乳房X光攝影是目前國際間最有效的乳癌篩檢工具，國健署為保障婦女健康提供2年一次乳房篩檢，然而陽性個案的後續追蹤診斷一直是各院需要努力改善的指標之一；因此，本研究嘗試使用品管圈的改善手法，並取得北部某醫學中心2017年乳房篩檢陽追率的數據62.64%，做為改善策略的基礎，進行為期兩年的改善計畫。導入QCC手法，針對乳房篩檢陽性個案追蹤完成率(以下簡稱陽追率)，分析2017年乳房篩檢登錄系統之民眾聯繫紀錄，並針對兩個月內未完成複檢/確診之204名個案逐案分析原因，運用柏拉圖找出三個需解決的要因，再使用決策矩陣圖評選13項對策，發展「提高民眾收到複檢訊息的比率」及「增強民眾了解複檢之重要性」兩項對策。最後設定陽性率、偽陽性率及陽追率為本研究計畫改善結果的成效指標。經由兩年的策略改善，結果至2019年底皆有顯著改善。額外發現藉由本計畫的策略執行，個管師聯繫複檢民眾時，拒絕複檢的情形亦有明顯改善，因此，也針對複檢民眾執行滿意度調查，共回收44份問卷，27位非常滿意、17位滿意，提出之回饋也列入下一次品管圈的改善目標。本研究目的為透過品質改善手法達成提升乳房篩檢陽性個案追蹤完成率之目標，並期望能藉經驗分享幫助同儕醫院改善乳房篩檢陽性個案追蹤完成率。本研究團隊將持續設定第二次的PDCA做改善專案，藉此提升醫療品質，以守護婦女健康，達成全程全區全人醫療照護為目標。

Mammograms is the most effective breast cancer screening tool in the world, the National Health Agency to protect women's health to provide a 2-year breast screening, but the follow-up diagnosis of positive cases has been one of the indicators that hospitals need to improve; Therefore, this study attempted to use the improvement of the QCC, and obtained data of 62.64 percent on the 2017 breast screening rate of a medical center in the north area of Taiwan, as the basis for improving the strategy, and conducted a two-year improvement plan. Used QCC technique, tracking completion rate for positive breast screening cases (hereinafter referred to as breast screening positive rate). Analysis of the 2017 breast screening log-in system of public contact records, and for 204 cases within two months of incomplete re-examination/diagnosis of the reasons for case-by-case analysis, using Plato to identify three needs to be resolved, and then use the decision matrix map to select 13 countermeasures, the development of two countermeasures. Finally, the positive rate, false positive rate and recall rate were the effectiveness index of the improvement results of this study plan. The purpose of this study is to achieve the goal of improving the completion rate of breast screening-positive cases through quality improvement techniques. And hope can help peer hospitals improve the rate of breast screening positive case tracking through experience sharing. The research team will continue to set up the second PDCA improvement project to improve the quality of care, to protect women's health, to achieve the entire region-wide medical care as the goal.