某三甲综合医院手术科室监管指标的分析

摘要

目的 通过分析某三级甲等医院手术科室运行和质量统计数据,提出科室管理和服务中存在的问题和建议,为改善医院管理和服务流程提供依据.方法 从医院质量监测系统(HQMs)、病案统计管理系统和感染管理信息系统中搜集2012年-2015年医院运行和病案首页资料,利用Excel的表格统计和柱状图、折线图等图表功能对手术科室各项指标进行数据处理,分析其意义.结果 14个手术科室的12项监测指标中,四个科室平均住院日高于12天、12个科室床位使用率超出85~93%的范围、七个科室三四级手术率低于50.24%、医院手术患者围手术期死亡率高于0.1%、两个科室手术患者感染率高于1.5%、年手术及操作占出院人次比例中单纯外科手术量低于35%,年外科手术人次占外科出院人次比例低于65%,不符合国家卫生计生委医疗质量指标值及全国统计基准值要求.结论 应降低平均住院日,合理控制床位使用率,提高三四级手术率,降低手术患者死亡率和感染率,提高工作负荷能力,保证患者手术质量和安全,提升医院手术管理水平.%Objective Through analysis on the operation and quality statistics of surgical departments in a Three A and Tertiary Hospital, to put forward the problems existing in the management and service department and the suggestion, and provide the basis for improving hospital management and service process.Methods From hospital quality monitoring system(HQMs), infection of medical record statistical management system and management information system to collect run hospitals and medical record home page data in 2012-2015, using the Excel table statistics and histogram, line chart functions such as operation department each index for data processing and analysis its significance.Results Among the 12 monitoring indicators of 14 surgery department, there were four departments had average length of stay longer than 12 days, 12 beds beyond the scope of 85 to 93%, utilization rate of seven departments three level 4 rate below 50.24%, the hospital surgery patients perioperative mortality rate was above 0.1%, 2 department surgery patient infection rate was higher than 1.5%, annual operation and operation of discharges in pure surgery for less than 35%, annual surgery people of surgical discharges less than 65%, was not in conformity with the national health and family planning commission of medical quality index and national statistical benchmark requirements.Conclusions We should reduce the average such confinement, reasonable control bed utilization rate, increase the rate of three level 4 operation, reduce mortality and infection rates surgery patients and improve the work load capacity, guarantee the quality and safety of patients, enhance the level of hospital operation management.