Medical quality and safety management team work plan

Days are like white horses passing by, without realizing it, our work will again be busy in the fullness of the joy of harvesting, write a plan for the next work to do! What kind of plan is effective? The following is my medical quality and safety management team work plan for you to organize, for your reference and reference, I hope to help friends in need.

Medical quality and safety management team work plan 1

Under the leadership and supervision of the hospital medical quality management committee, according to the hospital "medical quality and medical safety management and continuous improvement program" with reference to the Ministry of Health "20xx three-level specialized hospital review standard implementation rules", the development of this section of the medical quality and safety management of continuous improvement plans and management objectives.

I. Section management:

1, the establishment of the section quality control team, there is a division of labor, responsibility to the person. No less than once a month quality control activities, the department of diagnostic and treatment activities in all aspects of the inspection and monitoring, and fill in the requirements of the outpatient department quality control records.

2, regular meetings of the quality control team to study the quality and safety of the department, to ensure medical safety.

3, according to the actual situation of the department to develop a work plan, on time to complete the plan, and constantly improve the quality of medical care to strengthen the quality and safety awareness.

4, according to the department director manual, nurse manual project requirements on time to fill out.

Second, the medical quality management objectives

1, the strict implementation of the first physician responsibility system.

2, outpatient medical records written complete, standardized, accurate, grade A medical records ≥ 90%.

3, ask for a detailed history, physical examination carefully, to have a preliminary diagnosis.

4, reasonable examination, reasonable medication; specific medication in the medical record.

5, drug usage, dosage, duration and compounding reasonable.

6, prescription writing standardized and qualified, qualified rate ≥ 95%.

7, the second visit to the diagnosis is not clear, the receiving physician should:

A, ask the superior physician to consult;

B, hospitalization or effective communication with the patient's condition.

8, the third visit to the diagnosis is still not clear, the receiving physician should:

A, hospitalization;

B, the patient refused to hospitalization need to fulfill the signature procedure.

9, according to specialty admission.

10, the patient did not return to the examination, the doctor can not leave the post with the end of the day. If there is an emergency must leave, report to the outpatient department, arrange the relevant personnel to receive treatment.

11, do a good job of outpatient logbook registration.

12, infectious disease reporting rate of 100%

13, department staff "three basic" assessment reference rate, pass rate of 100%

Medical quality and safety management team work plan 2

First, gradually improve the quality control center organization and institutional construction system. Establishment of sound quality assessment standards

(a) the establishment of a perfect quality control center expert group.

(b) Assist in the establishment of medical quality control sub-centers.

In accordance with the requirements of the Ministry of Health's "Measures for the Management of Medical Quality Control Centers (Trial)" and the "Circular of the Sichuan Provincial Department of Health on the Construction of a Provincial Medical Quality Control Network," the construction of pediatric quality control sub-centers in various cities and states will be improved, and the quality control of pediatrics will be carried out in a comprehensive and effective manner.

Gradually complete the drafting of quality control standards for 11 specialized diseases, including neonatal, pediatric infectious diseases, pediatric gastroenterology, pediatric respiratory, pediatric heart disease, pediatric nephropathy, pediatric hematology, pediatric neurology, pediatric endocrinology, pediatric hereditary disease, pediatric immunity, etc., and formulate and improve the standards of medical quality management and control in pediatrics; strive to build a large pediatric team across the province; and provide a comprehensive and effective quality control for the health of children between the ages of 0 and 18 years.

Second, the province's pediatric management, quality control, operation of research, the use of multiple forms of on-site supervision and inspection

Comprehensive sorting of the province's pediatric specialty, discipline development and talent, diagnosis and treatment of the current state of the level of technical and capacity; carry out a survey of the spectrum of diseases, such as the incidence of nephrotic syndrome in children survey for the health administration and government decision-making basis. The competent authorities and government decision-making basis; complete 20xx quality control information collection, summary, analysis, evaluation, feedback, guidance and corrective measures or methods; the provincial pediatric quality control center experts will be together with the sub-center experts to the cities and states of the province's relevant medical institutions to inspect and guide the pediatrics to carry out quality control work on a random basis, to find out the problems, put forward the method of improvement; for the hospital level evaluation and assessment of the daily monitoring results data. The center's experts will go to the cities and states to inspect and guide the relevant medical institutions in the province to carry out quality control work.

Three, to strengthen the technical team talent construction, the full implementation of the technical training work

1, held a training meeting of members of the expert group, to strengthen the guidance of the primary health care institutions to standardize the work of the training. 20xx, the Sichuan Provincial Pediatrics Quality Control Center intends to convene no less than two times the provincial center of the expert group meeting, to enhance the guidance and training work of primary health care institutions to standardize. The standardization of the guidance and training work of primary care institutions.

2, the preparation of Sichuan Provincial Pediatric Quality Control Center training materials. According to the training objectives, the preparation of a "neonatal disease diagnosis and treatment training" teaching materials, combined with the content of the teaching materials for the training of relevant personnel.

3. Training for members of the Sichuan Pediatric Quality Control Center. With the help of national and provincial continuing medical education programs, the provincial center for the platform for the province's pediatric department standardized construction, the promotion of appropriate technology, the introduction of new technologies to carry out training; in order to standardize and improve the level of diagnosis and treatment of neonatal diseases of pediatricians, the center's goal for this year is to strengthen and regulate the construction of neonatology, management, diagnosis and treatment of diseases to do special training.

Fourth, the establishment and improvement of medical quality control center work information system construction work

(a) to carry out the relevant disease information reporting.

Gradually establish a pediatric diagnosis and treatment case information reporting system, designate a person in charge of information reporting, entry, and provide the necessary equipment and technical conditions for information reporting; the center will be reported to the province of pediatrics related diseases quality control information collection and collation, statistics, analysis, evaluation feedback, guidance on corrective measures or methods, at the same time, the quality control center to strengthen the technical guidance of the medical institution

(B) the establishment of medical quality control center adverse event information reporting system.

Gradually establish the medical quality control center adverse event information reporting system, make full use of the medical quality control center adverse event information reporting system as a platform for exchanging and sharing risk prevention experience, enhance the awareness of risk prevention, improve risk prevention ability, and ultimately achieve the goal of protecting patients' health and medical safety.

The use of the completed Sichuan Provincial Pediatric Quality Control Center website, expanding the province's pediatric quality control of publicity, the use of the network's convenience and openness, the training courseware, related forms and other information on the network, to strengthen the exchange of contact with the sub-centers, while continuing to improve the pediatric quality control center network construction, the opening of the remote consultation channel of the difficult diseases, and the organization of experts in a variety of forms of appropriate technology to promote lectures, The company's main goal is to improve the quality and safety of medical care through the use of a variety of appropriate technology to promote lectures, room inspections, difficult patient discussions, and death case discussions.

V. Other work

To assist and support the construction of pediatrics in cities and states, and to promote the construction of provincial or municipal key clinical specialties. Cc: National Health and Family Planning Commission, Department of Medical Affairs, Medical Management Division, Provincial Administration of Traditional Chinese Medicine, Provincial Health Law Enforcement and Supervision, provincial clinical quality control centers, the provincial eighty-first Rehabilitation Center.

Medical quality and safety management team work plan 3

In order to implement the medical core system, to ensure the improvement of the quality and safety of medical care in my department, to ensure the quality of medical records written within the quality and completion of medical indicators, to draw up the medical quality and safety of the current year's work plan

First, to strengthen the ideological understanding of the continuous development:

The director of the department, the head nurse continue to grasp the quality management, the implementation of the rules and regulations. Monthly meetings of the quality management committee, medical records quality control group meeting, hospital sensory group meeting, nursing management group meeting, medical safety group meeting, etc., standardize management, standardize medical behavior. So that each workstation in our department can work hard to improve the level of medical technology, and promote the sustainable development of the department.

Second, a clear section of medical, the main work indicators, and strive to complete:

1, bed utilization ≥ 92%

2, the average hospitalization days ≤ 8 days

3, three days after admission to the hospital to confirm the diagnosis rate of ≥ 90%

4, the average hospitalization days ≤ 2 preoperative days

5, the admission of Discharge diagnosis compliance rate ≥ 95%

6, hospitalized critically ill patients resuscitation success rate of ≥ 85%

7, pre- and post-operative diagnosis compliance rate of ≥ 90%

8, clinical and pathological diagnosis of compliance rate of ≥ 90%

9, the three basic assessment qualification rate = 100% (80/100 points)

10, outpatient medical record writing qualification rate of ≥ 90% (90/100 points)

10, outpatient medical records ≥ 90% (90/100 points or more)

11, Class A case rate ≥ 95%, no Class C medical records

12, medical equipment, instrumentation intact rate of ≥ 90%

13, first aid instrumentation, medication intact rate = 100%

14, antimicrobials ≤ 60%, DDD ≤ 40%, drug sensitivity > 80%, the rate of antimicrobials use of one type of incision = 100%

14, antimicrobials ≤ 60%, DDD ≤ 40%, drug sensitivity >80%, the rate of use of one type of incision = 100% (80/100 points). A class of incision antimicrobial use rate ≤ 30%

15, surgery 500

Third, improve the department of medical quality assessment work, the implementation of standardized quality management, the development of assessment standards, monthly inspection by the quality control officer, do a good job summarizing the feedback work.

1, with reference to the second-class hospital accreditation standards and three good and one satisfied with the accreditation standards, the department's monthly work, carefully scored, the results are linked to the bonus.

2, sound, the implementation of a variety of medical systems, requiring a variety of systems to implement record specification, complete project. The medical team strictly implement the three-stage check-in system, 48 hours after admission to the attending physician check-in, a week of director check-in, pre-operative, post-operative check-in superior physician, serious patients at any time to ask the superior physician check-in, the seriousness of the disease automatically discharged to ask the superior check-in, the serious patients on duty physician check-in after a good record of the course of the disease. Strengthen the management of informed conversation system, 72-hour conversation within the admission of non-surgical patients, conversation before, during and after surgery, implantation conversation, conversation at any time when critically ill, special diagnostic and therapeutic operations, treatment, medication conversation, blood transfusion consent conversation, anesthesia consent conversation before; strict implementation of the case discussion system, consulting system, surgical approval and surgical privileges system, and the system of handover, etc.. Each department holds a monthly meeting to analyze the problems, rectify and continuously improve.

Fourth, seriously do a good job of medical writing management

1, strengthen the medical record writers self-check, the department medical record quality team (relevant quality control personnel) monitoring. The department's medical records quality control officer monthly link and final medical records quality inspection, cultivate each quality control officer's medical records quality consciousness, deepen the inspector's perceptual cognition, the inspection results in a timely manner to reach their own section, to avoid the same error, so that the inspected person to pay attention to the first time to get feedback, real-time change, play a virtuous circle.

2, grasp the evaluation of the quality of medical records, the implementation of a combination of reward and punishment system of medical records of the department of the quality control officer every month on the ward for the final quality inspection of medical records, check the existence of the problem and the B, C medical records reported to the Office of Quality Control. The relevant departments of the quality control staff need to report the results of the inspection in a timely manner, such as continuous non-reporting will be deducted from the department of the month a certain assessment of the total points, and departmental bonuses are linked. To promote attention and mutual supervision, to avoid and reduce the incidence of defects in medical records, to improve the quality of medical records.

3, the implementation of the medical record inspection system, highlighting the key points of the monthly inspection focus on the following arrangements:

January: rational use of medication, including antibiotics, special governance and the use of medication, analysis and disposition of the situation.

February: "critical value" report registration, nursing staff timely report to the physician, the physician timely treatment and record,

March: the hospitalization & gt; 30 days of patients, to do a major check-up focus on the verification of evaluation records. Measures to shorten the average length of stay in the bottleneck of the waiting time of the measures to verify one by one, the implementation of the measures.

April: blood transfusion management system, including pre-transfusion application, blood preparation, laboratory items, application form written comprehensively; sign the patient's consent for blood transfusion before transfusion; rational use of blood, before and after the transfusion of the course of the analysis of the record. Inspection of the first quarter . Various kinds of discussion medical records (difficult, death, preoperative, discharge case discussion records).

May: random inspection of critical patients' superior checkup records, on-duty physician checkup records, critical illness notification, resuscitation records, etc..

June: the implementation of the preoperative condition assessment system and preoperative discussion system

Medical quality and safety management team work plan 4

I. Strengthen the formation of the medical quality office team, improve the quality of various medical systems and assessment standards.

The establishment of a perfect quality management system, standardize medical behavior is the core. Establishment of the actual quality management system in line with the hospital, the hospital set up the establishment of the executive vice president, the medical department and the clinical departments as members of the quality management committee and quality control assessment leading group, responsible for the quality management of the hospital. The hospital has formed a pattern of medical quality and medical safety management in which the main leader personally grasps; the leaders in charge specifically grasps; the functional departments grasps every day; and the clinical departments grasps all the time. Strengthen the clinical path management, through the trial period to carry out the management of medical services, efforts to improve the quality of medical care, to ensure medical safety as the goal of the full range of quality management.

Second, strengthen the medical quality management, to ensure and improve the quality of medical services.

Medical quality management is the core of hospital management, improve the quality of medical care is the management of the fundamental purpose of the hospital. Medical quality is the lifeline of the hospital, on the basis of improving the medical management system, to reduce the quality of medical defects, timely investigation and elimination of medical safety hazards, reduce the number of medical malpractice disputes, to eliminate medical accidents as the most important work. Strictly control the medical quality, require all departments to strictly implement the rules and regulations, standardize the diagnosis and treatment behavior, and adhere to the system of first diagnosis and responsibility, three-level check-up system, consultation for difficult patients, critical patients and pre-operative and post-operative discussion system. Enhance the sense of responsibility, pay attention to the dynamic analysis of medical activities, do a variety of precautionary measures to prevent problems before they occur. In view of the current increase in patients' demand for the right to medical information, improve the notification system. Strengthen the quality control management, inpatient medical records written in accordance with the Ministry of Health issued "medical record writing norms", "electronic medical records basic norms (for trial implementation)", "Chinese medical records written in accordance with the basic norms" and scoring standards for the implementation of prescription writing in accordance with the "prescription management approach".

Three, according to the trial period of the actual operation of the problems found in the optimization of medical service processes to improve the basis of medical quality.

Section, service marking standardized, clear, eye-catching, easy to understand. Adhere to the patient-centered, in the optimization of the medical process, to facilitate the patient to seek practical results, enhance the sense of service, optimize the development of the environment, and strive to provide patients with warm, convenient, high-quality medical services.

Four, the implementation of medical quality, medical safety education, is to strengthen the foundation of medical quality.

Strengthen the quality of education for all hospital medical staff so that all hospital workers have a correct outlook on life, values, professional ethics; the need for a strong sense of responsibility, professionalism, compassion; establish a solid sense of quality of medical care, medical safety awareness; comprehensively carried out in the hospital quality service and "safety is the savings, accidents is the waste! To carry out the activities of quality service and "safety is saving, accident is waste" in the hospital, to stimulate the dedication of the staff to learn and dedication, and to form a good atmosphere of comparison, learning, catching up and surpassing. The medical staff of the hospital is educated and trained in the "three basics and three rigors" in cooperation with the medical department and the department of science and education.

Medical quality and safety management team work plan 5

For the implementation of the medical core system, to ensure the improvement of the quality and safety of medical care in my department, to ensure that the quality of medical records written within the quality and completion of the medical indicators, the preparation of the current year's medical quality and safety work plan:

First, to strengthen the ideological understanding of the continuous development:

The director of the department, the head nurse to continue to grasp the quality management, the implementation of the rules and regulations. Monthly meetings of the quality management committee, medical records quality control group meeting, hospital sensory group meeting, nursing management group meeting, medical safety group meeting, etc., standardize management, standardize medical behavior. So that each workstation in our department can work hard to improve the level of medical technology, and promote the sustainable development of the department.

Second, a clear section of medical, the main work indicators, and strive to complete

1, bed utilization rate ≥ 92%.

2, the average hospitalization day ≤ 14 days.

3, admission three-day diagnosis rate ≥ 90%.

4, the average preoperative hospitalization days ≤ 3.

5, admission and discharge diagnosis compliance rate ≥ 95%.

6, hospitalized critically ill patients rescue success rate ≥ 85%.

7, before and after surgery diagnosis compliance rate ≥ 90%.

8, clinical and pathological diagnosis rate ≥ 90%.

9, three basic assessment pass rate = 100% (80/100 points).

10, outpatient medical record writing pass rate ≥ 90% (90/100 points or more).

11, Grade A case rate ≥ 90%, no Grade C medical records.

12, medical equipment, instrumentation intact rate ≥ 90%.

13, first aid equipment, drugs intact rate = 100%.

14, antimicrobial use 60%, DDD 40%, drug sensitivity 80%, antimicrobial restricted use rate of 50%.

15, 720 surgeries.

1, with reference to the second level of hospital accreditation standards and three good and one satisfied with the accreditation standards, the department's monthly work, carefully scored, the results and bonuses linked.

2, sound, the implementation of a variety of medical systems, requiring a variety of systems to implement record specification, complete project. The medical team strictly implement the three-stage check-in system, 48 hours after admission to the attending physician check-in, a week of director check-in, pre-operative, post-operative check-in superior physician, serious patients at any time to ask the superior physician check-in, the seriousness of the disease automatically discharged to ask the superior check-in, the serious patients on duty physician check-in after a good record of the course of the disease. Strengthen the management of informed conversation system, 72-hour conversation within the admission of non-surgical patients, conversation before, during and after surgery, implantation conversation, conversation at any time when critically ill, special diagnostic and therapeutic operations, treatment, medication conversation, blood transfusion consent conversation, anesthesia consent conversation before; strict implementation of the case discussion system, consulting system, surgical approval and surgical privileges system, and the system of handover, etc.. Each section holds a monthly meeting to analyze and rectify the problems and make continuous improvement.