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[1]魏楠鲁发国周佳姚海燕张艳丽.基于新一轮医院评审标准的数据核查常见问题与改进路径[J].中国卫生质量管理,2026,33(8):27-31.[doi:10.13912/j.cnki.chqm.2026.33.8.06]
　WEI Nan,LU Faguo,ZHOU Jia.Common Problems in Data Verification and Rectification Paths Based on the New Round of Hospital Accreditation Standards[J].Chinese Health Quality Management,2026,33(8):27-31.[doi:10.13912/j.cnki.chqm.2026.33.8.06]

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基于新一轮医院评审标准的数据核查常见问题与改进路径

《中国卫生质量管理》[ISSN:1006-7515/CN:CN 61-1283/R] 卷: 33 期数: 2026年8期页码: 27-31 栏目: 特别关注出版日期: 2026-08-15

Title:: Common Problems in Data Verification and Rectification Paths Based on the New Round of Hospital Accreditation Standards

作者:: 魏楠鲁发国周佳姚海燕张艳丽; 云南大学附属医院

Author(s):: WEI Nan; LU Faguo; ZHOU Jia; Affiliated Hospital of Yunnan University

关键词:: 医院评审; 数据核查; 数据质量; 数据治理; 整改路径

Keywords:: Hospital Accreditation; Data Verification; Data Quality; Data Governance; Rectification Path

分类号:: R197.3

DOI:: 10.13912/j.cnki.chqm.2026.33.8.06

文献标志码:: A

摘要:: 目的分析新一轮医院评审标准下数据核查中的常见问题，构建系统化的数据质量改进路径。方法采用文献分析、政策文本解读等方法，结合全国多家三级医院评审现场核查的共性问题与实践经验，基于《三级医院评审标准（2020年版）》《三级医院评审标准（2022年版）》《三级医院评审标准（2025年版）》及多个省份实施细则，对数据核查中的共性缺陷进行归因分析。结果将数据质量缺陷归纳为真实性、规范性、完整性、溯源性、管理机制5个风险层级；提出“源头治理—业务融合—双轨闭环改进”三位一体的全生命周期数据治理路径。结论医院应摒弃“迎检式”数据治理思维，构建常态化数据质量管理体系。

Abstract:: ObjectiveTo analyze the common problems in data verification under the new round of hospital accreditation standards, and construct a systematic rectification path for data quality. MethodsLiterature analysis and policy text interpretation were adopted. Combined with the common problems and practical experience from on-site accreditation verification of multiple tertiary hospitals across China, attribution analysis was conducted on the common defects in data verification based on the "Tertiary Hospital Accreditation Standards (2020 Edition)""Tertiary Hospital Accreditation Standards (2022 Edition)""Tertiary Hospital Accreditation Standards (2025 Edition)" and the implementation rules of multiple provinces.ResultsData quality defects were deconstructed into 5 risk levels: authenticity, standardization, completeness, traceability and management mechanism. A trinity full-life-cycle data governance path of "source governance - business integration - dual-track closed-loop improvement" was proposed.Conclusion Hospitals should abandon the "inspection-oriented" data governance mindset and build a normalized data quality management system.

参考文献/References:

［1］国家卫生健康委. 三级医院评审标准（2025年版）政策解读［EB/OL］. (2025-06-10)［2026-04-05］. https://www.nhc.gov.cn/yzygj/c100067/202506/0795d62 eece44307915d639486263a39.shtml.［2］国家卫生健康委. 关于印发《三级医院评审标准（2020年版）实施细则》的通知：国卫医发〔2021〕19号［EB/OL］. (2021-10-09)［2026-04-05］.https://www.nhc.gov.cn/yzygj/c100068/202110/838daad1061d4d47bae76fd0541f5730.shtml.［3］国家卫生健康委. 关于印发《三级医院评审标准（2022年版）》及其实施细则的通知：国卫医政发〔2022〕31号［EB/OL］. (2022-12-15)［2026-04-05］.https://www.gov.cn/zhengce/zhengceku/2022-12/ 18/content_5732583.htm.［4］国家卫生健康委. 关于印发《三级医院评审标准（2025年版）》的通知：国卫医政发〔2025〕4号［EB/OL］. (2025-06-10)［2026-04-05］. https://www.nhc.gov.cn/yzygj/c100068/202506/25229edc80d346 94b7debf54ddef9f9f.shtml.［5］张晨, 计虹, 金昌晓. 医疗数据质量分析与治理对策探讨［J］.中华医院管理杂志, 2020, 36(9):747-750.［6］关汭昕, 赵晓霜, 李虹彦, 等. 基于瑞士奶酪模型的患者安全链式管理体系研究［J］.中国卫生质量管理, 2025, 32(1):47-52.［7］徐悦, 张秉坤, 姚国东, 等. 基于医院评审标准的重点专业质量控制指标数据治理的思考［J］.中国卫生质量管理, 2024, 31(9):33-36, 42.［8］刘金婷, 常诚, 林宝禄, 等. 三级医院评审数据核查机制与系统性错误成因研究［J］.中国卫生质量管理, 2026, 33(1):28-32.［9］张金凤, 罗敏辉, 邹征强, 等. 基于等级医院评审标准的质量监测指标数据验证实践［J］.中国卫生质量管理, 2023, 30(6):37-40.

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更新日期/Last Update: 2026-08-15