基于鱼骨图分析法的病案质量持续改进

Continuous Quality Improvement of Medical Records Based on Fishbone Diagram Analysis

目的运用鱼骨图分析法,分析病案缺陷情况及产生原因,提出改进措施以提高病历书写质量。方法调取某三甲医院电子病历系统2018年1月1日-2020年12月31日的62792份全部出院病案作为改进前组;2021年1月1日-2021年12月31日的15214份出院病案作为改进后组,对全部病案进行质量监控。根据改进前组质控结果,分析病案各类缺陷的根本原因绘制鱼骨图。医院成立终末质量改进小组,提出切实改进措施,向全院科室推行改进。采用描述性研究方法比较改进前后组病案质控缺陷及构成比,采用χ^(2)进行检验。结果改进前组质控的62792份住院病案中,存在缺陷的病案6598份,检出10946条缺陷;改进后组的15214份住院病案中,缺陷病案为3406份,共检出3760条缺陷。住院病案首页缺陷改进前占33.70%和改进后占27.58%;病程记录缺陷改进前23.41%和改进后24.89%;检查检验报告单缺陷改进前18.82%和改进后20.62%。随机抽取改进前后各100份病案进行质控,改进前组住院病案首页缺陷为75%、病程记录缺陷为70%、诊断缺陷为73%、缺单缺页缺陷为77%,均高于改进后组的51%、59%、55%和53%,经χ^(2)检验,P<0.05,差异有统计学意义。结论鱼骨图分析法有助于查找病案缺陷发生的根本原因,有针对性的实施病案质量改进措施,可以降低病案缺陷率,促进病案质量持续改进,不断提高准确率。

Objectives By using fishbone diagram analysis,the defects of medical records and their causes were analyzed,and the improvement measures were put forward to improve the quality of medical records writing.Methods A total of 62,792 inpatient medical records from January 1st,2018 to December 31st,2020 were selected.Quality control was carried out according to regulations,found out the cause of defects,and draw a fishbone diagram after statistical analysis.After proposing improvement measures,15214 inpatient medical records from January 1st,2021 to December 31st,2021 were selected,and the accuracy of medical record quality before and after improvement were analyzed by descriptive research methods.Results The defect rate of 62,792 inpatient medical records before improvement was about 10.5%,and the defect rate of 15,214 inpatient medical records after improvement was about 8.28%,the satisfaction rate of medical records increased from 81%to 93%.The satisfaction of medical records with home page problems increased from 58%to 90%before improvement,the satisfaction of medical records with hospitalization record problems increased from 61%to 91%,the satisfaction of medical records with diagnostic problems increased from 65%to 87%,and the satisfaction of medical records with missing pages increased from 65%to 90%.The difference had statistics significance.Conclusions The fishbone diagram analysis method was helpful to find the root cause of medical record defects.Implementing medical record quality improvement measures according to the causes could reduce the medical record defect rate and promote medical record quality and improve satisfaction continuously.