Medical quality is a hospital survival and development of the fundamentals of a hospital level reflects, medical safety management is an important aspect of medical quality. I organized the "hospital medical quality management work summary" for reference only, I hope to help you!
Part I: hospital medical quality management work summary20xx year I adhere to the patient-centered service concept, to improve medical quality, reasonable fees, reduce medical costs for the starting point, and strive to provide patients with quality medical services. Now the 20xx medical quality management work is summarized as follows:
First, strengthen the medical quality management, ensure and improve the quality of medical services.
1, adhere to the hospital medical departments to carry out regular medical quality and medical safety inspection, and summarize and analyze. Reduce medical defects, timely investigation and elimination of medical safety hazards, reduce medical malpractice disputes, and eliminate medical accidents as a top priority.
2, conscientiously do a good job of legal practice management. Do not have a licensed physician qualification and licensed nurse qualification personnel are strictly prohibited.
3, strict quality of care, each department strictly implement the rules and regulations, standardize the diagnosis and treatment behavior, adhere to the system of responsibility for the first diagnosis, difficult and critical patients consultation and referral system, the quality of medical care is always in the first place, and resolutely put an end to the occurrence of medical accidents. Enhance the sense of responsibility, improve the precautionary measures to prevent the occurrence of accidents.
4, strengthen the quality of medical care, medical safety education, and organize the entire hospital staff to study the "Medical Practitioners Law", "Regulations on the Treatment of Medical Accidents" and other relevant laws and regulations, to enhance legal awareness.
5, to strengthen the quality of the hospital's medical staff education, establish a correct outlook on life, values, professional ethics. Educate the whole hospital medical staff to be patient-centered, medical quality as the core, improve service attitude, improve service quality, reduce medical errors
birth. Do a good job of continuing education, planned arrangements for personnel to higher hospitals for further training and to participate in short-term training courses organized by the Municipal Medical Association, and actively participate in the training of general practitioners organized by the Municipal Health Bureau. Regular business learning, pay close attention to all kinds of medical instruments and prescriptions of standardized writing work not to relax.
Second, strengthen the hospital infection management.
The establishment of the hospital infection management leading group, a person in charge, responsibility, strict implementation of the procedures to ensure medical safety. Regular hospital infection inspection, and summary, analysis, organization of the hospital medical staff to seriously study the "hospital infection management approach" and the relevant technical specifications of the training work, to strengthen the management of medical waste, to strengthen the key departments of the hospital (injection room) of the hospital infection control work, effective prevention and control of hospital infections, to ensure that the patient's medical safety.
Three, strengthen the hospital clinical drug management.
The medical staff of the "prescription management approach", "the guiding principles of clinical application of antimicrobial drugs," the strict implementation of the management system of special drugs and adverse drug reaction monitoring and reporting system, timely reporting and disposal of adverse drug reactions. To achieve the treatment of disease, rational inspection, rational use of drugs, standardized charges, to eliminate the abuse of drugs, indiscriminate inspection phenomenon.
Four, strengthen all kinds of information reporting, collection and analysis. Organizations throughout the hospital medical staff to study seriously the "Prevention and Control of Infectious Diseases Act", timely reporting of infectious diseases in the country.
20xx year, we will promptly rectify the existence of medical defects, and constantly improve the quality of medical care, to provide patients with safe, effective, convenient and inexpensive medical services.
Part II: hospital medical quality management work summaryOver the past year, under the leadership of the center and medical management team, through the quality management team all members, clinical departments and all employees of the *** with the efforts of the quality management has made certain achievements, is summarized as follows:
First, the department of the various medical staff are able to strictly implement a variety of
All medical staff in the department are able to strictly implement a variety of rules and regulations, the work of the basic embarked on the institutionalization, standardization trajectory.
Second, the quality of the talents have significantly improved, political quality, business quality significantly improved, medical ethics and medical style construction has achieved better results.
Three, medical management achievements
1, the quality of the case is significantly improved over previous years, hospitalization medical records written basically to meet the intended goals, the qualification rate of the preliminary statistics for 100%.
2, diagnosis and treatment quality: in and out of the hospital diagnosis compliance rate and pre- and post-operative diagnosis compliance rate have reached the predetermined goals. The outpatient and inpatient referral rates are close to the predefined goals, no sterile incision infections have occurred, and the prescription compliance rate is basically close to the predefined goals. Obstetrics and gynecology inpatient maternal mortality rate of 0, the incidence of neonatal tetanus is 0.
Fourth, the quality of care management
1, the service attitude is better, basically can wear uniforms, licensed to work.
2, the use of goods management and maintenance is better, especially in the management of rescue medicines and goods, basic class inventory, to ensure that the bridge on the smooth progress of the work. Medical quality management work summary
3, ward management work has improved over previous years. Plot health work better, ward items placed in an orderly manner.
4, can strictly implement the disinfection and isolation system, routine instrument disinfection pass rate of 100%, one person, one needle, one tube, one disinfection implementation rate of 100%.
5, can seriously depict the three test single, writing nursing records, timely implementation of medical advice, technical operation standardization, accurate. Nursing five form writing, nursing technical operation pass rate to meet the predefined target requirements, there is no reasonable error accident.
Fifth, medical technology
1, can seriously implement a variety of rules and regulations.
2, can conscientiously cooperate with various departments to do a good job in the analysis of the examination program, diagnostic report in a timely manner, the conclusion is accurate, the content of the perfect clear.
3, can reasonably use a variety of instruments, equipment, instruments, reagents and can be strictly managed and maintained.
4, can be timely and conscientiously do a variety of data statistics.
Six, pharmacy management
1, can conscientiously implement the relevant quality control system, measures.
2, can strictly implement the management of poisonous and narcotic drugs.
3, the purchase of drugs through regular channels.
4, dispensing prescription error rate of 0.
VII, problems and corrective comments
1, service attitude to be further improved.
2, business quality to be further strengthened and consolidated.
3, plot health work to be further strengthened.
4, the concept of asepsis to be further strengthened.
5, sterilization isolation system implementation to be further strengthened.
6, each department infection work records, data to be further improved.
7, adhere to the regular convening of meetings of the groups, management work to be further strengthened.
Part III: hospital medical quality management work summary
In order to thoroughly implement the spirit of the National Quality Work Conference, the strict implementation of the "State Council on strengthening the supervision and management of food and other product safety special provisions", received the Municipal Bureau "on the issuance of drugs and medical equipment quality and safety of special rectification action program" and the district government office "on the issuance of the Luzhou Longmaitan District Product Quality and Food Safety Special Rectification Actions Program notice", the leadership of my bureau attaches great importance to seriously organize and implement, in accordance with my bureau to develop and issue the "Sichuan Luzhou Longmatan Food and Drug Administration on the issuance of drugs and medical equipment quality and safety of special rectification action program notice" requirements for a period of four months of special rectification, the special rectification of the work carried out is summarized as follows:
First, the establishment of institutions, the implementation of the responsibility. Clear thinking, develop programs.
The establishment of the party secretary, Secretary Zhou Xiaoquan for the leader of the special rectification action leading group, a clear division of responsibilities for the smooth implementation of the special rectification action to lay the organizational foundation. I held a number of meetings of the Bureau of the party group, special study and deployment of special rectification action plan, clear rectification content, methods and steps, scientific organization, co-ordination arrangements. Developed and issued a "Sichuan Luzhou Longmatan Food and Drug Administration on the issuance of drugs and medical equipment quality and safety special rectification action program notice.
Second, extensive publicity, pay close attention to training.
xx September-October, phased organization of the region's drug business, medical device business enterprise in charge and quality management personnel nearly 1,200 people to carry out special training, the distribution of publicity materials more than 3,000 copies, so that they understand the "Special Provisions" of the profound connotation of the standardization of their business practices. Strengthen the quality awareness of enterprises, fully mobilize the initiative of enterprises. Since the special rectification action of the quality and safety of drugs and medical devices, I have repeatedly organized the jurisdiction of the pharmaceutical wholesale enterprises, retail enterprises and chain stores in my jurisdiction have a chain of enterprises held a meeting to arrange for the deployment of the relevant work, to fully mobilize the enterprise, so that enterprises really set up a quality first awareness, so that they take the initiative to do a good job in accordance with the relevant requirements of the self-checking and self-correction work.
Third, strengthen the supervision, pay close attention to the implementation.
I Bureau since September, the jurisdiction of nearly 250 times more than drug-related equipment units to carry out inspections,*** deployed 185 law enforcement officers, deployed 50 vehicles, filed 11 cases, involving 8,400 yuan, confiscation of illegal income of more than 6,000 yuan, a fine of more than 27,000 yuan, banned the illegal operation of the enterprise 2. After nearly four months of remedial action, the production, operation and use of drugs to further standardize the behavior of the drug market order to further improve the quality of drugs to further ensure that the people's awareness of the rational use of drugs to further enhance.
The main work carried out is:
(a) to check the implementation of the focus, standardize the behavior of drug production
in the production of drugs, the Bureau of the implementation of the quality management responsibility of drug manufacturers and raw and auxiliary materials purchased, the qualifications of the personnel, batch production records, quality inspection as the focus of the inspection content, strengthened the jurisdiction of the Sichuan Baoguang Pharmaceutical Co. Ltd. and Luzhou Jianping Hospital Preparation Room under our jurisdiction; in response to the problems found during the inspection, we have respectively put forward corrective opinions. During the special rectification period, the Bureau *** on the Sichuan Baoguang Pharmaceutical Co., Ltd. to carry out inspections *** 3 times, Luzhou Jianping Hospital to carry out inspections 2 times, deployed 18 inspectors.
(B) to check the implementation of gsp as the focus, standardize the drug business behavior
in the circulation of drugs, the Bureau of the implementation of gsp drug business enterprises, the qualifications and training of enterprise personnel and whether there is the existence of dependence on the operation of the business and over the scope of the business behavior as the focus of the Bureau of the strengthening of the supervision and inspection of the drug business enterprises within the jurisdiction of the supervision and inspection. Especially for the case of "7.26" fake human rabies vaccine and the case of Yongzheng's sales staff operating without license seized by the bureau, the bureau put forward two measures in strengthening the management of enterprise procurement and supply personnel:
One is to fix the drug purchaser responsible for the procurement of drugs between enterprises in the jurisdiction;
Two is to The second is that the enterprises will report the roster of sales personnel to the Bureau for the record. This effectively prevents the "extracorporeal circulation" of medicines and the phenomenon of "recognizing only faces but not enterprises" in drug procurement. Since the start of the remedial action, I **** deployed 112 inspectors, **** inspection of more than 210 times the drug business enterprises, for supervision and inspection of illegal behavior found in accordance with the provisions of relevant laws and regulations, the requirements of the deadline to be corrected, and four of the drug business enterprises to deal with the filing of the case.
(C) to increase the supervision of medical equipment business enterprises, standardize the operation of medical equipment
In the medical equipment business link, the Bureau of the operating business enterprises in accordance with the licensing matters of the business, there is no unauthorized reduction of operating conditions, purchase channels are standardized as the focus of the inspection, to strengthen the supervision of the medical equipment business enterprises, investigated and dealt with the illegal operation of medical equipment cases 2 cases. The remedial action, *** deployed law enforcement personnel 15 times, *** check medical equipment business enterprises more than 20 times, and investigate a case.
(D) to standardize the management of medical institutions pharmacy as the focus, standardize the use of drugs, medical equipment behavior
In the use of drugs, the Bureau of medicine and equipment purchase channels, medicine and equipment purchase records, drug storage conditions, the qualifications of the pharmacy staff as the focus, to strengthen the jurisdiction of the medical institutions to use the quality of medicine and equipment supervision; and at the same time, in order to further standardize the use of medicines and medical equipment in the medical institution At the same time to further standardize the use of drugs and medical devices in medical institutions, strengthen the quality management of medical institutions, I jointly issued with the Health Bureau "Luzhou City Longmatan District to carry out the creation of standardized pharmacy activities to implement the program", a clear creation of the objectives and requirements, put forward specific steps for implementation, the development of detailed acceptance criteria, prompting the management of my region's health care institutions, pharmacy management on the track to a more scientific and standardized. The special rectification, I *** deployed 46 law enforcement officers, *** check medical institutions 58 times, filed a case.
(E) strengthen the supervision of special drugs, standardize the sale and use of special management of drugs
In the supervision of special drugs, the Bureau focused on personnel and time, the use and operation of special management of drugs unit of the institutions and personnel, purchase channels, storage management and storage conditions, sales and use of management, transportation management, safety management, statistical reports and other aspects of the comprehensive inspection,** ** 36 inspectors, *** check business enterprises, the use of units 28 times.
(F) to strengthen the inspection of drug and device advertising, standardize the drug and device advertising market
To further rectify the drug and medical device advertising market, strengthen the monitoring of advertisements, I increased the inspection of illegal advertising, the advertisements that do not comply with the provisions of the resolute disgorgement. The special rectification, *** seized nearly 4,000 illegal printed materials, the removal of 57 billboards.
(VII) highlight the focus of the full flowering, to point to set up a typical, to enhance the overall image of the drug and equipment business enterprises in our region
In order to meet the higher level of inspection and guidance, to better enhance the level of lawful operation of drug business enterprises in our region, the level of service, in the previous stage of the remediation on the basis of the leading members of the group since November 22nd grouped package, to determine the focus of the four regions, that is, in order to choose the Shengjie Pharmaceutical Co., Ltd. of Nangguang Road, the 22nd door and small city back to Longwan old people's pharmacy as a demonstration store and the surrounding area, to the Red Star Farmers Market and Chunyu Road, a street diet area pharmacies as the focus, in the implementation of the eight aspects of the content of the hard work, and combined with the actuality of our region, to improve the "five uniforms", that is, a unified wall information, a unified clothing badges, a unified classification management logo. Clothing badges, unified classification management logo, unified information boxed, unified labeling. So far, the focus of the region, especially the two demonstration stores store hall store appearance has been greatly improved, the store hall clean and sanitary, no violation of the advertisement, the purchase of standardized bills binding, the implementation of the system is better, on duty personnel qualifications, drug safety awareness and service consciousness has increased significantly.
Part IV: hospital medical quality management work summaryFirst, strengthen the leadership, improve the understanding of the importance of medical quality management
Hospital management is closely related to the interests of the people, is one of the hot issues of great concern to society. Since the reform and opening up, the medical institutions adhere to the patient-centered, quality-centered service concept, and constantly deepen the reform, strengthen management, improve the service attitude, optimize the service environment, simplify the service process, improve the quality of service, to meet the masses of the basic medical needs, and effectively safeguard the people's health and safety of life. However, with economic and social development, the people's demand for medical services has become higher and higher. At the same time, the health reform is not in place, the development of health care is relatively lagging behind, the total amount of health care resources and the unreasonable structure of the double contradiction gradually emerged, the doctor and the patient conflict intensified, medical disputes occur from time to time, to the doctor and the patient caused great social and economic losses, serious interference with the normal working order of the medical institutions, damage to the overall image of the health system, to the community caused by the destabilizing factors.
In order to effectively solve these hotspots, difficult problems, and further improve the people's satisfaction with the work of medical services, our hospital from 20xx, the quality of medical management on the important agenda, through the whole process of health work, adhere to the annual organization of medical quality management activities. In order to strengthen the leadership of the activities, our hospital specifically set up a medical quality management activities leading group, specifically responsible for the supervision of medical quality management activities, regular inspection, assessment and scheduling of the activities carried out in a timely manner to detect and correct the existing problems. The requirements for the establishment of a sound hospital, section of the two levels of medical quality management organization, clear the main leader is responsible for the overall responsibility of the leaders in charge of the specific grasp; the function of the division of labor is clear, well-organized, conscientiously perform their duties to strengthen the activities carried out by the supervision and inspection of the situation, to ensure that the activities of the smooth implementation of the activities.
Second, a clear theme to ensure that medical quality management activities are rich in content
Third, to strengthen the training, and strive to enhance the business and technical capabilities of medical staff and level
Medical staff only through continuous training and learning, professional and technical knowledge and level can be The company's business is to provide a wide range of products and services to the public, and to provide a wide range of services to the public. For this reason, in the annual organization of medical quality management activities, we always put the training of medical personnel in an important position, take a variety of forms, comprehensive training of business and technical personnel, and strive to enhance the business and technical capabilities and level of medical personnel. Specific practices are:
First, the organization of health laws and regulations, rules and regulations, duties and procedures, routine norms of learning. We compile and print "Compilation of legal documents related to medical quality management", "hospital management system and personnel duties", requiring all personnel in each medical institution to have a manual, through the hiring of experts to give lectures, centralized learning units, self-study of medical personnel, lectures, typical case analysis and discussion, so that all personnel in each medical institution to understand and master the health laws and regulations, rules, regulations, duties, procedures, and routines to strengthen their legal awareness, enhance the legal awareness, and strengthen their legal awareness. Strengthen their legal awareness, enhance the conscientiousness of practicing according to law.
The second is to carry out various forms of training activities. Over the past few years, we have organized the training of the director, the training of business backbone, case writing training, "three basic" "three strict" training, nursing training, drug training, hospital infection knowledge training, medical dispute prevention and other training activities, so that the medical staff of the business technology The company's business is also a good example of how it can be used.
Third, the implementation of science and technology strategy. Firmly establish the idea of relying on scientific and technological progress in the development of health undertakings, to take the "invited in, sent out", the selection and training of subject leaders, in the continuing education of staff, to strengthen the construction of medical infrastructure and other measures, focusing on the training of talents, scientific research and specialty (project) construction, improve the overall level of health technology team. Medical quality management work summarizes the fourth is to standardize medical documents, strengthen the quality control of medical records. In accordance with the Ministry of Health, the State Administration of Traditional Chinese Medicine, "the basic norms of medical record writing", "xx province medical and nursing paper writing norms", "diagnosis and treatment routines and operating procedures", standardize medical personnel's medical record writing, improve the quality of medical and nursing paper writing; from 20xx, each year, insisted on the implementation of the quality of the medical record level by level of control and review. On the basis of the quality review of medical records at the hospital and department level in each medical institution, I randomly selected a certain percentage of discharged medical records, experts were drawn to centralized review, the results of the city notification, in accordance with the provisions of the treatment, and the medical staff's salary and benefits linked to effectively promote the quality of the medical records to improve.
Fifth, the organization of theoretical examinations and technical competitions. In the past three years, we have been training to improve the application of first aid techniques, procedures, common methods and treatment plans for the township health center medical staff as the focus, in accordance with the principle of easy to difficult, from shallow to deep, each year, the selection of appropriate technology to the township health center medical staff to promote. The method is: the bureau organizes experts to take theoretical lectures and on-site operation of the combination of the way, the organization of township health hospitals health care personnel training, application; the end of the year, the application of the mastery of all health care personnel to participate in the training of theoretical exams, based on which, select 3-5 commonly used technologies to organize competitions. Outstanding performance units and individuals, to give recognition and reward.
Sixth, actively participate in the training lectures organized by higher levels. Provincial and municipal organizations on a variety of medical quality management and business technology training lectures, and actively organize the units to participate in the study, so that medical staff to learn and accept new knowledge, new technologies, new ideas, new ideas.
Four, according to the law supervision, comprehensively improve the quality of medical management and service level
In order to ensure that the quality of medical management rules and regulations have been implemented, we have been adhering to the "law-based supervision, administrative management as a subsidiary, management and punishment," the quality of medical supervision mechanism. The first thing we do is to insist on supervision according to the law. First of all, adhere to the law supervision. We have changed the passive after-the-fact inspection into the active supervision beforehand, closely combined the comprehensive supervision and inspection of medical quality with the supervision and inspection of special key work, and strictly supervised and managed the medical institutions and medical personnel through the supervision instruments issued according to the law in the daily work; second, we focus on the implementation of various systems and measures. From the system, responsibility improvement to implementation, strengthen the management of the key links of medical quality, key departments and important positions, seriously implement the core system of medical quality and medical safety, timely detection and resolution of medical safety hidden trouble; third, sound organization, clear responsibility.
Requirements of the medical institutions to establish and improve the hospital and departmental medical quality management organization, to achieve a reasonable staff structure, a clear division of labor, work coordination, the development of medical quality management and continuous improvement of the program and the implementation of the organization. The director of the medical quality management of the first responsible person, leading the organization of functional departments, regular guidance on the quality of medical inspection, supervision and assessment; fourth, the formation of the system to implement the monitoring system. Bureau and the medical institutions of medical quality management organization, the development of medical quality assessment standards, to take the expert group quality assessment, section chief symposium, medical quality warning talk, medical quality dean of the big room, room visits to study and other forms of extensive medical quality inspection and supervision work.
Fifth, the effectiveness of the work and experience
Through the active development and effective implementation of the above measures, so that the city's medical institutions of the quality of care management, has achieved significant results: the medical technology level of the medical institutions to get a greater level of improvement, the vast number of medical personnel in accordance with the law to strengthen the awareness of the quality of health care services to get a lot of Improvement, medical disputes have been reduced year by year, especially accidental medical disputes have been very few, doctor-patient relationship has improved significantly, for three consecutive years to maintain the xx city democratic evaluation of the top three good results, to build a harmonious society has laid a solid foundation. In many years of medical quality management, we y appreciate:
(a) the quality of medical services is the lifeline for the survival and development of the hospital. Medical service quality is the core of hospital management, is the eternal theme of hospital management. In the increasingly fierce competition, only to establish the quality of medical services is the lifeline for the survival and development of the hospital this concept, adhere to the people to provide quality, safe, satisfactory medical services, social and economic benefits can be sustained growth.
(2) Technological innovation is the key to improve the core competitiveness of the hospital and inexhaustible power. Technological innovation, special diagnosis and treatment, science and education is the three major strategies of hospital management. Only by adhering to the advantages of hospitals, departments have characteristics, people have expertise in the development of ideas, hospitals can form and maintain the academic status of disciplines in the competition and technical level in the peer group, to occupy a larger market share, it is possible to be based in the market and development.
(C) people-oriented, patient-centered is to promote the fundamental concept of hospital development. In deepening the reform, change the concept, improve the service environment and service attitude, improve the work style, and establish a people-oriented service concept, which will help the level of medical services on a new stage, on the level.
(D) the combination of ethical construction and quality management is an effective way to solve the problem of medical ethics and medical style improvement. The combination of ethical construction management and medical service quality management, can be flexible management indicators into rigid management indicators, is an effective way to solve the technical quality management and functional quality management, is conducive to deal with the quality of medical services management, fee management, the contradictions arising in the process of ethical construction.
The city has done some work in the supervision of medical quality and achieved certain results. But from the higher requirements, compared with the brother city there is still a gap. In the future, under the correct leadership of the Zaozhuang Municipal Health Bureau, we will further update the concept, raise awareness, and take multiple measures to strengthen the quality of medical care management, to ensure medical safety, to promote the steady progress of the health industry, for economic development and social stability, to make a new and greater contribution!