Improve the quality of medical services hospital management program

In order to implement the spirit of the 16th National Congress of the CPC and the 3rd and 4th Plenary Sessions of the 16th CPC Central Committee, adhere to the "people-oriented" concept of scientific development, and promote the hospital to rectify the direction of running the hospital, firmly establish the "patient-centered" service concept and serve the people's purpose, strengthen hospital management, improve service attitude, standardize medical behavior, improve medical quality, ensure medical safety, and strive to solve the hot and difficult problems strongly reflected by the people. Strengthen hospital management, improve service attitude, standardize medical behavior, improve the quality of medical care, to ensure medical safety, and strive to solve the hot and difficult problems strongly reflected by the people, according to the spirit of the National Health Work Conference, the Ministry of Health and the State Administration of Traditional Chinese Medicine decided to carry out a "patient-centered to improve the quality of medical services as the theme

First, the guiding ideology

Deng Xiaoping Theory and the "Three Represents" as the guidance of the important idea, establish and implement the scientific concept of development, "patient-centered to improve the quality of medical services as the theme of "and adhere to the pursuit of social benefits, safeguard the interests of the masses, build a harmonious doctor-patient relationship in the first place, improve the hospital's "quality, safety, service, cost" and other management systems, explore the establishment of a long-term mechanism of scientific management of hospitals, and constantly improve the quality and level of medical services, so that medical services closer to the masses, closer to the community, and make the medical service more close to the public, close to the community. The company's products and services have been widely recognized by the public and the public as being of the highest quality.

Second, the scope of activities

National public hospitals of all levels and types in accordance with the principle of localized management, all participate in the "Hospital Management Year" activities, at the same time, to guide all types of private medical institutions to participate in the "Hospital Management Year" activities.

All public hospitals at all levels in the country participate in the "Hospital Management Year" activities in accordance with the principle of localized management.

Three goals and key requirements

(a) Improve the quality of medical care, ensure medical safety, ensure and consolidate the quality of basic medical care and nursing care, and improve the safety and effectiveness of medical services.

Key requirements:

1, strict implementation of health care management laws, regulations, rules and regulations, as well as diagnosis and care norms, routines, to do according to the law, behavioral norms.

2, improve and implement the hospital rules and regulations and personnel job responsibility system, especially the core system of medical quality and medical safety, including the first doctor is responsible for the system, the three-level physician room system, hierarchical care system, difficult cases discussion system, consultation system, critical patient rescue system, pre-operative discussion system, death case discussion system, checking the system, the basic norms of medical record writing and management system The system of handover and shift handover, and the system of technical access.

3, strict quality management of basic medical and nursing care, and strengthen the "three basic and three strict" training.

4, reasonable examination, rational use of drugs, treatment of disease. The focus is to implement the "Guiding Principles for the Clinical Application of Antimicrobial Drugs", adhere to the graded use of antimicrobial drugs, and gradually establish the dynamic monitoring of drug consumption and excessive warning system.

5, to strengthen the emergency department (room) capacity building, to achieve professional setup, staffing is reasonable, rescue equipment and facilities are available, intact. The emergency department (room) medical staff is relatively fixed, the duty physician competent emergency rescue work. The realization of emergency consultation quickly in place, emergency department (room), hospital, surgery, "green channel" smooth, improve the success rate of emergency patients.

6, strengthen the clinical laboratory indoor quality control and inter-room quality evaluation.

7, to strengthen the scientific and rational use of blood, to ensure blood safety, to eliminate illegal blood supply.

8, standardize disinfection, sterilization, isolation and medical waste management, effective prevention and control of hospital infections.

9, the hospital leadership regularly study to improve the quality of medical care and ensure medical safety.

(b) to improve the service process, to improve the environment, to facilitate the patient's access to medical care.

Key requirements:

10, optimize the process, simplify the link, reasonable layout and increase the service window, shorten the waiting time of patients.

11, departmental logo standardization, clear, eye-catching.

12, to provide patients with a clean, comfortable, warm environment and convenient service measures, so that there is a consultation desk, waiting chairs, large and medium-sized hospitals should have drinking water facilities, wheelchairs, telephones and so on.

13, shorten the various waiting and various examination appointments, report time. Create conditions to carry out the appointment booking service.

14, to provide privacy and good treatment environment.

(3) improve service awareness, improve service attitude, enhance patient communication, change service style, focus on honest service, build a harmonious doctor-patient relationship, to provide patients with warm, careful, loving, patient service.

Key requirements:

15, consciously safeguard the rights of patients, fully respect the patient's right to know and the right to choose.

16, good service attitude, standardized service language, put an end to raw, cold, hard, top, push phenomenon.

17, the establishment and improvement of the doctor-patient communication system, take the initiative to strengthen the communication with patients, patiently explain to the patient or explain the condition, and the use of easy-to-understand language.

18, the establishment and improvement of patient complaint handling system, publicize the telephone number of complaints, timely acceptance and processing of patient complaints.

19, regularly collect patients' opinions on hospital services, and timely improvement.

(d) strengthen financial management, regulate economic activities in accordance with the law, improve economic accounting and distribution methods, improve economic management, control medical costs, reduce medical costs.

Key requirements:

20, the hospital financial adhere to the "unified leadership, centralized management" principle, all financial activities must be included in the financial sector unified management. It is strictly prohibited to set up hospital departments, departments and offices off the books, "small treasury".

21, the establishment of standardized decision-making mechanisms and procedures for economic activities, the implementation of major economic matters leading the system of responsibility and accountability, the collective discussion of major projects in accordance with the prescribed procedures for approval, clearly defined levels, responsibility.

22, strengthen the management of drugs, materials, equipment and other supplies, strict implementation of the hospital's internal cost accounting system, strengthen management, plug the loopholes, and strive to reduce the cost of medical services and consumption of drugs and materials.

23, improve income distribution methods, both to break the egalitarianism, but also to prevent excessive disparity of income. It is strictly prohibited to link medical service income directly to personal income, and strictly prohibit departmental contracting.

(E) strict management of medical costs, to eliminate unreasonable charges.

Key requirements:

24, the strict implementation of the national drug pricing policy and medical service charges, the strict implementation of the two lines of drug revenue and expenditure. Prohibit the unauthorized establishment of new charges outside the state regulations, strictly prohibit the decomposition of the project, compared to the project charges and repeat charges.

25, to the public charges and standards. Improve the price announcement system, inquiry system, cost list system, improve the transparency of charges. Provide patients with timely fee inquiry services, and promptly deal with patients' complaints about irregular fees.

26, take the initiative to accept social and patient supervision of medical costs, reduce medical fee complaints.

27, timely disclosure to the community of the cost of a single disease, the average hospitalization days of a single disease.

(F) vigorously carry forward the spirit of Bai Qiu'en, strengthen the construction of professional ethics and industry style, establish good medical ethics, carry forward the good tradition of saving lives and treating patients.

Key requirements:

28, establish the purpose of wholeheartedly serving the people, in the work of insisting on carrying forward the humanitarian spirit of saving lives, and in the medical staff to carry out the evaluation of excellence, learning activities.

29, strengthen the medical ethics and medical education and system education, set up a loyal, dedicated, dedicated, civilized practice of medicine in the new health industry, and with the examination of medical practitioners, nurses practice certificate re-registration.

30, it is strictly prohibited for medical personnel to accept, ask for patients and their families "red packets" and other gifts; strictly prohibit medical personnel to accept medical equipment, medical devices, drugs, reagents, etc., the production and sale of enterprises or individuals in the name of kickbacks, commissions and other undue benefits.

31, strictly prohibit the implementation of drugs, instruments, laboratory reports and other special tests, such as "billing commission" and other methods, hospitals are strictly prohibited to the department or individual revenue targets.

32, it is strictly prohibited for medical institutions to use kickbacks, commission and other improper means to solicit patients from other medical institutions.

33, it is strictly prohibited to publish false medical advertisements to mislead patients and deceive the public.

For those who violate the above provisions, the health administrative departments and hospitals should be resolutely pursued and seriously dealt with.

Fourth, the implementation of the steps

(a) mobilization and deployment phase (April 20xx)

complete the "hospital management year" activities to prepare, mobilize and organize the work of the main To carry out the following work:

1, issued the program, the "Hospital Management Year" activities for the overall deployment; at the same time issued the "Hospital Management Evaluation Guidelines (Trial)" and "Chinese Medicine Hospital Management Evaluation Guidelines (Trial)", as the health, Chinese medicine administrative departments to strengthen the management of hospitals and evaluation of the work of the basis.

2, held a national conference on hospital management, the background, significance and overall requirements for the development of "hospital management year" activities to deploy.

(B) the organization and implementation phase (May - December 20xx)

1, the hospital self-examination and improvement work. Hospitals should focus on the implementation of the program, according to the "Hospital Management Year" work objectives and key requirements, a comprehensive self-examination, while promoting the "Hospital Management Evaluation Guidelines (Trial)", "Hospital Management Evaluation Guidelines (Trial)" implementation of the hospital to combine the actual hospitals, put forward the various improvement measures, and pay close attention to the implementation. Hospitals in the self-examination and improvement of the work stage, we should focus on the enthusiasm and creativity of the medical staff, learning advanced practices and experience, through self-examination and improvement of the work, and gradually realize the "hospital management year" activities target.

2, provincial health, Chinese medicine administrative departments in accordance with the functions of guidance, evaluation and supervision and inspection. In the hospital comprehensive self-examination and improve the work on the basis of provincial health, Chinese medicine administrative departments to carry out "hospital management year" activities to guide the hospital, the work requirements of the 'implementation of evaluation and supervision and inspection. Health, Chinese medicine administrative departments should pay attention to collect and summarize "hospital management year" activities in the good experience, good practices and good models, and timely promotion. All levels of health, traditional Chinese medicine administrative departments to establish and improve the information disclosure system, the social concern of the hospital service information to the public on a regular basis.

Provincial health, Chinese medicine administrative departments to carry out the province's "hospital management year" activities and the progress of the inspection results were reported to the Ministry of Health and the State Administration of Traditional Chinese Medicine.

3, the Ministry of Health, the State Administration of Traditional Chinese Medicine to organize random checks. In the hospital self-check and provincial health, Chinese medicine administrative departments to guide, evaluate, supervise and inspect on the basis of the Ministry of Health, the State Administration of Traditional Chinese Medicine will focus on the "hospital management year" activities of the work objectives and key requirements of the random inspection, and notify the results of the random inspection.

(C) summarize the stage (20xx January-March)

convene the national hospital management

experience exchange meeting, exchange of various places to carry out "hospital management year" activities, strengthen the hospital system, and then the "hospital management year" activities. At the same time, summarize and set up a number of advanced models of good management, good service, good social reflection, good benefits, publicity and reporting. At the same time, the study and deployment of the next year to promote hospital management in-depth work.

V. Work requirements

(a) Awareness-raising, strengthen leadership. to carry out the "hospital management year" activities is the health care system to implement the "people-oriented", adhere to the scientific concept of development, and effectively safeguard the rights and interests of the general public health of a major measure. All levels of health, Chinese medicine administration and hospitals at all levels should attach great importance to unify thinking, clear objectives, strengthen organizational leadership. To effectively grasp the hospital leadership team building, clear dean for the "hospital management year" the first responsible person. To "hospital management year" activities and maintain *** production party member advanced education activities closely integrated, give full play to *** production party members of the vanguard role, adhere to the advanced education and "hospital management year" activities, both without losing time, both promote.

(2) Local responsibility, hierarchical guidance.
Provincial health, Chinese medicine administrative departments in the "hospital management year" activities to give full play to the jurisdiction of the hospital management, guidance and supervision role, and is responsible for the organization and implementation. In accordance with the principle of hierarchical guidance, the provincial health, Chinese medicine administrative departments focus on three hospitals "hospital management year" activities, city, county (district) level health, Chinese medicine administrative departments were responsible for the second level and the first level of hospitals "hospital management year" activities. Provincial health, traditional Chinese medicine administrative departments should strengthen the lower level of health, traditional Chinese medicine administrative departments to guide and supervise the work of the intermediary organization to give full play to the role of the "Hospital Management Year" activities. The Ministry of Health and the State Administration of Traditional Chinese Medicine on the national "Hospital Management Year" activities for the overall deployment, guidance and necessary inspections. The Ministry of Health, the Ministry of hospitals to participate in the location of the provincial health administrative departments organized by the "hospital management year" activities; the State Administration of Traditional Chinese Medicine Bureau, the Bureau of hospitals to participate in the location of the provincial Chinese medicine administrative departments organized by the "hospital management year" activities.

(C) focus, combined with the actual . This program focuses on the requirements of the hospital in the "hospital management year" activities in the basic requirements, around the world, the hospital to determine the actual local, the hospital's specific requirements and work measures. The work should focus on the program, while promoting the implementation of the "Evaluation Guidelines for Hospital Management (Trial)" and "Evaluation Guidelines for Hospital Management of Traditional Chinese Medicine (Trial)", and formulating some quantitative management indexes with strong operability as far as possible. Health and Chinese medicine administrative departments should not only focus on the guidance, supervision and inspection of general hospitals, but also strengthen the inspection and guidance of specialized hospitals to promote the overall improvement of hospital management.

(D) in-depth publicity, extensive mobilization. To strengthen public opinion propaganda, to create a public opinion atmosphere focusing on patients, focus on management, focus on quality, focus on safety. Health News, China Traditional Chinese Medicine Newspaper, Hospital News, "China Hospital" and other media to open a column or special edition of the full report, the Ministry of Health and the State Administration of Traditional Chinese Medicine in their respective Web site to open a column, the "hospital management year" activities for dynamic reporting and commenting. The Ministry of Health and the State Administration of Traditional Chinese Medicine regularly coordinates the central media to report on the dynamic information of the activities of the "Hospital Management Year", and exchanges the practices and experiences of the activities of the "Hospital Management Year".

( V) Discover the problem and deal with it seriously. All levels of health, Chinese medicine administrative departments in the "hospital management year" activities to strengthen the supervision and management of medical institutions and medical personnel, the discovery of illegal and disciplinary behavior, should be dealt with seriously and will be informed and exposure.

(6) Summarize the experience and consolidate the results. "Hospital management year" after the end of the activities, all levels of health, Chinese medicine administrative departments and hospitals of all levels and types of work throughout the year to carry out a serious summary of the provincial health administrative departments can be organized to carry out horizontal exchanges between hospitals, hospitals to carry out their own summary of the situation of the improvement of the establishment of a mechanism to improve the system for the future to continue to strengthen the foundation of the management of hospitals.

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