【摘要】 医院以循证决策为驱动，融合全面质量管理理论，构建以“决策层—控制层—执行层”为核心的“三层四级”医院质量与安全管理体系，下设11个专业质量管理委员会，实现了组织架构的横向协同与纵向贯通。通过优化委员会成员结构、标准化工作流程、落实全员培训指导、强化数据驱动的质控指标监测评价，以及整合多维质量工具推动系统持续改进，有效促进了体系的高效运行，显著提升了多部门协作的管理效能，有力保障了医疗质量与安全目标的达成。更多还原

【Abstract】 The hospital is driven by evidence-based decision-making and integrates the theory of comprehensive quality management to build a "three-level and four-grade" hospital quality and safety management system with the layers of "decisionmaking — control — execution" as the core. It has 11 professional quality management committees, achieving horizontal coordination and vertical integration of the organizational structure. By optimizing the committee member structure, standardizing workflow, implementing training and guidance for all staff, strengthening data-driven quality control indicator monitoring and evaluation, and integrating multi-dimensional quality tools to promote continuous system improvement, the efficient operation of the system has been effectively promoted, significantly improving the management efficiency of multi-departmental collaboration, and effectively ensuring the achievement of medical quality and safety goals.更多还原