社区卫生服务中心全科医学临床质量状况及存在问题分析

Quality of General Medical Care in Community Health Centers in 2019-2020:Overview and Problems Analysis

背景加强临床质控督查是提高医疗质量的有效途径。通过全科临床质控督查可对区域内基层医疗卫生机构全科临床质量状况进行系统评估,进而发现问题。目的通过对2019、2020年上海市基层医疗卫生机构全科临床质控督查结果进行分析,了解上海市基层医疗卫生机构全科临床质量管理中存在的问题,并提出针对性、合理化的改进建议。方法2019、2020年采用整群抽样法,选取上海市全部社区卫生服务中心为研究对象,由上海市市、区两级全科临床质控督查专家采用上海市全科医学临床质量控制中心制定的《上海市社区卫生服务中心全科医学临床质控督查标准(基层医疗机构版)》,对上海市各社区卫生服务中心开展全科临床质控督查工作。于2021年5月采用描述性分析法比较和分析2019、2020年上海市全科临床质控督查结果,并对全科临床质控督查中发现的主要问题进行汇总分析。结果2019、2020年,上海市分别有243家和244家社区卫生服务中心接受全科临床质控督查。2019、2020年全市社区卫生服务中心全科临床质量平均标准总得分分别为(87.32±5.97)、(86.67±5.36)分。相较于2019年,2020年上海市社区卫生服务中心在基本条件(99.80%比99.93%)、全科医生人员配备及岗位职责(91.90%比93.44%)、全科医生诊疗能力(85.72%比85.82%)、全科医生慢性病管理与处置能力(80.95%比81.07%)、全科医学教学与科研(28.87%比29.99%)6个维度上的得分率升高,在全科医疗质量管理维度上的得分率降低(86.36%比85.76%)。从内容上看,全科临床质控督查中发现的问题主要集中于人员配备〔提及176次(22.03%)〕、全科医生应诊能力〔提及154次(19.27%)〕、住院病史质量〔提及92次(11.51%)〕、家庭病床病史质量〔提及91次(11.39%)〕、硬件配置〔提及91次(11.39%)〕5个方面。问题被提及率方面,排在前5位的问题顺次为:全科高级职称人数占注册全科医生人数比未达标〔提及84次(10.51%)〕、科研薄弱〔提及66次(8.26%)〕、每万常住人口拥有全科医生数不足3.5名〔提及61次(7.63%)〕、基本临床操作技能欠佳〔提及40次(5.01%)〕和家庭病床数量不足〔提及36次(4.51%)〕。结论以全科临床质控督查促进社区卫生服务中心全科临床质量提升初见成效。下一步,可通过深化全科医疗质量管理内涵、提升全科医生诊疗能力、提高教学和科研能力,推进社区卫生服务中心全科临床质量水平持续提升。

Background Strengtheningclinical quality control and supervision is one of the effective ways to ensure medical quality.Supervising the quality of general medical care in primary care settings in the local region could contribute to the systematical assessment of general medical care quality and identification of relevantproblems in such settings.Objective To analyze the supervision of quality of general medical care in Shanghai's primary care settings conducted in 2019 and 2020,and based on this,to give targeted,rational recommendations on the identified problems in quality management of general medical care.Methods The quality of general medical care in a cluster sample of community health centers(CHCs)of Shanghai was supervised in 2019 and 2020 by relevant experts from Shanghai's municipal and district general practice quality control departments using the Clinical Quality Control and Supervision Standards for General Medical Care in Shanghai's Community Health Centers(hereinafter referred to as CQCSS)developed by Shanghai General Practice Clinical Quality Control Center.In May 2021,the supervision results of the two years were analyzed using descriptive analysis,then compared,and the identified problems were summarized and analyzed.Results Two hundred and forty-three CHCs were involved in the 2019 supervision,and 244 were involved in the 2020 supervision.The average total CQCSS score for 2019 was(87.32±5.97)points,and that for 2020 was(86.67±5.36)points.Compared to the results in 2019,the scores of first-level indicators of basic conditions(99.93%vs 99.80%),staffing and determining job responsibilities of general practitioners(GPs)(93.44%vs 91.90%),diagnosis and treatment ability of GPs(85.82%vs 85.72%),chronic disease management ability of GPs(81.07%vs 80.95%)and scientific research and teaching levels(29.99%vs 28.87%)increased in 2020.The problems mentioned were mainly distributed in five aspects:staffing〔176(22.03%)〕,GPs'clinical management ability〔154(19.27%)〕,quality of inpatient medical records〔92(11.51%)〕,quality of home sickbed patients'medical records〔91(11.39%)〕,allocation of facilities〔91(11.39%)〕.In terms of the mentioned frequency,the top five problems were:ineligible senior GPs to registered GPs ratio〔84(10.51%)〕,poor scientific research〔84(10.51%)〕,less than 3.5 GPs per 1000 residents〔61(7.63%)〕,unsatisfactory clinical skills〔40(5.01%)〕,and insufficient number of home sickbeds〔36(4.51%)〕.Conclusion These two years of quality control supervision has initially promoted the quality improvementof general medical care in CHCs.To further improve it,it is suggested to take actions to deepen the core essence of general medical care quality management,improve the diagnosis and treatment ability of GPs,as well as their teaching and research ability.