黄青青　　陈洪

[摘要] 为了探讨PDCA在科室质量规范化建设中的应用，本研究以科室质量小组为抓手，科学开展Plan、Do、Check、Action阶段管理，通过现状分析进行工作筹划，采用加强管理机制、细化质量活动范畴、加强质量管理宣贯、规范质量改进项目、创新信息化管理等措施，开展质量持续改进工作。以质量监管“大环”运作，带动科室质量“小环”运转。通过一系列整改，医疗质量指标稳步提升，科室规范化发展，形成了一系列制度、流程和规范，安全文化氛围日渐浓厚。医院构建专业化质量管理模式，深化质量管理教育，加大质控信息化建设，可推动医疗质量持续改进。

[关键词] 科室质量小组;质量管理;PDCA;医疗质量;改进

[中图分类号] R197.3          [文献标识码] C          [文章编号] 1673-9701（2021）11-0154-04

Application of PDCA cycle in continuously promoting the standardized construction of department quality management

HUANG Qingqing   CHEN Hong

Department of Quality Management， Chinese People′s Liberation Army Characteristic Medical Center， Chongqing 400042， China

[Abstract] In order to explore the application of PDCA in the standardization construction of department quality， this study uses department quality team as the starting point to scientifically carry out Plan，Do，Check，and Action stage management. This study conducts work planning through current situation analysis， adopts strengthened management mechanisms， details the scope of quality activities， strengthens the publicity and implementation of quality management， standardizes quality improvement projects， innovates informatization management， and carries out the continuous quality improvement. The operation of the "big circle" of quality supervision drives the operation of the "small circle" of department quality. Through a series of rectifications， medical quality indicators have been steadily improved，departments have standardized development，a series of systems， procedures and norms have been formed， and the safety culture atmosphere has grown stronger. Establishing a professional quality management model in hospitals， deepening quality management education，and increasing quality control information construction can promote continuous improvement of medical quality.

[Key words] Department quality team; Quality management; PDCA; Medical quality; Improvement

WHO将医疗质量改进作为卫生领域的工作重点，倡导全球医疗机构积极采取有效措施持续提高医疗质量[1]。2012年起，随着我国新一轮医院等级评审正式启动，“以评促进、以评促改”逐步推进医疗质量持续改进和医院管理模式，医疗机构通过引入PDCA循环等先进质量管理理念，促进医院管理的可持续化发展[2-4]。2017年以来，本院质量管理科基于已有的管理模式，结合目标化、规范化、精细化管理，以PDCA循环提高科室质量管理品质，以质量监管层面的PDCA“大环”，带动各科室执行层面的数个PDCA“小环”，持续推进医疗质量改进工作，医疗数量、医疗质量指标稳步提升。

1 资料与方法

1.1 质量小组的设置

某院以科室或病区为单位共设立58个质量小组，负责科室质量与安全管理工作的计划、实施、监控、整改和落实。……