以内部审核促进医院质量管理持续改进

目的 分析医院质量管理体系运行情况，促进医院质量管理持续改进。方法 通过内部审核，发现不合格项并对其进行统计分析，找出影响医院质量管理的主要问题，采取相应的改进措施。结果 2003—2008年医院共组织内部审核7次，发出不合格项118项，通过采取纠正措施和预防措施，并制定医院质量管理工作重点，不合格项目逐年减少。 结论 医院质量管理体系的运行符合ISO9001标准的要求，是适宜的、有效的。内部审核促进了医院质量管理持续改进。

Improving the Quality Management in Hospital Continuously through Internal Audit

Objective To analyze the operation of the quality management system in hospital to improve the quality management in hospital continuously. Methods Carrying out internal audit, finding and analyzing statistics of the nonconformity items, identifying the main issues that influencing the quality management in hospital, and taking corresponding improvement measures. Results There were 7 internal audits carried out from 2003 to 2008, and 118 nonconformity items were found.The number of the nonconformity items was decreasing through taking corrective action and preventive action, and identifying the focus in hospital management. Conclusion The operation of the quality management system in hospital is appropriate and effective, being in line with ISO9001 standards. The quality management in hospital is improved continuously through internal audit.