目的 探讨 FOCUS-PDCA 程序在提高《三级查房制度》和《值班和交接班制度》规范落实中的应用效果。方法 2020 年 1 月，检查《三级查房制度》和《值班和交接班制度》落实情况，发现这 2 项医疗质量安全核心制度的规范落实率较低，存在 安全隐患。鉴于此，应用 FOCUS-PDCA 程序针对这 2 项制度的规范落实进行管理，并对改进前后的制度落实情况进行比较。结果 改进后《三级查房制度》和《值班和交接班制度》规范落实率比改进前明显提高。结论 运用 FOCUS-PDCA 程序能有效提 高医疗质量安全制度的规范落实，对保障医疗质量安全起促进作用。

Objective To explore the effectiveness of FOCUS-PDCA procedure in the implementation of Three-Tier Ward Round System and On-Duty and Shift Handover Systems. Methods In January 2020, an investigation on the implementation of the Three-Tier Round System and the On-duty and Shift Handover Systems showed that the implementation rates of these two core quality and safety systems in health care were low, which might cause potential safety problems. Therefore, we applied the FOCUS-PDCA procedure to improve the implementation of these two systems and compared the implementation statuses before and after improvement. ResultsAfter the improvement, the implementation rates of the two systems were significantly increased. Conclusion The FOCUS-PDCA procedure can effectively improve the standardized implementation of quality and safety systems in hospitals.