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FM-IQA-01-07 REV.03/2549

ดัชนีชวีัดคุณภาพClinical indicator Shock from DHF case at OPD 0 0 0 0 0 0 0 0 0 0 0Febrile Convulsion at OPD 0 1 0 0 0 0 1 1 0 0 0

Internal process indicator Staff injury 0 time 0 0 0 0 0 0 0 0 0 0

1 1 1 0 0 1 0 1 0 0Re - Visited in 24 hr (Same Dx) 0 time 0 0 1 0 0 0 0 0 0 0Medication Error 0 time 0 0 1 1 0 0 1 0 0 0Occurrence report 0 time 3 2 9 7 9 12 14 12 7 3

>90% 94% ### ### 100% ### ### ### ### ###Health education rate …( Vaccination ) 100% ### ### ### ### 100% ### ### ### ### ###

1 1 1 1 1 0 0 1 0 0

Hand washing before & after nursing care 100% ### ### ### ### 100% ### ### ### ###- Hand washing before nursing care 95% ### ### ### ### 100% ### ### ### ###- Hand washing after nursing care 95% ### ### ### ### 100% ### ### ### ###- Efficiency of hand wash 95% na ### 80% ### na ### na na ###

Service indicator - CSI External 4.46 4.48 4.47 4.49 4.5 4.48 4.46 4.48 4.35 4.39

รายงานวัตถประสงค์คณภาพ

ม.ค. ก.พ. มี.ค. เม.ย. พ.ค. มิ.ย. ก.ค. ส.ค. ก.ย. ต.ค. พ.ย.

นวนครั้งกรซอม code 8 / Quater  ≥1 ครั ้ง

- อัตราการเจาะเลือดหรอืแทง IV ครั ้งเดียว าเร็จ100%

านวนครั ้งการซอม code 5 ≥1 ครัง

≥ 4.5

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FM-IQA-01-07 REV.03/2549

ดัชนีชวีัดคุณภาพ

รายงานวัตถประสงค์คณภาพ

ม.ค. ก.พ. มี.ค. เม.ย. พ.ค. มิ.ย. ก.ค. ส.ค. ก.ย. ต.ค. พ.ย.านวนแบบสอบถาม ต่อเดือน 50 112 123 75 107 82 77 55 79 77 93

- CSI Internal > 4.0 4.39 4.34 4.40 4 4.41 4.44 4.51 4.48 4.40 4.11านวนแบบสอบถาม ต่อเดือน 30 40 39 32 30 33 39 40 30 30 30

- Customer complaint ( service ) 0 time 0 0 0 0 1 1- Waiting time15 14.1 13.62 16.3 17.48 14.88

70% 59% 60% 55% 59% 62% 51% 45% 53% 55% 57%5 3.59 4.01 3.34 4.26 4.17 5.12 6.19 4.67 4.43 3.98

80% 91% 84% 85% 81% 83% 61% 49% 85% 80% 91%Waiting time non Investigate to see Dr. within 10 mins

0 time 0% 0 0 0 0 1 2 0 0 0- % Follow up for Ped Specialist case 90% ### 91% 94% 87% 88% 77% 91% 93% 95% 94%% Follow up for General + Allergy + Skin Ped 80% 99% 99% 71% 52% 57% 72% 87% 90% 90% 92%Hub of eastern region indicator OPD -PedInbound referal case - 0 0 0 0 0 0 0 0 0 0Outbound referal case ( service) 0 time 0 0 0 0 0 0 0 0 0 0Outbound referal case ( Total ) 0 time 0 0 1 1 1 0 0 0 0 0

PCU - Ped

Waiting Time case ท ีระบุแพทย์ ( นาที )14.24

14.28

14.52

15.18

14.79านวนผ  ป่วยท ีระบุแพทย์ ไดตรวจภายใน15นาที

Waiting Time case ท ีไม่ระบุแพทย์ ( นาที )านวนผ  ป่วยท ีไม่ระบุแพทย์ ไดตรวจภายใน5นาที

- ผ  ปวยกลับไปโดยไม่ ไดรับการตรวจ

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FM-IQA-01-07 REV.03/2549

ดัชนีชวีัดคุณภาพ

รายงานวัตถประสงค์คณภาพ

ม.ค. ก.พ. มี.ค. เม.ย. พ.ค. มิ.ย. ก.ค. ส.ค. ก.ย. ต.ค. พ.ย.Inbound referal case - 3 2 4 5 2 1 14 3 5 2Outbound referal case ( service) 0 time 0 0 0 0 0 0 0 0 0 0Outbound referal case ( Total ) 0 time 6 1 4 3 8 6 3 3 2 2

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FM-IQA-01-07 REV.03/2549

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ITEM Target JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOVDE> 90% 95% 97% 96% 91% ### ### 95% 99% 95% 96%

d washing before & after nursing care 100% 100% ### 100% ###> 90% N/A 90% ### NA N/A NA NA

การปฏิบัตติามมาตรฐานการเจาะเลอืด > 90%4%

###%

99% ###100% % %

99%การปฏิบัติตามมาตรฐานการบริหารยา > 90% 95% 99% 99% 98% 99% 99% 98% 99% 99%d washing before & after care by Dr. 96.8 88% 84% 94% 100% 83% 87% 91% 91% ###

plete rate Nursing process (การ ชกระบวน

100 100 100 100 100 100การปฏิบัตติามมาตรฐานการแทง IV 100 100 100

100 100

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Occurent reportJan Feb Mar Apr May

Assessment / Reassessment Process 1

Billing & Payment

Blood / IV. Administration

Break Policy/WI/Regulation/RulesCancel OR. / Procedure / Investigation

Care

Cleaning

Code 8

Communication

Complications

Cost Estimation

Creiteria for admission relate event

Dangerous abbreviations

Delay Treatment/Cure/Care 1

Deny to Provide Service

Discharge ProcessDocument / Medical record 1 1 4 3

Environment

Equipment problem

Explanation / Instruction

Film X-ray CT/MRI Related Occurrence

Inappropiateness of Care 1

Inappropiateness of Discharge

Infectious control round 1 1

Infectious occurrence

Investigation process related events

IV administration

Laboratory related OccurrenceLine / Tube / Catheter 

Location /Transportation

Medical Record related events

Medication Error 

Medication Error (Administration Error) 1

Medication Error (Dispensing Error)

Medication Error (Pre-Administration Error)

Medication Error (Pre-Dispensing Error)

Medication Error (Prescribing Error) 1

Medication Error (Transcriping Error)

Medication Safety

Patient and Family EducationsPatient Identification

Pharmacy related occurrence

Policy / Working Instruction related events

Potential / Competency / Skill / Knowledge

Precaution / Isolation technique

Price

Re - Admission

Re - Investigation

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Re - Operation

Refer Out

Re-visit within 24 hrs. 1

Safe Surgical Team

Safety releted events

Security related events

Safety / Building / Environment 1 1Service behavior 

Sharp injury to staff 

Staff 

Suggestion 1 1 1

Timeliness 4 4

Transfer to higher level of care

Unexpected outcome

Unplanned departure

TOTAL 3 2 9 7 9

Jan Feb Mar Apr May3 2 9 7 9

Occurent reportJan Feb Mar Apr May

Assessment / Reassessment Process 1

Billing & Payment

Care

Communication

Dangerous abbreviations

Delay Treatment/Cure/Care 1

Document / Medical record 1 1 4 3

Environment

Inappropiateness of Care 1

Infectious control round 1 1

Medication Error (Administration Error) 1

Jan Feb Mar Apr May Ju

0

2

4

6

8

10

12

14

16

32

9

7

9

Occure

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Medication Error (Prescribing Error) 1

Re-visit within 24 hrs. 1

Safety / Building / Environment 1 1

Service behavior 

Safety releted events

Suggestion 1 1 1

Timeliness 4 4TOTAL 3 2 9 7 9

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Jun Jul Aug Sep Oct Nov Dec รวม1

1

1

3 1 1 1

1 1

1

1

1

1 2

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1

2 13 1

1 2

6 6 4 2 2

12 14 12 7 3 0 0 0

Jun Jul Aug Sep Oct Nov Dec12 14 12 7 3

Jun Jul Aug Sep Oct Nov Dec รวม1

1

1

3 1 1 1

1 1

1

1

1

1 2

Jul Aug Sep Oct Nov Dec

12

14

12

7

3

nce Report

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2 1

3 1

1

1 2

6 6 4 2 212 14 12 7 3 0 0 0