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1、WHO健康促进医院自我评估表Self-assessment Forms for Implementing Health Promotion in Hospitals前言： 医院健康促进的角色正在改变，不再只是局限于提供诊疗之外的生活型态卫教信息。健康促进已逐渐成为完整健康照护过程中不可或缺的一环，且与临床、教育、行为及组织议题息息相关1。为了改善慢性病与长期照护病人的照护质量，医院的健康促进活动必须能更妥善的嵌入于整个较大的医疗体系架构中。随着健康促进活动的范畴日益扩大，有关这些活动的质量评估与质量改善问题也开始受到重视。 一些提升健康照护质量的重要工具，例如专业共识指引、标准及成效指标，鲜少
2、专注在健康促进议题上。因此，世界卫生组织欧洲办公室发展出一套医院健康促进的自我评估工具，包含以下议题：医院管理政策、病人危险因子与健康需要评估、病人健康促进信息与健康促进介入、推动健康职场，以及医院与其他健康、社会服务和非正式的照护提供者之间的持续与合作关系2。 这份文件提供了个独立的工具以评估、追踪及改善医院的健康促进活动。进一步来说，这份文件应该可以帮助医院更容易:评估医院的健康促进活动；发展健康照护组织改善健康促进活动的能力；形成改善医院健康促进活动的建议；使所有医疗专业人员与病人更积极参与健康促进活动；增进与其他照护提供者的协调；改善员工及病人的安全与健康；增进健康照护业务与服务的现代
3、化和改变，使其更具效率和效能。健康促进在概念上涵盖甚广，包括各种活动、介入、方法与途径，有些实在太广泛了，我们决定选取在临床上最常见及有较强实证的议题，因此，有一些先前出现在健康促进医院网络指导文件中的健康促进活动并没有全部纳入3,4。在医院健康促进的18个核心策略一书，提供了一个较完整的架构，以引导医院策略性导入健康促进以及作为进一步发展健康促进标准的参考5。本评估表中有一些标准（像是病人评估或信息与介入）可直接连结到病人安全的议题6。然而，这份文件主要是提供额外工具，可更全面地增强病人与医院员工的权能，以补现行质量与安全活动之不足。 这份文件是针对所有对改善健康促进有兴趣的医院及质量机构所
4、设计的。我们鼓励从事质量改善工作的机构检视这些医院健康促进标准和指标，并将它们整合到现行的质量评估系统中。说明：1.本评估表内容系摘自Groene O ed. Implementing Health Promotion in Hospitals: Manual and Self-assessment Forms. Copenhagen: WHO Regional Office for Europe; 2006.2.欲申请成为台湾健康医院学会国际网络会员之医疗机构，敬请填写此份文件，进行自我评估，并作为导入、追踪及改善之基础。 3.若对于此份文件之内容或使用有任何疑问或指教，敬请随时与本学会联络
5、。电话：02-2826-7347。敬祝：健康平安、永续发展！ 台湾健康医院学会筹备处谨识 96.6.25Introduction:The role of health promotion in hospitals is changing. It is no longer restricted to providing additional lifestyle-related information to the patient after the clinical procedures have been completed. Health promotion is becoming an i
6、ntegral part of the health care process and is related to clinical, educational, behavioural, and organizational issues1. In order to improve the quality of care for patients with chronic diseases and long-term conditions, health promotion activities in hospitals need to become better embedded in th
7、e larger health systems framework. With the expanded scope of health promotion activities, questions are raised regarding the quality assessment and improvement of these activities. Among the prominent tools to improve quality in health care, such as professionally consented guidelines, standards an
8、d performance indicators, there is little focus on health promotion issues. We therefore developed a self-assessment tool for health promotion in hospitals that addresses the following issues: the hospitals management policy; the patients assessment with regard to risk factors and health needs, pati
9、ents health promotion information and -intervention; promoting a healthy workplace and continuity and cooperation of the hospital with other health, social and informal care providers2.This document provides a self-standing tool to assess, monitor and improve health promotion activities in hospitals
10、. In detail, this document should facilitate: assessing health promotion activities in hospitals; developing the capacity of health care organizations in improving health promotion activities; formulating recommendations for the improvement of health promotion activities in hospitals; involving all
11、professionals and the patient in improving health promotion activities; improving the coordination of care with other providers of care; improving the health and safety of staff and patients; assisting with modernizing and changing healthcare practice and service delivery to make it more efficient a
12、nd effective. Health promotion covers conceptually a broad range of activities, interventions, methods and approaches, some of which were too broad for the scope of this document. A decision was taken to address in this self-assessment tool only those issues that are most easily recognized by profes
13、sionals working with patients, and for which the strongest evidence base is available. Consequently some health promotion activities that were included in previous guiding documents of the Health Promoting Hospitals Network are not fully reflected3,4. A comprehensive framework to guide strategic imp
14、lementation of health promotion in hospitals and to guide the further development of health promotion standards is summarized in the Eighteen Core Strategies for Health Promotion in Hospitals5. Some of the standards (like patient assessment or information and intervention) are directly linked to pat
15、ient safety issues6; however, this document provides additional tools for a wider approach to empower patients and staff and to complement existing quality and safety activities.This document was developed for all hospitals and quality agencies interested in improving health promotion. Organizations
16、 working in the field of quality improvement are encouraged to review and incorporate the standards and indicators for health promotion in hospitals into their existing systems.参考数据：1. Groene O, Garcia-Barbero M. eds. Health promotion in hospitals. Evidence and quality management. Copenhagen, WHO Re
17、gional Office for Europe, 2005 (http:/www.euro.who.int/document/E86220.pdf, accessed 08 May 2006).2. Standards for Health Promotion in Hospitals. Copenhagen, WHO Regional Office for Europe, 2003 (http:/www.euro.who.int/document/e82490.pdf, accessed 08 may 2006).3. Ottawa Charter for Health Promotion
18、. Geneva, World Health Organization, 1986.(http:/www.who.int/hpr/NPH/docs/ottawa_charter_hp.pdf, accessed 08 May 2006).4. The Vienna Recommendations on Health Promoting Hospitals. Copenhagen, WHO Regional Office for Europe, 1997 (http:/www.euro.who.int/healthpromohosp/publications/20020227_1, access
19、ed 08 May 2006)5. Pelikan J, Dietscher C, Krajic K , Nowak P. Eighteen core strategies for Health Promoting Hospitals. In: Groene O, Garcia-Barbero M, eds: Health promotion in hospitals. Evidence and quality management. Copenhagen, WHO Regional Office for Europe, 2005: 48-67. (http:/www.euro.who.int
20、/document/E86220.pdf, accessed 08 May 2006).6. Forward Programme 2005. World Alliance for Patient Safety. Geneva, World Health Organization, 2004.(http:/www.who.int/patientsafety/en/brochure_final.pdf , accessed 08 May 2006)Standard 1. Management Policy标准一. 管理策略The organization has a written policy
21、for health promotion. The policy is implemented as part of the overall organization quality improvement system, aiming at improving health outcomes. This policy is aimed at patients, relatives and staff.医院有一健康促进的书面政策，此政策之执行系医院整体医疗质量改善系统中的一部份，其主要目的在增进健康。此一政策的对象是病人、家属、医院员工与小区。Objective 自评目标To describe
22、 the framework for the organizations activities concerning health promotion as an integral part of the organizations quality management system.描述医院健康促进活动的推动架构，此架构为机构医疗质量管理系统中重要的一环。Substandards子标准：1.1 The organization identifies responsibilities for health promotion.医院认同健康促进为医院的责任做到部份做到未做到1.1.1 The h
23、ospitals stated aims and mission include health promotion Evidence: e.g. time- table for the action.医院所宣示的愿景和目标中，有包涵健康促进。（例如【注】：在医院的宣誓、网站或相关文件中，有明确将健康促进列入。）做到部份做到未做到1.1.2 Minutes of the governing body reaffirm agreement within the past year to participate in the WHO HPH project Evidence: e.g. date f
24、or the decision or for payment of the annual fee.院方在过去一年内有确认（继续）参与WHO健康促进医院国际网络及台湾网络。（例如：有参与活动及缴交年费的记录。）做到部份做到未做到1.1.3 The hospitals current quality and business plans include health promotion (HP) for patients, staff and the community Evidence: e.g. health promotion is explicit in the plan of actio
25、n.医院目前的质量与经营计划有包括对于病人、家属、员工及小区的健康促进。（例如：在相关的计划与行动中，有明确提及健康促进。）做到部份做到未做到1.1.4 The hospital identifies personnel and functions for the coordination of HP Evidence: e.g. staff member nominated for the coordination of HP.医院有指派专责人员与分工，执行与健康促进有关之协调。（例如：已有相关同仁被任命协调健康促进业务。）【注】：本评估表括号内列举之例如事项，系指为了解该项目执行状况时可考
26、虑采用的作法。1.2 The organization allocates resources for the implementation of health promotion.医院配置资源以执行健康促进政策做到部份做到未做到1.2.1 There is an identifiable budget for HP services and materials Evidence: e.g. budget or staff resources.医院有明列健康促进相关的预算。（例如：预算或人力资源。）做到部份做到未做到1.2.2 Operational procedures such as cl
27、inical practice guidelines or pathways incorporating HP actions are available in clinical departments Evidence: e.g. check guidelines.已将健康促进服务纳入操作程序（如临床指引或临床路径）中，供临床部门使用。（例如：检视临床指引。）做到部份做到未做到1.2.3 Specific structures and facilities required for health promotion (including resources, space, equipment
28、) can be identified Evidence: e.g. facilities to lift patients available.有特定的空间及设施以执行健康促进。（例如：资源、空间、设备等。）1.3 The organization ensures the availability of procedures for collection and evaluation of data in order to monitor the quality of health promotion activities.医院应有收集及评估相关资料的步骤，以监控健康促进活动的质量。做到部份
29、做到未做到1.3.1 Data are routinely captured on HP interventions and available to staff for evaluation Evidence: e.g. availability assessed in staff survey.医院有例行性的收集健康促进介入资料且能够提供给相关人员做评估之用。（例如：询问相关员工是否可取得相关资料。）做到部份做到未做到1.3.2 A programme for quality assessment of the health promoting activities is establis
30、hed Evidence: e.g. time schedule for surveys is available.医院对健康促进活动有规划质量评估方案。（例如：有调查之时间或资料。）Standard 2. Patient Assessment标准二. 病人评估The organization ensures that health professionals, in partnership with patients, systematically assess needs for health promotion activities.医院应确认医疗专业人员，能够在与病人的伙伴关系中，系统
31、性的评估病人健康促进活动需要。Objective自评目标To support patient treatment, improve prognosis and to promote the health and well-being of patients.支持病人的治疗计划，增进病人预后，并促进病人的健康与安适。Substandards子标准2.1 The organization ensures the availability of procedures for all patients to assess their need for health promotion.医院必须确认对每
32、一个病人都有能评估其健康促进需要的程序。做到部份做到未做到2.1.1 Guidelines on how to identify smoking status, alcohol consumption, nutritional status, psycho-social-economic status are present Evidence: check availability.具备相关的临床指引，能辨识病人吸烟状态、饮酒状态、营养状态、心理-社会-经济状态。（例如：确认有无是类临床指引。）做到部份做到未做到2.1.2 Guidelines/procedures have been rev
33、ised within the last year Evidence: check date, person responsible for revising guidelines.临床指引或步骤在过去一年中有进行修订或检讨。（例如：检查修订日期及负责修订人员。）做到部份做到未做到2.1.3 Guidelines are present on how to identify needs for HP for groups of patients (e.g. asthma patients, diabetes patients, chronic obstructive pulmonary dis
34、ease, surgery, rehabilitation) Evidence: e.g. for groups of patients specifically treated in the clinical department.针对特殊族群病患(如：气喘、糖尿病、COPD、手术、复健病人)，有相关临床指引以评估其健康促进需要。（例如：有无对特定病人的相关临床指引。）2.2 The assessment of a patients need for health promotion is done at first contact with the hospital. This is ke
35、pt under review and adjusted as necessary according to changes in the patients clinical condition or on request.病人的健康促进需要评估必须在与病人第一次接触时完成，并且在病人临床状况有变化或有需要时能做适当检讨及调整。做到部份做到未做到2.2.1 The assessment is documented in the patients record at admission Evidence: for all patients. Identified by patient recor
36、ds audit.在病人住院时，会将其健康促进评估记录在病历中。（例如：从住院病历中可看到有相关记录。）做到部份做到未做到2.2.2 There are guidelines / procedures for reassessing needs at discharge or end of a given intervention Evidence: guidelines present.有临床指引或步骤，在病患要出院或临床介入告一段落时，会重新评估病人的健康促进需要。（例如：有相关的临床指引。） 2.3 The patients needs-assessment reflects infor
37、mation provided by others and ensures sensitivity to social and cultural background. 病人健康促进需要评估有涵盖其他照护者所提供的数据，并能注意到病人的社会状况及文化背景做到部份做到未做到2.3.1 Information from referring physician or other relevant sources is available in the patients record Evidence: for all patients referred from physician.在病人的病历上可
38、查到转介医师或其它相关来源所提供的数据。（例如：经转介来院的病人病历记录。）做到部份做到未做到2.3.2 The patients record documents social and cultural background as appropriate Evidence: religion that requires special diet or other specific attention. Social conditions indicating that the patient is at risk.在病历中适切地记载病人的社会及文化背景。（例如：因宗教信仰所需特殊饮食或其他需
39、要特别注意的事项。指出病人可能属于某些高危险群的社会状况记录。）Standard 3. Patient Information and Intervention标准三. 病人的信息与介入The organization provides patients with information on significant factors concerning their disease or health condition and health promotion interventions are established in all patient pathways.医院能提供病人有关于个人
40、疾病或健康状况的重要影响因子之信息，且已将健康促进介入建立到所有的临床照护路径中。Objective自评目标To ensure that the patient is informed about planned activities, to empower the patient in an active partnership in planned activities and to facilitate integration of health promotion activities in all patient pathways.确保病人被告知有关活动的规画，在规划的活动中与病人建
41、立积极的伙伴关系、提升病人权能，并且使健康促进活动与病人的所有临床照护路径有更好的整合。Substandards子标准3.1 Based on the health promotion needs assessment, the patient is informed of factors impacting on their health and, in partnership with the patient, a plan for relevant activities for health promotion is agreed.依据健康促进需要评估结果，告知病人影响他们健康的重大因素
42、，并与病人共同拟定适当的健康促进计划。做到部份做到未做到3.1.1 Information given to the patient is recorded in the patients record.Evidence: random review of patient records for all patients提供给病人的健康促进讯息有记载于病历中。（例如：病历纪录。）（注：可相对应于新制医院评鉴3.2.1.1）做到部份做到未做到3.1.2 Health promotion activities and expected results are documented and eval
43、uated in the records Evidence: e.g. patient records audit健康促进的活动及预期结果有记载及评估于病历中。（例如：病历纪录。）（注：可相对应于新制医院评鉴5.2.1.1及5.3.2.2）做到部份做到未做到3.1.3 Patient satisfaction assessment of the information given is performed and the results are integrated into the quality management system Evidence: e.g. various assess
44、ment methods: survey, focused group interview, questionnaire. Time schedule.对于提供给病人的讯息有作满意度评估，并将其评估结果纳入质量管理系统中。（例如：各种评估方法，如：调查、焦点团体会谈、问卷调查及其时间表。）（注：可相对应于新制医院评鉴7.3.1.5）3.2 The organization ensures that all patients, staff and visitors have access to general information on factors influencing health.
45、医院能确保所有病人、同仁及访客能够获得影响健康因子的一般信息。做到部份做到未做到3.2.1 General health information is available Evidence: e.g. availability of printed or online information, or special information desk.有提供一般性的健康信息。（例如：有印刷品或在线的健康信息，或有特别的咨询服务柜台。）（注：可相对应于新制医院评鉴7.1.3.2 、1.7.1.5）做到部份做到未做到3.2.2 Detailed information about high/risk
46、 diseases is available Evidence: e.g. availability of printed or online information, or special information desk. 提供有关高危险疾病的详细信息。（例如：有印刷品或在线信息，或有特别咨询服务柜台。）（注：可相对应于新制医院评鉴1.7.1.5、3.1.2.1）做到部份做到未做到3.2.3 Information is available on patient organizations Evidence: e.g. contact-address is provided.有提供病友团体
47、的信息。（例如：有提供联络地址）（注：可相对应于新制医院评鉴1.7.1.5）Standard 4. Promoting a Healthy Workplace 标准四：推动健康职场The management establishes conditions for the development of the hospital as a healthy workplace.在管理中建立有利于医院发展为健康职场的条件。Objective自评目标To support the development of a healthy and safe workplace, and to support health promotion activities of staff.支持健康及安全职场的发展，并支持员工的健康促进活动。Substandards子标准4.1 The organization ensures the development and implementation o
