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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 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.
