目的: 本研究旨在探索适应公立医院高质量发展需求的创新型医保—病案—质控一体化管理模式（以下简称“一体化管理模式”）,以提升公立医院医保结算清单管理水平,为公立医院精细化管理提供实践参考。方法 本研究通过分析公立医院医保、病案、质控管理现状,进一步以深圳市罗湖区人民医院（以下简称“罗湖医院”）为案例,探索一体化管理模式的内涵与实施路径,并对其实施效果进行分析评价。结果: 一体化管理模式实施后,罗湖医院医保结算清单正确率从85%提升至97%,病案首页数据信息正确率从92%提升至98%,平均医保业务处理时间从7个工作日缩短至3个工作日,临床科室对职能部门回复的满意度从75%提升至92%,人员利用率从83.33%提升至94.44%。结论: 一体化管理模式在提升医保结算清单正确率、病案首页数据信息正确率、工作效率、临床科室满意度以及优化人员配置等方面取得了显著成效,是适应医药卫生体制改革和公立医院高质量发展需求的有效管理方式。未来,应进一步加强信息化建设,完善管理机制,持续推进该模式的创新与发展。

Objective: This study aims to explore an innovative medical insurance, medical records, quality control integrated management model (hereinafter referred to as the "integrated management model") that meets the high-quality development needs of public hospitals, in order to improve the management level of medical insurance settlement lists in public hospitals and provide references for the practice of refined management of public hospitals. Method: This study analyzed the current situation of medical insurance, medical records, and quality control management in public hospitals, explored the connotation and implementation path of the integrated management model with the People's Hospital of Luohu District, Shenzhen (hereinafter referred to as “Luohu Hospital”) as a case study, and evaluated its implementation effect. Result: After the implementation of the integrated management model, the accuracy rate of the medical insurance settlement list in Luohu Hospital increased from 85% to 97%, the accuracy rate of medical record homepage data information increased from 92% to 98%, the average medical insurance business processing time was shortened from 7 working days to 3 working days, the satisfaction rate of clinical departments with functional department responses increased from 75% to 92%, and the personnel utilization rate increased from 83.33% to 94.44%. Conclusion: The integrated management model has achieved significant results in improving the accuracy of medical insurance settlement lists, medical record homepage data information, work efficiency, clinical department satisfaction, and personnel allocation. It is an effective management method that adapts to the needs of medical system reform and high-quality development of public hospitals. In the future, we should further strengthen information technology construction, improve management mechanisms, and continue to promote innovation and development of this model.