PDCA循环在医院医保违规管理的运用

Application of PDCA Cycle in Hospital Medical Insurance Violation Management

目的探讨PDCA循环管理对于规范诊疗行为及减少医保违规拒付中的作用。方法设定减少医保违规拒付的目标(P),采取培训、交谈、优化系统、反馈等一系列管理措施(D),然后进行效果检查评价(C),最后进行反思总结,形成事前提醒、事中监控、事后反馈整改的管理流程,并循环下去(A),即PDCA循环。结果经过PDCA循环,医保监控疑点涉及病历明显减少,差异有统计学意义(P<0.05),医保违规拒付涉及病历明显减少,差异有统计学意义(P<0.05),拒付金额较上半年下降73.58%。结论运用PDCA循环,对于加强医保管理、规范医疗行为、减少医保违规拒付具有良好效果。

Objective To explore the role of PDCA cycle management in regulating diagnosis and treatment behaviors and reducing medical insurance violations.Methods Set the goal of reducing medical insurance violations(P),adopt a series of management measures such as training,talking,optimizing the system,and feedback(D),and then perform the effect review and evaluation(C).The management process of monitoring during the event and feedback of the rectification after the event,and it continues(A),that is,the PDCA cycle.Results After the PDCA cycle,the medical records related to medical insurance monitoring doubt points were significantly reduced(P<0.05),and medical records related to medical insurance violations were significantly reduced(P<0.05),and the amount of non-payment declined by 73.58%compared with the first half year.Conclusion The use of the PDCA cycle has a good effect on strengthening medical insurance management,regulating medical behavior,and reducing medical insurance violations.