이 연구는 3차 진료기관 응급실의 기능을 정상화하기 위한 기초 자료를 수집하기 위하여, 한 3차 진료기관 응급실을 방문한 환자를 대상으로, 입원 결정서 발부와 환자의 입원 결정 양상 및 이에 영향을 미치는 요인을 파악하였다. 또한 적절성 평가 지침을 이용하여 응급실을 통한 입원의 적절성을 평가하였고 입원의 적절성과 응급실 입원 대기시간의 적절성에 영향을 미치는 요인을 분석하였다. 입원 결정서 발부에 영향을 미치는 요인은 환자의 내 외과계 구분, 진료과수, 환자 상태, 방문 경로, 방문 시간과 방문 요일이었다. 입원 결정서 발부 후 환자의 입원 여부는 환자의 성, 환자 상태, 방문 경로, 방문 요일에 따라 달리 나타났다. 환자의 연령, 내 외과계 구분과 방문 요일에 따라 입원의 적절성에 차이를 보였다. 입원 대기시간은 환자의 연령이 증가할수록 적절성이 낮았다. 이 연구를 통하여 응급실을 통한 입원 중 반수 이상의 입원이 부적절한 입원으로 평가되었고, 이 중 일부는 입원을 빨리 하기 위한 방법의 하나로 응급실을 편법으로 이용하고 있기 때문인 것으로 판단되었다. 또한 입원 결정서가 발부된 환자 중 상당수의 환자가 병상을 구할 수 없어 입원하지 못하고 있는 것으로 보아, 3차 진료기관의 환자 집중 현상과 응급실 과밀화 요인 해소를 위한 의료정책의 수립이 필요함을 확인할 수 있었다.

Background: Guideline for practice is useful because it can be the standard for assessment and way to improve quality. We need to take account of expert opinion and consensus as well as scientific evidences to develope practice guideline because it should be practical. Delphi method has been developed to gather opinions from experts fairly. This study was designed to develop practice guideline and apply it to practices as a method to improve quality in primary medical care. Methods: Hypertension(in adults over 18 years old) was selected as a target problem. Self questionnaires about management of hypertensive patients were developed by a researcher with advice of 11 experts. The questionnaires were designed to response as a 5 pont scale. The results of previous questionary were given to respondents in second and third questionnaires. If needed, the questionnaires were changed on the previous responses. The items with medium greater than or equal to 4 point in 1st and 2nd responses were accepted in guideline. The items with medium lesser than or equal to 3 point were questioned again about whether they can be excluded or not. The criteria for assessment was made with reference to guideline and applied to 85 hypertensive patients of 9 family practitioners. At 3 months after practice guideline had been given to family practitioners, performance of same practitioners was assessed with 36 new hypertensive patients. Results: 23 professors in family medicine, 22 family practitioners and 6 cardiologists, responded among 50, 50, 15 respectively. Practice guideline with 33 items was developed as a result of 3 times questionaires. The difference of responses between professors in family medicine, family practitioners and cardiologists was not significant. Performance of practice was improved in diagnosis, history taking about 6 fields, laboratory examination and decision making about time of pharmaceutical prescription. It was not improved in physical examination, life style modification, method of pharmaceutical prescription, choice of initial antihypertensives and history taking about duration of disease and diet habit. It was decreased in history taking about psychosocial factors. The assessment scores were low in history taking, physical examination and life style modification before and after use of practice guideline. Conclusion: Practice guideline for hypertension could be developed by Delphi method. Performance of practice improved partially after use of guideline.

Clinical trials of drugs on humans is the final and most important stage in evaluating the safety and efficacy of the drugs. Good Clinical Practice(GCP) standards were announced in 1987 to protect testees' rights as well as to ensure validity of the clinical trial results, but its implementation has been delayed until now. The purpose of this study is to evaluate the preparedness of the designated institutions to abide by GCP standards during clinical trials, and thereby to determine GCP implementability at the institutions. Survey on the status of clinical trials was conducted for the designated 83 clinical trial hospitals. Response rate was 95.2%. Donabedian's quality assessment model was applied as the basic framework for the study. And the relative - weights for the evaluation items were determined by expert's evaluation. Among the designated 83 hospitals, 39 conducted clinical trials to obtain drug manufacturing approval from 1990 to 1994. Only 19 institutions are found to be able to meet the requirements of KGCP. Structure variables - manpower, organization, and facility -, which are the basic elements for GCP, are evaluated as unsatisfied in many hospitals. Institutions which established IRB accounted for 41 or 51.9%, but those who have a protocol evaluation guideline, or Adverse Drug Reaction(ADR) reporting system were only 12 and 21 institutions, respectively. Also, the institutions providing educational programs on conducting clinical trials are few - 20. The study results indicates that the level of conducting KGCP is unsatisfactory. However, more institutions are expected to be able to meet the standards soon because GCP standards does not require so much regulation on facilities, but stress importance on research methodology and human right. At present as the institutions for clinical trials are primarily training hospitals with residency programs, such efforts as education will accelerate the implementability of GCP in Korea. Institutions must build the appropriate infrastructure and government must prepare to strongly enforce KGCP before it can successfully take place.

The Comprehensive quality assurance for radiation oncology provides an overall organizational structures, responsibilities, procedures, processes and resources for assuring the quality of patient management by radiation treatment. Superior performance of modern radiotherapy equipment will be essential part of quality assurance in radiation oncology, which high degree of accuracy and consistency should be maintained under the optimal quality assurance program. Besides quality control of all radiation equipment, this review also emphasizes quality assurance of clinical aspect such as adequacy of the medical decision-making which eventually leads to the treatment prescription, accuracy of treatment procedure from treatment preparation to radiation delivery, and the significance of assessment of treatment outcomes with structure and process.

Background: Clinical indicators are objective measures of process or outcome of patient care in quantitative terms. This study aims to review the medical records of patients who 'return to operating room during the same admission', which is one of the critical clinical outcomes, and describe the result by unplanned reoperation rate. Methods: Computerized patient registry was used for selecting subject conditions. For medical records retrieved, two nurse evaluators identified the presence of explicit reoperation planning in medical records. Results: Overall reoperation rate was 2.8% and unplanned reoperation rate 1.3%. The main category of reoperation cause was the postoperative bleeding. Duration of stay from previous operation to reoperation of the unplanned group, 12.7 days, was shorter than that of the planned(p< .05). The differences did not reach statistical significance in age, sex and length of stay. Conclusion: Results suggested that unplanned reoperation rate was lower than 'threshold' level other institutions had established. However, this result could become comparable only after management of medical records would be improved and risk adjusted.

Background: Korean Hospital Standardization Program(KHSP), as a hospital accreditation program initiated and promoted by Korean Hospital Association since 1981, has played a key role in the hospital quality improvement in structural aspect particularly. Recently, however, KHSP has been critisized by hospitals and health personnels in that it is unpractical to be utilized as an initiative to improve hospital quality. In particular, the section of quality assurance in KHSP, strongly influenced by old version of Hospital Accreditation of Joint Commission in U.S.A., has been required to be fundamentally revised. For design of new criteria in quality assurance section, a survey for evaluation of existing program and collection of opinions for ideal one was conducted. Methods: For a month in 1994, structured questionnaires were administered by mailing to 470 hospital staffs from 200 hospitals, participated in the survey for the 1994 KHSP in each hospital. The total number of respondents was 116. Results: Less than half of the respondents(34.5%) value positively on the impact of current KHSP in general on the quality improvement of their hospitals. Moreover, most responses indicated that KHSP should be reorganized towards more practical and applicable one. Current KHSP criteria for quality activities in hospitals were regarded as a unpractical one which should be basically renewed. For new criteria and standards, most respondents emphasized the importance of applicability of those in real situations. Conclusion: For the KHSP to be effective, new evaluation criteria for quality activities should be more practical and fully accommodated to hospital situations in reality.