PDCA循环在肿瘤专业病种DRG付费工作中的应用

Application of PDCA cycle in DRG payment for oncological diseases

目的探讨PDCA循环在肿瘤专业病种DRG付费工作中的应用。方法以天津某三级医院肿瘤专业病种2022年4月—2022年9月参与DRG付费的病例作为基线值,分析影响DRG付费的因素,按照PDCA循环在该医院的肿瘤专业病种开展改进措施,与2022年10月—2023年3月参与DRG支付的结算数据进行比较,利用SPSS 20.0分析病案首页数据填写质量对DRG入组率及次均住院费用、平均住院时间、CMI、医保支付率的影响,以此观察PDCA循环在肿瘤专业DRG支付工作中的应用效果。结果经过PDCA循环后,入组率由84.03%提升至89.98%,因主要诊断操作不匹配而无法入组的病例下降了22.78%,“违反无需填报和编码原则”和“主要手术操作编码漏填”两条歧义病例原因未再出现。由于歧义病例次均住院费用和平均住院时间高于正常入组病例,所以次均住院费用由22496.56元升至24714.92元,平均住院时间由7.50 d升至8.13 d。CMI由0.96升至1.08,医保支付率由107.93%升至130.67%。结论应用PDCA循环可有效提高病案首页质量,进而提升医保结算清单质量和DRG入组率,发现科室运行中存在的问题,促进肿瘤专业科室DRG支付改革顺利展开。

Objective This study aims to investigate the application of the Plan-Do-Check-Act(PDCA)cycle in the Diagnosis Related Group(DRG)payment system for oncological diseases.Methods We analyzed the factors influencing DRG payment and incorporated the PDCA Cycle in the oncological diseases at a tertiary hospital in Tianjin.The baseline data of cases participating in DRG payment from April 2022 to September 2022 were compared with the settlement data of cases participating in DRG payment from October 2022 to March 2023.SPSS 20.0 was used to evaluate the impact of data quality in medical record documentation on DRG admission rate,average hospitalization costs,average length of stay,Case Mix Index(CMI)value,and DRG settlement rate,so as to assess the effectiveness of the PDCA cycle in DRG payment within the oncological diseases at the hospital.Results Following the PDCA cycle,the DRG admission rate increased from 84.03%to 89.98%,and the cases ineligible for inclusion decreased by 22.78%due to mismatched main diagnosis and procedures.“Violations of the reporting and coding principles that do not require reporting”and“omission of primary surgical procedure codes”were no longer observed as reasons for failed DRG inclusion.Ambiguous cases with both average hospitalization costs and average length of stay higher than those of normal inclusion cases,leading to an increase in the average hospitalization cost from 22496.56 yuan to 24714.92 yuan,and the average length of stay increased from 7.50 days to 8.13 days.The CMI value increased from 0.96 to 1.08,and the DRG settlement rate increased from 107.93%to 130.67%.Conclusion The PDCA cycle can effectively enhance the quality of medical record documentation,leading to improved quality in medical insurance settlement lists and DRG admission rates.It can help identify operational issues within the department and promote the smooth implementation of DRG payment reform in the oncological department.