戴明循环法在高值医用耗材相关病历记录质量管理中的应用

Application of Deming cycle in quality management of medical record related high value medical consumables

目的:探讨戴明循环(PDCA)法在高值医用耗材相关病历记录质量管理中的应用。方法:抽查病历中出现的高值医用耗材条形码粘贴不规范、知情同意书遗漏缺失不完整、手术记录内容遗漏或含糊不清等突出问题,运用PDCA法的计划阶段(plan)、执行阶段(do)、检查阶段(check)和处理阶段(act)循环管理进行剖析,采用鱼骨图分析高值医用耗材病历缺陷原因,开展高值医用耗材临床应用监测与评估,从加强卫生相关法律法规培训、一体化病历系统信息化管理以及建立健全医院高值医用耗材考核体系等制定高值医用耗材病历记录整改措施。结果:医院高值医用耗材病历记录应用PDCA法后考核不合格的病历情况逐年下降,书写不合格率从PDCA法应用前的24.02%降至2.23%。结论:PDCA法应用于高值医用耗材病历记录质量管理,能提高高值医用耗材病历书写质量,规范医务人员诊疗行为,强化高值医用耗材的合法合规使用意识,减少不必要的高值医用耗材使用,节省医疗资源。

Objective:To explore the application of Deming cycle(plan-do-check-action,PDCA)method in the quality management of medical records of high value medical consumables.Methods:This paper analyzed the series of outstanding problems in spot check of medical records,such as nonstandard barcode pasting of high-value medical consumables,incompleteness and omission of informed consent form,and omission or ambiguity of operation records.The deficiency reasons of medical records of high-value medical consumables were analyzed through operated the cycle management of planning stage(plan),implementation stage(do),inspection stage(check)and processing stage(act)of PDCA method and through adopted fishbone diagram.And the monitor and assessment of clinical application of high value medical consumables were implemented.And the rectification measures of medical record of high value medical consumables were formulated from three aspects included strengthened laws and regulations training that was relevant with sanitation,the information management of integrated medical record system and establishing and improving evaluation system of high value medical consumables of hospital.Results:After the PDCA method was applied in the medical records of high-value medical consumables of hospital,the situation of medical records that failed to pass the examination decreased year by year,and the writing error rate decreased from 24.02%pre applying PDCA method to 2.23%post applying PDCA.Conclusion:The application of PDCA method in the quality management of medical record of high value medical consumables can improve writing quality of medical record of high value medical consumables,and regulate the behaviors of diagnosis and treatment of medical personnel,and intensify the lawful and compliant usage consciousness,and reduce the unnecessary use of high value medical consumables,and save medical resource.