基于三级公立医院绩效考核的实验室质量持续改进  

The Continuous Quality Improvement of Medical Laboratories Based on Performance Assessment of Tertiary Public Hospitals

作　　者：孙欣燕 夏永泉[2] 唐健[1] 沈瀚[2] 戴蕾[2] 薛缪群[1] SUN Xinyan;XIA Yongquan;TANG Jian;SHEN Han;DAI Lei;XUE Miaoqun(Office of Quality Management,Nanjing Drum Tower Hospital,The Affiliated Hospital of Nanjing University Medical School,Nanjing,Jiangsu 210008;Department of Medical Laboratory,Nanjing Drum Tower Hospital,The Affiliated Hospital of Nanjing University Medical School,Nanjing,Jiangsu 210008)

机构地区：[1]南京大学医学院附属鼓楼医院质管办,江苏南京210008 [2]南京大学医学院附属鼓楼医院医学检验科,江苏南京210008

出　　处：《江苏卫生事业管理》2022年第6期714-717,共4页Jiangsu Health System Management

基　　金：南京市医学科技发展资金资助项目(YKK18089);南京大学医院管理研究所课题研究项目南京鼓楼医院医学发展医疗救助基金会资助(NDYG2020033)。

摘　　要：目的:研究在制定并实施针对国考第13项指标(通过国家室间质量评价的临床检验项目数)的管理措施后,医院实验室质量的改进效果。方法:统计2018年—2021年南京鼓楼医院实验室参加国家临检中心室间质量评价的相关数据,对比分析管理措施实施前后医学检验科及全院实验室通过国家室间质评的临床检验项目数(参加率及合格率)。结果:2020年起,医学检验科及全院实验室参加率均保持100%。2021年全院实验室通过率达99.6%,较2018年提升4.7%;医学检验科通过率达100%,较2018年提升6.4%,明显高于2018年—2019年(P<0.05)。结论:完善实验室质量管理体系建设,加强常态化监督管理和考核,强化专项业务培训,拓展质量管理覆盖面等管理措施的实施,有助于提高医院通过国家室间质量评价的临床检验项目数,提升实验室质量。Objective:To study the improvement effects of medical laboratory quality after the hospital formulated and implemented management practices for the 13 th performance indicator of National Performance Assessment(the number of clinical test items that passed national external quality assessment). Method:Summarize hospital laboratories’ data of External Quality Assessment(EQA) which provided by National Center for Clinical Laboratories from 2018 to 2021. Compare and analyze participation rates and pass rates of national EQA before and after the management practices. Results:The participation rates of Department of Medical Laboratory and the whole hospital have remained 100% since 2020. In 2021,the pass rate of the hospital reached 99.6%,an increase of 4.7% over 2018. The pass rate of Department of Medical Laboratory reached 100% in 2021,an increase of 6.4% over 2018. The pass rates of Department of Medical Laboratory and the whole hospital from 2020 to 2021 were significantly higher than those of 2018 to 2019(P<0.05). Conclusion:The implementation of management practices,including improving the system construction of laboratories,strengthening normal supervisions and evaluations,enhancing professional training,and expanding the quality management to all clinical laboratories in the hospital,has increased the data of clinical test items of national EQA and improved the quality of all medical laboratories.

关 键 词：室间质量评价 公立医院 绩效考核 质量管理 

分 类 号：R197.32[医药卫生—卫生事业管理]