Basic standards for level II hospitals
This standard is a necessary condition for the validation of the qualification of level II hospitals, and those who have reached the qualifying line of this standard can only participate in the grade review.
I. Scale of the hospital
There should be a scale of the hospital that is compatible with the mission, function, technical level and management requirements of the second-level hospital.
1. No less than 100 beds.
2. Each bed unit necessary facilities to meet the prescribed requirements (see Annex VI).
3. Each bed floor space of not less than 45 square meters.
4. The net usable area per bed unit is not less than 5 square meters.
5. Daily average of outpatient visits per outpatient building area of not less than 3 square meters.
6. The ratio of beds to the number of hospital employees is 1:1.3-1.5.
7. Must be equipped with nationally recognized qualifications of health professionals. Health technicians account for no less than 75% of the total number of employees in the hospital.
Two, hospital functions and tasks
(a) medical and health services
To the community can provide comprehensive and continuous medical care, preventive health care and rehabilitation services.
1. Undertake the region (prefecture, city, county) within the common diseases, common diseases and more difficult to diagnose and treat the task; rescue acute and critical illnesses; accept the first level of medical and health institutions referrals.
2. Carrying out daily pre-hospital first aid; undertaking on-site first aid for disaster accidents, and rapidly organizing matching first aid teams to receive batches of patients for in-hospital first aid.
3. Carrying out health education and mastering disease dynamics in the community. Participate in preventive health care and rehabilitation services in the community.
(2) Teaching and research work in conjunction with medical treatment
1. Be able to undertake further training and training of various types of health technicians in the primary health care units and on-the-job education for the staff of the hospital.
2. It can undertake clinical teaching in secondary health schools and clinical internships for students in medical and health schools above the secondary level.
3. Be able to undertake provincial or municipal research projects.
(3) Guiding the grass-roots level
Collaborating with the relevant departments to guide the primary medical and health care units in the region to do a good job in community treatment, preventive health care, rehabilitation and mental health. It establishes regular business relationships with first-level hospitals, carries out two-way referrals, helps develop new technologies, solves difficult problems and trains health technology and management personnel.
Three, hospital management
Hospitals should have a sound management system, with the appropriate organizational structure, personnel, systems, measures, implementation of the program and its assessment and evaluation methods.
(a) organizational management
Necessary are:
1. administrative management organization
2. medical, preventive, teaching, research management organization
3. nursing management organization
4. financial management organization
5. general security organization
6. ideological and political work and professional ethics Education Management Organization
7. Necessary Committees
(2) System Management
According to the requirements and relevant provisions of the "National Regulations on Hospital Work, Hospital Work System and Duties of Hospital Workers" issued by the Ministry of Health in 1982 and taking into account the actual situation of the hospital, it is necessary to formulate a set of practicable rules and regulations and to have the corresponding education, implementation, supervision, inspection, evaluation, rewards and punishments. In addition, there are corresponding education, implementation, supervision, inspection, evaluation, reward and punishment methods. The necessary systems should include:
1. hospital work system
2. all levels and types of personnel job responsibility system
3. various technical procedures
4. staff continuing education system
(3) administration
1. there is a sound administrative organization, there is a hospital leader in charge of administrative work.
2. There is a long-term development plan, annual work plan, quarterly arrangements and the progress of the completion of the plan, indicators, measures, steps, as well as checking the summary.
3. Hospitals have a variety of administrative management system, and organization and implementation. The necessary systems are: the meeting system, the hospital general duty system, medical and administrative inspection system, paper file management system.
4. There are the masses to register letters to the room, visits, hospital records.
5. Hospital leaders should often go into the department, the community to understand the situation, to seek advice to improve the work.
(D) medical management
1. There is a sound medical management organization, staffing is reasonable, there is a corresponding work system, there is a deputy hospital in charge of medical work.
2. Developing practical medical construction plans and work plans for the whole hospital and organizing their implementation.
3. There is a sound medical work system, practical technical procedures and quality standards of medical care.
4. Establishment of sound medical quality management organization, regular activities, medical, nursing, medical quality supervision, inspection, evaluation, and put forward ideas for improvement. The necessary quality management organizations are: medical care quality management committee, pharmacy management committee, hospital infection control committee, case management committee.
5. Strengthen the technical training and assessment of operational personnel, and establish the operational and technical files of health technicians.
6. Non-state-recognized qualifications of technical personnel shall not be directly engaged in medical medical technology and nursing technology.
(E) Nursing Management
Managed in accordance with the relevant requirements of the Nursing Management Standards and Accreditation Methods.
(F) Teaching and research management
Teaching:
1. There is a sound teaching management organization, and there is a leader of the hospital who is responsible for teaching management.
2. There are practical teaching planning and work plan, and organization and implementation.
3. There is a sound teaching work rules and regulations, to achieve supervision, inspection and evaluation.
4. There are appropriate teaching facilities and equipment.
5. "Teaching hospitals" recognized by the Ministry of Health, according to the Ministry of Health "National Higher Medical Schools Teaching Hospitals Interim Provisions" (to be issued) for management.
Scientific research:
1. There is a full-time (part-time) staff responsible for scientific research management and a corresponding work system.
2. Establishment of scientific and technological personnel, scientific research results files.
3. Encourage the development of medicine and management of scientific research.
(VII) information management
1. There is a sound information management organization and related work system.
2. There should be a library (room) and a sufficient number of medical books and periodicals.
3. There are full-time managers who deal with medical, management and library information.
4. The information provided by all departments in the hospital should be true, complete and accurate, and timely analysis, feedback and utilization.
(VIII) measurement management
According to the "Chinese People's *** and State Measurement Law", the hospital must strengthen the measurement of work management.
1. There are responsible for measuring the management of the department or personnel.
2. Establishment of the relevant measurement management system, including:
(1) measurement management approach.
(2) measurement of personnel responsibilities.
(3) measuring instruments cycle verification system.
3. The use of national legal units of measurement.
4. In the use of mandatory calibration of measuring instruments should be checked periodically.
(IX) financial management
1. There are financial institutions, reasonable staffing, clear scope of responsibility, and a sound job responsibility system and work system.
2. There is a full-time (part-time) fee management personnel, strict implementation of medical fee standards, the implementation of price tags, and accept public supervision.
3. Accounting vouchers, books, statements in line with the accounting system.
4. Establishment of accounting files and management system.
5. There is a sound financial and accounting supervision system, the violation of financial and price discipline should be dealt with seriously and promptly.
(J) audit management
1. There is an audit organization parallel to the financial institutions or the rank of the corresponding auditor, staffing is reasonable, and has a certain degree of audit expertise.
2. Regular audit supervision of financial income and expenditure and related economic activities.
3. Supervision and inspection of the safety and integrity of funds and property, as well as the soundness and effectiveness of the internal control system.
4. Regularly check and evaluate the efficiency of the use of funds and property and make recommendations for improvement.
5. No major loss and waste, embezzlement and theft and serious violations of financial regulations.
(XI) equipment management
1. There is a sound management organization, the implementation of program management.
2. More than 10,000 yuan of large precision instruments to be purchased to have the appropriateness and feasibility of the demonstration, the purchase to acceptance, the use of a person to keep.
3. Medical equipment has a regular maintenance, repair and update system to ensure that medical work needs.
(XII) general management
1. There are sound general management organization, job responsibilities and work system.
2. General supplies are managed on a quota basis, and there is a sound system of purchasing, acceptance, warehousing, distribution, and scrapping.
3. Proactive and timely service for all departments in the country, especially clinical departments, to do the three under (under the receipt, under the delivery, under the repair), to ensure that the three through (water, electricity, gas), not two leaks (leakage of water, leakage of electricity), and to do the two satisfaction (staff, patient satisfaction).
4. There are unexpected power supply measures to ensure temporary lighting.
5. Ambulances are equipped with basic equipment and medicines and are on call to ensure medical treatment, rescue and transfer of patients.
(xiii) building management
1. The hospital's new construction, remodeling and expansion, after the feasibility study, to adapt to the overall development plan, information preservation is complete.
2. New hospital site selection, layout, design should be reasonable, in line with building codes and hygiene requirements.
3. The architectural layout of the hospital parts (outpatient department, inpatient department, medical and technical departments, operating room, disinfection and supply room, emergency department (room)) and the flow of people are reasonable. (Indoor lighting, color design in line with the requirements of hygiene).
4. Old hospital buildings have maintenance plans and budgets, and seriously implemented. Shall not engage in medical activities in dangerous buildings.
4. Quality management
(a) The hospital should have a practical quality management program.
(B) there are hospital and departmental level quality management organization.
(3) quality management focuses on: medical, nursing, medical technology, teaching, research and case quality.
(4) There are quality education, supervision, inspection and evaluation systems and improvement programs.
(v) Nosocomial infection control
1. The infection control organization shall be in accordance with the Interim Measures for the Establishment of a Sound Hospital Infection Management Organization issued by the Ministry of Health in 1988.
2. There are hospital-wide infection control programs, countermeasures, measures, effects and evaluation.
3. Establishment of strict sterilization, isolation and infectious disease registration and reporting system. The setup of infectious disease room should be in accordance with hygienic requirements.
4. There is an on-the-job education system for nosocomial infection control, and health care workers must establish the concept of asepsis and perform correct aseptic technical operations.
5. There is a rational use of antibiotics management.
6. There are measures to monitor the cleanliness of special areas (e.g., operating rooms, sterilized supply rooms, labor and delivery rooms, infants' rooms, neonatal wards, treatment rooms, etc.).
7. On-site inspection to meet the specified requirements.
V. Ideological and political work and medical ethics construction
1. A strong ideological and political work management system and the corresponding work system.
2. To formulate plans on ideological and political work and medical ethics and medical style construction, and organize and implement.
3. Implementation of the party's line, guidelines, policies, party, government, workers, and the management of the ****, and do a good job of regular ideological and political work of the whole hospital staff, and regularly organize learning, research, analysis and summary.
4. conscientiously implement the "medical personnel code of medical ethics and implementation measures", there are medical ethics education measures. Strictly implement the pre-service education system.