i

CCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCooooooooooooooooooooooooooooooooooooonnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnttttttttttttttttttttttttttttttttttttteeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeennnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnntttttttttttttttttttttttttttttttttttttsssssssssssssssssssssssssssssssssssss

>>> 325 B

| PR1~PR7 | 1 11 29() 14:0015:30

PR1 3

PR2 6 CHA

PR3 Simulation 8

PR4 10

PR5 13

PR6 T-cannula occlusion 16

PR7 18

| PR8~PR14 | 2 11 29() 16:3018:00

PR8 21

2012

ii

PR9 Non value added activity 24

PR10 27

PR11 30

PR12 33

PR13 36

PR14 Protocol 39

>>> 324

| PR15~PR21 | 1 11 29() 16:3018:00

PR15 45

PR16 49

PR17 SMS 51

PR18 MRI 53

PR19 56

PR20 Communication 59

PR21 (2010-2011, CQI) 62

| PR22~PR28 | 2 11 30() 08:3010:00

PR22 64

PR23 67

PR24 69

iii

PR25 72

PR26 QI 74

PR27 77

PR28 Project 3S 81

| PR29~PR35 | 3 11 30() 11:0012:30

PR29 84

PR30 (TAT) 87

PR31 ! (Everyday is Cheer-up day) 89

PR32 () 92

PR33 3 STEPS 95

PR34 (CRE : Customer Relationship Experience) 97

PR35 (6 ) 100 CHA

>>> 325 B

| PR36~PR42 | 1 11 30() 08:3010:00

PR36 105

PR37 107

PR38 110

PR39 TURN OVER TIME 113

PR40 115

iv

PR41 117

PR42 120

| PR43~PR49 | 2 11 30() 11:0012:30

PR43 123

PR44 125

PR45 128 CHA

PR46 130

PR47 6 133

PR48 135

PR49 137

>>> 323

| PR50~PR56 | 11 29() 14:0015:30

PR50 141

PR51 143

PR52 145

PR53 147

PR54 150

PR55 153

PR56 156

v

>>> 325 A

| PR57 | 11 29() 14:0015:30

PR57 Abdomen, Hip, Pelvis, L-spine, T-spine AP Low Dose Technique 161

| PR58 | 11 29() 14:0015:30

PR58 163

| PR59~PR60 | 11 29() 14:0015:30

PR59 (NST) 168

PR60 171 CHA

| PR61 | 11 29() 14:0015:30

PR61 173

| PR62 | 11 29() 14:0015:30

PR62 175

| PR63 | 11 29() 14:0015:30

PR63 AGS(Asan Global Standard) 178

>>> 324

| PR64~PR70 | 11 29() 14:0015:30

PR64 183 CHA

vi

PR65 186

PR66 (CQI) 188

PR67 191

PR68 196

PR69 199

PR70 3 20% 202

>>> 322

| PR71~PR77 | 1 11 29() 14:0015:30

PR71 CP 207

PR72 209

PR73 CP 212

PR74 CPR guideline 215

PR75 CP 218

PR76 Arterial catheter management 221

PR77 CP 223

| PR78~PR84 | 2 11 29() 16:3018:00

PR78 226

PR79 regimen 228

PR80 PRN 231

vii

PR81 235

PR82 Check Sheet 237

PR83 239

PR84 one stop 241

>>> 323

| PR85~PR91 | 1 11 29() 16:3018:00

PR85 247

PR86 249

PR87 253

PR88 Dysphagia CP 256

PR89 259 CHA

PR90 262

PR91 264

| PR92~PR98 | 2 11 30() 08:3010:00

PR92 267

PR93 270

PR94 Implant - - 272

PR95 Cardiac CT 275

PR96 - Push 278 CHA

viii

PR97 281

PR98 Critical Value 285

| PR99~PR105 | 3 11 30() 11:0012:30

PR99 287

PR100 Process 289

PR101 291

PR102 293

PR103 Peak Time 295

PR104 (6 ) 298 CHA

PR105 301

>>> 322

| PR106~PR112 | 1 11 30() 08:3010:00

PR106 305

PR107 308

PR108 310

PR109 312

PR110 318

PR111 320

PR112 323

ix

| PR113~PR119 | 2 11 30() 11:0012:30

PR113 325

PR114 Pneumatic instrument Process 327

PR115 330

PR116 333

PR117 336

PR118 340

PR119 () 343

>>> 306

| PR120~PR126 | 1 11 29() 14:0015:30

PR120 349

PR121 351

PR122 354

PR123 357

PR124 / 359

PR125 361

PR126 364

| PR127~PR133 | 2 11 30() 08:3010:00

PR127 366

x

PR128 / 369

PR129 371

PR130 373

PR131 376

PR132 378

PR133 , 382 CHA

>>> 325 A

| PR134~PR140 | 1 11 29() 16:3018:00

PR134 1Kg 1 387

PR135 ( ) 389

PR136 393

PR137 Burn 395

PR138 397

PR139 400

PR140 Screening 403

| PR141~PR147 | 2 11 30() 08:3010:00

PR141 406

PR142 408

PR143 411

xi

PR144 413

PR145 (VRE) 6-sigma 416

PR146 IPSG ( ) 418

PR147 Medication Errors 420

| PR148~PR154 | 3 11 30() 11:0012:30

PR148 422

PR149 424

PR150 426

PR151 , 428

PR152 ( ) 431

PR153 , 434

PR154 438

>>> 306

| PR155~PR163 | 1 11 29() 16:3018:00

PR155 443

PR156 MAKING 445

PR157 447

PR158 DRG 7 450

PR159 EMRESD CP 452

xii

PR160 QI 454

PR161 456

PR162 458

PR163 scope 460

| PR164~PR172 | 2 11 30() 11:0012:30

PR164 463

PR165 466

PR166 468

PR167 470

PR168 473

PR169 476

PR170 479

PR171 482

PR172 484

>>> 322

| PR173~PR177 | 11 29() 15:3016:30

PR173 489

PR174 491

xiii

PR175 Project. ( !!) 493

PR176 496

PR177 504

>>> 322

| PR178~PR180 | 11 30() 10:0011:00

PR178 509

PR179 511

PR180 513

P1 519

P2 522

P3 525

P4 527

P5 529

P6 531

P7 533

P8 536

P9 538

xiv

P10 540

P11 542

P12 544

P13 546

P14 548

P15 (PCVC) 551

P16 553

P17 KCL 555

P18 558

P19 complication 560

P20 562

P21 565

P22 567

P23 569

P24 572

P25 575

P26 578

P27 System & Culture 580

P28 583

P29 586

P30 589

xv

P31 591

P32 593

P33 () 595

P34 CP 599

P35 601

P36 process 603

P37 606

P38 609

P39 611

P40 613

P41 Portable 615

P42 617

P43 619

P44 622

P45 624

P46 628

P47 , , 630

P48 632

P49 634

P50 636

P51 Linac-gram Film & Simulation Film Scan PACS UP-load 638

xvi

P52 Error Zero 640

P53 642

P54 645

P55 647

P56 () 649 CHA

P57 AMA discharge 651

P58 CT 655

P59 657

P60 659

P61 661

P62 663

P63 665

P64 TAT 667

P65 670

P66 672

P67 () / 674

P68 676

P69 hand book 678

P70 680

P71 682

P72 684

xvii

P73 686

P74 688

P75 (Lending) 691

P76 693

P77 695

P78 697

P79 699

P80 702

P81 CP 704

P82 707

P83 709

P84 712

P85 714

P86 718

P87 ( ) 720

P88 723

P89 725

P90 CP 728

P91 731

P92 733 UNIT

P93 735

xviii

P94 738

P95 740

P96 744

P97 Process Blood culture 746

P98 748

P99 750

P100 752

P101 755

P102 , 758

P103 761

P104 763

P105 765

P106 767

P107 769

P108 772

P109 776

P110 778

P111 783

P112 786

P113 788

P114 Flow 790

xix

P115 , CP 792

P116 EMR 794

P117 796

P118 799

P119 801

P120 804

P121 806

P122 808

P123 810

P124 812

P125 816

P126 818

P127 820

P128 823

P129 826

P130 829

P131 833

P132 (activity conference) 835

P133 837

P134 840

P135 842

xx

P136 844

P137 846

P138 848

P139 851

P140 (PEAK) 853

P141 856

P142 Process 858

P143 860

P144 862

P145 865

P146 868

P147 871

P148 Checklist 873 CHA

P149 875

P150 877

P151 880

P152 883

P153 885

P154 887

P155 889

P156 892

xxi

P157 895

P158 (VAP) 897

P159 901

P160 904

P161 906

P162 908 CHA

P163 910

P164 912 CHA

P165 915

P166 917

P167 920

P168 922

P169 925

P170 928

P171 930

P172 932

P173 934 CHA

P174 937 CHA

P175 VOC(Voice Of Customer) 939

P176 943

P177 946

xxii

P178 948

P179 Upgrade 950

P180 954

P181 956

P182 958

P183 960

P184 963

P185 965

P186 967

P187 969

P188 971

P189 973

P190 (() ) 976

P191 978

P192 980

P193 process 982

P194 985

P195 987

P196 989

P197 991

P198 993

xxiii

P199 FUN 995

P200 SMS 998

P201 1000

P202 1004

P203 1006

P204 1008

P205 1011

P206 1014

P207 CP 1016

P208 CP 1018

P209 ESR 1020

P210 MRI 1022

P211 NICU 1025

P212 PEAK 1028

P213 Postpartum bleeding 1030

P214 QI 1032

P215 RCT CP 1034

P216 SICU 1036

P217 TAT 1038

P218 Timeout 1040

P219 VCUG , , 1042

325B

11 29() 14:0015:30PR1PR7 1

11 29() 16:3018:00PR8PR14 2

2012 3

, , , ,

14W

1

, .

, .

.

,

.

2

.

.

2 .

3

1)

2) - 10 ( )

4

1) .

- : .

- : 14 20

2) (10 )

- : 131 ( : 6.55 -> QI )

4 2012

5

1)

. : notify notification

form notify .

.

. : SR form

.

. : .

2)

: sedative ,

.

3)

: .

6

1)

.

. notification form

. SBAR seizure notify form

2)

. , . . ,

test .

3)

. sedative .

. .

4)

.

5)

( : ) .

7

- 20

(6.58 (QI ) -> 3.05 (2011)-> 2.46 (2012)

1)

.

2012 5

.

. notify .

. Notification .

- 20

: (60% (QI ) -> 100% (2011)-> 90% (2012) notification form : (40% (QI ) -> 92.9% (2011)-> 100% (2012)

2)

.

: test

3)

.

.

. confirm .

> - seizure f/u

(20% (QI ) -> 64.3% (2011) -> 67.9% (2012)

* 100% lorazepam 2mg

4)

.

. O2 inhalation brain damage

>

: 100%

5)

. focus

. event

focus

- seizure f/u

(25% (QI ) -> 72.7% (2011) -> 84.8% (2012)

8

1)

flow 2

(6.58 (QI ) -> 3.05 (2011)-> 2.46 (2012) .

2)

. flow update

( manage F/U - )

. flow SBAR notication form

manage .

. QI

data .

6 2012

CHA 81

1

80%

, (, , , , )

.

.

2

, , ,

.

.

3

4

1) - :

( ), ,

(1) : (3/1~3/31) 250

(2) : (6/1~6/30) 243

2) : 81 13, 81

3) : 18 5

2012 7

5

1) : 3.45(69%)

2) : total 250 31 12.4%

) , : 12

) , , : 5

) , , , : 1

) , : 13

6

1)

) :

) :

2)

) : ,

) :

.

3) : 18

7

1) : 3.45

(69%) 4.1 (82%) 13% .

2) : : 3/1~3/31 total 250 31

12.4% , : 6/1~6/30 total 243 16

6.5% 5.9%

.

8

, .

.

.

8 2012

Simulation

1

. ,

.

.

.

, ,

simulation

.

2

, ,

.

.

Simulation

.

3

, , Simulation ,

.

2012 9

4

,

, .

5

,

. , 1 3 .

.

6

, , Simulation

.

Simulation setting . Simulation

. CPR

CPR

.

7

610 .

, Simulation .

8

.

,

.

10 2012

141

1

,

. 141 ,

, ,

.

,

.

2

3 '15 ' 56.7%, '

' 12.6% 15 69.3%

. 31.5% ,

.

3

( / *100), (

/ *100), ( /

*100), .

4

141 : 2012 3~4 D-duty, E-duty

(1. , 2. ,

, 3. , 4. , 5.

, 6., 7. , 8. , 9., 10. , 11.)

2012 11

.

2012 4 . 2012 3

.

5

1) 31.5%, (36.9%), (10.7%),

(12.3%), , (9.1%),

(8%), (6.4%)

.

2)

,

, ,

.

3) 10.7%

33.3% .

.

4) ,

.

6

1)

: ,

,

2)

PI 2~3/

3) ,

, PI

12 2012

7

34.1% 68.6%

, 33.3% 25% ,

80.4% 94.4%

.

31.5% 59.3% .

8

,

,

.

,

. 6

, .

2012 13

93

1

.

, NCCN(National Comprehensive Cancer Network)

.

(2006) 10.6% .

WHO 3

,

.

.

2

3 15.8% ,

30~35% .

, ,

, .

, ,

,

,

. , , ,

.

3

, 7 , ,

, .

14 2012

4

7 2011 4 1

~30 20 , 2011 71~8 31

15 19 .

2011 5 20~27 , 2011 6 16~20 .

2011 4 14~16 , 2011 8 18~20

.

5

,

, ,

, ,

.

6

1) 7 , ,

.

2) ,

NRS .

3)

.

4) ,

, ,

,

.

5) , 7

,

.

7

. , 7 50.0 73.3

46.9% , 55.1 80.1 45.4% ,

61.6 83.7 35.9% , 44.7

90.0 102.9% .

2012 15

8

,

, 7

. ,

, .

,

.

.

16 2012

T-cannula occlusion

1

trachostomy

CPCR . tracheostomy

T-cannula occlusion .

2

,

tracheostomy

T-cannula .

T-cannula ,

T-cannula . T-cannula occlusion T-cannula

.

3

T-cannula , T-cannula occlusion

nebulizer .

4

T-cannula occlusion ,

T-cannula , nebulizer

.

2012 17

5

fishbone diagram

T-cannula , ,

nebulizer .

6

T-cannula 2, 2

T-cannula orientation

2 . 1 2000cc

, nebulizer

feedback . T-cannula occlusion

T-cannula occlusion

emergency kit .

7

T-cannula 16.2%, 3.4% nebulizer

4.8% .

8

T-cannula occlusion

,

. T-cannula occlusion

, T-cannula .

18 2012

, , , , , ,

1

, ,

, allergy reaction, speed shock fluid overload, , catheter

embolism ,

.

.

, ,

, ,

.

,

QI .

2

, .

, , ,

.

,

.

, .

,

.

2012 19

3

QI

,

.

4

170

.

5

, 60%,

38.4%, Regurgitation 17.3%, 4.7% .

, .

6

1) ,

2)

3) ,

4)

5) ,

7

IV start

.

.

.

, .

20 2012

8

QI .

,

.

2012 21

, , , , , , , , , , , , , , ,

1

,

.

.

.

.

2

,

, 30% .

3

.

: / : ([ - ]/

)*100

4

,

2 .

2 .

22 2012

5

.

,

. ,

, ,

. ,

,

.

6

3 , 9 1 .

.

,

.

,

.

. , , ( , ,

) .

.

7

2

Microsoft Excel program . 2.4

1.6, 33.3% .

, , , ,

2.9, 1.8 37.9% .

, , 1.4

1.1, 0.9 23.0% .

2012 23

8

30%

.

.

,

.

24 2012

Non value added activity

, , , , , , , , , , , , , ,

1

1 ,

.

2

, ,

,

.

3

Non value added activity ,

20% 5

4 .

.

4

2011 2 9 ~ 2 15 9

130 non value added activities , QI

50 80

, , 22 .

, ,

.

2012 25

5

22 Non value added activity , , ,

.

6

.

.

,

.

, , , ,

.

,

.

7

12.0

9 , 4.45,

4.36 .

4.64 .

, .

. 9

331 221 37% ,

41.6 21.5 53% .

4.77. 211 167 21% .

9

.

. Non value added activity QI ,

4 ,

. 2011

, 2012

26 2012

.

.

8

1)

, .

.

2) Non value added activity ,

,

.

2012 27

, , , 12

1

3

, , 30 1

. ,

.

,

.

.

2

10 ~ 1 40.4

, (8

) 1 20 ~ 3 20 2 30 ,

.

,

,

QI .

3

10% .

1 .

28 2012

4

7 1

. Duty

.

5

(work sheet) ()

, , , ,

, , .

/ , ,

. Duty 9 25,

9 9, 11 9

.

6

1. method(2 or 3 ) .

: 2, 3 .

:

2. , , LIST

, .

3. .

4. . (

, BST Check, check, B/W Check, , work sheet )

5. 8 .

6. , , .

7.

.

8. .

9.

.

10. 30 Campaign ( : 30 , : 30 , : 30 )

.

11. .

( : , : EMR , : EMR

)

2012 29

7

2011 40 1 32 8

, 2 23 1 2 17 . ,

9 25 1 9 6, 2 9 7 18 ,

9 9 1 9 5, 2 8 58 11 , 11

9 1 10 36, 2 9 16 1 20 9 54

1 2 9 7 47 . 1

20

.

8

15 . method

functional 39 24 15 , Team 41

19 22 Team

. method 6.7( ) 4, 8, 9(

) team method . 9 54

9 7 47

. 17

8 55 , 28 9

13 .

2013 7 DRG . DRG

.

. Team method

.

30 2012

24

1

2012

79% . benzodiazepine

Midazolam , ,

.

.

2

20

flumazenil 0.25mg . flumazenil

. ,

, 20

flumazenil ,

. ,

event, midazolam ,

.

.

.

3

,

(5 )

.

2012 31

4

2011 ,

. 2012 14

4 2012 7 23 9 19

Flumazenil

.

5

2011 217

46.54% . 4 40

10% . 126

21.1%, 3.9% 32.54%

1 .

6

. Flumazenil

20

flumazenil . ,

. Richmond Agitation-Sedation Scale

,

Modified Aldrete score (, , , , ) 9 , 9

, , 2 .

,

.

7

1) 1.04% 0.42%

46.54% 40% .

2) 10% 0% .

3) 21.1% 22.3%, 42.2% 43.8%

, 31.3% 30.8%, 3.9% 3.1% .

4) 1 32.54% 36.2%, 4

45.24% 56.9%, 8 18.25% 6.2%, 8~12 1.59%

32 2012

0%, 12 2.38% 0.8% . 77.78%

4 93.1% 4

.

5) 34.56 26.73 7.83 .

.

8

. Flumazenil ,

.

.

.

2012 33

1,

1,

1,

2,

2,

2,

2

1,

2

1

,

. (2007, )

(2008, ).

.

, .

2

,

, .

, ,

, ,

, .

, , .

3

20% ,

90% , 5 .

4

2012 4 1 8 31

, , .

34 2012

5

1)

3 ,

. 5 , 5

. 5

4 .2)

(1) 5 3.28, 5 1.78. 5 4.67, 4.77.

(2)

4.79 .

6

, ' PI .

.

7

1) 3.28 1.78 2.62 .

2) 4.67

.

3) 4.77 ,

4 .

4)

4.79 95.8% .

2012 35

8

(2011, e daily).

, ,

.

.

36 2012

1

24 3

. 3 --

7.5-7.5-9, 8-8-8 . -

- 8-8-8 . 8-8-8

,

. 2010

. ,

.

2

, ,

, , overtime

. ,

.

.

.

3

.

4

, 6 .

2012 37

5

. -- 8-8-8

() 21.8%, 7.5-7.5-9(1) 47.7%, 7.5-7-9.5(2) 17.8%

1 , 30 1

.

overtime 1~1 30 . 39.4% , ,

. overtime , , ,

, .

52.6%, 44.4%, 3% .

.

6

TFT 8 ,

. -- 7.5-7.5-9

, (3 ), , , 5

1 .

.

7Am~8Am 30

. 30

.

,

--, 8-7.5-8.5 10 1

, 20 1 . 55.1%

10 (, , ) 3

. 52.6%

7 .

, .

7

50.5

57.1 . 8-8-8 8-7.5-8.5

. 9.6, 6.2,

9.9, 4.8, 1.3 . 14.1 .

38 2012

8

2011 . 3 , . 6.6

. , . QI

,

.

. overtime ,

.

2011

Protocol

18

1

.

24G, 18G Medicut

, . ,

. QI

Protocol

.

2

.

.

.

3

1) Protocol .

2) Check List 90%

.

3) 10% .

40 2012

4

1)

- :

- : 57, 75

2)

- : 2012 4 16 ~ 5 30

- : 2012 8 18 ~ 9 21

- : Check List

( Check List, )

5

1)

.

2)

.

3)

.

4)

.

6

1) Protocol

.

2) check list

.

3) Check List :

72 96 .

.

4) .

5) .

6) ()

.

2012 41

7

1) .

2) 4.32(86.4%)

4.82(96.4%) .

3) (Grade 1 ) 12% 5.9%

.

4) 3(72~96)

14(20%) 38(55.9%)

.

8

. 2

.

.

.

324

11 29() 16:3018:00PR15PR21 1

11 30() 08:3010:00PR22PR28 2

11 30() 11:0012:30PR29PR35 3

2012 45

, , , , , , , , , ,

( )

1

, . , ,

. 3 .

.

.

. QA

,

,

.

2

.

, , ,

. , , ,

VIP . ,

.

.

.

3

1) ( SMS )

2)

46 2012

3)

4)

5)

6)

7) 15

4

1) 2009 2011 3

2)

3)

4) 2012

5)

6)

7) 10

8) SMS

9)

10) 15

11) 2012

5

2012 1 8 2011

. 2011

. 2012

2011 0.4

. 10

.

10 95%

10 .

.

6

1)

- 30 SMS SMS

- 1

2012 47

- - .

- , , ,

2)

3)

4)

-

-

-

5)

-

- - - SMS

7

1) .

30 SMS

SMS

.

. 1

.

.

2) , , , .

, ,

. QA

24 .

3) .

2011 2012 10% ,

.

4) .

5

, ,

.

5) .

-

.

48 2012

- , .

- .

- , SMS

.

8

2012 66.5 81.5 QA 73.5, 86.1

. 86.1 91.7

.

.

.

.

2012 49

1

, .

2

2011

85%

.

3

1) : 4 ( , , , )

60 .

2) : 2011 1~ 8, 2012 1~ 8 .

4

1) : 1 2011 51~630(60)

( )2 2012 701~730(60)

2) : 3) : , , FAX

50 2012

5

1) : .( ), . .( )

2) : . .

6

1)

. (URC) . .

2) :

1, 2 . 2 1 . , e-mail , . .

7

2012 , ,

, FAX . 2011 85% 2012 2

90% 2011 2012 8% .

8

.

. .

2012 51

SMS

, , , , ,

1

.

.

, QI .

2

3( 1 , 1 , 2 ) ,

.

SMS

. SMS

.

3

SMS , QI

, , .

4

200 , SMS

, , , Likert 5 .

52 2012

5

SMS 1 ,

200 98 49%

, SMS (52)53% SMS .

6

SMS ,

,

.

, .

7

, 35.5% ,

SMS 1 29 3

. , GS

17 5 .

3.54 4.51 ,

2.9 4.24 .

.

8

SMS

.

,

. ,

20% ,

.

2012 53

MRI

, , , , , ,

1

MRI 110db ,

. 30 .

MRI

, .

2

MRI 2 2006 85

, 340 MRI . MRI

, , , .

2011 4900 MRI ,

107 100

16% . MRI MRI

.

3

1) ,

2)

3) MRI (, , )

54 2012

4

1) : 2012 3 2 ~ 4 30 2 MRI

400 ( ) .

2) : 2012 5 1 ~9 30 5 MRI

800 .

3) : 2012 3 2 ~ 9 30 7

1200 .

5

MRI (12%), (11.5%), (7.5%), (6.5%)

, 17.5%, 0.5% . ? 97% , 7080 (27%), (15.5%), (5%), (3.3%), (2%)

.

6

1) ( , , )

(, ) .

2) ( , ,

) ,

.

3) MRI

.

4) MRI (, , )

.

7

1) :

95% 3% MRI

96% .

99% .

2) :

.

3) :

2012 55

17.5% 8.8% .

0.5% 0.6% ,

.

4) N- : MRI N

6 35 , MRI

.

8

,

.

.

, ,

.

56 2012

1

.

(, , , ) .

2

, , .

1) ( , , )2) ( , , )

3) ( , )

4) ( , , )

:

3

1)

2)

3)

4)

4

1) QA 1

(39, 2, 100 )2) ( 9 : 00~11 : 00 , 3~8)

3) (3~8)

4) (3~8)

2012 57

5

1) - , , 2) - ,

3) -

4) - , , CS

6

1)

- ( ) (2013.5 )

- 2 2

-

2)

- ,

- ,

- (vein viewer vision)

3)

- (24 , , )

- capillary (skin puncture)

4)

- ( 7 : 30 7 : 00 30 )- ( 7 : 00~9 : 00 2 1 )

- CS

7

QA 3 9 5.6%

. 2.1%, 10.9%, 20%, 7.5% .

90% ,

.

.

58 2012

8

. QA

. , .

,

( ), .

2012 59

Communication

1

.

, .

?

?

? ?

.

2

.

, ,

.

()

.

.

60 2012

3

, .

.

.

4

. .

5

80%

, 31% . 78%

.

6

() ,

() . ,

.

7

83% ,

5% ,

72% .

.

2012 61

8

.

. ,

.

62 2012

(2010-2011, CQI)

1

.

.

, 2010 QI .

CQI

.

2

.

.

.

3

. , (TAT) ,

,

. , , .

2012 63

4

, 48 .

3 .

.

5

2011 1 2010 .

.

6

2010

.

Q&A .

.

7

.

. 2010 QI 2011

.

1 3 .

8

.

. ,

.

64 2012

, , , , , , , , ,

1

. 2011 7 15 ,

80.2% 15 62% . 2011

30%

60% .

2

(

180)

, .

, ( 180) 80%

, 80% .

3

( 180) .

4

1) : 2011 7

, ,

2) ( 180)

2011 1~7, 2011 8~12

3) ( 180)

2012 65

2011 7 12( )

4)

2011 4~7, 8~12

5)

2011 726~81, 2012 13~114

5

, , (

, ), , ,

, , ( , CT. MRI ),

(), , .

( 180)

.

6

1) ( ) 2) :

: : : 1

3) :

20

1

7

=> ( 180) 68% 72.5%

=> 48 16

=> ( , )

1) : : 10.5(9.5 ), : 10(15 ), : 21.5(48.5 )

2) : 10(39 )

=> 70% 96%

66 2012

8

( ) , (, )

. QI

( 450)

.

2012 67

1

.

. ,

( ) .

, ,

.

.

2

2 94% . 2011.12.01~2012.2.29

56.1%. VOC

: , .

: .

: . ,

( ) .

3

2 6

.

68 2012

4

2011.3.1 ~2012.2.29 CT, MRI, , , , ,

6 2

.

5

94% ,

71.9% .

,

.

6

6 2

.

,

,

- () . ,

7

2 120

29 .

,

. 2

.

8

.

.

. ,

.

2012 69

, , , ,

11 Unit

1

, ,

, .

, .

2

,

, ,

.

.

3

, ,

.

4

C 41,

50 91. SPSS ver 12.0

, ,

t-test.

70 2012

5

- 4.6 4.14 13%

- 3.3 3.63 10%

- 61.3 71.2 10% .

6

1)

, ,

2)

, ,

3) ,

, , ,

4)

1 : 1 , .

7

1)

- (, , , )

-

-

2)

- ,

- Call bell

3)

- ,

-

-

8

, ,

2012 71

. QI

.

.

72 2012

, , , , , , , , , , , , ,

92

1

2008 7 5822 1

7730 .

2 .

. , . ,

, , .

,

. ,

.

2

.

, , ,

, ,

.

3

6 5 5 , 1

.

2012 73

4

2012 2~9 10 20

.

5

60%, 45%, 60%, 90%, 45% 60% 90% . 70% ,

.

6

() , , , ,

.

7

5 17% 79% 63% , 0% 75% .

100% 75% .

8

,

. , ,

.

.

74 2012

QI

, , , , , , , ,

1

10.8% ,

.

.

2

1 45% . care

(needs) , , ,

.

3

1) 1 : 4.42/5

- (12) : 4.27/5

- : 4.27/5

- , : 4.47/5

- : 4.41/5

- : 4.68/5

2) 1 ,

- : 51.6/100

- : 52.5/100

2012 75

4

1)

- : 65

- : 2011 4 1 ~ 20

2011 99 ~ 23

- : 60, 57

- :

2)

- : 12, 13, 14, 15

- : 2011 4 1 ~ 20

2011 9 9 ~ 23

- : , 63

- :

5

1)

5 4.42 .

, . 25%

4.5 12 (4.27) .

2)

51.6 (, 2004) , 52.5

57.5 . 10% .

6

1)

- : (, , )

-

2) .

3)

- 1

-

76 2012

7

1)

.

2)

.

3) , , ,

4) 000 .

8

1) , ,

.

2) ,

.

3) , , ,

.

2012 77

1

, , , ,

, , , ,

.

.

.

.

2

1)

(1)

10X10

, .

.

(2)

.

.

3

78 2012

.

1) .

2) .

3) .

4) .

4

1) : 2011 3 27 6 30 2011 7 1 9 10

2) : 91

3) :

4) :

.

5

1)

43(47%), 48(53%) 31(34%) 60

(66%). 10 1(1%), 20 3(3%), 30 2(2%), 40 24(26%),

50 61(65%).

78(86%) 13(14%) .

52(57%) .

.

69(76%) (2) .

2)

.

72(79%) 13(14%) .

11(12%) .

2012 79

.

71(78%) .

.

6

1) 22

2)

(1) 3 : , ,

(2) 4-5 :

(3) 5-6 :

(4) 6-9 : 2

3)

(1)

.

.

(2)

.

.

.

7

.

, .

.

.

.

80 2012

8

( )

.

.

.

2012 81

Project 3S

, ,

1

. 2011 CS

.

2012 QA .

2

Service, System, Space

, .

3

QA .

: / *100 -

- Service, System, Space

4

, , QA

/ 2 .

1) : 1 2012 3, 2 2012 10

2) : ,

82 2012

5

- 1

1) Service /

2) System /

3) Space ,

6

1) Service

" " (leaflet)

2) System

( )

() - 12 : 00, - 12 : 0012 : 30

3) Space

=>

7

, Service

"" .

System ,

. , Space

, .

,

.

2012 83

8

.

.

84 2012

1

.

,

.

,

. 2010 18,521

38.5%(7,123) 61.5%(11,398)

, ,

.

.

2

,

. ,

. ,

, .

3

2012 85

4

2011.4.11-4.22 10

359 . ,

.

5

13% , 70% .

70% ,

. 1

60% .

6

7 : 30-9 : 10 10 : 00-11 : 00

,

,

. , ,

, , ,

. .

7

4 10 7 522 4 2

10 5.35 4.57 . 77% ,

70% ,

.

(92%), 8% .

293(56%), 137(26%), 132(25%) 50%

, , .

86 2012

8

QI 10 : 00-11 : 30

, 50%

.

.

. Happy call

.

2012 87

(TAT)

1

TAT(Turnaround time) .

.

2

,

.

.

3

1)

2) OCS

3) TAT

4

1) 2012 4 100

.

2) 100 2012 3 6 2

OCS , .

88 2012

5

1) ,

2) (2012 4~5)

2012 4~5 4560

OCS .

2

3) (2012 6~7)

2012 6~7 4584

OCS .

2

6

1) 2) 2 2

.

3) .

7

1) ,

2) , ,

3)

8

( )

~ . 30

( 70m) . 15

20~30 .

TAT .

2012 89

! (Everyday is Cheer-up day)

, , , , ,

1

QI ,

.

.

2

, , , ,

. , .

.

3

.

4

1) 2012 3 12-21, 1 3-4

4 Focus Group Interview . Focus Group Interview ,

8 ( , , ,

, , , , ) .

8 83

.

2) , 2012 4 5-9

90 2012

.

92.5% , 91.4%

.

5

, 5 2.44 3.64

. , , , ,

.

,

, . ,

.

6

1)

(1) (CDP : Continuous Dialogue Program)

( ) .

, ,

.

, , , .

(2)

, ,

,

, .

2)

(1)

,

, , .

3)

(1) OMEGA

OMEGA nurse

. OMEGA nurse

.

2012 91

- OMEGA nurse

Opening() --- ,

Moving() ------ ,

Emotioning() ---- ,

Giving( ) ----- ,

Amaging( ) ---- ,

7

.

8

, .

,

. .

OMEGA nurse

.

.

92 2012

()

( TFTeam)

1

, .

,

. (JCI)

.

2

1) :

2) : Open

3) :

4)

3

1) 2)

4

1) (2011. 4. 15~4. 20) - : 290(, )

- : , , , ,

2012 93

, , ,

8(Likert 5 )

2) (2010. 12~2011. 10, 11) :

5

, ,

, ,

. can , open .

6

1)

- - : - : , Can

, Betadine ball

2)

- Can

- Betadine ball Betadine Ball

3)

4) , Feedback

7

1) ,

2) : (5) 2.53.8 (2.33.7), (3.13.3), (2.63.8), (2.23.9), (2.43.7)

3)

- () : 4.9 3.3

- () : 13.4 7, 150 60

4) : Betadine Solutin ball 198,572 ( 3,761,952 3,563,380)

94 2012

8

( )

. ,

. , Feedback ,

, .

2012 95

3 STEPS

121

1

.

, ,

. ,

, ,

`3 STEPS

.

2

, , , , , .

, ,

.

`3 STEPS ` ,

.

3

3 STEPS `- call. call. call -

.

4

`3 STEPS ,

, , .

96 2012

5

, 1-2, , ,

, ,

.

6

, , , , 3 STEPS ` 3 STEPS .

7

3 STEPS ` 80

96.9 16.9 .

8

/ ,

'3 STEPS '

80 5 96.9 16.9

.

.

2012 97

(CRE : Customer

Relationship Experience)

1

.

QI .

7000 . 3 2

5000 Follow-Up .

1 : 1 (CRE : Customer Relationship Experience)

. (contact)

(CRE)

.

2

. 80%

, .

. ,

.

,

.

.

3

1) (nmCRE : nuclear medicine Customer Relationship Experience))

98 2012

2) (nmCRE MOT)

3)

4

2011, 2012 .

1) Follow-Up

2)

3) 1 : 1 (nmCRE)

5

(CRM) (CRE) .

2009 2011 12 , 90

.

.

6

1) (nmCRE)

1 : 1 CRE ,

(nmCRE) .

2) (nmCRE MOT)

(nmCRE)

3)

5

7

2011 5 2012 8 5365 .

.

MOT , ,

, , .

2011 78, 2011 80.5, 2012 80.6

. 2012 .

2012 99

8

? . 1 : 1 .

,

.

.

100 2012

(6 )

, , , , , , , , , ,

CHA

1

2009 2010 29% , 2010 25%

.

2

2

. 2011.8.8 ~

2011.8.13 358 13 .

13 30%

.

3

1) : 13

2) ( ~ 7 )

4

1)

2011.01.03~2011.06.30 20, 277

13

2)

2011.8.8~2011.8.13 358

2012 101

5

1) .

2) .

3) (, , ).

4) 1 / 20 3 .

5) .

6) .

6

1) , (Quick Fix)

- 2011 9 5

- , 4 5

- ,

8 ( )

2) (Quick Fix)

.

.

3)

, ,

.

4) 5) SMS

SMS

6)

- 8 30 12

- 11 40 , 10

10~11

7) One-Stop Card

- ,

- , , X-

8) SMS

10 SMS ,

9) 10)

102 2012

7

1)

2011.08.29~11.30 12,699

13 . 22.1% 41%,

0.732 1.72 .

2)

2011.11.16~2011.11.22 210

. 76.5 80,

2.57 2.81 .

8

SMS

40% , , ,

.

1) ,

OCS

2) i-PAD

325B

11 30() 08:3010:00PR36PR42 1

11 30() 11:0012:30PR43PR49 2

2012 105

1

2010 7 FDI

( )

14 cycle50

. ()

.

2

1. 3~4 .

2.

3.

4.

3

1.

2. strip stick

3. culture

4

2010 7 2011 12

, .

106 2012

5

1. , .

2. 14, 10

.

3. (bedside ) .

6

1. .

2. strip stick - 10 7 .

3. () , ,

7

1. 3 6~7 .

3. .

4. .

5. .

6. .

8

.

50%

.

()

.

2012 107

,

1

.

,

. Pouch

.

.

QI .

2

.

, , , , ,

.

50% .

3

1)

2) ()

4

1) : 2012.04 ~ 2012.09

2)

108 2012

3)

5

.

,

, 6 . ,

, ,

.

6

,

, 2 .

1) : , , (72), (62)

2) : , ,

3) : 2

6, 3 , 18

4) : 2 6

7

1) : 3, 3 72

2 12 .

2) : 3 30 QI

12 , 1/3

.

8

4 6 75

.

.

1) 30 12

.

2012 109

2) 30 12 60%

.

.

110 2012

,

92

1

40~50%

.

. EMR

.

()

.

.

.

2

EMR

. (OCS+Written Chart)

OCS confirm

.

.

. 1 , ,

1

.

.

2012 111

3

1) 100%

2) ()

4

1) 2012 2 1 2 29 92 81

OCS Review . 92

.

2)

. 3, 4

8 .

5

1) 2012 2 92 81 .

18 78%

.

2) .

72%

1 .

6

1)

EMR / .

. 1

1 Y 1 . .

2) .

6 48%

.3)

.

112 2012

7

23% 88% 65%P

.

.

72% 82%

.

8

.

50%

.

.

2012 113

TURN OVER TIME

, , , ,

Unit

1

.

Turn Over Time

2 . Turn Over

Time

.

2

2011 4 turn over time

, , ,

. Brain storming Endoscope

, , EMR , Process

, Communication

, , .

-

Turn over time AM 8 : 00 ~ PM 4 : 30

.

3

Turn Ove Time 20 16 20% .

114 2012

4

2011. 8. 8. 2011. 10. 21. Turn over time Monitoring sheet AM 8 : 00

~ PM 4 : 30 Turn over time 16 720

.

5

720 Turn over time 16 226 16 494

20 , ,

, , .

6

1) Package

, .

2) , ,

Package .

3) , , Process .

4)

- .

7

1) Turn over time 20 15 5 .

2) Endoscope Pack .3) Setting .

4) EMR , .

8

QI Turn over time 20 15 5 .

Endoscope , Package

,

Setting , EMR

, .

.

1) .

2) Package .

2012 115

, , , ,

9B

1

,

.

.

2

, ,

, .

, ,

gauze(4*5 gauze & burn gauze) 40%

.

3

, .

4

dressing room 20

.

5

(32.5%), (32.5%),

(20.0%), (15.0%) .

116 2012

6

1)

-

2)

- dressing room

3)

- 5 .

4) D-set 4*5 gauze 2 , burn gauze 300 gauze .

7

6.75%, 4*5 gauze 1 17.53%, burn gauze 1

12.34% .

8

dressing room

. 95.0% 8.395

. gauze dressing

gauze gauze .

,

, .

.

part 1

.

2012 117

1

45%~65% .

.

.

2

,

,

.

.

3

, ,

, .

4

, , ,

Room, ,

.

(967) 2011 3

. 2010 9 ~ 2011 2 6 .

118 2012

5

1- , 2-

, 3-, 4- 7 3.0 .

3 194,475,523,

350.

.

6

1) .

, code

.

2) ( 7Room ) .

,

Room .

3) .

4) sign .

.

5) (4 ) .

.

6) . 10

.

7

2011 919~20 7 39

,

3.4 3.6 ,

, Room ,

,

, QI

. 4

4 25 2

8% 4 12 11 92%

84% . room, OCS

2012 119

3 194,475,523, 10

152,669,604 41,805,919 21% .

350 377 27 8%

5% .

8

1)

8% 15% QI

.

2) : , Room OCS

QI

Room .

120 2012

,

1

,

2011 QI .

2

(25) ,

, 2011 QI

80% (80%) .

3

. (%) : 80%

- (%, 2009, 2011 ) = {(2011/2011)-(09/09

)}100. (80%)

4

. - 1/

. - 2009 2011

(SAP) ()

.

2012 121

5

.

. 1 . ,

.

6

. Supply

. Supply

. ,

.

. 1/

Feedback

7

.

: 2011 1~9 9, 011, 036 .

. 2009, 2011 1~8

80% (93%).

: 2009 27,521,442

. 2009

2011 ,

.

. Supply 89%

94%.

-

Supply

.

. Supply 25 22 .

-

122 2012

8

(SAP)

(9, 011, 036) .

72% 93% (2009 27,521,442 )

89% 2011 QI .

,

.

2012 123

, , , , , , , ,

, ,

1

, ,

. ,

(Time-related shelf-life) (Event-related shelf-life)

.

,

2 . 2000 QI 7,

4, Set 2 , 2010

,

.

2

1)

2011 8 10 2011 9 21(3, 4, 6) 162

9 , 8 31, 9 7, 9 21

7 .

(1)

: . : 1 .

(2)

, , 2 : , Dressing car : , Dressing car : , Dressing car : ,

2)

(1)

124 2012

(Biological

indicator) BI

, (

, , ) .

(2)

: Thioglycollate Broth . 10ml Thioglycollate broth

Forceps .

35 7 .(3) 9

9, 2 .

3

24.5 AAMI(1984) 18~24 8

, 62.5% AAMI(1998) 35~70% .

9 , 162 42 7

4

, .

2000

.

. 2000 2010 QI

4 , 2011 CQI

.

(2004) 744 154

~423 , (2003) 208

245 . 2

, CQI

4 , 2011 446

2012 140 306(68.6%) .

. ,

, .

,

.

2012 125

, , , ,

1

.

, , . , ,

. ,

.

.

2

.

,

. ,

. ,

.

.

.

3

1)

2)

3)

126 2012

4

1) Check list 3.12~4.10

2)

3)

4)

5

2X2

gauze 220, 3X3 gauze 120, Saliln 150, S-cotton 45, L- cotton 25,

510 34%, 37%, 30Kg .

6

1) 2 x 2 gauze 60 50, 3X3 gauze 70 50,

Saline 200 160, S-cotton 2/3 1/3

2) Potadin, Alcohol, H2O2

, ,

3) (60), (30), (10)

7

1) : 2X2 gauze 220 78 65%, 33 gauze 120 46 62%, Saline 150 62 59%, S-cotton 45 40

11%, 535 226 58%

2) : 6.08kg 1.36kg 5kg ,

6.5kg 1.56kg 5kg, 10.22kg 2.64kg 8kg, H2O2

7.46kg 1.94kg 6kg, 30kg 8kg 22kg .

3) : 510 78 85%

4) : 4X8 gauze 1 35 1 7 21 ,

2X2 gauze 15 8 45 , 3X3 gauze 20 4 22 , Saline

12 8 37 , 2 5 .

5) 79% .

2012 127

8

, , , , ,

, . .

.

128 2012

CHA

1

Set

List, Single ,

,

.

2

, Set

.

,

.

3

,

4

1)

(1) : 2012 326 ~ 42

(2) : 2012 626 ~ 82

2) : ,

3) :

4) : PASW Ver.19

2012 129

5

66% Set

Single 55% 57% .

Set ,

. 40%, 25%

.

6

1)

(1)

(2)

2) :

(1)

(2) :

3)

(1) Set

(2) Single

7

5%, 48%, 47%

.

40% 90% , 57 16

31 15 261 , 25% 90%

.

8

Set Tape

, . ( : )

Set Tape . Set Single Tape

.

130 2012

, , , , , ,

1

,

. ,

.

. ,

,

.

2

.

.

.

3

2011~2012 9 .

4

, casecart bag

.

2012 131

5

2011 4.7%, 3.5%.

231, 64. ,

trocar 148

.

6

1) 2 -

2) -

3) ,

4)

5) casecart bag - 174, 379

7

4.2%, 3.5% .

210, 30 .

4.8% 9.0%

. 7.6% 53.0%

.

, 80(28.3%) ,

105(37.2%) .

( )

.

1)

2011 2012

(%) 4.7 4.2

() 231 210

(%) 3.5 3.5

() 64 30

132 2012

2)

2011(%) 2012(%)

1.79 1.38

0 0

1.43 1.3

0.10 0.06

1.52 1.44

1.14 0.44

0 0

1.06 1.43

0.07 0

1.14 1.65

8

.

.

.

2012 133

6

1

(, ,

) 2011 2 8

21,675,940, 32,401,642 . ,

20112 8 64,400,000 44,862,935

.(17,065 )

.

2

->->->Calibration->QC->Test-> -> 8.

Map 22

82.8% 6 .

1)

2)

3) Clot

4)

5)

6)

, ,

.

1) : (Interface)

, .

2) : .

3) : , .

.

134 2012

1) : Pay-off matrix, (, ,

) . (

, )

2) : Box plot 750t->400t .

750t

.

3) : .

3

3,078,264 .

1,004(1,064 60 ) x 3,066

4

, , 3 ,

, ,

, .

, .

2012 135

1

2006

.

, 2010 ,

.

2

,

,

. ,

, .

2010 EO GAS , 6,

3, 3, STEAM 2

EO GAS . EO GAS

,

, 2011 EO GAS, STERRAD, STEAM

.

3

, , 2 EO GAS , STERRAD

, STEAM 27, 15, 6 .

, , .

136 2012

4

3 959 2010 1 10

, 2011

6 , , , 2

STEAM 2 2 8

.

, . 2010

.

5

1) 2010 STEAM 10 27, 15, 2

6 100% .

2) 2011 EO GAS, STERRAD, STEAM 6 27,

15, 15, 2 6 .

3) , ,

.

4) ,

. 24, 70% .

6

2010 STEAM , 2011

STEAM EO GAS, STERRAD 6, 3,

3, 2 1 .

, , .

7

, .

.

QI ,

.

2012 137

1

, ,

, , (, ), ,

.

.

2

.

3

4

1)

(1) : 2012 3 1 ~ 2012 4 30

(2) :

.

2)

(1) : 2012 8 1 ~ 2012 8 31

(2) : .

138 2012

5

1) 1 , ,

" " 54%, " " 38%, "

" 48%, " " 32% .

53.9%

90.3% 5.9%

.

2)

6% , 3.9% .

6

1)

2)

3)

7

1) 6%

4.2% 6.9% 5.3% .

3.9% 0.5% , 4.3%

1.0% .

2) .

8

QI

. QI

80%

.

, (, , , )

1% .

323

11 29() 14:0015:30PR50PR56

2012 141

()

1

.

.

. , sonographer ,

,

, sonographer .

, , .

2

(Turn Around Time, TAT :

)

, ,

.

.

, TAT

.

.

3

(TAT)

.

142 2012

4

(TAT) ( , , ) (, CT, )

5

97 set code program ,

.

6

4 (Normal, Concentric LVH, Nonvalvular A.fib, Heart transplantation)

set code 26 ,

set code sonographer senior sonographer

. set code

.

7

set code 62.5% 77.7%

64.8 50.8 14 . (TAT) 15.44 5.13

.

8

(TAT) 15.44 5.13 ,

set code 64.8 set code 50.8 21.6%

. set code 78% set code

62% , set code

.

, set code

1~2 TAT

. set code sonographer set

code

.

2012 143

1

EMR

.

. , ,

.

2

, . care plan

care plan

.

.

3

care plan , ,

.

4

2 (HD#3)

care plan . ,

, , 2 .

144 2012

5

Care plan 0%

.

37.5%, 23.3%, 26.6%

care plan .

6

Focus-DAR SOAP

. care

plan , .

7

Care plan 0%

100% .

37.5% 87.5% 133%, 23.3% 87.5% 275%

, 26.6% 89.1% 234% .

8

care plan , ,

, ,

.

.

.

2012 145

1

.

.

2

full term

.

3

KCD-6 KCD-6 () .

4

KCD-6 , DB

. 2012 1~3

, 7~8

.

146 2012

5

EMR DB

KCD-6 ,

.

,

.

6

1. KCD 6

2.

3.

4.

5.

7

.

8

.

2012 147

1

2011 3 2011 9 30 ,

, ,

,

.

2

,

.

,

, .

3

1) 30

.

2) , ,

.

3) OCS PW() .

148 2012

4

3

30 , , ,

PW 6 12

PW .

5

30 16 53.3%

PW PW 6 12 5.6%

, 3 PW OCS

.

6

1)

Policy - ()

- , ,

:

2)

safety box , CCTV ,

4)

: 1 ( , e-campus ), , ,

7

1) 30 16 53.3% ,

30 29 96.7% .

.

2) ()

85%

, 96.3% ,

safety box

2012 149

96.6% 47.4%

, . 3) PW()

PW 6 12

5.6% 82.5% .

OCS Log in PW

.

8

/

.

. ,

, , , ,

, .

150 2012

,

1

.

.

,

QI .

2

.

1) : JCI (EMR)

2) : ( )

3) :

3

1) :

2) () :

4

1(2010. 12. 20 ~ 22), 2(2011. 1. 3 ~ 5)

(Admission note)

.

2012 151

5

1) 1 : 77.1%, : 42.5%

2 : 86.3%, : 45.5%

2)

(, , , Brief op note ) 95% ,

90%

3)

2011. 2 ~ 2011. 6

6

JCI EMROCS ( )

7

1)

, 100% . , 95.7% .

(Pre op. note, Brief op. note, , ) QI Pre op. note 92.8%94.8%, Brief op. note 85%

96.2%, 91.7% 97%, 52.7% 97.8% QI

.

2) 44.1% 81.7%, 82.1% 96.3%, 44%

82.7% QI .

3) 96.1% 98.5%, 92.3% 95.5%,

93.1% 98% QI .

8

100%

, 95% .

, .

96.3%, 80% .

152 2012

, .

20 ,

98% .

QI ,

( ) .

95%

, feedback

.

2012 153

1

.

, , .

.

2

.

,

.

.

3

: 24 = 24 / 100

: daily = daily / 100

: 48 = 48 / 100

154 2012

4

2011.08.01 ~ 08.31 , ,

.

5

6

: .

: , , . ,

.

- 2012 1 1

- 2012 7 2 ,

(2418) : 18 24

.

-

.

- .

- 3 , 1

- , .

: .

- Plan Plan - -

2012 155

SMS : Staff .

: ( )

- Finding

7

: 84.8%(22.7%), 68.0%(37.9%), 56.9%(13.3%)

: 99.7%(0.3%), 89.1%(28.8%), 97.6%(27.6%)

- ,

.

8

24

18.8 1.8 , ,

, .

,

. 2012 10

QI

. .

156 2012

, , , ,

1

. .

,

,

QI .

2

, ,

.

.

.

3

1) : 10%

2) : = /

4

1) :

2) : 2011 3~5

3) : , , , ,

4)

:

2012 157

: : + : +[ : ] : + () +

5

1)

,

2)

: (40%) : (100%) : + (60%) : + [ : ](100%) : + () + (100%)

6

"" ,

.

1)

1 (20113~5) .

. 2) "INHIS LIVE"

: PLIF 8 (2011.6.14 ) : 2011.4.8 : + 5 (2011.6.14) : + [ : ] 4 (2011.6.13) : + + 7 (2011.6.17)

3) INHIS LIVE

: (20117~9)

4)

,

158 2012

7

1) 8.7% : 8/92()() / () : 8/26() (30.7%) : 0/13() (0%) : 0/7() (0%) : 0/40() (0%) : 0/6() (0%)

2) : 8, 2, 2(2011.11.7 )

8

QI 67.6% 8.7%

QI

.

1)

2)

.

325A

11 29() 14:0015:30PR57PR63

2012 161

Abdomen, Hip, Pelvis, L-spine, T-spine AP

Low Dose Technique

, , , , , ,

1

.

2

, . DR system , F/S, CR system

3

Abdomen, Hip, Pelvis, L-spine, T-spine AP

4

(2011 4~12), (2012 4~12) Abdomen, Hip, Pelvis, L-spine, T-spine AP

5

1) DR F/S, CR system , ,

.

2) (accuracy) (reproducibility) .

162 2012

6

1) DR system kVp 15%

2) QA/QC

7

kVp 15% Abdomen 22%, Pelvis 28%, L-spine 21%, T-spine

23%

8

, QA/QC

QA/QC .

2012 163

, 6

1

,

.

,

2011

QI . ,

,

,

, 2012 QI

CQI .

CQI .

2

.

,

.

1)

2) CP(Clinical Pathway) ,

3)

4)

5)

6) .

164 2012

,

.

,

QI

.

3

1)

2)

4

. : 2011. 1 ~ 2012. 9

.

(1)

.

(2) .

(3) , ,

.

(4)

5

.

(1) () - ,

- ,

-

-

()

(2)

-

2012 165

-

(3) ATC()

- ATC() ,

.

-

-

-, (4) -

- ,

QI 1 3

,

.

(1)

-

2012 15%

- ,

(2)

-

2012 50%

-

-

(3) Call

- ,

Call

.

(1)

- .

-

(2)

166 2012

-

-

(3)

- CP (Clinical Pathway) ,

CP .

-

.

(1)

- 2011 20%

. ,

-

(2)

-

(3)

- ,

-

6

QI 2011 14,566,492

( 1,213,874), CQI 2012 1 9

4,788,662( 532,073) 60% .

,

2012 3 1

.

7

2012 CQI

50%, 7% 3% 60%

. 40%

2012 167

7%, e-kit

3%, 16%,

14%

.

, ,

.

168 2012

(NST)

, , , , , , *

, *

1

, 40% , 75%

. ,

. ,

, (KSPEN) (, NST) NST .

NST program , NST ,

.

2

NST NST program ,

, . NST

NST program ,

.

3

1) NST

2) NST

3) NST

4

1) NST

2) NST

2012 169

3) ASPEN, ESPEN

4) 2011 12011 9 NST program

5

NST program , , .

NST NST , ,

NST NST

.

6

1) NST NST .

2) NST ASPEN, ESPEN ,

NST , , NST

.

3) NST program (NST

) , .

- Nutrition Score

-

-

- NST

- NST

4) NST NST NST ,

. .

7

1) NST

(NST) , , ,

9 point

.

2) NST ,

(1) NST

NST 1 2

. , ICU NST

.

(2) NST

170 2012

(day) NST .

(3) NST NST

(day) 1, 2

, 2 1

.

(4) NST NST

1 91.7% 2 100%

.

3)

2 , 2, 7

. 7 .

8

(NST)

NST .

40 (KSPEN) NST

NST . ,

NST NST

.

2012 171

CHA

1

.

40% ,

75% .

.

2

48 ,

. %IBW(ideal body weight), serum albumin, total lymphocyte

count 3 2 .

, . ,

. ,

, , , . ,

,

, , .

,

.

3

172 2012

4

.

5

34,

16(47%), 18(53%),

16(88%) 1 .

,

, .

6

TFT ,

, , , . ,

, ,

. ,

, .

7

47.0% 73.0%, 26.0% ,

(x=6.489, p=0.011).

8

.

, , .

2012 173

1

1~5 % .

.

.

.

.

2

2008

3 , 2009

2011 5 % .

, .

3

72 , .

1) 72

.

2) , 72

.

4

2011 11 1231 72

. 82 %

.

174 2012

5

2011 1 72

, . 2011 6 KCD

400 .

(A09), (J18),

(J06), (L50), (R50)

2~7 % .

, , , , , , , , TOP 10

57 % .

, .

6

, 4

case .

, , set .

,

. .

7

2011 0.67 %, , 2.07 % .

, ,

.

8

.

, .

.

.

2012 175

, , , , , ,

1

, , , ,

, , ,

, .

.

2

,

, .

,

, , . QA

.

3

1) , , , 90%

2) ( )

3) (2010 1.5kg 2011 1.5kg )

4) /

5)

6) (Post conceptual age)

176 2012

4

, 2010 5-9, 2011

5-9 EMR .

1)

- ,

- ,

- ,

- / , ,

2)

- setting , , , ,

3)

- , , ,

5

2010 5 1 9 30 1.5kg

29, 385 68 .

27

19 9(47.4%) .

19 6(31.6%) .

. 34

36 2 .

.

,

, .

.

6

8 ,

, 17 . ,

. minimal handling

, sucking

34 , ,

2012 177

NIDCAP .

,

NICU NICU

, ,

. , ,

, , ,

.

7

27 16 47.4% 46.4%

. 31.6% 78.6% ,

. , 36 2 35 4 4

, 2.18kg 2.256g 76g , 68 60

8 . ,

, 70.6 78.18 .

41.2, 86.8, 6 87.2 ,

69 98 29 . 82.5%

99.1%.

8

2010 5 9 5

, , , , ,

,

, 27 16

11 47.4% 46.4% .

362 354 4 ,

68 60 8 .

,

.

178 2012

AGS(Asan Global Standard)

*,

*,

*,

**,

**,

**,

**,

**,

**

*(8 ), 1