| Purpose:To understand the status quo of Department of thoracic surgery in 2014 two ward executive PDCA circulation method and the existing problems,evaluation of the effect of PDCA cycle to improve the quality of medical records,to provide decision-making basis for hospital quality management,to ensure medical safety and the quality of the.Hospital electronic medical records are convenient and safe,greatly improve the efficiency of medical records writing,reducing the burden on doctors.The management process of the implementation of electronic medical records in the hospital,adhering to the principle of PDCA,namely the meter(play),(do),(check),(action),can effectively improve the quality of medical records,medical records continue to reduce the incidence of B,promote the hospital management quality control on automation and scientific and standardized,full real-time quality control of rail,ensure medical safety and quality,is worthy of discussion.Method:This topic is to meet the level of hospital review "in the background,in order to improve the medical quality management level as the theme,with the level of hospital review requires the implementation of continuous improvement of medical quality management in hospital,in December 2013 to set up a comprehensive quality and safety and continuous improvement of Management Committee,the Department established quality and safety management team to carry out activities,the implementation of the" PDCA cycle "activities in the hospital,monitoring and management of all aspects of hospital level quality control group focuses on the quality of medical records of Department of thoracic surgery.In the implementation of the PDCA cycle process,the requirements of the chest A,B ward combined with the actual situation of the undergraduate room in accordance with the overall requirements of the hospital,in order to implement the system,the full implementation of the PDCA cycle,and a detailed record of the implementation of PDCA cycle.From January 2014 to December 2014,A chest B ward quality and safety activities group according to the records,"the implementation of the review of three grade tumor hospital rules(2011 Edition)" on medical quality improvement and inspection requirements,combining with the working experience of the management of execution related evaluation elements of PDCA circulation,alternative elements in the list summarized,and to evaluate the importance,urgency and feasibility of policy,etc.,the evaluation of PDCA cycle management execution factors questionnaire was designed,and by means of letters for fourteen and the continuous improvement of quality and safety management of small group leaders,the management group leader anonymously submit comments.After several repeated consultation and feedback,the evaluation factor scores for Level 3 is "important" and 4 "very important",identified as the final evaluation factors,finally make the PDCA cycle management execution evaluation standard for evaluation.According to the evaluation criteria by using expert scoring method,scoring PDCA cycle implementation of chest A and B in a month,with an average score of 12 months of the year as 2014 of the Department PDCA cycle implementation score more than 90 points assessed for the effective implementation of the following 90 points following evaluation for effective implementation.The safety of medical quality and continuous improvement of quality of medical records management survey team Department of thoracic surgery through on-site inspection and questionnaire,randomly selected from the chest A,B ward records 120 copies each,were in accordance with the "standards" evaluation of hospital medical records,more than 90 points assessed as grade a medical record,90 rated B records.Then by the hospital level quality control group by using the method of brainstorming,centered around people,material,material,method and environment five aspects of drawing fishbone,reasons for the defects of medical records were analyzed;then,the root cause tired's curve to find defects in medical records more,put forward the effective measures of innovation.At the same time,to investigate the cognition and satisfaction of PDCA circulation management.By using independent sample t test,chi square test,and the two factor repeated measurement of variance analysis and other statistical methods,the two ward of the PDCA cycle and the implementation of the quality of medical records are analyzed and compared,in order to evaluate the PDCA cycle in the effective implementation of the effect of improving the quality of medical records.Result:1.During the implementation of the PDCA cycle in the hospital,was evaluated according to the "PDCA circulation management execution evaluation standard for evaluation of chest A in PDCA",execution score of 93 points,for the effective implementation of PDCA ward,execution of chest B in PDCA score of 75.25 points,for the effective implementation of PDCA in circulation.2.In the Shanxi Province Tumor Hospital thoracic A ward and chest B ward of the two departments of similar size,were treated with lung cancer and esophageal cancer patients.A total of 240 medical records from patients,diseases,clinical staging and hospitalization days.There were no significant differences in age and gender;physicians of medical records,educational level,professional title were not statistically significant;physician ward two sampling records in the medical records of patients with clinical features and characteristics of the basic balance.3.Grade a medical record rate of chest A in PDCA cycle was 90% before,did not reach the hospital setting and 98% above the standard,and the effective implementation of PDCA cycle was increased to 98.33%,reached the hospital standards;quality score records with the implementation of PDCA cycle to promote a rising trend;the quality of medical records and scores patients with advanced cancer early medical quality score of cancer patients increased significantly;the effective implementation of PDCA cycle after the medical record quality score is 94.3 points;the average recovery of medical records for 5.06 days after discharge of the patients.A medical record chest B ward rate was 90.83% before the execution of a PDCA loop,did not reach the hospital setting and 98% above the standard,because it is not the effective implementation of the PDCA cycle,after the implementation of PDCA grade a medical record rate is only 91.67%,the increase is limited;in the implementation of PDCA cycle during the medical record quality score with the implementation of PDCA cycle to promote is also showing a trend of slow growth,but its growth rate is not obvious,in patients with advanced cancer medical record quality score increased approximately;PDCA cycle after the implementation of the quality of medical records for the total score 92.8 points;the average recovery of medical records for 6.24 days after discharge of the patients.The effective implementation of PDCA circulation in the chest A ward in the above medical records quality evaluation indicators are better than the PDCA circulation of the B ward,and there was statistical difference.From the different clinical stages of patients with medical perspective,medical quality score in patients with early cancer than in advanced cancer,the quality of medical records of patients with early stage score averaged 94.8 points in patients with advanced medical quality score from 92.3 to 92.7;early cancer patients medical recovery days than in advanced cancer,recovery of medical records the early days with an average of 4.7 days,the medical records of the recovery days,patients in 6 ~ 6.5 days,showed that patients with early cancer without advanced cancer patients with complex disease,short hospitalization time,medical record content is relatively simple,less likely to have defects,the quality of medical records with higher scores,recovery of medical records timely.4.Chest physicians believe that the proportion of PDCA in A cycle is important for 86.7%,and in B was 46.7%,A was significantly higher than that in the chest chest in B;A in physician satisfaction of PDCA cycle working in more than 90%,the average satisfaction rate was 95.2%,the average satisfaction rate was 88.53% in B ward,A ward in 6.7% higher than B.Conclusion:1.Chest A in implementing the PDCA cycle,director of unremittingly,the implementation of strong staff,the reasonable construction of the work flow,target clear,clear division of labor,formulated a reasonable incentive mechanism,therefore,effectively improve the execution of PDCA cycle.2.In the hospital during the PDCA cycle,chest A in the effective implementation of the PDCA cycle,the quality of medical records increased greatly,and the chest outside the B ward without the effective implementation of the PDCA cycle,the quality of medical records increased slowly,that the effective implementation of PDCA cycle can not only improve the staff quality management consciousness,effectively solve the causes of defects medical records,and improve the quality of medical records.3.In the implementation of the PDCA cycle in the hospital,the effective implementation of the PDCA cycle of the physicians of the PDCA cycle of the importance of a deeper understanding of the work,and enhance their own quality management awareness and grasp.Physicians are also satisfied with the PDCA cycle,and have a high sense of identity for PDCA cycle management. |
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