PDCA循环在恶性肿瘤病案质控中的应用  

Application of PDCA Cycle in the Quality Control of Medical Records of Malignant Tumors

作　　者：张磊[1,2] 武正清[1,2] 吴志坚[1,2] 

机构地区：[1]郴州市第一人民医院,郴州市423000 [2]南华大学医院管理研究所,郴州市423000

出　　处：《中国病案》2017年第11期22-25,共4页Chinese Medical Record

摘　　要：目的通过PDCA循环等管理工具及手段,全面提高某院恶性肿瘤放化疗病案质量和肿瘤专科医务人员病案书写水平,并推广相应经验。方法运用PDCA循环基本理论,综合运用新旧QC七大工具中的检查表、鱼骨图等统计管理方法,对恶性肿瘤放化疗病案存在的问题、各类影响因素、整改措施及效果检验等方面进行全面分析,并将病案质量数据进行统计分析。结果实施PDCA循环后某院恶性肿瘤放化疗病案质量明显改善,经过2个PDCA循环后,甲级病案率达97.5%,P<0.05,差异有统计学意义。各项具体缺陷原因分析中,无病理或不详缺陷从13份下降至7份、无开具资质从106份下降至13份、无上级医师签字从19份下降至1份、实验室资料未查或不详从29份下降至2份、缺告知书从23份下降至5份。结论 PDCA等管理工具的运用使某院恶性肿瘤放化疗病案质量明显提高,使得恶性肿瘤放化疗更加标准化、规范化。Objectives Through the application of PDCA cycle management tools and methods, to improve the quality of medical records of radiotherapy and/or chemotherapy of malignant tumor, improve the level of medical records writing and to share the successful experience. Methods With the application of the basic theory of PDCA cycle, the old and new QC seven tools（techniques） checklist, the Gantt chart, histogram, and fishbone diagram to comprehensive analysis the problems, influencing factors, the rectification measures, effect inspection and other aspects of medical records of malignant tumor patients with chemotherapy and/or radiotherapy. And the data of quality of medical records were statistically analyzed. Results With the implementation of PDCA cycle, the medical records quality of radiotherapy and/or chemotherapy of malignant tumor patients in our hospital had significantly improved. After two PDCA cycles, the rate of Grade-A medical record up to 97.5%, P0.05, the difference was statistically significant. The specific analysis of defects in PDCA after two cycles, no pathological or unknown defects records from 13 down to 7, issued qualification records from 106 down to 13, no superior physician signature records from 19 dropped to 1, laboratory data not found or unknown records from 29 down to 2, no informed consent records from 23 dropped to 5. Conclusions The application of PDCA and other management tools improved the quality of radiotherapy and/or chemotherapy in our hospital, and the treatment of malignant tumor were more standardization and normalization.

关 键 词：PDCA循环 恶性肿瘤 质量控制 

分 类 号：R197.323[医药卫生—卫生事业管理]