60 2022 ANNUAL REPORT OF CHILDREN’S HOSPITAL OF SHANGHAI
抓運(yùn)營(yíng)、提效能，促進(jìn)醫(yī)院治理精細(xì)化和專(zhuān)業(yè)化
Focus on operation, increase efficiency, and strengthen fine and professional hospital management
管理運(yùn)營(yíng) Management & Operation
1. 聚焦質(zhì)量與安全，全面提升醫(yī)療質(zhì)量管理水平。一是完
成 2021 年度國(guó)家三級(jí)公立醫(yī)院績(jī)效考核工作。我院國(guó)家監(jiān)測(cè)指
標(biāo)得分 778.8 分，考核等級(jí) B 級(jí)，位列全國(guó)兒童專(zhuān)科醫(yī)院績(jī)效
考核第 9 名。針對(duì)歷年考核結(jié)果，對(duì)標(biāo)國(guó)家標(biāo)準(zhǔn)、兄弟醫(yī)院考
核情況以及全國(guó)三級(jí)兒童專(zhuān)科醫(yī)院平均水平，梳理重點(diǎn)關(guān)注指
標(biāo)和薄弱指標(biāo)，制定改善舉措。二是強(qiáng)化醫(yī)療質(zhì)量監(jiān)督管理。
根據(jù)上級(jí)部門(mén)及醫(yī)院關(guān)于醫(yī)療質(zhì)量、醫(yī)療安全及疫情防控的要
求，結(jié)合市衛(wèi)監(jiān)所、市病歷質(zhì)控專(zhuān)家督查意見(jiàn)，定期調(diào)整臨床
科室醫(yī)療質(zhì)量考核標(biāo)準(zhǔn)，對(duì)重點(diǎn)關(guān)注內(nèi)容及專(zhuān)家反饋情況加強(qiáng)
監(jiān)督，并加強(qiáng)考核力度。同時(shí)進(jìn)一步深化內(nèi)涵質(zhì)量考核維度、
考核方法與內(nèi)容，探索應(yīng)用 DRGs 數(shù)據(jù)對(duì)臨床科室的產(chǎn)能、病
種結(jié)構(gòu)、費(fèi)用構(gòu)成等進(jìn)行分析，促進(jìn)病種結(jié)構(gòu)調(diào)整、內(nèi)涵質(zhì)量
持續(xù)增長(zhǎng)。三是不斷深化抗菌藥物使用監(jiān)管。重新梳理抗菌藥
物使用監(jiān)控指標(biāo)，并納入每日績(jī)效簡(jiǎn)報(bào)；優(yōu)化抗菌藥物管理系
統(tǒng)和抗菌藥物使用強(qiáng)度計(jì)算方法，完善抗菌藥物使用知識(shí)庫(kù)，
加強(qiáng)對(duì)臨床科室抗菌藥物使用培訓(xùn)。2022 年門(mén)急診患者抗菌藥
物使用率 20.02%，同比下降 5.61 個(gè)百分點(diǎn)；住院患者抗菌藥
物使用率 43.57%，同比下降 2.67 個(gè)百分點(diǎn)。
Focusing on quality and safety, the hospital comprehensively increased the medical
quality management level. First, the hospital received the performance assessment
of national third-level public hospitals in 2021. With national monitoring index score
of 778.8 points and assessment grade B, the hospital ranked ninth in the performance
assessment of children's specialized hospitals in China. Based on the assessment results
over the years, the key indicators and weak indicators were sorted out with reference
to the national standards, the assessment of brother hospitals and the average level of
2. 持續(xù)深化績(jī)效改革，積極推進(jìn)綜合績(jī)效管理。一是建立
“ 醫(yī)院 - 部門(mén) - 科室 ” 三級(jí)績(jī)效管理架構(gòu)。建立了醫(yī)院綜合績(jī)效
管理委員會(huì)（領(lǐng)導(dǎo)小組）和綜合績(jī)效（運(yùn)營(yíng)）管理核心工作小組，
各臨床醫(yī)技科室建立科室綜合績(jī)效管理小組。二是建立健全綜
合績(jī)效管理相關(guān)管理制度。定期召開(kāi)綜合績(jī)效（運(yùn)營(yíng)）管理核
心小組會(huì)議，建立了各部門(mén)之間高效有序的協(xié)同聯(lián)動(dòng)工作機(jī)制。
三是進(jìn)一步完善醫(yī)院綜合績(jī)效指標(biāo)體系。初步擬定了醫(yī)院層面
19 個(gè)維度 72 項(xiàng)重點(diǎn)監(jiān)測(cè)指標(biāo)以及科室層面 11 個(gè)維度 31 項(xiàng)重
點(diǎn)監(jiān)測(cè)指標(biāo)，不斷深化綜合績(jī)效監(jiān)測(cè)分析，以指標(biāo)為引導(dǎo)，持
續(xù)推進(jìn)醫(yī)院及科室運(yùn)營(yíng)管理。
The hospital sustainably deepened performance reform and actively advanced
comprehensive performance management. First, the three-level performance
management structure of “hospital-department–section” was set up. The hospital
comprehensive performance management committee (leading group) and the
comprehensive performance (operation) management core working group were formed,
with section comprehensive performance management group established in the clinical
and medical technician departments. Second, the hospital established and perfected the
comprehensive performance management system. The core group meeting was held
regularly for comprehensive performance (operation) management, and an efficient and
orderly collaborative working mechanism was established among all departments. Third,
the hospital further improved the comprehensive performance indicator system. 72 key
monitoring indicators from 19 dimensions at the hospital level and 31 key monitoring
indicators from 11 dimensions at the department level were preliminarily formulated
to continuously further the comprehensive performance monitoring and analysis, and
continue to facilitate the hospital and department operation and management under the
guidance of the indicators.
third-level children's specialized hospitals in China to formulate improvement measures.
Second, the hospital strengthened medical quality supervision and management.
According to the superior department requirements and hospital requirements for
medical quality, medical safety and epidemic prevention and control, the hospital took
into consideration the supervision opinions of municipal health supervision institute
and municipal medical records quality control experts, regularly adjusted the medical
quality assessment standards for clinical departments, strengthened the supervision on
key concerns and expert feedback, and intensified the assessment. At the same time, the
hospital further elaborated on the assessment dimension, assessment method and content
of connotation quality, explored the application of DRGs data to analyze the productivity,
disease structure, cost composition of clinical departments, so as to better adjust disease
structure and promote the sustained growth of connotation quality. Third, the hospital
constantly strengthened supervision over the use of antibiotics. The hospital reorganized
the monitoring indicators for antimicrobial use and incorporated them in the daily
performance briefing. The antibacterial drug management system and the calculation
method of antibacterial drug use intensity were optimized, the antibacterial drug use
knowledge base was perfected, and the training was strengthened on antibacterial drug
use in clinical departments. In 2022, the utilization rate of antibiotics among outpatient
and emergency patients was 20.02%, down 5.61 percentage points year on year; the
utilization rate of antibiotics among inpatients was 43.57%, down 2.67 percentage points
year on year.
