Ultrasound quality control in Fujian Province: current status and improvement strategies

doi:10.3877/cma.j.issn.1672-6448.2022.03.014

Abstract

Abstract:

Objective

To explore strategies for improving the ultrasound quality control in Fujian Province, China by analyzing the current status of ultrasound quality control in medical institutions.

Methods

According to the Evaluation Standards of Ultrasound Quality Control Inspection in Fujian Province and based on PDCA cycle principle, the inspection results of three quality control indicators - ultrasound professional team structure, follow-up of ultrasound cases & consultation and discussion of difficult cases, and ultrasound quality control and safety management - in medical institutions in Fujian Province in the period of 2017—2019 were comparatively analyzed. The evaluation results of each indicator were rated into four levels: A, B, C, and D. Cochran-Armitage trend test was used to analyze the annual change trend of each grade proportion.

Results

The proportion of levels A and B of the three indicators, ultrasound professional team structure, follow-up of ultrasound cases & consultation and discussion of difficult cases, and ultrasound quality control and safety management, was increasing year by year in the period of 2017—2019, while the proportion of levels A and B showed a general downward trend. Statistical differences over time were determined by the Cochran-Armitage trend test (Z=2.106, 2.25, and 4.2578; P=0.035, =0.024, and＜0.001, respectively).

Conclusion

The popularization and application of the Evaluation Standards of Ultrasound Quality Control Inspection in Fujian Province, based on the PDCA cycle principle, helps to continuously improve the ultrasound quality control in Fujian Province, thereby strengthening the construction of ultrasound medical quality management and control system.

Key words: Ultrasonography, Quality management, PDCA

Shun Chen, Ensheng Xue. Ultrasound quality control in Fujian Province: current status and improvement strategies[J]. Chinese Journal of Medical Ultrasound (Electronic Edition), 2022, 19(03): 267-271.

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URL: https://chaosheng.cma-cmc.com.cn/EN/10.3877/cma.j.issn.1672-6448.2022.03.014

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References 8

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等级	评价结果	PDCA循环内容
A-优秀	有持续改进，成效良好	PDCA
B-良好	有监管有结果	PDC
C-合格	有机制且能有效执行	PD
D-不合格	仅有制度或规章或流程，未执行	仅P或全无

等级	评价结果	PDCA循环内容
A-优秀	有持续改进，成效良好	PDCA
B-良好	有监管有结果	PDC
C-合格	有机制且能有效执行	PD
D-不合格	仅有制度或规章或流程，未执行	仅P或全无

指标	分级	评价内容
超声专业队伍结构	【Ｃ】	（1）医师、护士和辅助人员配备合理，满足临床工作需要。每台仪器配1～2名医师，有开展介入超声的每台配2～3名医护人员。（2）各级各类人员具有相应资质和执业资格。超声医师需取得《医师执业资格证》并按注册的执业地点、执业类别（临床）、执业范围（医学影像和放射治疗专业）从事超声诊疗工作，不得跨范围执业；护士需持有《护士执业证书》。（3）超声医学专业人员应有《福建省超声医学水平证书》。
	【Ｂ】符合“Ｃ”，并满足	（1）根据医院功能任务与设备的种类设若干（≥2）专业组，由具备副高以上专业技术职称人员负责。（2）各专业组人员梯队结构合理。（3）科主任具备副主任医师以上专业技术任职资格。
	【Ａ】符合“Ｂ”，并满足	（1）科主任为主任医师，具有较强的学术影响力。（2）专业组齐全（心脏、腹部、浅表、血管、介入、妇产），均由副主任医师及以上人员担任组长。
超声病例随访与疑难病例会诊、讨论	【Ｃ】	（1）开展重点病例随访与反馈。（2）有专人负责并定期召开疑难病例分析与读片会。（3）疑难病例分析与读片会由科主任或副主任医师以上主持，并有文档图片记录。（4）阳性率、符合率统计。
	【Ｂ】符合“Ｃ”，并满足	（1）每月开展重点病历随访与反馈。（2）疑难病例分析读片会PPT等资料完整，≥2次/月。（3）疑难病例分析与读片会参加人员覆盖科室80%人员。（4）开展疑难病例会诊工作，会诊病例报告必须双签。
	【Ａ】符合“Ｂ”，并满足	（1）每月开展全面随访分析与反馈。（2）通过随访结果分析，能够改进诊断工作，提高诊断质量。
超声质量控制与安全管理	【Ｃ】	（1）由科主任及相关人员组成科室质量与安全管理小组，人员职责明确，内容具体。（2）实行医院科室两级质量与安全管理，设立相关指标、工作方案。（3）有明确的医疗差错事故的报告、处置流程，并执行到位。（4）医疗安全（不良）事件报告内容完整。（5）定期接受质量与安全管理的培训学习，参加省市级质量控制培训学习。
	【Ｂ】符合“Ｃ”，并满足	（1）根据工作方案，开展质量安全检查，落实相关措施，有完整的工作记录。（2）全面开展检查阳性率统计与分析。（3）全面开展超声诊断与术后病理符合率统计与分析，符合率≥90%。（4）省市级质量控制培训学习覆盖率＞50%，参加国家级质量控t制培训学习。（5）实行医院科室两级质量与安全管理，定期开展工作（每年≥4次），主管部门应监督到位并有反馈。
	【Ａ】符合“Ｂ”，并满足	（1）医院科室两级管理能够结合国家、省市相关质量控制要求，认真开展质量与安全管理，并体现持续改进。（2）质量与安全管理考核结果应用于科室和个人考核。（3）省市级质量控制培训学习覆盖率＞60%，且科主任、质量控制管理员应参加国家级质量控制培训学习。

指标	分级	评价内容
超声专业队伍结构	【Ｃ】	（1）医师、护士和辅助人员配备合理，满足临床工作需要。每台仪器配1～2名医师，有开展介入超声的每台配2～3名医护人员。（2）各级各类人员具有相应资质和执业资格。超声医师需取得《医师执业资格证》并按注册的执业地点、执业类别（临床）、执业范围（医学影像和放射治疗专业）从事超声诊疗工作，不得跨范围执业；护士需持有《护士执业证书》。（3）超声医学专业人员应有《福建省超声医学水平证书》。
	【Ｂ】符合“Ｃ”，并满足	（1）根据医院功能任务与设备的种类设若干（≥2）专业组，由具备副高以上专业技术职称人员负责。（2）各专业组人员梯队结构合理。（3）科主任具备副主任医师以上专业技术任职资格。
	【Ａ】符合“Ｂ”，并满足	（1）科主任为主任医师，具有较强的学术影响力。（2）专业组齐全（心脏、腹部、浅表、血管、介入、妇产），均由副主任医师及以上人员担任组长。
超声病例随访与疑难病例会诊、讨论	【Ｃ】	（1）开展重点病例随访与反馈。（2）有专人负责并定期召开疑难病例分析与读片会。（3）疑难病例分析与读片会由科主任或副主任医师以上主持，并有文档图片记录。（4）阳性率、符合率统计。
	【Ｂ】符合“Ｃ”，并满足	（1）每月开展重点病历随访与反馈。（2）疑难病例分析读片会PPT等资料完整，≥2次/月。（3）疑难病例分析与读片会参加人员覆盖科室80%人员。（4）开展疑难病例会诊工作，会诊病例报告必须双签。
	【Ａ】符合“Ｂ”，并满足	（1）每月开展全面随访分析与反馈。（2）通过随访结果分析，能够改进诊断工作，提高诊断质量。
超声质量控制与安全管理	【Ｃ】	（1）由科主任及相关人员组成科室质量与安全管理小组，人员职责明确，内容具体。（2）实行医院科室两级质量与安全管理，设立相关指标、工作方案。（3）有明确的医疗差错事故的报告、处置流程，并执行到位。（4）医疗安全（不良）事件报告内容完整。（5）定期接受质量与安全管理的培训学习，参加省市级质量控制培训学习。
	【Ｂ】符合“Ｃ”，并满足	（1）根据工作方案，开展质量安全检查，落实相关措施，有完整的工作记录。（2）全面开展检查阳性率统计与分析。（3）全面开展超声诊断与术后病理符合率统计与分析，符合率≥90%。（4）省市级质量控制培训学习覆盖率＞50%，参加国家级质量控t制培训学习。（5）实行医院科室两级质量与安全管理，定期开展工作（每年≥4次），主管部门应监督到位并有反馈。
	【Ａ】符合“Ｂ”，并满足	（1）医院科室两级管理能够结合国家、省市相关质量控制要求，认真开展质量与安全管理，并体现持续改进。（2）质量与安全管理考核结果应用于科室和个人考核。（3）省市级质量控制培训学习覆盖率＞60%，且科主任、质量控制管理员应参加国家级质量控制培训学习。

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