基于三甲复审实践的消毒供应室质量管理SOP的编制应用  

Compilation and Application of SOP Quality Control in the Sterilization and Supply Department on Basis of Review Phase in A Third-Grade Class A Hospital

作　　者：刘肖[1] LIU Xiao(Sterilization and Supply Department, Baise People’s Hospital,Baise Guangxi 533000, Chin)

机构地区：[1]百色市人民医院消毒供应室,广西百色533000

出　　处：《中国继续医学教育》2018年第2期42-44,共3页China Continuing Medical Education

基　　金：广西百色市科学研究与技术开发计划项目(百科计150707)

摘　　要：目的通过三级甲等医院复审实践,引入并应用持续质量改进(PDCA循环)管理工具,研究制定医院消毒供应室质量管理体系标准操作程序(SOP),实现对质量控制工作的标准化、规范化、统一化管理。方法在等级医院的复审实践过程中,对常用设备仪器和操作的操作流程及质量标准进行全面的研究、提炼和总结,在持续改进后,研究制定医院消毒供应室质量管理体系SOP,并在工作实践中,将SOP应用于规范日常各项技术操作、员工培训和考核。结果 1年时间完成40个关键控制点40个SOP的编制,通过3年应用实施,使腔镜手术器械清洗合格率由95%提高到100%;在医院每季度的质控检查中,合格率由97%提高到100%;操作考核成绩合格率由94%提高到100%,优秀率由85%提高到96%;SOP的应用依从性由83%提高到100%;使医院顺利通过等级医院复审。结论 SOP的编制应用,实现管理科学化,流程规范化、标准化,提高消毒供应室的工作效率和服务满意度,有效预防和控制医院感染,保障医疗安全。Objective On basis of review phase of the third-grade class A hospital, introduce and apply the continuous quality improvement（PDCA circulation） management tool, study and formulate SOP quality controls in the sterilization and supply department, achieve standardization and unification in quality control management. Methods During reviewing for the hospital rank of qualification, for those commonly used instruments, studied and distilled and summarize their operations and operation process and quality controls, after continual improving, worked out the SOP quality control system in the sterilization and supply department, and then applied SOP toregulateroutine operation and operational procedures, also applied in employees＇ training and their appraisement. Results In one year, worked out 40 critical control points and 40 SOP items; in practice of 3 years proved that the cleaning and disinfection qualification rate for mirror cavity surgical instruments been increased from 95% to 100%; and qualification rate been increased from 97% to 100% in quarterly quality control check up, operation qualification rate been increased from 94 % to 100%, excellent rate been increased 85% to 96%; the application compliance of SOP been increased from 83 % to 100%. And these results met the standard requirements in the hospital rank reviewing. Conclusion compiling and applying of SOP proved that achieved scientific management and specified and standardized process, heightened the management system and operation effectiveness and operation quality, improved work effectiveness and satisfaction of medical service, and prevented and controlled hospital infection effectively in the sterilization and supply department.

关 键 词：消毒供应室质量管理 标准操作程序 PDCA循环 实施 

分 类 号：R197[医药卫生—卫生事业管理]