PDCA管理模式对于降低儿科医保违规收费发生率的作用研究  

A Study on the Role of PDCA Management Model in Reducing the Incidence of Pediatric Medical Insurance Violation Fees

作　　者：付洪杰[1] 纪鑫[1] 邢秀桂 Fu Hongjie;Ji Xin;Xing Xiugui(Department of Pediatric Respiratory Medicine,Binzhou Medical University Hospital,Binzhou,Shandong 256000)

机构地区：[1]滨州医学院附属医院儿童呼吸科,山东滨州256000

出　　处：《科技与健康》2024年第8期5-8,共4页Technology and Health

基　　金：滨州医学院附属医院“质量管理项目”(2022015)。

摘　　要：观察运用PDCA管理模式对于降低儿科医保违规收费发生率的作用。将2022年1月—2022年5月未实施PDCA管理模式前的儿科住院医保拒付费用作为对照组,2022年6月—2022年10月实施PDCA管理模式后的儿科住院医保拒付费用作为观察组。采用甘特图和柏拉图工具,比较PDCA管理模式下(2022年6月—2022年10月)和未实施PDCA管理模式前(2022年1月—2022年5月)儿科医保违规收费的金额和占比。结果显示,与对照组2022年1月—2022年5月儿科违规收费金额及占比相比,观察组2022年6月—2022年10月儿科违规收费金额明显减少,儿科违规收费占比明显减小,费用从322190元降低至9166.43元,占比从82.35%降低至27.69%,且组间数据差异具有统计学意义(P<0.05)。研究发现,PDCA管理模式能够显著降低儿科医保违规收费的金额和占比,可进一步规范诊疗行为,优化收费流程,最终提升医院医保管理质量,维护医、保、患三方权益,增加医院的经济效益与社会效益。Observe the effect of using the PDCA management model on reducing the incidence of pediatric medical insurance violations.Take the pediatric inpatient medical insurance refusal expenses before implementing the PDCA management mode from January 2022 to May 2022 as the control group,and the pediatric inpatient medical insurance refusal expenses after implementing the PDCA management mode from June 2022 to October 2022 as the observation group.Using Gantt chart and Plato tools,compare the amount and proportion of pediatric medical insurance violations under the PDCA management mode(June 2022-October 2022)and before the implementation of the PDCA management mode(January 2022-May 2022).The results showed that compared with the control group from January 2022 to May 2022,the observation group had a significant decrease in pediatric non-compliant fees from June 2022 to October 2022,and the proportion of pediatric non-compliant fees decreased significantly.The fees decreased from 322190 yuan to 9166.43 yuan,and the proportion decreased from 82.35%to 27.69%.The data difference between the groups was statistically significant(P<0.05).Research has found that the PDCA management model can significantly reduce the amount and proportion of pediatric medical insurance violations,further standardize diagnosis and treatment behavior,optimize charging processes,ultimately improve the quality of hospital medical insurance management,safeguard the rights and interests of doctors,insurance,and patients,and increase the economic and social benefits of hospitals.

关 键 词：PDCA 儿科 医保 违规收费 

分 类 号：R197.1[医药卫生—卫生事业管理]