落实“超声危急值10分钟内通报完成率”质控目标及改进策略

Implement the Quality Control Objective and Improvement Strategy of"Completion Rate of Ultrasonic Critical Value Notification within 10 Minutes"

目的探讨厦门市公立医院落实“超声危急值10分钟内通报完成率”质控目标及改进策略。方法厦门市超声医学质量控制中心于2022年7月-10月对42家公立医院开展第二季度与第三季度“超声危急值10分钟内通报完成率”专项督导,现场采集数据并进行整理和描述性分析。结果超声危急值报告制度覆盖率从第二季度的78.6%增加至第三季度的97.6%,全员培训率从66.7%增加至85.7%,流程优化率从73.8%增加至100%,标准化登记完成率从64.3%增加至90.5%;超声危急值病例随访率从96.1%增加至100%,超声危急值病例超声诊断符合率从93.6%增加至99.5%;超声危急值通报率从95.4%增加至98.8%,超声危急值10分钟内通报完成率从95.4%增加至100%。第三季度和第二季度均仅有28.6%医院建立了超声危急值信息化管理系统。结论通过专项督导,厦门市公立医院超声危急值10分钟内通报完成率达到目标值100%。各级医院仍需建立并优化超声危急值报告制度,实施全员培训;搭建超声危急值信息化管理平台,优化上报流程;完善超声科质量管理制度,开展质控评价。

Objective To explore the implementation of quality control objectives and improvement strategies of"completion rate of ultrasonic critical value notification within 10 minutes"in Xiamen public hospitals.Methods A total of 42 public hospital were supervised specially on the"completion rate of ultrasonic critical value notification within 10 minutes"by the Ultrasonic Medical Quality Control Center of Xiamen in July and October 2022,on-site data collection and descriptive analysis were performed.Results The coverage of the critical value reporting system increased from 78.6%in the second quarter to 97.6%in the third quarter,the training rate increased from 66.7%to 85.7%,the process optimization rate increased from 73.8%to 100%,and the standardized registration completion rate increased from 64.3%to 90.5%.The follow-up rate of critical value of ultrasound increased from 96.1%to 100%,the diagnostic conformity rate of critical value of ultrasound increased from 93.6%to 99.5%,the notification rate of critical value of ultrasound increased from 95.4%to 98.8%,and the completion rate of critical value of ultrasound within 10 minutes increased from 95.4%to 100%.However,only 28.6%of hospitals in the third quarter and the second quarter established the information management system of ultrasonic critical value.Conclusion Through special supervision work,the completion rate of critical ultrasound value notification within 10 minutes in Xiamen public hospitals reached 100%of the target value.Hospitals at all levels still need to establish and optimize the ultrasonic critical value reporting system and implement all staff training;establish an information management platform for ultrasonic critical value,optimize the reporting process;improve the quality management system of ultrasound department and carry out quality control evaluation.