 12.
*
-1
*
-250*
*
3.5 Rating ERating D Rating C Rating C10%
*
3.5 Rating B C10%5%Rating A B10%20%10%
*
3.5 Class 1~3
*
3.5 12 30 3123
*
3.5 1234
*
3.5 1conclusion or recommendation 2process
* 10%
50%
*
*
3.63.6.1Rating ERating D Rating C Rating C
*
3.6.1Rating B C
Rating A B
*
3.6.1AdjuvantNeoadjuvantConcurrent Chemoradiotherapy, CCRT
*
3.6.11 peer review article234
*
AdjuvantNeoadjuvantCCRT*
*
3.6.2 Rating ERating DRating CRating C 3.6.1 prescriptionRating B CprescriptionRating A B
*
3.6.2 1.prescription
*
regimen *
*
3.6.3 Rating ERating D Rating C Rating CRating B CRating A B
*
3.6.3
*
3.6.3 123
*
3.6.3
*
3.6.3 ( spill kits ) 1
Class II BClass III
*
3.6.3 2
*
A B
*
*
3.6.4 Rating ERating D Rating C Rating CRating B CRating A B
*
3.6.412
*
3.6.4
*
3.6.43.6.3
*
*
*
3.73.7.1Rating ERating D Rating C Rating C
*
3.7.1Rating B CRating A B
*
3.7.112 permanent sectionHer-2 / neu CAPTAF
*
*
*
3.7.2Rating ERating D Rating C Rating CRating B C
*
3.7.2Rating A B
*
*
*
3.8 Rating E Rating D Rating C Rating CRating B C
*
3.8Rating A B
*
3.8 CT MRI
*
*
*
3.9Rating ERating D Rating C Rating Ccurative intent Rating B CRating C curative intent
*
3.9Rating A BRating C curative intent
*
3.9 12CTVPTV
*
3.91peer review article234
*
3.912CCE
*
*
*
3.10 Rating ERating D Rating C Rating CRating BRating A
*
3.10 103
*
*
*
4.1 123 / 4Rating E
Rating DRating C
*
4.1 Rating CRating B CRating A B
*
4.1 / Port - AHickmanPICC /
*
4.1 3.6.4
*
QCCRCAPDCA -1*
-2
*
*
4.2 Rating E Rating D Rating C Rating C Rating B C Rating A B
*
4.23.6.4
*
*
*
4.3 Rating ERating D Rating C Rating CRating BRating A
*
4.3
*
4.31.3341 3.6.4
*
QCCRCAFMEA PDCA PDCA PDCA PDCA 2
100%*
*
4.4Rating E Rating D Rating C Rating C
*
4.4Rating B C208020Rating A B 6 50%
*
4.4 20
*
4.4666
*
8 50%
progress note
*
*
4.5Rating ERating D Rating C Rating C 50 Rating B C Class1~2 400
*
4.5Rating A B 103100
*
4.51 1 2 234 C
*
2
100103*
*
4.6 Rating ERating D Rating C Rating CRating B C
*
4.6Rating A B
*
4.6
*
4.6
A intake BMI
*
Rating B A Rating B Rating A 4 *
*
*
5.1 Rating ERating D Rating C Rating CRating B CRating A B
*
5.1 2 PDCA
2
*
*
5.2 Rating ERating DRating CRating B CRating A B
*
5.2
*
*
*
6.1 Class1~2 2,000 A IRB Class1~2 2,000 1 A
*
6.1 IRB
*
*