中华护理杂志 ›› 2026, Vol. 61 ›› Issue (19): 2612-2619.DOI: 10.3761/j.issn.0254-1769.2026.19.003

• 护理质量与安全管理专题 • 上一篇    下一篇

2 377所医院消毒供应中心质量管理体系建设现状调查研究

乔赛男1(), 杜志娟1, 陈璐2, 赵越2, 李保华3,*()   

  1. 1 清华大学北京清华长庚医院消毒供应中心 北京市 102218
    2 清华大学北京清华长庚医院护理部 北京市 102218
    3 首都医科大学附属北京朝阳医院消毒供应中心 北京市 100020
  • 收稿日期:2026-02-28 出版日期:2026-10-10 发布日期:2026-09-28
  • *通讯作者: 李保华,E-mail:13521202831@163.com
  • 作者简介:乔赛男:女,本科,主管护师,E-mail:qsna00079@btch.edu.cn
    第一联系人:

    乔赛男:研究设计及实施、数据采集及分析、论文撰写及修改;杜志娟:数据收集与整理、统计分析、论文修改;陈璐、赵越:统计分析、论文修改;李保华:研究设计及指导、论文修改

Investigation on the current situation of quality management system construction in central sterile supply departments of 2 377 hospitals

QIAO Sainan1(), DU Zhijuan1, CHEN Lu2, ZHAO Yue2, LI Baohua3,*()   

  1. 1 Central Sterile Supply Department, Beijing Tsinghua Changgung Hospital,School of Clinical Medicine,Tsinghua Medicine,Tsinghua University, Beijing 102218, China
    2 Department of Nursing, Beijing Tsinghua Changgung Hospital,School of Clinical Medicine,Tsinghua Medicine,Tsinghua University, Beijing 102218, China
    3 Central Sterile Supply Department, Beijing Chaoyang Hospital,Capital Medical University, Beijing 100020, China
  • Received:2026-02-28 Online:2026-10-10 Published:2026-09-28
  • * Corresponding author: LI Baohua,E-mail:13521202831@163.com

摘要:

目的 调查医院消毒供应中心(central sterile supply department,CSSD)质量管理体系建设现状,分析不同级别医院的差异,为推动CSSD规范化建设提供参考依据。方法 采用便利抽样法,2025年5月12—30日,通过自制问卷对31个省(自治区、直辖市)2 456所医院开展横断面调查。该问卷基于结构-过程-结果模型,内容包含结构(制度建设、人力资源配置满意度)、过程(信息化管理)、结果(质量监测指标设置、持续质量改进)3个维度,共31个条目。采用描述性统计分析管理现状,并比较不同等级医院之间的差异。结果 发放问卷2 456份,回收有效问卷2 377份,有效问卷回收率为96.78%。结构维度:95.00%以上的CSSD均建立岗位职责、应急预案、操作规程、工作流程、消毒隔离制度、设备设施管理制度及不良事件报告制度等;人力资源配置满意度方面,18.13%的CSSD管理者认为完全满足,人员充足能高质量完成工作,54.77%的CSSD管理者认为基本满足,有时工作较忙但能应对,三级医院人员配置满意度高于二级医院(P<0.001)。过程维度:仅28.23%的CSSD实现质量敏感指标信息化管理,23.52%的CSSD信息系统具备质量控制功能,21.37%的CSSD信息系统具备人员工作量分析功能。结果维度:器械清洗质量合格率指标的设置率为95.37%,灭菌质量合格率、包装合格率、灭菌湿包率等指标的设置率依次为89.27%、89.19%、77.41%,器械供应及时率指标的设置率最低,仅为25.54%。在持续质量改进活动开展方面,尚有9.42%的CSSD从未开展。结论 国内CSSD质量管理体系结构框架基本成型,但过程管理薄弱,信息化追溯深度及持续质量改进机制等方面仍有待提升。

关键词: 中心供应室, 医院, 质量管理体系, 结构-过程-结果, 调查, 医院感染控制, 护理

Abstract:

Objective To investigate the current status of quality management system construction in central sterile supply departments(CSSDs) of hospitals across China,to analyze differences between hospitals of different levels,and to provide references for promoting standardized CSSD construction. Methods A national cross-sectional survey was conducted from May 12 to 30,2025,using convenience sampling. A validated,self-developed questionnaire was administered to 2,456 hospitals across 31 provinces in China. The questionnaire,based on the “Structure-Process-Outcome” Model,encompasses 3 dimensions:Structure(institutional development,satisfaction with human resource allocation),Process(information management system),and Outcome(establishment of quality monitoring indicators,continuous quality improvement),consisting of 31 items in total. The descriptive statistical analysis was conducted to assess the current status of hospital management practices and compare variations across hospitals stratified by administrative grade. Results A total of 2,456 questionnaires were distributed,yielding 2,377 valid responses,resulting in an effective response rate of 96.78%. In structural dimensions:over 95.00% of CSSDs have established formal regulations covering core operational domains(including job responsibilities,emergency response plans,standard operating procedures,workflow protocols,disinfection and isolation practices,equipment and facility management,and adverse event reporting systems). Regarding satisfaction with human resource allocation,18.13% of CSSD managers reported being fully satisfied,noting that staffing levels were adequate to complete tasks to a high standard,while 54.77% reported being generally satisfied,noting that although workloads were sometimes heavy,they were manageable. Notably,satisfaction with personnel allocation was significantly higher in tertiary hospitals than in secondary hospitals(P<0.001). In the process dimensions:only 28.23% of CSSDs have achieved information-based monitoring of quality-sensitive indicators;23.52% of CSSDs possess information systems with built-in quality control functionalities;merely 21.37% of the CSSD information systems support quantitative analysis of personnel workload. In the outcome dimensions:the setting rate for the instrument cleaning quality pass rate indicator was 95.37%. The setting rates for other indicators—listed in descending order—were as follows:sterilization quality pass rate(89.27%),packaging quality pass rate (89.19%),sterilization wet-pack rate(77.41%). The sterile item timely supply rate had the lowest proportion of hospitals conducting monitoring,at only 25.54%. Finally,regarding continuous quality improvement activities,9.42% of CSSDs reported no engagement in structured continuous quality improvement activities. Conclusion The structural framework of the domestic CSSD quality management system has largely taken shape,but process management remains weak,and there is still room for improvement in areas such as the depth of digital traceability and mechanisms for continuous quality improvement.

Key words: Central Supply Department, Hospital, Quality Management System, Structure-Process-Outcome, Survey, Hospital Infection Control, Nursing Care