基于FOCUS-PDCA法改进住院病案首页质量的效果评价

Evaluation of Improving the Quality of Inpatient Medical Record Front Pages Based on FOCUS-PDCA

目的探讨运用FOCUS-PDCA方法提高住院病案首页填写质量的有效性,促进住院病案首页质量的持续提升,为医疗机构和各卫生行政部门提供更为精准的基础数据。方法运用FOCUS-PDCA方法加强某院住院病案首页数据质量管理,比较措施实施前2021年4月1日-2021年6月30日和措施实施后2022年4月1日-2022年6月30日各1500份住院病案首页身份证号码等基本信息错误率、主要诊断选择错误率、主要诊断编码错误率、主要手术选择错误率和主要手术编码错误率的变化。结果FOCUS-PDCA方法实施后,住院病案首页身份证号码、联系人姓名和邮编等易错基本信息的错误率明显下降,分别由6.53%、4.87%、3.67%将至0.93%、1.40%、0.40%,P<0.05,错误率差异具有统计学意义;主要诊断选择、主要诊断编码、主要手术操作选择和主要手术操作编码错误率分别由11.73%、10.20%、14.53%、9.47%降至3.13%、4.47%、3.67%、5.53%,P<0.05,错误率差异具有统计学意义。结论运用FOCUS-PDCA作为住院病案首页质量提升的基本管理工具,对住院病案首页身份证号码等基本信息、主要诊断选择、编码和主要手术操作选择、编码等重要数据指标质量的持续提升具有促进作用。

Objectives This study aims to explore the effectiveness of FOCUS-PDCA in improving the quality of filling the front page of medical records,so as to promote the continuous improvement of the quality of the front page of medical records and provide more accurate basic data for medical institutions and various health administrative departments.Methods FOCUS-PDCA method was used to strengthen the data quality management of the front page of medical records in a hospital.1500 medical records from April 1,2021 to June 30,2021 before the implementation of the measures and 1500 medical records from April 1,2022 to June 30,2022 after the implementation of the measures were compared from the perspectives of the error rate of basic information such as the ID card number on the front page,the error rate of main diagnosis selection,the error rate of main diagnosis code,the error rate of main surgery selection,and the error rate of main surgery code.Results After the implementation of FOCUS-PDCA method,the error rate of easily mistaken basic information such as ID card number,contact name and zip code on the front pages of the medical records decreased significantly from 6.53%,4.87%,3.67%to 0.93%,1.40%,0.40%,respectively(P<0.05).The differences in error rates were statistically significant.The error rates of major diagnosis selection,major diagnosis coding,major surgical operation selection and major surgical operation coding decreased from 11.73%,10.20%,14.53%,9.47%to 3.13%,4.47%,3.67%,5.53%respectively(P<0.05).The differences in error rates were statistically significant.Conclusions Using FOCUS-PDCA as the basic management tool for improving the quality of the front pages of medical records can promote the continuous improvement of the quality of important data indicators such as the basic information,main diagnosis selection,coding,and main surgical operation selection,coding on the front page of medical records.