National tertiary public hospital performance appraisal: Using FOCUS-PDCA to improve external quality assessment.

ABSTRACT

PURPOSE: To innovatively use the FOCUS-PDCA quality improvement strategy to establish an external quality assessment (EQA) working group to continuously improve EQA performance, an important indicator of the national tertiary public hospital performance appraisal. METHODS: The project was carried out at the National Center for Clinical Laboratories. Using FOCUS-PDCA, which combines problem-focused steps (FOCUS) and improvement steps (PDCA), a project team was established to carry out improvement work. Root cause analysis was carried out to analyze the problems in quality control from EQA project application to results analysis and an improvement plan was implemented according to the steps of FOCUS-PDCA. The project was executed in three cycles from 2019 to 2021 to obtain more satisfactory results. RESULTS: After implementing three cycles of FOCUS-PDCA, the EQA participation rate increased from 66.5% in 2018 to 100% in 2021, and the EQA pass rate increased from 94.9% in 2018 to 99.3% in 2021. Consequently, the hospital moved into the top 50 in performance assessment for the first time in 2020 and ranked 27th in 2021. CONCLUSION: The use of the FOCUS-PDCA quality improvement strategy can improve the EQA performance of national tertiary public hospitals and help them achieve satisfactory results in the national examination.