浅谈三级综合医院医疗质量管理的基本做法

目的持续改进医疗质量,保障患者安全。方法回顾性分析2007～2009医疗质量管理过程。结果根据法律法规的要求结合医院实际,制定院科二级医疗质量管理方案,以各级各类医务人员违规记分管理为抓手,持续改进医疗质量,保障患者安全。患者满意度得到明显提高,各级医务人员诊疗行为进一步规范,运行病历和终末病历质量明显提高,住院患者平均住院天数从13.6d降至11.85d,入出院诊断符合率、手术前后诊断符合率等16项主要质控指标均达部颁标准,运行病历质量合格率达95%以上。结论完善的院科二级医疗质量管理方案是三级综合医院质量管理的基础;实施医务人员违规记分管理是持续改进医疗质量的重要抓手。

Discuss about Three-level General Hospital in the Basic Practices of Medical Quality Management

Objective Aim to continual improvement of medical quality to guarantee the safety of patients. Methods Retrospective analysis of 2007-2009 three years of medical quality control process. Results According to the requirements of the law, and Combining with the actual situation in our hospital, we formulated medical quality management plan. To various types of medical personnel at all levels of management as the starting points violation, continued to improve medical quality, to protect patient safety.Discharge diagnosis accuracy, surgical diagnostic accuracy et al of main quality indexes reached the standard. The running medical record quality qualified rate reached above 95%. Conclusions The perfect quality management of medical hospital division is the basic quality of general hospital management;Implement staff illegal scorecard management is an important means of the continuous improvement of medical quality.