60 2022 ANNUAL REPORT OF CHILDREN’S HOSPITAL OF SHANGHAI
抓运营、提效能，促进医院治理精细化和专业化
Focus on operation, increase efficiency, and strengthen fine and professional hospital management
管理运营 Management & Operation
1. 聚焦质量与安全，全面提升医疗质量管理水平。一是完
成 2021 年度国家三级公立医院绩效考核工作。我院国家监测指
标得分 778.8 分，考核等级 B 级，位列全国儿童专科医院绩效
考核第 9 名。针对历年考核结果，对标国家标准、兄弟医院考
核情况以及全国三级儿童专科医院平均水平，梳理重点关注指
标和薄弱指标，制定改善举措。二是强化医疗质量监督管理。
根据上级部门及医院关于医疗质量、医疗安全及疫情防控的要
求，结合市卫监所、市病历质控专家督查意见，定期调整临床
科室医疗质量考核标准，对重点关注内容及专家反馈情况加强
监督，并加强考核力度。同时进一步深化内涵质量考核维度、
考核方法与内容，探索应用 DRGs 数据对临床科室的产能、病
种结构、费用构成等进行分析，促进病种结构调整、内涵质量
持续增长。三是不断深化抗菌药物使用监管。重新梳理抗菌药
物使用监控指标，并纳入每日绩效简报；优化抗菌药物管理系
统和抗菌药物使用强度计算方法，完善抗菌药物使用知识库，
加强对临床科室抗菌药物使用培训。2022 年门急诊患者抗菌药
物使用率 20.02%，同比下降 5.61 个百分点；住院患者抗菌药
物使用率 43.57%，同比下降 2.67 个百分点。
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. 持续深化绩效改革，积极推进综合绩效管理。一是建立
“ 医院 - 部门 - 科室 ” 三级绩效管理架构。建立了医院综合绩效
管理委员会（领导小组）和综合绩效（运营）管理核心工作小组，
各临床医技科室建立科室综合绩效管理小组。二是建立健全综
合绩效管理相关管理制度。定期召开综合绩效（运营）管理核
心小组会议，建立了各部门之间高效有序的协同联动工作机制。
三是进一步完善医院综合绩效指标体系。初步拟定了医院层面
19 个维度 72 项重点监测指标以及科室层面 11 个维度 31 项重
点监测指标，不断深化综合绩效监测分析，以指标为引导，持
续推进医院及科室运营管理。
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.
