【摘要】 目的探讨利用戴明(PDCA)环联合品管圈改革医保管理体系的效果。方法在医院层面建立以医保科为基础的多科联合制定医院医保管理制度,遵循PDCA循环优化制度,在科室层面建立以科室负责人为主的医保品管圈活动,促进科室人员主动积极参与医保管理。结果医保管理改革后医保扣罚例数由2018年的393例降至2019年的174例,同比下降55.73%;扣罚费用从73 400.11元降低至49 137.66元,同比下降33.06%。临床一线科室医保违规现象大幅减少。对一些拒付金额同比增幅较大的违规情况可以及时发现其原因并整改。结论 PDCA联合品管圈活动的应用,可以有效提高医保管理质量,减少医保违规风险。更多还原

【Abstract】 Objective To explore the effect of PDCA combined with quality control circle(QCC) to reform the medical insurance management system.Methods At the hospital level, a medical insurance management system of multi-departmental joint development based on the medical insurance department was established, and the PDCA cycle optimization system was followed. At the department level, the medical insurance QCC activities with department leaders as the main body were established to promote the department staff to actively participate in the medical insurance management.Results After the reform of medical insurance management, the number of medical insurance deduction cases decreased from 393 cases in 2018 to 174 cases in2019, with a decrease of 55. 73% compared with the corresponding period last year; the refused payment decreased from 73400.11 to 49137. 66, a decrease of 33. 06% compared with the corresponding period last year. Medical insurance refused payment in clinical departments has been greatly reduced. The reason for large refused payment growth of some cases could be found and rectified in time.Conclusion The application of PDCA combined with QCC can effectively improve the quality of medical insurance management and reduce the risk of medical insurance punishment.更多还原