背景 依本院2010年調查病人在出院準備服務滿意度調查中，發現本病房病人對自我照護指導滿意度為84分與全院滿意度的平均90分比較明顯偏低，且常接獲出院病人打電話至病房詢問有關器官移植後自我照護的問題，以查閱病歷及電訪調查共30位，結果發現出院準備服務移植照護指導項目完整率為75%及移植病人出院自我照顧知識答對正確率平均69%偏低。
目的 提升出院準備服務移植病人住院期間出院準備服務照護指導完整率至100%及移植病人出院自我照顧知識答對正確率至95%以上。
解決方案 藉由提供出院準備服務資料夾以統整醫療團隊完整的照護相關資料，提供住院移植病人參閱、制定並使用自我照顧知識查檢表、建立照護指導標準流程及制定定期稽核及持續追蹤機制。
結果 出院準備服務移植照護指導完整率提升至100%及自我照顧知識答對正確率提升至98%。
結論 以病人為中心的照護理念，透過跨領域團隊共同照護的合作模式，有效率的整合資源，提升移植病人後續照護及生活品質。此專案有效提升出院準備服務移植照護指導完整率，也提升移植病人自我照護知識。

Background & Problems: The average score for satisfaction with self-care instructions among transplant patients was 84 out of 100 in a 2010 survey of patient satisfaction with discharge-planning services. This score was significantly below the hospital average of 90. In addition, discharged patients made more frequent telephone inquiries to healthcare providers to ask questions about post-organ-transplantation self-care. A follow-up study targeted a sample of 30 discharged transplantation patients using hospital medical record reviews and telephone inquiries. This survey found a transplant instruction completion rate of 75% during discharge preparation and 69% accuracy among participants in answering self-care knowledge questions. Both figures were lower than expected.
Purposes: The goal of this project was to increase the instruction completion rate from 75% to 100% and the percentage of correct answers to self-care knowledge questions self-care knowledge from 69% to 95%.
Resolutions: This study integrated all relevant nursing information into a standardized discharge-planning service booklet that was given to inpatients for reference. Furthermore, a self-care checklist was developed and introduced. Finally, a standard procedure for delivering nursing instructions and a regular audit and follow-up monitoring system were established.
Results: The nurses’ instruction completion rate rose to 100% and the percentage of questions on self-care knowledge correctly answered by patients increased to 98%.
Conclusions: Adopting a patient-centered philosophy of care and a model of interdisciplinary collaboration effectively integrated resources and promotes nursing quality and quality of life for transplant patients. The project effectively improved the completing rate for post-transplant discharge-planning service instructions and enhanced the selfcare knowledge of transplant patients.