学习“保柏认证－患者部分”，感觉我国的差距不小！
6a.Patient Charter患者约章Yes/No/Other 是/否/其他Reason原因
6a.1Does the Hospital have a Patient Charter?医院是否有患者约章？
This should be a written and clearly accessible document that relates to treating the patient as an individual. Please attach a copy 患者约章应该是为患者提供人性化服务的书面规程，并且该规程方便取阅。请提供复印件y
6a.2Does the hospital have a written policy regarding patient confidentiality? Please attach a copy医院是否有涉及患者保密的书面制度？请提供复印件
6a.3Are all areas accessed by patients (including external areas, rooms and reception) clean, comfortable, spacious, welcoming, pleasant and clearly sign-posted? 患者进入的所有区域（包括外部区域、房间及接待处）是否都清洁、舒适、宽敞、温馨，且有清晰的标识？
6a.4Is privacy and dignity of patients a priority and respected at all times?患者的隐私和尊严是否得到优先考虑且始终都受到尊重？
6a.5Are private rooms available for patients?是否为患者提供单人房间？
6a.6During examinations; 检查时：y
Are changing facilities adequately private?是否有足够的单人更衣室？
Are gowns available?是否有检查服？
Is there a safe place to store clothing and possessions?是否有一个安全的地方可储存患者的衣物？
6a.7Are adequate toilet facilities available?是否有足够的卫生间？
6a.8Are adequate washroom facilities available?是否有足够的洗手池？
These should have hot water, antiseptic hand wash and paper towels available at all times.洗手池应该随时有冷热水，消毒洗手液和擦手纸。y
Free text: please describe 请予描述y
6a.9When examination of a patient is necessary are chaperones available to accompany the patient?当需要做检查时，是否允许陪护在场？
6a.10Are there recreational areas in the hospital where patients can go? 医院里是否设有娱乐区？
6a.11Are the cultural/religious beliefs of patients upheld and respected? 患者的文化／宗教信仰是否得到维护并受到尊重？
6a.12Is a place of worship available within the hospital?医院里是否设有祷告室？
6a.13Are different religious beliefs taken in to account with respect to meals and diet?餐饮方面是否考虑到了各种不同的宗教信仰？
6b. Patient Rights患者权利Yes/No/Other 是/否/其他Reason原因
6b.1Are patients clearly informed of their right to:患者是否被明确告知如下各方面的权利：y
· Seek clear explanation of a proposed treatment 寻求所建议治疗方案的明确解释
· Seek a second opinion 寻求其他专家的意见
· Discontinue treatment 中断治疗
· Refuse Treatment 拒绝治疗
· Make a complaint 投拆
· Have visitors (at suitable times) 接受来访者探视（适当的时间）
· Decline to participate in research 拒绝参加临床研究
· Organ and tissue donation 器官捐赠
6b.2Does the hospital pay special attention to the needs of: 医院是否对以下人员的需要给予了特别关注：y
· Elderly patients 老年患者
· Physically impaired patients 精神病患者
· Patients with poor mobility, eg wheelchair users活动障碍患，如使用轮椅者
· Visually impaired 视力障碍者
· Hearing impaired 听力障碍者
· Children儿童
· Patients with learning disabilities学习障碍者
· High risk patients 高危险病人
Free text: please give examples (this might be items such as wheelchair access, lifts and ramps, large print patient information, audible patient information)请举例说明（比如轮椅通道，电梯，斜坡，放大字体的患者资料，可听的患者资料）y
6b.3Does the organisation have appropriate policies to cover: 医院是否有相应的制度规范以下工作
· Appropriate pain management 适当的疼痛管理
· End of life care 临终关怀
6b.4Do policies on end of life care cover: 临终关怀的制度是否包括y
· Ongoing assessment of the patient 对病人情况的实时评估
· The specific needs of the patient and family 病人及家属的特殊要求
·
Ensuring comfort and dignity of the patient 尽力确保病人的无痛苦及尊严
6c. Patient information患者信息Yes/No/Other 是/否/其他Reason原因
6c.1aDoes the hospital promote its facilities and services to the local community 医院是否在当地宣传自己的医疗设施及服务
6c. 1bDoes the hospital promote its facilities and services to an international community
医院是否向外国人宣传自己的医疗设施及服务
6c.1cDoes the hospital have a website that displays: 医院是否有网站并提供以下信息y
· a list of services available 提供的医疗服务
· information about clinicians practicing at the hospital and their speciality 关于医生及其专业的简介
· information about how to make an appointment 关于如何预约
· contact information 医院的联系方式
·
complaints process 投诉建议流程
6c.1Does the hospital display information about its departments and services? 医院是否明示各科室的信息？
6c.2Is there appropriate sign-posting for departments and facilities?(This means large, bright signs and easy to follow directions)各科室是否有适当的指示标识？（标识应该够大，够清楚，并容易懂）
6c.3Is information available in simple written format for common procedures and interventions?
常用的检查和治疗方面的信息是否以简明易懂的书面形式提供给患者？
6c.4Is there information available about carer and relative access to unit?是否有看护和亲属进入病房方面的信息？
6c.5Is there information available about how a patient may make suggestions, log a complaint or give positive feedback to the hospital? 是否有如何提意见，如何投诉或表扬的信息？
6c.6 Is there written information regarding support groups, charities and voluntary organisations?是否有援助团体、慈善团体和志愿组织方面的书面资料？
6c.7Does the hospital inform patients how to access clinical trials/experimental treatments should they wish to? 如果病人有兴趣加入，医院是否会向其介绍如何参与临床试验？
6d.Patient Safety患者安全Yes/No/Other 是/否/其他Reason原因
6d.1Does the hospital have a clinical governance committee?This is a committee which meets to discuss all aspects of patients, staff and organisational safety and quality in and around the hospital.医院是否有一个临床管理委员会？委员会会议会讨论患者，员工和医院安全的各方面问题以及医院的质量问题。
6d.2Does the hospital collect data on the following categories:
(We may request sight of such information)医院是否按照以下类别统计数据：（我们可能会要求浏览这些信息）y
· Inpatient mortality 住院患者死亡率
· Neonatal mortality (if applicable) 新生儿死亡率（如适用）
· Perioperative mortality 围手术期死亡率
· Caesarean sections (elective and emergency) 剖腹产（择期和急诊）
· Unplanned return to theatre 非预期的二次手术
· Unplanned re-admission following daycase procedures 门诊手术患者未预期住院
· Unplanned second operation within 6 weeks of surgery 术后6周内非预期的第二次手术
· Unplanned re-admission within 28 days of discharge 出院28天内非预期再住院
· Unplanned transfer to ICU 非预期转入重症监护病房（ICU）
· Unplanned transfer to another unit 非预期转入其他科室
· Surgical site infections 手术部位感染
· Post-operative pulmonary embolism术后肺栓塞
· Hospital acquired infections 医院获得性感染
· Falls 跌倒
· Pressure ulcers 褥疮
· Adverse clinical incidents 不良临床事件
· Near misses 侥幸避免事件
6d.3How regularly is the above data reported? 以上数据的报告周期是多久？y
Free text: please give details:请提供详情：y
6d.4 How is this information acted upon to improve patient safety?上述信息是如何被用于提高患者安全的？y
Free text: please give details:请提供详情：y
6d.5Please provide some details on how information is collected or reported, and how changes are then implemented:请提供关于信息收集，报告，然后进行改进的详情：y
Free text: please give details:请提供详情：y
6d.6Clinical audit includes comparisons between departments and organisations where appropriate to benchmark clinical standards 临床稽查/审计是否包括相关部门之间的对比以确定相应的临床标准
6d.7Does the hospital submit data on clinical quality/audit to external databases? 医院是否将临床质量/稽查的数据披露给第三方机构或外部数据库？
y
6e.Patient Consent患者知情同意Yes/No/Other 是/否/其他Reason原因
6e.1Please attach copies of consent forms请提供知情同意书复印件y
6e.2Please confirm that:请确认以下各项：y
For examination verbal consent always obtained and documented? 对于检查，是否都要取得患者口头同意并加以记录？
For invasive procedures, is written consent always obtained and documented?对于隐私处置，是否取得患者口头同意并加以记录？
6e.3Is a standardised adult consent form used?成人的知情同意书是否采用标准化格式？
6e.4Is this available in English?是否有英文的知情同意书？
6e.5Is the consent available in any other languages? (is so which)是否有其他语言的知情同意书？（如有，是什么语的？）
Free text: please give details:请提供详情：y
6e.6Are consent forms structured to allow for patient and doctor signatures? 知情同意书中是否要求患者和医生签字？
6e.7Are all consent forms dated and signed by the patient?知情同意书是否都要注明日期，并由患者签字？
6e.8Are all consent forms dated and signed by the professional completing them?知情同意书是否都要注明日期，并由填写的医生签字？
6e.9Are specific paediatric consent forms used?是否有专门的儿科知情同意书？
6e.10Are paediatric consent forms structured to allow for a signature and date from legal guardian/authorising person as applicable?儿科知情同意书是否要求法律监管人/委托人签字，并注明日期？
6e.11Does the hospital employ a policy regarding the age at which a patient (considered a minor in law) is able to autonomously consent of refuse treatment?医院是否有制度涉及可以自主签订拒绝治疗书的患者年龄？
6e.12Does the hospital have a consent form for use if a patient is unable to consent for themselves?当患者本人不能为自己签订知情同意书时，医院是否有其他格式的知情同意书？
6e.13Is there a written policy which governs the use of the above?是否有书面的制度涉及以上状况？
6e.14When taking consent, are the following documented:当签订知情同意书时，是否记录以下各项：y
· Patient name 患者姓名
· Patient date of birth 患者出生日期
· Unique patient identifier code 患者唯一识别码
· Name of operation/procedure 手术／处置的名称
· Location on the body or verification of the side of surgery (e.g. left or right)
手术部位确认（例如，左或右）？
· Possible serious adverse incidents (e.g. death, loss of limb)可能发生的严重不良事件（例如，死亡、四肢缺损）
· Possible side effects 可能发生的副反应
· Possible alternative treatments 可能的备选治疗方案
· Indication that supplementary aids for information have been provided (e.g. information leaflets)指出辅助性信息已向患者提供（例如，宣传单页）
6e.15For procedures which involve anaesthesia, does the consent form include: 对于涉及麻醉的处置，知情同意书是否包括：y
· Type of anaesthetic (for example GA, LA, spinal, or epidural,) 麻醉类型（例如，全麻，局麻，腰麻或硬膜外麻醉）
· Options available 备选方案
· Specific risks with the selected type of anaesthesia 所选麻醉类型的特定风险
Free text: please add any additional details regarding the consent procedure for interventions and anaesthesia followed in the hospital. 其提供关于处置和麻醉知情同意书方面的规范详情。y
6e.16Are specific consent forms used for any clinical research or experimental treatments to ensure patients are fully informed of all treatment decisions? 针对参与临床研究或试验的病人，是否有相应的知情同意书以确保病人知晓所有相关的治疗信息？
6e.17Does the hospital have a policy that states which treatments/procedures need specific informed consent? 医院是否有制度表明有哪些治疗需要特殊的知情同意？
6f. Patient Satisfaction患者满意度Yes/No/Other 是/否/其他Reason原因
6f.1Are any tools used to monitor patient satisfaction? Please supply是否使用工具来监测患者满意度？请提供
6f.2Does the hospital employ a customer satisfaction survey? Please attach a copy医院是否使用患者满意度调查问卷？请提供复印件
6f.3
What percentage of patients receives a customer satisfaction survey to complete? 参与满意度调查的患者所占百分比是多少？
6f.4What is the response rate expressed as a percentage of all surveys distributed?满意度调查问卷的答复率为多少？
6f.5How often are the results reported?调查结果多久报告一次？
6f.6Does the survey include:调查问卷是否包括：y
· Overall satisfaction score 整体满意度评分
· Views on clinical care 对于临床服务的看法
· Views on personalised care 对于人性化服务的看法
· Views on medical staff 对于医务人员的看法
· Views on attitude of nursing staff 对于护理人员态度的看法
· Views on attitude of administrative staff
对于行政人员态度的看法
· Views on facilities - Beds, bathrooms, toilets 对于医院设施的看法-病床，洗手间
· Views on cleanliness 对于清洁度的看法？
· Views on catering 对于餐饮服务的看法
· Views on being kept well informed 对于被很好告知的看法
· Views on feeling safe
对于安全的看法
· Whether the patient would recommend the hospital 患者是否会推荐该医院
6f.7Is there a written process for ensuring patient feedback leads to change in practice?是否有书面流程确保通过患者的反馈信息实施改进？
6f.8Please provide an example of your questionnaire and copy of latest report.请提供一份患者满意度调查问卷以及最近一期满意度调查报告y
Free text: please
provide any further details on the process:请提供相关书面流程y
6gCustomer Complaints Process患者投诉流程Yes/No/Other 是/否/其他Reason原因
6g.1Is there a written and dated procedure for dealing with complaints from patients?有关于处理患者投诉的，书面的，且标明日期的程序？
6g.2Is there a specific department which deals with patient complaints?有指定的处理患者投诉的部门吗？
6g.3Do patients have easy access to information about how to complain?患者能否方便获得如何投诉的信息？
6g.4Does this procedure have defined steps to ensure the following steps:投诉处理程序是否包含以下各项：y
· Acknowledgement of complaint 投诉确认
· Appropriate processing 适当处理
· Escalation as appropriate 适当逐级上呈
· Time scales for response 时序表
· Response to patient 答复患者
· Legal consideration 法律考虑
· Using the complaint to improve process 借助投诉改进流程
6g.5Is the complaints process audited
to observe:是否对投诉处理程序进行稽查，以了解以下各项：y
· Actual number of complaints, both formal written and formal verbal 实际投诉数量，包括正式书面的和正式口头的
· Number of complaints as a percentage of total admissions 投诉数量占住院人数的百分比
· Complaints resolved within specified timeframe (recommend 28 days) 规定时间（建议28天）内解决的投诉数量？
· Number of unresolved complaints 尚未解决的投诉数量？
6h.The Foreign Patient 外籍患者Yes/No/Other 是/否/其他Reason原因
6h.1Are there processes to ensure the following for foreign patients: 是否有相应的规范确保外籍患者的以下要求：y
· Availability of translators as required 24 hours a day (including emergency) 如需要，可提供24小时翻译(包括急诊)
· Provision of written health information in English 提供书面的英文资料
· Provision of consent forms in English 提供英文的知情同意书
· Respect of particular cultural sensitivities of patient (e.g. gender of treating staff, post-operative care, mixed sex accommodation, washing and bathing) 尊重患者特殊的文化特性（例如，诊疗人员的性别、术后看护、男女混住病房、清洗和沐浴）
· Respect for particular religious beliefs 尊重特殊的宗教信仰
· Provision of multi-faith support services 提供多种信仰支持服务
· Catering for specific dietary requirements (for example vegetarian, kosher, halal) 满足特殊饮食要求（例如，素食者的，犹太教的，伊斯兰教的要求）
· Sensitivity to the family’s beliefs 尊重患者家人的信仰
· Liaison with medical staff in patient’s country of origin 与患者原居住国的医务人员联系
· Facility for patient to communicate with home country (e.g. international telephone facility) 为患者提供与原居住国联络的设施（例如，国际长途电话）
理念不一样，管理不一样，所以。。。
去年起我院开展读书年活动，院长推荐大家学习的三本书：“致加西亚的信”（全国销量第六）“海恩法则”还有就是“向世界最好的医院学习管理”，号召大家写读书体会。
海恩法则我曾发过帖子向大家介绍，现在看到icchina 的这个帖子后，我又向大家推荐一本书“向世界最好的医院学习管理”，对于我们来说梅奥诊所带来的是全新的理念。 在当当网可以买到。 要是都能完成这些条款，一定是一家深受欢迎的好医院啦。
里面不少还涉及感染控制的问题！ 回复 9# 柳莹依
谢谢推荐，我打算到网上书店去掏一下啦！ 回复 1# icchina
在大陆还真没有看见医院里有祷告室的，只是去年在台湾见过。也没有看见少数民族食堂~{:1_6:} 回复 13# 无极紫晶
紫晶版主有所不知，我院就有基督教、佛教、伊斯兰不同宗教的场所。在患者入院宣教时就有介绍，患者家属可以在不同的宗教崇拜室祷告亲人平安健康。 达到保柏认证的标准，“以病人为中心”、“患者至上”将不再是空话，医疗安全才能真正有所保障。 "致加西亚的信"不是全国销量第六，而是全球！
100年来，《致加西亚的信》一书以不同的方式在全世界广泛流传，成为有史以来最畅销的书籍之一。2000年被美国《哈奇森年鉴》和《出版商周刊》评选为有史以来世界最畅销图书第6名。本书所推崇的关于敬业、忠诚、勤奋的思想观念影响了一代又一代人，一个国家又一个国家。
我们都需要时常读这本书，因为它所推崇的精神在哪个国家哪个制度下都是得到认可的，每当接受上级的嘱托的时候，每当遇到困难的时候，我总会想到那个可以将信送给加西亚的人：罗文。每当我完成一项重要工作的时候，我就会想到：我也可以做了一次罗文。6月份在来南京的路上，我又再次读了这本书，感受良多，为此给儿子写了一封4页纸的电子家书，他们这些年轻人同样需要培养罗文的精神。 在当当网有
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