In 20xx, our department will carefully analyze the problems existing in the secondary standard inspection, do a good job in nursing quality management, do a good job in basic medical services for patients, put all basic nursing work in place, and put all safety measures in place to ensure the most basic medical safety for patients.
First, link quality.
(1) and 20xx years, our department continued to maintain the medical quality management team, conducted regular medical quality inspection and evaluation, analyzed the reasons, put forward rectification measures, supervised the implementation of various rules and regulations, operating procedures and operating routines, and maintained the continuous improvement of medical quality;
(2), department blood. In 20xx, our department continued to strengthen the management of blood use, standardized management in strict accordance with the requirements of blood use management, rational use of blood, timely registration, and regular statistical analysis.
③ Hospital infection. Our department continues to maintain the hospital infection management team, conscientiously implement the hospital infection management system, and regularly train and assess the department staff on hospital infection knowledge. Hospital infection management team regularly or irregularly carries out hospital infection quality inspection, causes analysis, timely feedback and rectification, and conscientiously implements various hospital infection standard operations in accordance with the hospital infection management manual.
Second, the nursing quality management safeguard measures
(1) In 20xx, our department continued to maintain the nursing quality management team, regularly carried out nursing quality inspection and evaluation, analyzed the reasons, put forward rectification measures, urged the implementation of various rules and regulations, operating procedures and operating routines, and maintained the continuous improvement of nursing quality; Combined with clinical practice, the quality control system is constantly improved, and the assessment contents and scoring standards of nursing quality are further improved, such as ward management, basic nursing, specialist and first-class nursing, disinfection and isolation, writing of nursing documents, management of first-aid articles, and nursing safety management. , evaluate and analyze the quality of nursing every month, and formulate corresponding corrective measures.
(2) The head nurse and the responsible nurse should supervise and correct the problems existing in nursing work at any time, and announce the outstanding problems at the morning meeting to let the nurses know the existing problems and solutions.
(3) Check all kinds of articles, medicines and ambulances regularly every month, and find out expired articles and medicines in time. Ensure medical safety.
(4) Establish an effective nursing quality management system, and set up a group of experienced nurses to participate in nursing quality control to ensure the quality of nursing work.
(5) Implement the quality control network with the head nurse's nursing team leader as the quality controller of the department, and gradually implement everyone's participation in quality management to achieve the goal of total quality control.
(6) Give play to the role of nursing quality monitoring team, pay attention to link quality control and track the rectification effect of key issues. Implement a combination of daily inspection and monthly inspection.
(7) Strengthen implementation, supervision and inspection, and attach importance to the supervision of the quality of nurses' operation process. Pay special attention to quality control management, make everyone participate, * * ensure quality, give full play to the role of nursing quality control personnel, all staff participate in nursing management, and have inspection records, analysis, evaluation and improvement measures.
(8) Strengthen the management of nursing defects and nursing disputes, adhere to strict supervision of all aspects of work quality, find potential safety hazards, and take timely measures to nip nursing errors and accidents in the bud.
(9) Strengthen the training of medical and nursing laws and regulations, improve the legal awareness of nursing staff, care according to law, and protect the legitimate rights and interests of patients and nurses.
(10) Conduct basic nursing operation training every month to strengthen the normal operation of nursing staff and conduct assessment. Find the problems in operation and correct them in time.
(1 1) The nurses in each shift check the doctor's orders, and the head nurse checks them every week to ensure the correct implementation of the doctor's orders.
(12) Office nurses check the writing of nursing documents every day. The discharged medical records are reviewed by the office nurses, and finally submitted to the medical record room by the head nurse.
(13) Establish nursing safety management, conduct nursing safety knowledge training every month, and explain nursing problems inside and outside the hospital.
Strengthen the safety awareness of nursing staff, improve the safety early warning work, find and analyze the hidden dangers of nursing safety in time, and put forward improvement measures.
Third, nursing indicators:
(1) basic nursing qualified rate "90%
(2) The qualified rate of specialist and first-class nursing is 90%.
(3) The intact rate of first-aid articles reaches 100%.
(4) The qualified rate of nursing document writing was 90%
(5) The qualified rate of "three basics" assessment of nursing staff reached 100%.
(6) The qualified rate of disinfection and sterilization of conventional instruments is 100%.
(7) The annual incidence of bedsore is 0 (except the inevitable bedsore).
Department Work Plan of Quality Control Team in 2020 (II)
In order to seriously implement the key points of hospital work in 20xx, the ISO900 1-2000 quality management standard was fully implemented around "patient-centered and quality-centered", the scientific and standardized management of nursing work was continuously strengthened, the overall improvement of nursing quality was promoted, and the service goal of "providing high-quality and safe nursing for patients and improving nursing work" was realized. According to the spirit of nursing department and the actual situation of our department,
The first is to update the concept of nursing management and service and improve the quality of nursing. Do people-oriented, pay attention to humanized service, and carry out the activity of "patient satisfaction department" in depth. Strictly implement the protective medical system, always think of the patient, and do not judge the patient's condition, surgical effect and surgical complications at will to reduce the psychological burden of the patient. Effectively change the service concept and working mode, ensure the service for patients in the nursing work state, meet all reasonable needs of patients, create a warm and comfortable hospitalization environment for patients, and realize patients' satisfaction with nursing work ≥95%. Pay attention to strengthen communication with doctors, collect patient information, gain understanding, trust and support, continuously improve internal service quality, better cooperate with treatment, and achieve the satisfaction of clinicians with nursing work ≥98%.
Second, strengthen the management of nursing quality and safety to ensure that the annual accident rate is zero. Formulate strict departmental rules and regulations, organize regular discussion and analysis of errors and accidents, and put forward rectification opinions on recurring problems to prevent errors and accidents. Use morning meetings, nursing business learning and other forms to enhance nurses' service awareness, so as to achieve active service, warm reception and careful introduction. All nursing and treatment operations should greet patients, adopt encouraging language and move gently, so that patients can feel the warmth like relatives.
Three, strictly abide by the "hospital infection management norms", conscientiously implement the "disinfection and isolation system". Further improve the working system of each class and strictly control the flow of personnel. Strictly implement aseptic operation technology, correct people and things that violate aseptic principle in time, and prevent hospital infection. The implementation rate of one needle and one tube per person 100%, the infection rate of aseptic incision ≤0.5%, and the qualified rate of disinfection and sterilization of conventional instruments 100%.
Fourth, do a good job in the management of emergency medical equipment to ensure that the intact rate of emergency medical equipment is 100%. Check carefully when each shift is handed over, so that it is in good condition and the accounts are consistent. Strengthen the training of nursing staff in first aid knowledge, rescue procedures, rescue drugs and the use of rescue instruments, so that everyone can master and use them skillfully. After receiving the notice of emergency patients, they can quickly carry out surgical rescue in the shortest time and cooperate with the rescue work flexibly and skillfully.
Five, according to the requirements of "Sichuan province medical nursing document writing standard", strengthen the management of nursing document writing, so that the writing is serious, timely and standardized, consistent with the actual nursing process, and the qualified rate of nursing document writing is ≥95%.
Six, strengthen the on-the-job training of nursing staff, and constantly improve the professional and technical level. The average level of three basics of nursing staff is ≥85 points; The qualified rate of nursing technology operation is ≥ 95%; Support nursing staff to participate in continuing education and training, with continuing education credits of 25 points or more per person per year. Encourage nursing staff to participate in self-study, correspondence and various classes and seminars, so that nursing staff can grasp the new trend of nursing development and the new theories and technologies related to nursing in time, continuously improve the professional level of nursing staff, and better cooperate with the operation department to develop new business and technologies. Encourage the majority of nursing staff to actively write papers, and strive for general practice to publish or exchange papers at or above the municipal level ≥ 1. According to the nursing training plan, arrange personnel to go out for further study, improve the level of specialized nursing, and thus promote the technical level of general practitioners.
Seven, in strict accordance with the charging standards, so that all accounts receivable, accounts receivable do not leak. If there are any questions and disputes, check and deal with them in time. Regularly check and collect the medical and office supplies of the department to reduce waste and loss. Special person is responsible for the maintenance of medical equipment, understand the performance and usage of the equipment, and ensure the normal operation of the clinic.
Eight, establish a perfect nursing quality monitoring system, the department quality control team to strengthen self-examination, found problems in a timely manner to improve; Regularly discover nursing hidden dangers, analyze and give feedback, so as to make all work procedural and standardized. By counting the total number of inpatients, satisfaction survey, whether there are mistakes, negligence and complaints, and quality control of nursing department, we can improve and promote nursing work and continuously improve the quality of nursing in our department.
Nine, strengthen the management of clinical teaching, do a good job in teaching. According to the requirements of the internship program, make a teaching plan, arrange special lectures, constantly improve teaching methods according to clinical teaching experience, strengthen the cultivation and improvement of teaching ability of teaching teachers, conscientiously implement the "360 Project" and successfully complete the teaching work.
X. Make preparations for the relocation of the new ward building. Seriously implement the quality management standards of nursing department, strengthen the quality control of undergraduate nursing, further standardize the nursing workflow, conduct quantitative assessment and quality analysis on time, and all quality control indicators meet the quality objectives of nursing department. Organize to learn the related knowledge of new surgical nursing, and make preparations for the relocation of ward building.
Eleven, all nursing staff in our department will work closely with clinicians under the leadership of the hospital and the nursing department to ensure medical safety, improve service attitude, improve nursing quality, ensure that all quality control indicators meet the quality objectives of the nursing department, and create good social and economic benefits.
Department Work Plan of Quality Control Team in 2020 (III)
20xx is a year in which our hospital continues to deepen hospital reform, expand the medical market in an all-round way, further improve service attitude, improve service quality, shape the image of the hospital, keep pace with the times and achieve a new leap. The quality team will adhere to "one center" and realize "one focus", "two teams" and "three norms". That is, adhere to the patient-centered, focus on consolidating the nursing foundation, attach importance to the construction of head nurses and nursing staff, implement ward management norms, nursing system norms and nursing technology operation norms, and promote the technical level of nursing management and service quality to a new level. Make the nursing quality meet the standard requirements.
First, strengthen the education of nursing staff's awareness of quality management laws and regulations, especially the "Measures for the Administration of Nurses" to clarify the quality standards and management methods of nursing work, so as to achieve full attention to the implementation of * * *.
Second, strengthen the quality training of personnel at all levels, constantly improve the comprehensive quality of personnel at all levels, attach importance to nurse-patient communication skills and skills, especially strengthen the training of head nurses' ideological quality, management quality and professional comprehensive quality, and improve their scientific management ability. The "people-oriented" management and service concept runs through the whole process of nursing work, and the two-level management and service concept of nursing department = head nurse runs through the whole process of nursing work. Conscientiously implement the two-level management system of nursing department and head nurse and the management system of department responsibility group, ensure the responsibility to the people, carry out on-the-job assessment, strive to improve the basic quality, link quality and terminal quality, and emphasize the process quality management of the department.
Three, all departments to develop practical quality service measures and assessment regulations. Emphasize humanized nursing service and provide personalized nursing service for patients. The department conducts a satisfaction survey on inpatients once a month, and holds two symposiums on holidays to conduct a satisfaction survey on each discharged patient; The nursing department regularly surveys the satisfaction of discharged and hospitalized patients every quarter. The nursing department should check the satisfaction at any time.
Four, continue to modify and improve the evaluation standard of nursing quality, especially nursing defects and comprehensive quality of nursing.
Five, strengthen nursing safety management, and put the "three basics" and "three strictness" style throughout nursing activities and nursing management activities. Establish the viewpoint of "three-level prevention" of quality and conscientiously implement various nursing management systems; Implement the zero report system of nursing defects, strengthen the management of nursing defects, and prevent nursing complications, nursing disputes and nursing accidents.
Six, continue to undertake the task of clinical teaching of nursing major in higher and technical secondary schools, conscientiously do a good job in practical teaching, implement two-way assessment, and guide nursing students to apply nursing procedures to their work.
Seven, strengthen the holiday and weekend nursing quality assessment, strengthen the head nurse time night rounds. Improve the quality of nursing work in holidays and night shifts. Increase the intensity of irregular and comprehensive spot checks at ordinary times, pay attention to the coincidence of theory with the actual situation of patients, and put an end to fraud.
Eight, urge departments to seriously implement the hospital infection management norms, disinfection technical specifications, medical waste management regulations, occupational exposure protection, public health emergencies, etc. Do a good job of protection to prevent infection.
Nine. Time and method of assessment: A combination of regular and irregular assessment is adopted.
Ten, urge managers at all levels to standardize the recording, sorting, filing, assessment and summary of all kinds of information.