According to the hospital's 2017 Medical Quality Management Committee work plan, various work indicators were drawn up and gradually implemented and completed. However, there are still many shortcomings, in the future work to improve and perfect, now the 2017 annual medical quality management committee work is summarized as follows:
First, the management of lawful practice: In order to further strengthen the implementation and implementation of lawful practice, and to protect medical safety, the medical regulations section to strengthen the hospital's lawful practice of checking, supervision, implementation, feedback, organization and implementation of learning, requires that Annual organization of 2-4 times the hospital-wide study of laws and regulations, department monthly study 1-2 times, the year regularly organized hospital-wide examination, the content of the study of the "Chinese People's *** and the State Law on the Prevention and Control of Infectious Diseases", "Regulations on the Management of Medical Institutions", "Medical Practitioners Law", "Maternal and Child Health Care Law", "Regulations on the Handling of Medical Accidents", "Drug Administration Measures" and "and" etc., requiring each study record, strengthen the practice of admission Management, according to Huaihua City Hospital of Traditional Chinese Medicine practice access management implementation rules, requiring the director of each department to strictly control the entry gate, non-licensed personnel must be practicing under the guidance of a licensed physician, violators of the rules for the implementation of the management of access to practice in strict accordance with the penalties. In order to cope with the rising medical disputes and complaints in the first half of the year, from August 11 to September 12, the organization carried out a medical safety rectification activities. Through the study, improve the awareness of the whole hospital staff to practice medicine according to law, to protect the medical safety, hospital medical disputes and complaints have decreased significantly, the quality and efficiency of medical services have also been effectively enhanced, so far, this year, the whole hospital medical disputes occurred in 32 cases, no medical accidents occurred.
Second, the construction of the system: continue to improve the system, pay close attention to the implementation, and continue to improve the quality of health care
1, regular quality inspection: Medical Department of the hospital's various clinical departments to carry out quality inspections, the quality of health care management of the core system into the quality of the inspection content: (1) the first physician responsible for the management of the system: to check the receiving physician to deal with the patient in a timely manner and comprehensively, the difficult and critical patients to ask for advice from a superior physician, other problems will be invited to the relevant departments to ask for advice from a superior physician, the problem of the other departments to ask for advice. Physicians, other departmental problems to invite the relevant consultation situation, the third-level physician check-ups, shift handover records, difficult, fatal cases, pre-operative discussion of the contents of the transcript, to understand the implementation of the system. (2) Strengthening the management of the top five hospitalized diseases: each department is required to report the top five diseases of the department and be familiar with them. (3) Supervise each department to formulate and implement 18 Chinese medicine diagnosis and treatment plans for common diseases and Chinese medicine advantageous diseases according to the characteristics of the specialty of the department, and issue clinical pathways for 24 diseases. (4) Medical record writing and case management: In strict accordance with the requirements of the Basic Norms for Medical Record Writing in Chinese Medicine, we conducted supervisory inspections of the quality of medical documents twice a week, which effectively reduced the rate of defective medical records. In order to cooperate with the implementation of the "Basic Norms for Medical Record Writing in Chinese Medicine" (2017 edition), timely study was organized for medical staff, and it was emphasized that while the clinical medical staff did detailed notification when patients were entering and exiting from hospitals, and during all kinds of examinations and surgeries, the notification must be carefully and completely filled out in the corresponding informed notification letter. Strict implementation of the "Basic Norms for Medical Record Writing in Chinese Medicine", the inspection of running medical records as a top priority to check, the inpatient medical record, the first page of the case, the doctor's order form, the first record of the course of the disease, the record of the superior physician's checkups, the informed consent for surgery, the informed consent for anesthesia, the informed consent for special examinations and special treatments, and the discharge records, etc., have been made accordingly, and the contents of the medical records have been seriously affecting the quality of medical care, which may result in medical disputes. The hidden problems such as the timeliness of medical record writing, the superior physician's examination records, the signature of the patient or the patient's family on the informed consent, rescue records and alterations, etc., from the medical link to plug the leaks and prevent errors, improve the rate of Class A medical records, unqualified medical records in accordance with the provisions of the penalties.
2, in the multi-disciplinary collaboration, the first case of knee replacement surgery in our hospital was a complete success.
3, in line with the hospital's third session of the Chinese medicine culture festival, organized a medical record writing contest, the participating medical records qualified rate of 100%.
4, strengthen the three basic training and assessment system implementation and implementation In order to improve the level of medical technology in our hospital, according to the actual situation of our hospital, the beginning of the year to draw up the three basic training plan, from the outsourcing of further training, departmental organization of the study and the hospital-wide study of the combination of business learning, to try to improve the level of medical technology; medical department to organize 2-4 times a year to train and study, to carry out two assessments, scheduled for June and December.
Three.
Third, quality management has begun to show results
1, the actual results: January-December this year, outpatient volume of 155,828 (128071 the previous year), a year-on-year increase of 21.67%, 8,479 emergency room visits, 310 times the rescue of critical cases, the average length of stay 2.88 days; discharged patients were 12,782 (11549 the previous year), an increase of 10.68%; all the patients were discharged, a year-on-year increase of 10.68%; the whole hospital, a year-on-year increase of 10.68%, a year-on-year increase of 10.68%. 10.68%; hospital bed days for 140121 (107,785) days, an increase of 30.84%; bed occupancy rate of 94.46%, an increase of 12.51%;, the number of bed turnover of 31.25, a year-on-year decrease of 8%; the average number of days of hospitalization of 9.87 days, a year-on-year decrease of 3.01 days; the number of surgical procedures for the same period in the previous year, 3476 (3755) cases, a year-on-year increase of 8.03%; the number of patients discharged to 12782 (previous year 11549), an increase of 2.88 days. Year-on-year growth of 8.03%; a variety of auxiliary tests and many indicators have improved to varying degrees: of which: gastroscopy 1426 times, pathology 4142 times, 898 times of pathological cytology; radiological examination of 42816 times, of which 7315 CT examination, the positive number of 5689; electrocardiography 11539 times, ultrasound examination 13334 times; clinical test 1257401 person-times, biochemical examination 368865 person-times; service concept has improved, strengthen the doctor-patient communication, promote the harmonious development of doctor-patient relationship, doctor-patient conflicts reduce, medical disputes decline, strengthen the right of informed consent of the patient and the right to privacy 'protection work.
2, the quality of care Over the past three months, the hospital in general, the quality of care compared to the previous year, a slight decline, mainly due to the individual department director did not seriously review the core system, some doctors are indifferent due to the awareness of the quality of the case, the reasonable examination, rational use of medication and antimicrobials have improved, many indicators have improved significantly.
3, service (1) to strengthen the doctor-patient communication, build a harmonious doctor-patient relationship In the past six months, to strengthen the construction of doctor-patient communication, doctor-patient communication into the scope of quality management, requiring medical staff in the patient's admission to the hospital that is formally introduced to the patient's condition to the patient or family members, the examination and treatment means and the Department, the hospital, so that the patient to understand their own medical condition and the level of medical technology of the hospital, and listen carefully to the patient or family members, the desirable views of the patient, and the patient, the patient, the patient and family members. Listen carefully to the patient's or family's opinions, and incorporate the desirable opinions or suggestions into the future management. (2) find defects, grasp the rectification, improve patient satisfaction Hospitals pay close attention to the management of service defects, find shortcomings in patient satisfaction, each defect seriously investigate, implement and feedback, improve service attitude at any time to improve the patient's satisfaction with practical action. (3) The doctor-patient conflict is reduced, the decline in medical disputes.
Fourth, the main deficiencies in the current year
1, according to law: part of the department to their own guidance to the signing of the unlicensed personnel is not timely, in the monthly supervision or more or less have appeared in the management of access to practice is not strict.
2, the quality of medical care: (1) the quality of medical documents in some departments is poor: mainly in the superior physician's examination record (and the first record of the same disease), the preoperative discussion on the record is not standardized, and the printing of medical records is often wrong phenomenon. (2) Antimicrobial application, part of the department did not strictly grasp the indications of the existence of abuse of antimicrobials. (3) outpatient medical records are not standardized, and even individual physicians did not write.
V. Continuous improvement measures
1, to strengthen the study of laws and regulations, strengthen the supervision efforts, and strictly good access to practice, so that medical personnel at all levels consciously practicing law, according to law.
2, to strengthen the study of various types of quality management system, to improve the quality of medical care, to achieve the diagnosis of standards, treatment based on the purpose of reducing the patient's hospitalization time and cost.
3, continue to do a good job in the "basic norms for the writing of Chinese medical records" (2010 version) of the training to improve the quality of medical record writing. Strengthen the "three basic and three strict", and constantly improve the quality of medical staff and practice level, and continuously improve the quality of medical services
4, improve service attitude, improve service quality, and build a harmonious new doctor-patient relationship
5, do a good job in the inpatient wards before the relocation of the overall arrangements and coordination work.