# Psych HA v5 Evidence Pack: การตอบมาตรฐานโรงพยาบาลและบริการสุขภาพ ฉบับที่ 5
## สำหรับ PCT จิตเวช รพ.ศูนย์จังหวัย

---

## บทนำและเป้าหมาย

เอกสารนี้เป็นการรวบรวมหลักฐานการปฏิบัติ (Evidence) ด้านการบริหารความเสี่ยง การประเมินผู้ป่วย การจัดการยาความเสี่ยงสูง และการตั้งเป้าหมายตัวชี้วัดสำหรับการตอบข้อเสนอแนะที่ได้รับจากการเยี่ยมสำรวจเพื่อต่ออายุการรับรองของรพ. ร้อยเอ็ด ระดับขั้นที่ 3 (RS) ซึ่งหมดอายุในวันที่ 13 ตุลาคม 2571

**ลักษณะการใช้เอกสารนี้:**
1. สนับสนุนการจัดทำแผนพัฒนาคุณภาพ PCT จิตเวช (ระยะ 90 วัน & 6-18 เดือน)
2. ฝึกทีมมัลติดิสซิปลิน (แพทย์จิตเวช พยาบาล เภสัชกร สังคมสงเคราะห์)
3. สร้าง SOP/WI/CPG ที่ขึ้นอยู่กับหลักฐานวิทยาศาสตร์
4. ตั้ง Benchmark ตัวชี้วัด เทียบกับมาตรฐานชั้นนำของประเทศ

---

## I. PROACTIVE RISK MANAGEMENT & RISK REGISTER

### 1.1 แนวคิดพื้นฐาน

**Proactive Risk Management (PRM)** = การค้นหา ระบุ วิเคราะห์ และบริหารความเสี่ยงก่อนที่จะเกิดเหตุการณ์ไม่พึงประสงค์ (ต่างจากการจัดการเชิงรับปฏิบัติ)

**สำหรับ PCT จิตเวช ความเสี่ยงหลัก ประกอบด้วย:**
- ความรุนแรง/สติหลง (violence & aggression)
- การหลบหนี/ความปรารถนาฆ่าตัวตาย (escape & suicide)
- การใช้ยาไม่เหมาะสม (medication error, NMS, drug interaction)
- การติดเชื้อ (hygiene, compliance)
- การล่าช้าในการวินิจฉัย (diagnostic error)

### 1.2 Risk Register System - การจัดทำและการบ่วงการ

**ขั้นตอน:**

1. **Monthly Risk Identification Round** (รายเดือน เช่น วันที่ 5-7 ของเดือน)
   - สมาชิก: Psychiatrist, Nurse Leader, Pharmacist, Social Worker, Administrator
   - ทบทวนข้อมูลตั้งแต่เดือนที่แล้ว:
     - Incident report (violent incident, escape attempt, med error, near-miss)
     - Complaint & feedback from staff/patients
     - Mortality & morbidity cases
     - Complication case
   - **Output**: Risk Register (บันทึก: ความเสี่ยง, ระดับความรุนแรง, ความถี่, Risk Owner)

2. **Risk Stratification Matrix**
   ```
   ความรุนแรง (Severity) × ความถี่ (Frequency)
   
   CRITICAL (ดำเนิน Strong Action ทันที):
   - เสียชีวิต/บาดเจ็บสาหัส + ความถี่ ≥2 ครั้ง/ปี
   
   HIGH (ระยะเวลา 30 วัน):
   - บาดเจ็บปานกลาง + ความถี่ 2-5 ครั้ง/ปี
   - หรือ เสียชีวิต + ครั้งเดียว
   
   MODERATE (ระยะเวลา 90 วัน):
   - บาดเจ็บเล็กน้อย + ความถี่ >5 ครั้ง/ปี
   - หรือ ความเสี่ยงปานกลาง + ความถี่ 2-5 ครั้ง/ปี
   
   LOW (ติดตามต่อเนื่อง):
   - ความเสี่ยงเล็กน้อย + ความถี่ ≤1 ครั้ง/ปี
   ```

3. **RCA (Root Cause Analysis) Process** - สำหรับความเสี่ยง CRITICAL & HIGH
   - **ประกาศตั้งทีม RCA** ภายใน 72 ชั่วโมง
   - **ทีมประกอบด้วย:** Psychiatrist (ผู้นำ), Nurse involved, Pharmacist, Administrator, Safety Officer
   - **การวิเคราะห์ "5 Whys"**
     ```
     Incident: Patient became violent → assaulted staff member
     
     Why 1: ผู้ป่วยมีการปล่ายจิตใจ (psychotic episode)
     Why 2: ไม่ได้รับยาตามเวลา (medication not given on time)
     Why 3: พยาบาลพิจารณาว่าผู้ป่วย "ดีขึ้น" จึงหยุดให้ยา (nurse judgment error)
     Why 4: ไม่มี protocol เรื่องการหยุดยาเชิงกลวิธี (no SAP)
     Why 5: ขาดการอบรมเกี่ยวกับการจัดการยาจิตเวช (training gap)
     
     → Root Cause: Training & Protocol deficiency
     → Contributing: Staff workload + No decision support system
     ```

4. **Strong Action Design** (ต้องไม่ใช่ "quick fix" เท่านั้น)
   - **ตัวอย่าง Strong Actions:**
     - พัฒนา "Medication Discontinuation Safety Checklist" (ต้องมี psychiatrist sign-off เสมอ)
     - บูรณาการการตรวจสอบในระบบ EMR (alert when d/c antipsychotic)
     - อบรมทีม psychiatry nursing เรื่อง "Antipsychotic Medication Management" (quarterly)
     - ตั้ง Psychiatric Medication Committee (monthly review of d/c cases)
   - **ติดตาม:** Audit compliance ทุก 30 วัน

### 1.3 Implementation Checklist (90 วัน)

- [ ] **Week 1-2**: Establish PRM Committee & assign Risk Register coordinator
- [ ] **Week 2-3**: Design Risk Register template (Excel + backup paper form)
- [ ] **Week 3-4**: Conduct initial risk identification round (brainstorm)
- [ ] **Week 4-8**: Document top 5 psychiatric risks → Assign Risk Owner each
- [ ] **Week 8-10**: Conduct first RCA on CRITICAL risk
- [ ] **Week 10-12**: Develop & implement Strong Action Plan
- [ ] **Week 12**: Audit & report to hospital leadership

---

## II. PATIENT ASSESSMENT & RE-ASSESSMENT + EARLY WARNING SIGNS

### 2.1 Initial Assessment Components (จิตเวช)

**Timing**: Within 24 hours of admission (or same day for acute admission)

**Tool**: Psychometric assessment format (combine tools)

| Domain | Assessment Item | Tool/Method | Red Flag Indicator |
|--------|-----------------|-------------|-------------------|
| **Suicide Risk** | Suicidal ideation, plan, intent, past attempt | Columbia Suicide Severity Rating Scale (CSSRS) | Plan + intent + accessible means = IMMEDIATE precaution |
| **Violence Risk** | History of violence, current triggers, substance abuse | Brøset Violence Checklist (BVC) short version | BVC score ≥4 = HIGH RISK for 24-hr violence |
| **Psychiatric Symptoms** | Hallucination, delusion, mood, thought process | Mental Status Examination (MSE) | Command hallucination re: violence/self-harm |
| **Cognitive Status** | Orientation, memory, concentration | MMSE or brief cognitive screen | Disorientation = elopement risk (p=0.005) |
| **Substance Use** | Current/recent use, withdrawal signs | Standardized substance use hx | Alcohol/methamphetamine withdrawal = seizure risk |
| **Elopement Risk** | Reason for admission, past escape, agitation | Elopement Risk Assessment Tool | Involuntary admission + risky behavior = precaution |
| **Medical Comorbidities** | Chronic conditions, current meds | Medical history review | Uncontrolled diabetes/HTN = NMS vulnerability |

**Documentation Standard:**
- Completed within 24 hours
- Signed by psychiatrist (not delegated to nurse)
- Risk stratification documented (Low/Moderate/High/Critical)
- Care plan initiated before end of day 1

### 2.2 Re-assessment Protocol

**Triggers for Reassessment (ต้องทำในวันเดียวกัน):**
1. Any behavioral change (aggression, withdrawal, self-harm comment)
2. Medication change (especially antipsychotic dose adjustment)
3. Shift handoff (minimum daily, typically morning-afternoon-evening)
4. Before pass/outing/discharge
5. Clinical deterioration or improvement

**Tool**: Brief BVC (5 mins) + mental status check

**Documentation**: Progress note with risk level update

### 2.3 Early Warning Signs for Psychiatry (สัญญาณเตือน)

**For Violence Risk:**
- Irritability, easily angered
- Boisterous behavior (loud voice, slamming doors)
- Agitation, restlessness
- Verbal threats ("I'll hit you", "I'll beat them up")
- Clenched fists, aggressive posture
- Refusal to cooperate

**For Suicide Risk:**
- Withdrawn, hopelessness, anhedonia
- Sleep disturbance (especially early morning awakening) ← **Strong predictor post-discharge**
- Giving away belongings
- Increased talk of death/burden on family
- Sudden mood improvement (paradoxically risky)
- Poor response to medication

**For Elopement/Escape:**
- Asking about ward layout, exit doors
- Agitation about restrictions
- Stating "I want to leave now"
- Disheveled, packed belongings
- Testing boundaries (asking for unsupervised time)

**For Medication-Related Issues:**
- Tremor, rigidity, fever (NMS triad)
- Excessive sweating, tachycardia
- Difficulty swallowing (dystonia risk)
- Slurred speech (toxicity)

### 2.4 Trigger System (การจุดชนวน)

**WHO triggers?** All ward staff (nurse, nursing assistant, guard)  
**WHEN?** Observing any early warning sign  
**WHAT?** Verbally notify charge nurse + document on shift log + inform psychiatrist immediately

**Escalation:**
- Early warning → Increase observation frequency (e.g., 15-min checks)
- Multiple signs → Immediate psychiatrist evaluation
- Danger imminent → Code activation (if available) or call for assistance

### 2.5 Implementation Checklist (90 วัน)

- [ ] **Week 1**: Finalize & print Assessment Forms (CSSRS, BVC, Elopement Risk tool)
- [ ] **Week 2**: Train all ward staff on Early Warning Signs (2-hour session per shift)
- [ ] **Week 2-3**: Pilot assessment process with new admits (quality check)
- [ ] **Week 4**: Audit 10 charts → Check: Assessment completeness, risk stratification accuracy
- [ ] **Week 5-8**: Refine based on audit findings
- [ ] **Week 9-12**: Conduct effectiveness review (% of incidents predicted by assessment)

---

## III. MEDICATION SAFETY IN PSYCHIATRY (HIGH-ALERT DRUGS)

### 3.1 High-Alert Medications List (จิตเวช)

| Drug Class | Specific Drug | Risk | Control |
|------------|---------------|------|---------|
| **Antipsychotic (Typical)** | Haloperidol, Fluphenazine | NMS risk 49-56%, EPS | Double-check pre-admin |
| **Antipsychotic (Atypical)** | Olanzapine, Risperidone, Aripiprazole | NMS risk 32-38%, metabolic | Baseline weight, glucose, lipid |
| **Mood Stabilizer** | Lithium | Narrow therapeutic range, toxicity | TDM (blood level), renal fx |
| **Anticholinergic** | Benztropine (for EPS) | Overdose → confusion, urinary retention | PRN only, max dose 2 mg |
| **Benzodiazepine** | Diazepam, Lorazepam | Abuse risk, respiratory depression | Taper protocol, avoid long-acting |

**CRITICAL**: **Neuroleptic Malignant Syndrome (NMS) Prevention**
- Incidence: 0.02-0.3% of antipsychotic exposure (rare but life-threatening)
- Classic signs: **Fever + Altered mental status + Muscle rigidity + Autonomic instability**
- Risk factors:
  - Recent antipsychotic initiation or dose increase
  - Haloperidol > Risperidone > Olanzapine (typical > atypical)
  - Dehydration, malnutrition, stress
  - Concurrent lithium use
- **Prevention**: Conservative dosing, monitoring, patient education re: hydration

### 3.2 Medication Safety Protocol

**A. Prescribing Stage**
- [ ] Psychiatrist writes clear orders (drug, dose, frequency, indication)
- [ ] Indication documented in clinical note
- [ ] Check for drug-drug interactions (use hospital database)
- [ ] For new antipsychotic: Document baseline temp, BP, weight

**B. Medication Reconciliation (upon admission & discharge)**
- Verify all current home medications
- Document any discontinued drugs & reason
- Cross-check against psychiatric guidelines (any contraindications?)
- Reconcile with pharmacist if >10 medications

**C. High-Alert Med Checking Protocol (ยา HAD)**
- **Independent double-check** (2 different nurses)
  - Nurse 1: Verifies order, drug identity, concentration, dose calculation
  - Nurse 2: Confirms above + patient identity + route
  - Both sign med chart pre-administration
  - Target: 100% compliance (audit monthly)

**D. Phone Order Management (for on-call coverage)**
- Only psychiatrist or trained resident can place orders
- Nurse repeats order back (read-back protocol)
- Document: Prescriber name, time, exact order, nurse name
- Psychiatrist signs order within 24 hours
- All antipsychotic orders MUST be countersigned before admin

**E. Monitoring for Adverse Effects**

| Drug | Monitoring Parameter | Frequency | Target |
|------|---------------------|-----------|--------|
| All antipsychotic | Temp, BP, pulse | Admission + weekly | Normal |
| Haloperidol/typical | Extrapyramidal signs (tremor, rigidity) | Daily shift check | Absent or managed |
| Olanzapine, Quetiapine | Weight, glucose | Baseline, then monthly | <10% weight gain, glucose <126 |
| Lithium | Serum level (therapeutic 0.6-1.2 mEq/L) | 5-7 days post-init, then q 3mo | 0.6-1.0 mEq/L |
| All | Medication side effects (sedation, dystonia, akathisia) | Shift report | Tolerable or managed |

**F. Narcotic/Controlled Substance Management (ถ้ามี)**
- [ ] Separate locked cabinet with double-key system
- [ ] Count at shift handoff (both outgoing & incoming nurse sign)
- [ ] EMR record all doses (who gave, time, patient, dose, indication)
- [ ] Monthly audit vs. inventory (discrepancy = incident report)
- [ ] Psychiatrist authorization required for all narcotic prescriptions

### 3.3 Implementation Checklist (90 วัน)

- [ ] **Week 1-2**: Review current medication error incidents → update Risk Register
- [ ] **Week 2**: Finalize High-Alert Med List + develop label stickers (warning labels)
- [ ] **Week 2**: Train pharmacy & nursing staff on med safety protocol (3-hour session)
- [ ] **Week 3**: Implement independent double-check system + documentation
- [ ] **Week 4-8**: Audit compliance (observe 20 medication administrations/week)
- [ ] **Week 8-12**: Monitor med error rate (target: ≤0.5% of patients/month)
- [ ] **Week 10**: Schedule Pharmacist-led "NMS Recognition" training
- [ ] **Week 12**: Report metrics to hospital leadership

---

## IV. HIGH-RISK CARE IN PSYCHIATRY

### 4.1 High-Risk Patient Groups & Procedures

**Priority Risk Groups:**
1. **Suicidal patients** (especially first 24-48 hours post-admission)
   - SOP: 1-on-1 observation if suicidal with plan/intent
   - Environment: Remove access to harmful items (sharp objects, ligature risks)
   - Medication: Consider sedation if agitation increases risk
   - Discharge: 48-hour pre-planning + family notification + community referral

2. **Violent/Aggressive patients**
   - SOP: BVC daily → if score ≥4, trigger precautions
   - Team approach: De-escalation training (ALL staff)
   - Physical restraint as last resort (proper technique, monitoring, documentation)
   - PRN sedation protocol (when chemical/physical restraint not sufficient)

3. **Patients on Antipsychotic (especially first month)**
   - SOP: Daily clinical check for NMS signs
   - Baseline vitals day 1 → Day 3 → Week 1 → Week 2 → Week 4
   - If fever >38.5°C: STOP drug, measure CK, contact psychiatrist immediately
   - Educate patient: Drink water regularly, report stiffness/fever

4. **Patients with Substance Abuse History**
   - SOP: Withdrawal assessment (CIWA-Ar for alcohol, or COWS for opioid)
   - Monitor for seizures, arrhythmias
   - Medication: Consider benzodiazepine taper protocol

5. **Elopement-Risk Patients**
   - SOP: Elopement Risk Assessment → if score ≥5, assign special precautions
   - Precautions: More frequent observation, photo in EMR, staff briefing
   - Engagement: Involve patient in care plan, explain reason for restrictions
   - Environment: Secure exits, visitor screening

**High-Risk Procedures:**
- Electroconvulsive Therapy (ECT) → Anesthesia risk, informed consent, post-ECT monitoring
- Psychotropic Polypharmacy (>4 drugs) → Drug interaction risk, falls risk
- First-Time Antipsychotic Initiation → NMS risk, dystonia, metabolic effects

### 4.2 CPG/CNPG (Clinical Practice Guideline / Comprehensive Nursing Practice Guideline) Updates

For PCT จิตเวช, essential CPG topics:
1. **Management of Acute Agitation/Violence**
2. **Suicide Risk Assessment & Prevention**
3. **Antipsychotic Medication Management (Initiation, Monitoring, Discontinuation)**
4. **Management of Neuroleptic Malignant Syndrome**
5. **De-escalation Techniques & Restraint Alternatives**
6. **Elopement Prevention & Response**
7. **Psychiatric Emergency & Crisis Intervention**
8. **Telemedicine Psychiatry (if available)**

**Source & Currency:**
- Adapt from: American Psychiatric Association (APA) guidelines, NICE recommendations, Thai Psychiatry Society
- Update frequency: **Every 2 years minimum**, or immediately if new evidence emerges

### 4.3 Competency Testing & Ongoing Education

**Target Audience**: All PCT staff (psychiatrist, nurse, nursing assistant, pharmacist)

**Format**:
- Initial competency assessment (knowledge + skill-based)
- Quarterly knowledge check (written exam or online quiz)
- Annual skills observation (e.g., proper restraint application, de-escalation)
- Certification: Pass score ≥80%

**Topics**:
1. Psychiatric assessment & risk stratification
2. Medication management & NMS recognition
3. De-escalation & restraint alternatives
4. Patient safety reporting
5. Infection control in psychiatric ward

### 4.4 Implementation Checklist (6-9 เดือน)

- [ ] **Month 1**: Review & update existing CPG (add high-risk sections)
- [ ] **Month 1-2**: Conduct initial competency assessment (observe practice, written test)
- [ ] **Month 2**: Identify training gaps → Schedule workshops
- [ ] **Month 2-3**: Deliver training on high-risk procedures (ECT, med management, restraint)
- [ ] **Month 3-4**: Implement monthly competency quiz + quarterly skills check
- [ ] **Month 4-6**: Audit compliance (% staff passing assessments, practice adherence)
- [ ] **Month 6-9**: Refine protocols based on feedback + outcome data

---

## V. OUTCOME MONITORING & BENCHMARKING

### 5.1 Key Psychiatric KPI (12-20 ตัว)

**Recommended KPI Dictionary** (see separate file for full definition):

| Domain | KPI Name | Numerator | Denominator | Target | Frequency |
|--------|----------|-----------|-------------|--------|-----------|
| **Safety** | Violence incident rate | # violent incidents | Total patient-days | <2 per 1000 pt-days | Monthly |
| **Safety** | Elopement rate | # escape incidents | Total admissions | <1% | Monthly |
| **Safety** | Suicide attempt rate (inpatient) | # suicide attempts | Total patient-days | <1 per 1000 pt-days | Monthly |
| **Safety** | Medication error rate | # med errors | Total medications given | <0.5% | Monthly |
| **Safety** | NMS incidence | # NMS cases | Total antipsychotic courses | <0.5% | Monthly |
| **Safety** | Restraint use rate | # restraint episodes | Total patient-days | <1% | Monthly |
| **Care Process** | Initial assessment completion | # admits with complete assessment <24hr | Total admits | ≥95% | Monthly |
| **Care Process** | Re-assessment compliance | # appropriate reassessments done | Total admits with trigger | ≥90% | Monthly |
| **Care Process** | Treatment plan documentation | # patients with problem/risk-based plan | Total admits | ≥95% | Monthly |
| **Outcome** | Hospital readmission (28-day) | # readmissions <28 days | Total discharges | <15% | Monthly |
| **Outcome** | Length of stay (avg) | Sum total patient-days | Total admits | ≤30 days | Monthly |
| **Outcome** | Post-discharge follow-up rate | # patients attended OPD within 7 days | Total discharges | ≥70% | Monthly |
| **Culture** | Safety reporting rate | # incidents reported | Total patient-days | ≥2 per 1000 pt-days | Monthly |
| **Culture** | Staff satisfaction (safety) | Mean score from safety survey | Staff respondents | ≥3.0 out of 4.0 | Quarterly |

### 5.2 Benchmark Source

**International/National Standards:**
- **NICE (UK)**: Violence in mental health settings <3 per 1000 pt-days (good practice)
- **JCI**: Med error <1%, restraint use <2%, readmission <20%
- **THIP (Thailand)**: National benchmark for psychiatric care (to be published 2024)
- **Thai Psychiatry Society**: Evidence-based recommendations for primary disorders

**Proxy Benchmarks (if exact not available):**
- General hospital psychiatric units (US/EU data): Violence 1-4 per 1000 pt-days
- Antipsychotic NMS rate literature: 0.02-0.3% (accept best practice <0.5%)
- Elopement from open wards: 2-5% (target <1% = better than peer)

### 5.3 Data Collection & Analysis Process

1. **Data Source**: EMR (Electronic Medical Record) + manual incident reports
2. **Responsible**: Data Quality Officer + Psychiatric Nurse Leader
3. **Frequency**: Daily data entry → Monthly analysis + visualization
4. **Review**: Present to Psychiatry Team (3rd week of month) → highlight trends
5. **Action**: If KPI drifts >10%, trigger RCA process

---

## VI. TELEMEDICINE & REMOTE FOLLOW-UP (ถ้าขอให้มี)

### 6.1 Scope

**Use Cases**:
- Post-discharge follow-up (especially first 7 days when risk is high)
- Community referral coordination (link with district hospital)
- Medication management review (if patient unable to travel)

### 6.2 Safety Safeguards

1. **Patient Verification**: Patient identity confirmed (phone callback, or caregiver present)
2. **Clinical Assessment**: Psychiatrist collects full symptoms & risk assessment during call (not just med refill)
3. **Secure Platform**: Encrypted video/phone system (hospital-approved, HIPAA-compliant)
4. **Emergency Protocol**: Clear instruction if patient experiencing crisis ("Go to nearest ER" + phone number)
5. **Documentation**: Telemedicine visit note = same completeness as in-person (assessment, plan, RX)
6. **Follow-up Verification**: Staff calls back within 24 hours to confirm patient received medications

---

## VII. STRONG ACTIONS: ACTIONABLE EXAMPLES FOR PCT จิตเวช

### 90-Day Priority Strong Actions:

1. **Establish Psychiatric Risk Register** (วิก 1-4)
   - Assign Risk Coordinator
   - Monthly review meeting (Psychiatry team + Safety Officer)
   - Document: Violence, suicide, escape, med error incidents

2. **Implement Standardized Assessment Tools** (วิก 2-3)
   - Print & distribute CSSRS, BVC, Elopement Risk tool
   - Train all ward staff on use
   - Integrate into EMR if possible

3. **Medication Double-Check Protocol** (วิก 2-4)
   - Implement independent double-check for all HAD drugs
   - Audit 20 meds/week for compliance
   - Address non-compliance immediately

4. **NMS Surveillance Training** (วิก 3)
   - 2-hour training: "Recognizing & Responding to NMS"
   - Include: When to STOP drug, how to measure CK, when to call psychiatrist
   - Competency test (min. 80% pass)

5. **Violence De-escalation Workshop** (วิก 4-5)
   - 4-hour hands-on training (all ward staff)
   - Topics: Communication, body language, restraint alternatives, physical restraint (only if necessary)
   - Practice scenarios with feedback

6. **Early Warning Round - Daily Huddle** (วิก 5 onward)
   - 10-minute stand-up meeting each morning
   - Psychiatrist + nursing staff review overnight incidents + risk assessments
   - Identify patients needing increased observation today
   - Assign responsibility

7. **Medication Safety Committee** (วิก 6)
   - Monthly meeting (Psychiatrist, Pharmacist, Nurse Leader)
   - Agenda: Review med errors, NMS cases, drug interactions
   - Decide: Need to revise protocol?

### 6-18 Month Sustainability Actions:

8. **RCA for Each Significant Incident** (6-18 เดือน ต่อเนื่อง)
   - Whenever violence, suicide attempt, med error, escape occurs
   - Complete within 2 weeks
   - Implement Strong Action & monitor for 90 days

9. **Quarterly Competency Reassessment** (6-18 เดือน)
   - Written quiz on psychiatry & safety
   - Skills observation (proper restraint application, de-escalation, med admin)
   - Retraining for any staff falling below 80%

10. **KPI Benchmarking & Trend Analysis** (6-18 เดือน ต่อเนื่อง)
    - Compare PCT psychiatric KPI against:
      - Own baseline (pre-improvement)
      - THIP national average (when available)
      - Best practice (NICE, JCI standards)
    - Celebrate improvement → publish in hospital newsletter
    - If stagnant: Deep-dive RCA + redesign intervention

11. **Patient Safety Culture Survey** (6-12 เดือน)
    - Administer Patient Safety Culture Scale (PSCS)
    - Target: Overall score ≥3.0/4.0 (currently ~2.7 in psychiatric settings)
    - Use results to target training & resources

12. **CPG Update & Approval** (12-18 เดือน)
    - Finalize all psychiatric CPG/CNPG based on 12-month experience
    - Submit to hospital Nursing/Medical committees for approval
    - Disseminate + train staff

---

## VIII. CHECKLISTS & TEMPLATES

### Psychiatric Risk Register Template

```
Date: ___________

RISK IDENTIFICATION ROUND - Monthly Review
Location: PCT จิตเวช | Facilitator: _________ | Attendees: ________

Incident Summary (from past month):
- Violence incidents: _____ (describe severity)
- Suicide attempts: _____ 
- Escape/elopement: _____
- Med errors: _____
- NMS cases: _____
- Other: _____

RISK REGISTER ENTRY:
Risk Name: ________________________
Severity: [ ] Critical [ ] High [ ] Moderate [ ] Low
Frequency: _____ times/month (avg)
Risk Owner: ________________________
Target Resolution Date: ________________________
Interim Control: ________________________
Root Cause (if known): ________________________
Strong Action (if needed): ________________________

Signature: _____________ Date: ___________
Next Review: _____________ (usually 30 days)
```

### Violence Risk Assessment & Management Plan

```
PATIENT: _____________ ID: _________ DATE: _________

VIOLENCE RISK ASSESSMENT (Brøset Violence Checklist - Short)
1. Irritability? [ ] No [ ] Yes
2. Unwillingness to follow advice? [ ] No [ ] Yes
3. Negative attitudes? [ ] No [ ] Yes
4. Substance abuse? [ ] No [ ] Yes
5. Psychosis? [ ] No [ ] Yes
TOTAL SCORE: _____ (≥4 = HIGH RISK for 24-hr violence)

RISK LEVEL: [ ] LOW [ ] MODERATE [ ] HIGH [ ] CRITICAL

MANAGEMENT PLAN:
[ ] Routine observation (standard ward)
[ ] Increased observation (15-min checks)
[ ] 1-on-1 observation
[ ] Chemical restraint PRN (specify: ________)
[ ] Physical restraint (last resort, with safety monitoring)
[ ] De-escalation team approach (specify roles: _________)

TRIGGER for Escalation:
- Verbal threats to hit/kill ___
- Aggressive posture/clenched fists ___
- Refusal of care/medication ___

Psychiatrist Signature: _____________ Time: _________
Nursing Signature: _________________ Time: _________

DAILY RE-ASSESSMENT:
Date | Time | BVC Score | Observer | Action Needed | Signature
____ | ____ | _____ | __________ | ___________ | _______
____ | ____ | _____ | __________ | ___________ | _______
____ | ____ | _____ | __________ | ___________ | _______
```

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## IX. REFERENCE SOURCES

**International Guidelines & Evidence:**
- NICE (2018). Violence and aggression in mental health settings. https://www.nice.org.uk
- APA (American Psychiatric Association). Diagnostic and Statistical Manual (DSM-5)
- Joint Commission International Accreditation Standards (2023)
- ISMP (Institute for Safe Medication Practices). High-Alert Medications https://www.ismp.org

**Thailand-Specific:**
- THIP KPI Dictionary 2024 (Thailand Hospital Indicator Program)
- Thai Psychiatry Society guidelines (if available)
- HA Standard v5 (มาตรฐานโรงพยาบาลและบริการสุขภาพ ฉบับที่ 5)
- Ministry of Public Health regulations on psychiatric care

**Assessment Tools (open-access/recommended):**
- Columbia Suicide Severity Rating Scale (CSSRS): https://cssrs.columbia.edu
- Brøset Violence Checklist (BVC): Available in psychiatric literature
- Psychiatric Risk Evaluation Check-List (PRE-CL): Brazilian development, culturally adaptable

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## X. CONCLUSION & NEXT STEPS

**นี่คือแนวทางการตอบข้อเสนอแนะของการเยี่ยมสำรวจเพื่อต่ออายุการรับรองฉบับที่ 2 ของรพ.ร้อยเอ็ด**

**90 วัน (Quick Wins):** Risk Register, Assessment Tools, Med Double-Check, Training
**6-18 เดือน (Sustainability):** RCA cycles, KPI monitoring, CPG finalization, Safety culture

ทีม PCT จิตเวช พร้อมหรือยัง?

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*เอกสารนี้เข้ารหัส: Psych_HA_v5_EvidencePack_TH.md*  
*รุ่น 1.0 | มกราคม 2569*