Abstract: Objective　To explore the application effect of PDCA cycle method in the quality management of hospital tumor registration and reporting. Methods　A retrospective survey method was used to select 1 340 tumor cases in a tertiary oncology medical consortium hospital in Inner Mongolia from January to December 2021, including 672 males and 668 females, aged (50.5±1.2) years. The PDCA cycle method was carried out on the basis of routine quality management (formulating questionnaires, daily random and regular inspection of tumor reports, full-time staff review, publicity and training of tumor registration and reporting, etc.). The cyclical quality control was carried out by 4 steps: plan, namely analyzing the reasons by the brainstorming method; do, namely setting up a quality control team, strengthening the three-level quality control supervision, and improving the information system; check and action, namely combined random and regular inspections. The completeness rate and accuracy rate of tumor registration and reporting and underreporting rate were compared before and after PDCA cycle management. Chi-square test was used for statistical analysis. Results　The accuracy rate and completeness rate of tumor registration and reporting and underreporting rate were 68.89% (62/90), 65.56% (59/90), and 73.33% (66/90) within 3 months before the implementation of PDCA cycle method; those were 87.78% (79/90), 94.44% (170/180), 96.67% (261/270), 84.44% (76/90), 91.11% (164/180), 93.33% (252/270), 43.30% (39/90), 25.56% (46/180), and 8.89% (24/270) within 3, 6, and 9 months after the implementation of PDCA cycle method; the reporting quality was significantly improved, and the underreporting rate was significantly decreased, with statistically significant differences (all P<0.05). Conclusions　PDCA cycle method used in the quality management of hospital tumor registration and reporting, effectively improves the accuracy rate and completeness rate of tumor reports and reduces the underreporting rate. PDCA cycle method has strong operability and high application value, and is worth popularizing.

Key words: PDCA cycle method, Application, Tumor registration and reporting, Quality management, Effect assessment

摘要： 目的　探讨PDCA循环法在医院肿瘤登记报告质量管理中的应用效果。方法　采用回顾性调查法，选取内蒙古某三甲肿瘤专科医联体医院2021年1—12月肿瘤患者1 340例作为研究对象，其中男672例，女668例，年龄（50.5±1.2）岁。在常规质量管理（制定调查表、日常随机和定期检查肿瘤报告、专职人员审核、开展肿瘤登记报告宣传、培训等）基础上采用PDCA循环法，即计划（plan）：头脑风暴法分析原因；实施（do）：成立质控小组，强化三级质控监管力度，完善信息系统等；检查（check）和处理（action）：随机和定期检查相结合；4个阶段进行循环式质量控制。对比实施PDCA循环法管理前后肿瘤登记报告质量的完整率和准确率及漏报率的变化情况。统计学方法采用χ²检验。结果　实施PDCA循环法前3个月（1—3月）肿瘤报告卡填写质量准确率为68.89%（62/90）、完整率为65.56%（59/90），漏报率为73.33%（66/90）；实施PDCA循环法后3、6、9个月肿瘤报告卡填写质量准确率分别为87.78%（79/90）、94.44%（170/180）、96.67%（261/270），完整率分别为84.44%（76/90）、91.11%（164/180）、93.33%（252/270），漏报率分别为43.30%（39/90）、25.56%（46/180）、8.89%（24/270），报告质量明显提高，漏报率显著降低，差异均有统计学意义（均P<0.05）。结论　在医院肿瘤登记报告工作中采用PDCA循环法进行质量管理，有效提高了肿瘤报告质量的准确率和完整率，降低了漏报率，且PDCA循环法可操作性强，具有较高的运用价值，值得推广。

关键词: PDCA循环法, 运用, 肿瘤登记报告, 质量管理, 效果评价