Three dimensional theory Evaluation path Hierarchical hospital accreditation
江南大学附属医院（无锡市第四人民医院）科研项目，项目编号（FYGL201802）
从医疗质量的三维理论出发，以《江苏省三级综合医院评审标准实施细则（2017版）》为标准，结合医院实际设计内审评价路径，对自评等级进行质量监测、评估和反馈，取得了良好的效果，以麻醉质量与安全管理为例进行了内审经验的分享，注重制度、规范及各种管理规定的执行、落实和持续改进，保障患者安全，提升医疗质量。
Based on the three-dimensional theory of medical quality and from the implementation of the “Jiangsu Provincial TertiaryLevelComprehensive Hospital Accreditation Criteria （2017 Version）”，this paper designs the internal audit evaluation path with hospital practical situations，and carries out quality monitoring，evaluation and feedback，take anesthesia quality and safety management as examples to share the experience of evaluation，pay attention to the implementation of the system，norms and various management regulations and implementation to protect patient safety and improve the quality of medicine.