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新版三级医院评价标准发布,DRG成核心评价体系

2021-01-04 陈鹏 健康界

12月28日,国家卫生健康委(下文简称国家卫健委)发布了《三级医院评审标准(2020年版)》(下文简称2020版标准)。这是继2011年国家卫健委发布《三级综合医院评审标准(2011年版)》(下文简称

12月28日,国家卫生健康委(下文简称国家卫健委)发布了《三级医院评审标准(2020年版)》(下文简称2020版标准)。这是继2011年国家卫健委发布《三级综合医院评审标准(2011年版)》(下文简称2011版标准)后9年来第一个全新的标准版本。

动脉网对2020版标准和2011版标准进行了比较。发现2020版在DRG上着墨甚多,可以这么说,DRG将成为未来三级医院评审标准的重要组成部分!

注重日常,更为客观,DRG成2020版标准核心评价标准

在2020版标准中,最为重要的修改部分便是将所有内容分为三个部分。其中,第二部分为医疗服务能力与质量安全监测数据部分,共设74节240条监测指标,在评审综合得分中的权重不低于60%,可以说是重中之重。

相比2011版标准,2020版标准的第二部分内容主要增加了医院资源配置、质量、安全、服务、绩效等指标监测以及DRG评价、单病种质控和重点医疗技术等日常监测数据的比重,并大量应用DRG评价体系。毫不夸张地说,DRG是贯穿整个2020版第二部分内容的核心主线。

2020版标准的医疗服务能力指标中包括收治病种数量(ICD-10四位亚目数量)、住院术种数量(ICD-9-CM-3四位亚目数量)、DRG-DRGs组数、DRG-CMI、DRG时间指数和DRG费用指数共六项指标。这些指标均与DRG直接相关。

医院质量指标则包括年度国家医疗质量安全目标改进情况、患者住院总死亡率、新生儿患者住院死亡率、手术患者住院死亡率、住院患者出院后0-31天非预期再住院率、手术患者术后48小时/31天内非预期重返手术室再次手术率和115个ICD低风险病种患者住院死亡率等指标。这些指标或多或少也与DRG存在关联。

2011版标准的第七章中也对医院的医疗服务能力提出了相应的要求。如治疗质量日常监测指标中包括手术冰冻与石蜡诊断符合例数、恶性肿瘤手术前诊断与术后病理诊断符合例数、住院患者死亡与自动出院例数、住院手术例数及死亡例数、住院危重抢救例数与死亡例数、急诊科危重抢救例数与死亡例数,以及新生儿患者住院死亡率。

而在可与2020版标准DRG内容直接对标的住院患者医疗质量与安全监测指标中,2011版以重返率(再住院与再手术)、死亡率(住院死亡与术后死亡)、安全指标(并发症与患者安全)三类结果质量为重点,包括住院重点疾病(总例数、死亡例数、2周与1月内再住院例数、平均住院日与平均住院费用)、住院重点手术(总例数、死亡例数、术后非预期再手术例数、平均住院日与平均住院费用)、麻醉和住院患者安全类指标。

细化来看,2020版标准中的收治病种数量(ICD-10四位亚目数量)、住院术种数量(ICD-9-CM-3四位亚目数量)、DRG-DRGs组数三项指标代表了医院医疗服务能力的“广度”。这三项指标覆盖的DRG组数越多说明医院技术越全面。假设一家综合医院当年可以覆盖400多分组,同一区域的另一医院只能覆盖200多,说明后者综合服务能力不如前者。

DRG-CMI则可以衡量整体医疗服务的“深度”,即技术难度高低,越高说明医院医疗服务的难度越高。假设某地医院病例平均权重数平均值为1,A医院在同等病例数量下的平均权重为1.5,B医院仅有0.7。那A医院技术水平较高,B医院技术水平较低。

DRG时间指数是指医院治疗某病组所需要花费的平均时间,DRG费用指数则是指医院治疗某病组所需要花费的平均费用。这两项经过权重调整后的指标可以衡量医院的效率。

由于DRG对数据采集具有极高的要求,因此,2020版标准还对数据采集标准进行了统一规定。所采集的数据来源于国家医疗质量管理与控制信息网(NCIS)、全国医院质量监测系统(HQMS)以及各省级相关数据收集系统,有着统一的数据要求及标准。

其所使用的ICD编码则基于《疾病分类与代码国家临床版2.0》,即通常所指的“临床版ICD-10”;所使用的手术操作编码则为《手术操作分类代码国家临床版2.0》,即通常所指的“国临版ICD-9-CM3”。

相比之下,2011版标准虽然也规定了疾病分类编码和手术操作代码。但当时我国DRG发展尚未形成统一的论调,各地所采用的编码和DRG分组器也有较大差异。最为关键的是,由于当时没有统一客观的数据采集来源和标准,数据可用性并不好。

总的来说,在2011版标准的评价主要以较为笼统的数据作为评价标准。因此,相比2011版标准,2020版标准更加重视日常质量管理和绩效,同时也有可以依据的数据指标,更为客观。DRG则将在其中发挥核心作用,是否很好地理解并掌握DRG这一工具将成为医院是否能够通过三级医院评审的关键。

提质增效,2020版标准的其他改进

除了将DRG这一重大变化外,2020版标准相比2011版标准也有一些其他的明显改进。

首先是充分融入新颁政策和医改要求,体现时代性。2020版标准在保持2011版标准延续性的基础上,融入《基本医疗卫生与健康促进法》《医疗纠纷预防与处理条例》《医疗质量管理办法》《医疗技术临床应用管理办法》《医疗质量安全核心制度要点》等近年来颁布实施的法律、条例、规章相关内容以及分级诊疗体系建设、现代医院管理制度等改革要求。

与此同时,针对目前的新冠疫情,2020版标准还增加了新冠肺炎疫情常态化防控相关要求。在2020版标准第一部分前置要求的第三节中便对“安全管理与重大事件”做出了下列定义:发生定性为完全责任的一级医疗事故或直接被卫生健康行政部门判定的重大医疗事故;发生重大医院感染事件,造成严重后果;发生因重大火灾、放射源泄漏、有害气体泄漏等被通报或处罚的重大安全事故;发生瞒报、漏报重大医疗过失事件的行为;发生大规模医疗数据泄露或其他重大网络安全事件,造成严重后果。

第二,则是之前提到的由主管定性想客观定量转变,增强科学性。通过引入更为科学客观的DRG评价体系,2020版标准希望指导各地由以现场检查、主观定性、集中检查为主的评审形式转向以日常监测、客观指标、现场检查、定性与定量相结合的评审工作模式。

第三则是梳理整合并简化实地评审条款,提升操作性。2020版标准现场检查部分共24节183条,较2011版标准的66节354条有大幅度压缩。

一方面,全面梳理整合原标准中的重复条款,提高工作效率;另一方面,对原标准中操作性不强,或者可以用日常数据监测替代现场检查的条款进行了剔除或调整,提高标准的可操作性。

最后,2020版标准更加注重借鉴国际、国内先进理念和经验,体现兼容性。它充分借鉴了国际上部分医院评价机构的工作方法和标准,并采纳了国内一些省市好的经验和做法,与国际国内评审评价管理先进理念更加契合和兼容。

写在最后

作为一种管理工具,DRG兼具“控费”与“质量管理”两大用途。事实上,由美国耶鲁大学研发的第一代DRG系统是一种质量管理工具,目的是帮助临床医生和医院监控服务质量和服务利用率。

在2020版标准中,DRG被提高到了核心工具的地位。这意味着我国所有三级医院,以及希望升级为三级医院的二级医院在接下来的时间中都需要尽快熟悉并推动DRG工具在院内的应用。

与此同时,在支付端,国家医保局也在力推CHS-DRG和DIP。由于2020版标准针对全国所有三级医院,并未指出例外。这意味着即使DIP试点城市的三级医院仍然需要在评审标准上使用DRG工具,考虑到医保版编码可实现对卫健委版编码100%映射。或许,这也从侧面反应了DIP和DRG未来的走向。

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    2021-01-06 tsing_hit
  3. [GetPortalCommentsPageByObjectIdResponse(id=1689577, encodeId=bd6816895e7a2, content=<a href='/topic/show?id=ad0619e19b0' target=_blank style='color:#2F92EE;'>#三级#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=116, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=19719, encryptionId=ad0619e19b0, topicName=三级)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=0eeb28833546, createdName=luckyshitiancai_42705693, createdTime=Tue Apr 20 18:07:31 CST 2021, time=2021-04-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1322879, encodeId=7aad13228e9ca, content=<a href='/topic/show?id=0c5d62457e' target=_blank style='color:#2F92EE;'>#DRG#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=140, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=6245, encryptionId=0c5d62457e, topicName=DRG)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=dcaa509, createdName=tsing_hit, createdTime=Wed Jan 06 13:07:31 CST 2021, time=2021-01-06, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1444669, encodeId=b05c144466930, content=<a href='/topic/show?id=3d9291459d1' target=_blank style='color:#2F92EE;'>#评价#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=100, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=91459, encryptionId=3d9291459d1, topicName=评价)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=1fee5134542, createdName=huagfeg, createdTime=Wed Jan 06 13:07:31 CST 2021, time=2021-01-06, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1540302, encodeId=bf4b1540302ad, content=<a href='/topic/show?id=a1a8914e051' target=_blank style='color:#2F92EE;'>#评价标准#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=83, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=91470, encryptionId=a1a8914e051, topicName=评价标准)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=5fa213200151, createdName=xqptu, createdTime=Wed Jan 06 13:07:31 CST 2021, time=2021-01-06, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=913789, encodeId=cabf913e8960, content=认真学习!, beContent=null, objectType=article, channel=null, level=null, likeNumber=165, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=20341326639, createdName=zhuwei1441, createdTime=Tue Jan 05 08:13:32 CST 2021, time=2021-01-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=913784, encodeId=ab90913e84b0, content=很好的进步!, beContent=null, objectType=article, channel=null, level=null, likeNumber=107, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20210703/9c448fe1b3b54fd7bc9477662f4861bb/4bdadad22bfd46f2921aabb4c40265d3.jpg, createdBy=a8d81938466, createdName=weigq, createdTime=Tue Jan 05 07:54:02 CST 2021, time=2021-01-05, status=1, ipAttribution=)]
    2021-01-06 huagfeg
  4. [GetPortalCommentsPageByObjectIdResponse(id=1689577, encodeId=bd6816895e7a2, content=<a href='/topic/show?id=ad0619e19b0' target=_blank style='color:#2F92EE;'>#三级#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=116, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=19719, encryptionId=ad0619e19b0, topicName=三级)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=0eeb28833546, createdName=luckyshitiancai_42705693, createdTime=Tue Apr 20 18:07:31 CST 2021, time=2021-04-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1322879, encodeId=7aad13228e9ca, content=<a href='/topic/show?id=0c5d62457e' target=_blank style='color:#2F92EE;'>#DRG#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=140, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=6245, encryptionId=0c5d62457e, topicName=DRG)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=dcaa509, createdName=tsing_hit, createdTime=Wed Jan 06 13:07:31 CST 2021, time=2021-01-06, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1444669, encodeId=b05c144466930, content=<a href='/topic/show?id=3d9291459d1' target=_blank style='color:#2F92EE;'>#评价#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=100, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=91459, encryptionId=3d9291459d1, topicName=评价)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=1fee5134542, createdName=huagfeg, createdTime=Wed Jan 06 13:07:31 CST 2021, time=2021-01-06, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1540302, encodeId=bf4b1540302ad, content=<a href='/topic/show?id=a1a8914e051' target=_blank style='color:#2F92EE;'>#评价标准#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=83, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=91470, encryptionId=a1a8914e051, topicName=评价标准)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=5fa213200151, createdName=xqptu, createdTime=Wed Jan 06 13:07:31 CST 2021, time=2021-01-06, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=913789, encodeId=cabf913e8960, content=认真学习!, beContent=null, objectType=article, channel=null, level=null, likeNumber=165, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=20341326639, createdName=zhuwei1441, createdTime=Tue Jan 05 08:13:32 CST 2021, time=2021-01-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=913784, encodeId=ab90913e84b0, content=很好的进步!, beContent=null, objectType=article, channel=null, level=null, likeNumber=107, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20210703/9c448fe1b3b54fd7bc9477662f4861bb/4bdadad22bfd46f2921aabb4c40265d3.jpg, createdBy=a8d81938466, createdName=weigq, createdTime=Tue Jan 05 07:54:02 CST 2021, time=2021-01-05, status=1, ipAttribution=)]
  5. [GetPortalCommentsPageByObjectIdResponse(id=1689577, encodeId=bd6816895e7a2, content=<a href='/topic/show?id=ad0619e19b0' target=_blank style='color:#2F92EE;'>#三级#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=116, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=19719, encryptionId=ad0619e19b0, topicName=三级)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=0eeb28833546, createdName=luckyshitiancai_42705693, createdTime=Tue Apr 20 18:07:31 CST 2021, time=2021-04-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1322879, encodeId=7aad13228e9ca, content=<a href='/topic/show?id=0c5d62457e' target=_blank style='color:#2F92EE;'>#DRG#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=140, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=6245, encryptionId=0c5d62457e, topicName=DRG)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=dcaa509, createdName=tsing_hit, createdTime=Wed Jan 06 13:07:31 CST 2021, time=2021-01-06, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1444669, encodeId=b05c144466930, content=<a href='/topic/show?id=3d9291459d1' target=_blank style='color:#2F92EE;'>#评价#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=100, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=91459, encryptionId=3d9291459d1, topicName=评价)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=1fee5134542, createdName=huagfeg, createdTime=Wed Jan 06 13:07:31 CST 2021, time=2021-01-06, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1540302, encodeId=bf4b1540302ad, content=<a href='/topic/show?id=a1a8914e051' target=_blank style='color:#2F92EE;'>#评价标准#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=83, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=91470, encryptionId=a1a8914e051, topicName=评价标准)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=5fa213200151, createdName=xqptu, createdTime=Wed Jan 06 13:07:31 CST 2021, time=2021-01-06, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=913789, encodeId=cabf913e8960, content=认真学习!, beContent=null, objectType=article, channel=null, level=null, likeNumber=165, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=20341326639, createdName=zhuwei1441, createdTime=Tue Jan 05 08:13:32 CST 2021, time=2021-01-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=913784, encodeId=ab90913e84b0, content=很好的进步!, beContent=null, objectType=article, channel=null, level=null, likeNumber=107, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20210703/9c448fe1b3b54fd7bc9477662f4861bb/4bdadad22bfd46f2921aabb4c40265d3.jpg, createdBy=a8d81938466, createdName=weigq, createdTime=Tue Jan 05 07:54:02 CST 2021, time=2021-01-05, status=1, ipAttribution=)]
    2021-01-05 zhuwei1441

    认真学习!

    0

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    2021-01-05 weigq

    很好的进步!

    0

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