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三级公立医院绩效考核与数据质量控制

2019-08-15 国家卫生健康委 国家卫生健康委

8月13日,国家卫生健康委发布了《按照属地化原则开展三级公立医院绩效考核与数据质量控制工作的通知》。 各省、自治区、直辖市及新疆生产建设兵团卫生健康委,医管中心: 按照《国务院办公厅关于加强三级公立医院绩效考核工作的意见》(国办发〔2019〕4号,以下简称《意见》)明确的工作原则和要求,请各地根据本省实施方案,抓紧启动三级公立医院绩效考核工作。同时,为确保绩效考核数据客观真实可比,


8月13日,国家卫生健康委发布了《按照属地化原则开展三级公立医院绩效考核与数据质量控制工作的通知》。

各省、自治区、直辖市及新疆生产建设兵团卫生健康委,医管中心:

按照《国务院办公厅关于加强三级公立医院绩效考核工作的意见》(国办发〔2019〕4号,以下简称《意见》)明确的工作原则和要求,请各地根据本省实施方案,抓紧启动三级公立医院绩效考核工作。同时,为确保绩效考核数据客观真实可比,各地要对辖区内三级公立医院报送国家三级公立医院绩效考核管理平台(以下简称管理平台)的数据进行质控,具体要求如下:

一、数据质控内容及时间

我委将于8月12日开放管理平台(https://www.nmpas.org.cn),供三级公立医院自查填报的数据及佐证材料,同时供省级卫生健康行政部门开展数据质控工作。

(一)三级公立医院自查要求。各三级公立医院要根据《三级公立医院绩效考核操作手册》以及本地三级公立医院绩效考核实施方案的要求,对医院上报的数据和佐证材料进行认真核查和质量控制。

1.第一阶段:国家监测指标4、5、6、8、9、10、13、14、24、45、46、48、53、54、55的质控工作由我委负责,非国家监测指标52的质控工作由国家发展改革委公共信用信息中心负责,上述数据质控完成后将嵌入管理平台,供各地参考使用。其中指标45、46,请各三级公立医院根据实际情况,于8月20日前在国家医疗机构、医师、护士电子化注册系统(机构端)内对人员信息进行维护,麻醉和病理在岗医师信息应当维护到具体科室。医院应当于8月20日前完成除我委负责的其他国家监测指标的质控工作,形成第一阶段分析报告(模板在管理平台上下载),报属地省级卫生健康行政部门,并上传至管理平台。

2.第二阶段:各三级公立医院应当在8月31日前完成非国家监测指标的质控工作(除指标52外),形成第二阶段分析报告(模板在管理平台上下载),报属地省级卫生健康行政部门,并上传至管理平台。

(二)省级卫生健康行政部门数据质控要求。

1.核查医疗机构基本信息。8月25日前,按照《医疗机构管理条例实施细则》《国务院关于批转发展改革委等部门法人和其他组织统一社会信用代码制度建设总体方案的通知》《医疗机构基本标准(试行)》《2018国家卫生健康统计调查制度》的要求,核查并规范三级公立医院的第一名称、法人和其他组织统一社会信用代码、医疗机构执业许可证登记号、医疗机构等级、医疗机构类别等,确保医疗机构信息真实准确。

2.核查病案首页数据。10月1日前,各省级卫生健康行政部门依托本省份病案质控中心,在国家病案管理质控中心的支持下,结合实际制定用于本省绩效考核的四级手术目录、微创手术目录,并核查病案首页相关数据。

3.核查绩效考核相关指标数据。对辖区内三级公立医院上报的数据进行核查和质量控制,形成本地三级公立医院第一阶段、第二阶段绩效考核整体数据质控分析报告(模板在管理平台上下载),分别于8月25日前、10月1日前上传至管理平台。

二、补充指标数据及佐证材料

(一)补充指标50每百名卫生技术人员科研项目经费佐证材料。各三级公立医院要于8月20日前将2018年科研经费立项相关佐证材料上传至管理平台(模板在管理平台下载)。

(二)补充指标32辅助用药收入占比指标数据。各三级公立医院要于8月20日前按照《关于印发第一批国家重点监控合理用药药品目录(化药及生物制品)的通知》(国卫办医函〔2019〕558号)要求,对2016-2018年辅助用药收入占比进行数据测算,并在管理平台补充填报相关数据。

三、其他要求

(一)根据操作手册要求,数据来源标注为财务年报表的指标,各三级公立医院应当与本医院财务年报数据进行比对,并按照财务年报表数据进行填报。如医院与卫生健康行政部门没有预算管理关系,或虽有预算管理关系但执行的是非医院会计制度的,医院应当认真核实数据,按照两个阶段的时间节点要求完成质控工作,并由省级卫生健康行政部门复核确认。

(二)各三级公立医院数据质控发现问题时,应当向属地省级卫生健康行政部门报送书面报告,经同意后在管理平台进行数据更正,填写详细的情况说明,并由省级卫生健康行政部门复核确认。省级卫生健康行政部门数据质控中发现的问题,要及时通知并督促辖区内相关医院进行数据更正,并填写情况说明。质控后的数据用于各地绩效考核使用。

(三)各地要认真落实《意见》要求,搭建绩效考核信息系统平台,组建绩效考核专家委员会,建立绩效考核数据质量控制体系。对质控过程中发现的编造、谎报、瞒报等情况,我委将予以通报批评并取消医院当年绩效考核资格。

国家卫生健康委医政医管局联系人:肖莉、王斐

联系电话:010—68791885、68791889

国家卫生健康委医管中心联系人:褚湜婧、翟晓辉

联系电话:010—68791681、68791678

国家卫生健康委办公厅

2019年8月8日

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    2019-08-17 whlxd
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