某三级甲等医院构建基础医疗质量评价体系的实践探索  

Practice and Exploration of Constructing Evaluation System of Basic Medical Quality in a Tertiary First-Class Hospital

作　　者：杨晓钟[1] 苏凌璎 周立涛[2] 王兆宇[2] 张红[2] 仲韵[2] YANG Xiaozhong;SU Lingying;ZHOU Litao;WANG Zhaoyu;ZHANG Hong;ZHONG Yun(General Office,the Affiliated Huai′an No.1 People′s Hospital of Nanjing Medical University,Huai′an Jiangsu 223300,China;Office of Medical Affairs,the Affiliated Huai′an No.1 People′s Hospital of Nanjing Medical University,Huai′an Jiangsu 223300,China)

机构地区：[1]南京医科大学附属淮安第一医院院长办公室,江苏淮安223300 [2]南京医科大学附属淮安第一医院医务处,江苏淮安223300

出　　处：《中国卫生标准管理》2024年第13期51-56,共6页China Health Standard Management

基　　金：国家卫生健康委医院管理研究所医疗质量(循证)管理研究重点项目(YLZLXZ23K006);江苏省医院协会医院管理创新研究课题(JSYGY-2-2023-304)。

摘　　要：构建并完善基础医疗质量评价体系,提升医疗质量与安全。以某三级甲等医院为例,该院从患者服务、手术管理、危急重症、病历质量、合理诊疗、科室管理6个维度构建基础医疗质量评价体系,在体系中增加专项质控考核和平台科室质量评价体系,将评价结果与科主任管理绩效和科室绩效挂钩,并在此基础上构建科主任评价体系。该体系的构建形成了全方位医疗质量监管机制,激发科室主动参与质控管理,有助于发现医疗质量薄弱环节并持续改进,并可实现医疗质量安全的分层管理。基础医疗质量评价体系的建立有助于全方位了解全院科室医疗质量管理问题,提升质控管理成效,为医院夯实高质量发展根基。The article construct and improve the evaluation system of basic medical quality,and to improve the medical quality and safety.Taking a tertiary first-class hospital as an example,the hospital had built an evaluation system of basic medical quality from six dimensions:patient service,surgical management,critical and severe disease,quality of medical record,reasonable diagnosis and treatment,and department management.Special qualitycontrol assessment and quality evaluation system of platform department were added into this system,and the evaluation results were linked with management remuneration of department director and department remuneration,and on this basis,an evaluation system of department director was built.The construction of this system formed an all-round supervision mechanism of medical quality,stimulated departments personnel to actively participate in quality-control management,helped to find out the weak links of medical quality and continuously improved them,and finally realized hierarchical management of medical quality and safety.The establishment of evaluation system of basic medical quality is helpful to fully understand the problems of medical quality management in all departments of the hospital,can improve the effect of quality-control management,and lay a solid foundation for the hospital′s high-quality development.

关 键 词：基础医疗质量 平台科室 专项质控考核 质控管理 科主任评价 高质量发展 

分 类 号：R197[医药卫生—卫生事业管理]