為進一步貫(guan)徹落(luo)實《醫(yi)(yi)療(liao)質(zhi)量(liang)(liang)管(guan)(guan)理(li)辦法》（國家(jia)衛生(sheng)和(he)計劃生(sheng)育委(wei)員會令第10號(hao)）《醫(yi)(yi)療(liao)質(zhi)量(liang)(liang)控(kong)制中(zhong)心(xin)管(guan)(guan)理(li)辦法（試行）》（衛醫(yi)(yi)政發〔2009〕51號(hao)），加強(qiang)醫(yi)(yi)療(liao)質(zhi)量(liang)(liang)安(an)全管(guan)(guan)理(li)，完善醫(yi)(yi)療(liao)質(zhi)量(liang)(liang)管(guan)(guan)理(li)與控(kong)制體系，規范醫(yi)(yi)療(liao)質(zhi)量(liang)(liang)控(kong)制中(zhong)心(xin)的建設與管(guan)(guan)理(li)，國家(jia)衛生(sheng)健康委(wei)組(zu)織制定了《醫(yi)(yi)療(liao)質(zhi)量(liang)(liang)控(kong)制中(zhong)心(xin)管(guan)(guan)理(li)規定》。
一、制(zhi)定背景
持續改進醫(yi)療(liao)(liao)質(zhi)(zhi)(zhi)(zhi)量(liang)(liang)，保(bao)障醫(yi)療(liao)(liao)安全(quan)，為人民群眾提供安全(quan)、優質(zhi)(zhi)(zhi)(zhi)的(de)(de)醫(yi)療(liao)(liao)服務(wu)是衛生(sheng)健(jian)康(kang)工(gong)(gong)作(zuo)的(de)(de)核(he)心(xin)任務(wu)。把握醫(yi)療(liao)(liao)服務(wu)質(zhi)(zhi)(zhi)(zhi)量(liang)(liang)內在(zai)發(fa)展規律，充分調動和(he)激發(fa)行業(ye)的(de)(de)內生(sheng)動力，是實(shi)現醫(yi)療(liao)(liao)服務(wu)質(zhi)(zhi)(zhi)(zhi)量(liang)(liang)提升的(de)(de)必由之徑。多年(nian)(nian)來(lai)，國家(jia)和(he)各地在(zai)加強醫(yi)療(liao)(liao)質(zhi)(zhi)(zhi)(zhi)量(liang)(liang)管(guan)(guan)理(li)(li)方面做了大量(liang)(liang)工(gong)(gong)作(zuo)，取得了顯(xian)著成(cheng)(cheng)效，這些工(gong)(gong)作(zuo)和(he)成(cheng)(cheng)效離不開專業(ye)質(zhi)(zhi)(zhi)(zhi)控(kong)(kong)組(zu)織(zhi)的(de)(de)支持。為規范質(zhi)(zhi)(zhi)(zhi)控(kong)(kong)組(zu)織(zhi)管(guan)(guan)理(li)(li)，充分發(fa)揮質(zhi)(zhi)(zhi)(zhi)控(kong)(kong)組(zu)織(zhi)在(zai)醫(yi)療(liao)(liao)質(zhi)(zhi)(zhi)(zhi)量(liang)(liang)安全(quan)改進工(gong)(gong)作(zuo)中(zhong)的(de)(de)作(zuo)用(yong)，2009年(nian)(nian)原衛生(sheng)部(bu)印發(fa)《醫(yi)療(liao)(liao)質(zhi)(zhi)(zhi)(zhi)量(liang)(liang)控(kong)(kong)制(zhi)(zhi)中(zhong)心(xin)管(guan)(guan)理(li)(li)辦(ban)法(fa)(fa)(試行)》(以(yi)下簡稱《辦(ban)法(fa)(fa)》)，加強對(dui)醫(yi)療(liao)(liao)質(zhi)(zhi)(zhi)(zhi)量(liang)(liang)控(kong)(kong)制(zhi)(zhi)中(zhong)心(xin)(以(yi)下簡稱質(zhi)(zhi)(zhi)(zhi)控(kong)(kong)中(zhong)心(xin))的(de)(de)建設和(he)管(guan)(guan)理(li)(li)，此后(hou)，質(zhi)(zhi)(zhi)(zhi)控(kong)(kong)中(zhong)心(xin)逐漸成(cheng)(cheng)為醫(yi)療(liao)(liao)質(zhi)(zhi)(zhi)(zhi)量(liang)(liang)管(guan)(guan)理(li)(li)與控(kong)(kong)制(zhi)(zhi)體(ti)系(xi)的(de)(de)中(zhong)堅力量(liang)(liang)。2016年(nian)(nian)國家(jia)衛生(sheng)健(jian)康(kang)委以(yi)部(bu)門規章形(xing)式公布《醫(yi)療(liao)(liao)質(zhi)(zhi)(zhi)(zhi)量(liang)(liang)管(guan)(guan)理(li)(li)辦(ban)法(fa)(fa)》，進一(yi)步明確了質(zhi)(zhi)(zhi)(zhi)控(kong)(kong)組(zu)織(zhi)在(zai)醫(yi)療(liao)(liao)質(zhi)(zhi)(zhi)(zhi)量(liang)(liang)管(guan)(guan)理(li)(li)與控(kong)(kong)制(zhi)(zhi)體(ti)系(xi)中(zhong)的(de)(de)作(zuo)用(yong)。
隨著我國進(jin)入高質(zhi)(zhi)(zhi)量發(fa)展(zhan)階段，人民群眾對醫療(liao)質(zhi)(zhi)(zhi)量的(de)(de)要(yao)求日益增(zeng)高，對質(zhi)(zhi)(zhi)控中心工(gong)(gong)作科學(xue)化(hua)(hua)、專業化(hua)(hua)、精細化(hua)(hua)程(cheng)度(du)要(yao)求也(ye)越來越高。近年來的(de)(de)工(gong)(gong)作實踐(jian)(jian)證明，質(zhi)(zhi)(zhi)控中心的(de)(de)設置需要(yao)科學(xue)規(gui)劃、質(zhi)(zhi)(zhi)控中心的(de)(de)管理(li)和工(gong)(gong)作機(ji)制也(ye)需要(yao)進(jin)一步健全。為引(yin)導質(zhi)(zhi)(zhi)控中心規(gui)范健康發(fa)展(zhan)，結合實踐(jian)(jian)經(jing)驗(yan)，在以往(wang)工(gong)(gong)作的(de)(de)基礎上，國家衛生健康委組織制定(ding)了《醫療(liao)質(zhi)(zhi)(zhi)量控制中心管理(li)規(gui)定(ding)》(以下簡稱(cheng)《規(gui)定(ding)》)。
二(er)、主要內容(rong)
《規(gui)(gui)定(ding)(ding)(ding)》針對(dui)新時(shi)期(qi)的(de)(de)(de)要(yao)求和(he)質(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)控(kong)中(zhong)(zhong)(zhong)心(xin)管(guan)(guan)理(li)運(yun)(yun)行(xing)(xing)(xing)中(zhong)(zhong)(zhong)存在的(de)(de)(de)共性問(wen)題，從質(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)控(kong)中(zhong)(zhong)(zhong)心(xin)的(de)(de)(de)規(gui)(gui)劃(hua)(hua)設(she)(she)置(zhi)(zhi)、工作(zuo)(zuo)(zuo)(zuo)(zuo)職能(neng)、運(yun)(yun)行(xing)(xing)(xing)監管(guan)(guan)等方面(mian)細化(hua)管(guan)(guan)理(li)規(gui)(gui)定(ding)(ding)(ding)、明(ming)確工作(zuo)(zuo)(zuo)(zuo)(zuo)要(yao)求。一是(shi)(shi)(shi)明(ming)確質(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)控(kong)中(zhong)(zhong)(zhong)心(xin)規(gui)(gui)劃(hua)(hua)設(she)(she)置(zhi)(zhi)。統籌規(gui)(gui)劃(hua)(hua)質(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)控(kong)中(zhong)(zhong)(zhong)心(xin)的(de)(de)(de)專業領域和(he)工作(zuo)(zuo)(zuo)(zuo)(zuo)方向(xiang)，合理(li)布(bu)局(ju)。首批規(gui)(gui)劃(hua)(hua)設(she)(she)置(zhi)(zhi)的(de)(de)(de)質(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)控(kong)中(zhong)(zhong)(zhong)心(xin)包(bao)括臨床、醫技、管(guan)(guan)理(li)3大類6個(ge)領域60個(ge)具體(ti)方向(xiang)。二是(shi)(shi)(shi)建(jian)立質(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)控(kong)中(zhong)(zhong)(zhong)心(xin)動(dong)態管(guan)(guan)理(li)機制。完(wan)善各級質(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)控(kong)中(zhong)(zhong)(zhong)心(xin)的(de)(de)(de)產生(sheng)機制，建(jian)立公開(kai)透明(ming)、擇優(you)設(she)(she)置(zhi)(zhi)的(de)(de)(de)制度；建(jian)立質(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)控(kong)中(zhong)(zhong)(zhong)心(xin)退(tui)出機制，對(dui)質(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)控(kong)中(zhong)(zhong)(zhong)心(xin)進(jin)行(xing)(xing)(xing)動(dong)態調(diao)整(zheng)，充分調(diao)動(dong)和(he)激發質(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)控(kong)中(zhong)(zhong)(zhong)心(xin)的(de)(de)(de)內(nei)生(sheng)動(dong)力。三是(shi)(shi)(shi)強化(hua)質(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)控(kong)中(zhong)(zhong)(zhong)心(xin)工作(zuo)(zuo)(zuo)(zuo)(zuo)保障(zhang)(zhang)。要(yao)求各級衛生(sheng)健康行(xing)(xing)(xing)政部門對(dui)質(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)控(kong)中(zhong)(zhong)(zhong)心(xin)開(kai)展工作(zuo)(zuo)(zuo)(zuo)(zuo)予以(yi)政策保障(zhang)(zhang)，對(dui)掛靠(kao)單位為質(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)控(kong)中(zhong)(zhong)(zhong)心(xin)開(kai)展工作(zuo)(zuo)(zuo)(zuo)(zuo)提(ti)供的(de)(de)(de)支持(chi)和(he)保障(zhang)(zhang)作(zuo)(zuo)(zuo)(zuo)(zuo)出基本要(yao)求。四是(shi)(shi)(shi)規(gui)(gui)范質(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)控(kong)中(zhong)(zhong)(zhong)心(xin)運(yun)(yun)行(xing)(xing)(xing)管(guan)(guan)理(li)。對(dui)質(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)控(kong)中(zhong)(zhong)(zhong)心(xin)的(de)(de)(de)職責任務、組織架構、人(ren)員配置(zhi)(zhi)、數據使(shi)用、資金(jin)管(guan)(guan)理(li)等方面(mian)作(zuo)(zuo)(zuo)(zuo)(zuo)出規(gui)(gui)定(ding)(ding)(ding)，進(jin)一步強調(diao)目標(biao)導(dao)向(xiang)，在保障(zhang)(zhang)質(zhi)(zhi)(zhi)(zhi)(zhi)(zhi)控(kong)中(zhong)(zhong)(zhong)心(xin)有序合規(gui)(gui)運(yun)(yun)行(xing)(xing)(xing)的(de)(de)(de)同時(shi)，提(ti)升工作(zuo)(zuo)(zuo)(zuo)(zuo)效率。
三、工作要求
各級衛生健康行(xing)政部門根據(ju)本轄(xia)區質(zhi)控(kong)工(gong)作(zuo)需要(yao)和(he)上級質(zhi)控(kong)中(zhong)(zhong)心(xin)(xin)(xin)的設(she)置情況，做好本級質(zhi)控(kong)中(zhong)(zhong)心(xin)(xin)(xin)的規(gui)劃、設(she)置、管理和(he)考核工(gong)作(zuo)，確(que)保質(zhi)控(kong)中(zhong)(zhong)心(xin)(xin)(xin)專(zhuan)業布局合理、擇優設(she)置，并為(wei)質(zhi)控(kong)中(zhong)(zhong)心(xin)(xin)(xin)開展工(gong)作(zuo)提供(gong)充分的政策保障(zhang)，利用質(zhi)控(kong)中(zhong)(zhong)心(xin)(xin)(xin)不斷提升醫(yi)療質(zhi)量安全水平；掛(gua)靠單位為(wei)質(zhi)控(kong)中(zhong)(zhong)心(xin)(xin)(xin)工(gong)作(zuo)開展提供(gong)必要(yao)的設(she)備、設(she)施(shi)、人員和(he)經(jing)費等保障(zhang)條件，確(que)保質(zhi)控(kong)中(zhong)(zhong)心(xin)(xin)(xin)工(gong)作(zuo)有序開展。
各級(ji)質(zhi)控中心(xin)在本級(ji)行政部門指導(dao)下，按照要求充分(fen)掌(zhang)握本專(zhuan)業本轄區(qu)醫療質(zhi)量(liang)安(an)(an)全(quan)現狀，充分(fen)挖(wa)掘(jue)、分(fen)析、利用醫療質(zhi)量(liang)安(an)(an)全(quan)數據，定期(qi)發布質(zhi)控信息，制(zhi)定質(zhi)量(liang)安(an)(an)全(quan)改(gai)進(jin)長期(qi)規劃、方案以(yi)及當前改(gai)進(jin)目標的綜(zong)合策略和(he)具體改(gai)進(jin)措施，發揮行業管理(li)和(he)引(yin)領作用，指導(dao)各級(ji)醫療機構落實醫療質(zhi)量(liang)管理(li)要求，促進(jin)醫療質(zhi)量(liang)安(an)(an)全(quan)同質(zhi)化，保(bao)障患者安(an)(an)全(quan)。
