医院质量与安全内部评价体系建设的难点及对策

2013年,中南大学湘雅医院以医院等级评审等外部评审为契机,创立了"医院质量与安全内部评价体系",通过定期开展内审培训、数据监测、现场评价等活动,发现、反馈、分析、整改问题,借助FOCUS-PDCA、QCC、RCA等质量管理工具推动医院质量持续改进,实现了从被动评审向主动内审、常态化内审、信息化内审转变,形成了"自我改进、自我突破"的湘雅模式。针对内审工作开展过程中难点问题、重要环节及对策效果作具体介绍,为正在借鉴内审理念进行医院质量与安全改进的管理者提供参考。

Difficulties and Countermeasures of the Internal Evaluation System of Hospital Quality and Safety

In 2013,Xiangya Hospital of Central South University established"hospital quality and safety internal evaluation system"by taking the opportunity of hospital grade evaluation and quality and safety evaluation.Through regular internal audit training,data monitoring and on-site evaluation,problems were found and actively fed back,analyzed and rectified. Continuous improvement of hospital quality was promoted with the help of FOCUS-PDCA,QCC,RCA and other quality management tools to realize the transformation from passive review to active,normalized and information-based internal review,and to form the"self-improvement and self-breakthrough"of Xiangya model.In the paper,the difficulties,important links and countermeasures of internal audit that hospital managers pay attention to are introduced in detail,so as to provide reference for hospital managers who are learning from the concept of internal audit to improve hospital quality and safety.