Hospital total quality management system

The hospital total quality management system merges dedicated quality control for the national assessment and hospital accreditation with closed-loop daily quality control at both hospital and department level, helping hospitals build a broad quality control system covering hospital-level oversight, functional control, department quality control, and execution at the post level. Following a dynamic closed-loop principle, it interconnects the accreditation and national assessment management modules, the functional modules for medical affairs and nursing, the quality control modules for adverse events and quality inspections, and the organizational modules for department management and department quality control teams, creating a management mechanism in which accreditation standards, quality benchmarks, business procedures, and base data are dynamically linked.

Policy background

On May 29, 2023 the National Health Commission issued the Action Plan for Comprehensively Improving Medical Quality (2023-2025), requiring medical institutions at secondary level and above to "strengthen basic medical safety management and improve routine monitoring, analysis, and feedback of medical quality and safety." The Accreditation Standards for Tertiary Hospitals (2022 edition) refine indicator definitions, specify monitoring data for hospital quality and safety indicators, key specialty quality control indicators, and single-disease quality control, and form an objective evaluation system along the lines of "structure, process, outcome," which — combined with on-site inspection — makes up an accreditation standard system balancing objective and subjective evaluation.

Core capabilities

• Hospital-level modules: the three parts of the Accreditation Standards for Tertiary Hospitals (2022 edition) — prerequisites, monitoring data on service capability and quality and safety, and on-site inspection — together with management of national assessment and high-quality development policy requirements.
• Functional modules: medical affairs, nursing, infection control, pharmacy affairs, blood use, along with committee management, human resources, and research management.
• Department modules: department authorization teams, QC teams, routine inspections, continuous improvement, technical records, and adverse event reporting.

Product strengths

The system uses a modular design: modules can be installed independently, bundled, or implemented in sequence, across two product lines — systematic quality control and domain-specific quality control. The design emphasizes combining accreditation with daily work, real-time presentation, automatic statistics, information sharing, ease of evaluation, and traceability. Original content from quality control forms, reports, and records is processed digitally; management rules become computation rules that link four levels across hospital and department vertically and multiple professions horizontally, connecting rule-setting, execution, monitoring and evaluation, and continuous improvement into one closed loop.