目的探讨综合性教学医院消化内镜医院感染管理与持续改进经验,预防和减少医院感染的发生。方法按照《内镜清洗消毒技术操作规范》2004年版要求,结合医院特点,将内镜医院感染管理考核指标进行量化,纳入全院医疗质量检查管理体系,定期检查考评和反馈。结果 3年来未发生医院感染暴发流行,2007-2009年内镜科医院感染管理质量从86.0分升至98.0分,实现了持续质量改进。结论搞好内镜医院感染管理,院领导重视和支持是关键,定期监测和检查是落实制度实现持续改进的有效手段和措施。 Objective To explore the experience of digestive endoscopy hospital infection management and continuous improvement in comprehensive teaching hospital to prevent and reduce the occurrence of nosocomial infection. Methods According to the requirements of the 2004 edition of Operational Specifications of Endoscopic Cleaning and Disinfection Technology, combined with the characteristics of the hospital, the indicators of endoscopic hospital infection management were quantified and included in the hospital medical quality inspection management system. Periodic examinations and feedbacks were made. Results Outbreak of nosocomial infection did not occur in the past three years. The quality of infection management in endoscopic hospital increased from 86.0 to 98.0 in 2007-2009, achieving continuous quality improvement. Conclusions To do a good job of infection management in endoscopic hospital, it is the key to attach importance to and support of hospital leaders. Regular monitoring and inspection are effective measures and measures to implement the system to achieve continuous improvement.