中国医疗管理科学2025年3月第15卷第2期 Chinese Journal of Medical Management Sciences, Mar. 2025, Vol. 15 No. 250
丰成祥 王晓敏 李静 马西文
【摘要】目的 探索建立科学的全面质量管理体系，以应对医院评审工作常态化的新要求。方法 成立全面质量管理办公室，
组建质管员队伍，构建以委员会为抓手的“大质控”体系，并从月度质控与不良事件正反两个方向查找质量管理问题，持续提
升医疗质量。结果 医院临床路径覆盖率、病案首页主要诊断编码正确率、静脉血栓栓塞症规范预防率、手术患者并发症发生率
等各项关键指标有了明显改善，质量改进案例屡获大奖，医院三级公立医院绩效考核排名由 B++ 上升至 A 序列。结论 层级明
晰、运行高效的“大质控”体系能够有效应对医院评审新要求，从而促进医院高质量发展。
【关键词】全面质量管理体系；医院评审；医疗质量
【中图分类号】R197
Practice of constructing a "Big Quality Control" management system in public hospitals
Feng Chengxiang, Wang Xiaomin, Li Jing, Ma Xiwen. Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou
450000, Henan Province, China
Corresponding author: Ma Xiwen, Email: qmzlglbgs@163.com
【Abstract】Objective To explore the establishment of a scientific comprehensive quality management system in response to the new
requirements for the normalization of hospital accreditation. Methods A comprehensive quality management office was established, and
a team of quality control personnel was assembled. Besides, a "Big Quality Control" system with committees as the core was constructed.
Quality management issues were identified from both positive and negative aspects through monthly quality control assessments and
adverse event reviews, thus continuously improving medical quality. Results Significant improvements were observed in various key
indicators, including the hospital's coverage rate of clinical pathway, accuracy of coding the main diagnoses on the front page of medical
records, standardized prevention rate of venous thromboembolism, and the incidence of complications in surgical patients. Quality
improvement cases have repeatedly won awards, and the hospital's ranking in the performance evaluation of tertiary public hospitals has
risen from B++ to the A sequence. Conclusion A clearly structured and efficiently operated "Big Quality Control" system can effectively
address the new requirements of hospital accreditation and promote high-quality development of hospitals.
【Key words】Comprehensive quality management system; Hospital accreditation; Medical quality
DOI：10.3969/j.issn.2095-7432.2025.02.009
基金项目：郑州市 2022 年度社会科学调研课题项目（ZSLX2022+0203）
作者单位：450000 郑州，郑州大学附属郑州中心医院
通信作者：马西文，Email: qmzlglbgs@163.com
构建公立医院大质控管理体系的实践探索
医疗质量管理
随着现代医院管理制度的推进和《三级医院评
审标准（2022 年版）》新要求的提出，医院需将传
统的单一医疗质控方式发展为覆盖全院、全员、全
过程的质量管理模式，建立从“单兵作战”到“团队
协作”、从“条块监管”到“系统工程”的全面质量管
理体系，将评审要求纳入质量管理体系并使之有效
落实。我院是一所集医疗、教学、科研为一体的综合
性三级甲等医院，医院 2020 年以三级甲等医院复审
为契机，成立了全面质量管理办公室（以下简称质
管办），积极探索构建“大质控”管理体系的实施路
径并不断加以完善，取得了明显效果，实现了医疗
质量的持续提升。
1“大质控”的概念
目前“大质控”尚无明确的定义 [1]，赖登祥等 [2]
认为医院“大质控” 的本质是“医院全面质量管理”
（Hospital Total Quality Management, HTQM），并总
结了“大质控”的 4 个特征：一是质管办是独立于
