PDCA循环法减少医院医疗费用违规率的应用  

Application of PDCA Cycle Method in Reduction of Hospital Medical Expenditure Violation

作　　者：林铭[1] 陈国强[1] 张莉[1] 周秋兰[1] 张宝嫦[1] 尹志坚[1] 刘玲[1] 

机构地区：[1]佛山市第一人民医院,广东佛山528000

出　　处：《现代医院》2017年第1期40-42,46,共4页Modern Hospitals

摘　　要：目的探讨应用PDCA循环法减少医院医疗费用违规率的效果与意义。方法根据社保管理部门医疗费用审核规则要求,利用PDCA循环对全院各科室开展减少医院医疗费用违规率的医保管理模式。结果违规社保管理部门医疗费用审核规则的项目大幅度减少,2016年上半年医疗费用信息监管系统中我院月平均违规总数量由原来的133例下降到43例,有效减少医保结算差额。结论通过引入PDCA循环模式,规范医疗行为,规避不良医疗行为风险,优化收费流程,有效减少医院医疗费用违规率,提高医保费用偿付率,持续提高医院医保管理质量及效率。Objective To explore the effect and significance of using PDCA cycle to reduce the rate of hospital med-ical expense violation. Methods According to the requirements of the medical insurance examination rules released by the social security management department, the PDCA cycle was used to carry out the medical insurance management mode for reducing the rate of hospital medical expense violation in each department. Results The rate of hospital medical expense violation significantly reduced. In the first half of 2016, the total number of irregularities in the medical expense information monitoring system decreased from 133 cases to 43 cases, effectively reducing the medical insurance settlement balance. Con-clusion The PDCA cycle model can standardize medical behaviors and avoid the risk of adverse medical behaviors, optimize the charging process, effectively reduce the rate of hospital medical expenses violation and increase the reimbursement rate of medical insurance costs to continuously improve the quality and efficiency of hospital medical insurance management.

关 键 词：PDCA循环法 医疗费用违规率 医院医保管理 

分 类 号：R197.32[医药卫生—卫生事业管理]