Ministry of Health
Hospital hierarchical management standards are the objective basis for the standardized management of our hospitals. At different levels, strengthen medical services and hospitals to achieve hospital management in the macro-management, micro-management of the dual mechanism to improve the hospital function when the sound consolidation of the three-tier medical preventive system, to better play the overall effect to achieve the full and rational use of limited health resources, to promote the development of science and technology, to strengthen the medical ethics and medical ethics, and constantly improve the quality of product quality of medical services, and better for the people's health. Services. But also can mobilize the enthusiasm to support the development of health care services. Hospital management at different levels is a major reform of the hospital management system.
"General hospital hierarchical management standards are, from the actual situation in China, under the guidance of modern scientific management theory, summed up the experience of 3 health network construction in China, and create a "civilized hospital activities, organized by the Ministry of Health, the Department of 11 provinces, municipalities directly under the Central Government and CASS Academy of Medical Sciences. Beijing University of Chinese Medicine and other units after full investigation and drafting research and demonstration. Related issues are as follows:
The standards of hospitals at all levels The basic standards of hospitals at all levels must comply with the standards, and the hospitals open the eligibility criteria. Separate separate assessment of the basic standards, scores and grading criteria assessment. To meet the requirements of the "basic standards" will not be approved as an ineligible hospital, the hospital's new license application will not be approved.
Hospital grading criteria at all levels: According to the mission and function, hospitals are divided into three levels, namely hospitals, secondary hospitals and tertiary hospitals. According to the level of the hospital, the level of quality and management level, and with reference to the technical level of the necessary facilities are divided into A, B, C level, tertiary hospitals additional principals.
Assessment Criteria: Temporarily take a micrometer-based assessment method before the establishment of the mathematical model scoring method. In the assessment of qualifications of the hospital revenue total performance band rating grade.
Category A: grading criteria assessment to achieve a score of 900 points or more (including 900 points).
B: Grading criteria evaluation shall be 750 to 899 points.
Category C: Grading criteria evaluation for less than 749 points. (Including 749 points)
These three PL hospitals in addition to to the hospital criteria must meet the necessary conditions of the hospital.
4. Hospital evaluation application form: hospitalization procedures, must be to the Accreditation Commission of the Accreditation Commission determined that the main basis for hospital accreditation. Requirements for hospitals must be carefully and factually fill out the declaration.
Standard fittings: the specific requirements of the standard indicators and assessment checkpoints description.
"General hospital grading management standards are far from perfect, only as a draft in the national trial. About the trial to propose amendments to the standard, so that it is gradually improved.
Hospitals, primary hospitals (hospitals) standards
Hospitals are primary health care institutions that provide medical, preventive, health care and rehabilitation services directly to the community, the implementation of primary health care in our country, "everyone has the right to enjoy a certain population (≤ 100,000 dollars) health security," the global goal of the primary health care sector. Health care sector.
Basic criteria for a hospital
This criterion is a prerequisite for validation of hospitals in order to participate in the rating and qualification to meet the standard qualifying line.
The basic criteria include the following seven aspects:
First, the size of the hospital
The size of the hospital should be adapted to the hospital's functions, tasks and management requirements.
(1) The number of beds should be no less than 20. If it is below the limit, you must provide a reasonable explanation.
The facilities required for the bed unit to meet the requirements (see Annex VI).
Floor area per bed? Not less than 45 square meters.
Hospital officer ratio for 4 beds:1:1-1 .4 number of workers.
The ratio of health workers in the hospital staff accounted for 80% to 85% of the total (non-medical personnel are not allowed to engage in medical, medical technology and nursing.)
Second, the functions and tasks of the hospital
A hospital should assume the medical and health services in the community and certain health care management.
(A) preventive health care
Good community health and epidemic prevention work, including immunization programs, infectious diseases, parasitic diseases and endemic diseases under the guidance of the higher level of health supervision and management of the health epidemic prevention department, implementation.
Active? In maternal and child health care work for women, infants and young children frequently occurring census and treatment, to carry out the production system of marriage, education, care, and promote the science of midwifery and work.
Family planning surgery and technical guidance.
To take a variety of forms of health education, popularization of health knowledge factors, endangering the health status of the community population, and improve the residents' self-care ability and overall health.
(B) medical services
Complete community outpatient clinics for common diseases, multiple diseases, hospital diagnosis and treatment (including home beds) acute, weight, maintenance of vital signs of critically ill patients ambulance, and organization of referral tasks.
2. Universal first aid knowledge and techniques to the masses, hospital medical staff must master effective unarmed CPR.
Depending on the conditions, to carry out community-based rehabilitation health care, mental health services, chronic non-communicable diseases control population.
(C) health management
Under the leadership of the local government and higher health administrative departments, according to the local socio-economic development plan, to assist in the development and implementation of community-based primary health planning.
Cooperating with the relevant departments, mobilizing and organizing the public to carry out patriotic health activities to gradually improve the health status of the public.
Implement national health regulations and supervise and manage related industries in the community.
4. To be responsible for the management and technical guidance of village health organizations and individual practitioners, and to train village doctors, health workers and midwives.
Three, hospital management
Hospitals should have a sound management system, institutional measures, supervision, assessment and evaluation. Some of the labor administration. Business management and ideological and political work.
(A) the basic system
In accordance with the "National Hospital Regulations", the hospital system and the duties of hospital staff by the Ministry of Health issued by the relevant provisions of the Ministry of Health in 1982, the Chinese hospitals, the actual, must be carefully formulated and strictly enforced rules and regulations, including:
Hospital system. In addition to the general hospital system, including maternal and child health care, health epidemiology, home hospital bed system in rural areas of doctors and other work system guide.
2 personal responsibility at all levels.
The working procedures of the technology.
4. system of continuing education for workers.
(B) Information Management
Health Statistics System (Trial) "by the Ministry of Health and comprehensive information management full-time (part-time) staff.
Information collection, storage, analysis, feedback and utilization, and effective.
3 library management system with the right amount of medical books and journals.
(C) Financial Management
A financial institution or full-time accountant.
2 Accounting vouchers, books, statements, and accounting system compliance.
Accounting records management system.
4 accounting supervision and audit system is sound, and strict compliance with the financial, price self-discipline, do not allow arbitrary charges.
(D) Equipment Manager
1 Designated personnel or part-time staff to manage the hospital's equipment.
Medical equipment storage, use, maintenance and regular system maintenance to ensure that medical work is done.
3The creation of documents? documents for critical equipment.
(E) General Manager
General supplies quota management, perfect procurement, acceptance, warehousing, distribution, waste regime.
2. Proactive, timely service for the hospital to ensure timely maintenance of water, electricity, clothing, catering and various facilities.
(F) Construction management
Hospital buildings meet health requirements, maintenance system for old buildings, unreasonable building renovation program.
2. shall not be used for dangerous, especially engaged in medical activities, not in dilapidated houses.
Four, quality management
(A) time (part-time) personnel responsible for the hospital's overall quality management, establish and improve a progressive quality assurance system.
(B) the hospital's total quality management program, and conscientiously implement.
(C) control of nosocomial infections:
Infection control agencies should be in line with the Ministry of Health in 1988 "to establish and improve the organization and management of hospital infection control interim measures".
2. Hospital-wide infection control program.
3. Establishment of strict sterilization and isolation and infectious disease registration and reporting system, asepsis requirements.
4 The nosocomial infection control education system, medical staff must establish the concept of asepsis and correct aseptic technique.
Rational use of antibiotics management methods.
6 Insurance governance measures for special areas (e.g., operating rooms, treatment rooms, supply rooms, labor and delivery rooms, etc.).
Disinfection supply room should meet the acceptance standard of disinfection supply room of the Ministry of Health Hospital (Trial)".
V. Ideological and political work and medical ethics
To realize the Party's line, guidelines, policies, the Party and government working groups to make concerted efforts, ideological work and medical ethics, organization and implementation of the plan.
The ideological and political work management system and work system.
Conscientiously carry out the implementation of ethical guidelines and methods for medical personnel, developed and adhered to before the position of the education system.
To establish a system of mass supervision.
According to surveys, patient satisfaction, community hospital regulations or contract units.
6 sound honest measures of medical practice.
Sixth, hospital safety
1. Establish and improve the hospital's safety and security management system, hand or part-time personnel responsible.
2. Develop the usual safety and emergency management program, and regular inspection.
3 high-risk equipment and areas? High voltage system, operating room, radiology room, distribution room, safety management measures.
4, equipped with the necessary firefighting equipment.
5. Highly toxic, narcotic drugs, psychotropic substances management system, and strictly enforced.
6. Lighting system in the event of an accident, is a safe alternative source of light to ensure emergency needs.
7, the environment in the hospital
Focus on the hospital's sanitation, hygiene systems and measures, by a person in charge.
2 clinics, wards and other medical areas no smoking.
3. Focus on the hospital's greening, greening area compatible with the hospital area (including indoor and outdoor planting, three-dimensional greening).
4. Harmless treatment of dirt, sewage treatment, in line with health standards.
Noise above 50 decibels outpatient, ward, operating room noise is not higher than 38 decibels.
6. General lighting of the operating room has 100 meters, candle work area lighting 2000-3000 meters candle.
A hospital grading standards
This standard is the standard for hospital construction and development, but also the level and quality of the evaluation basis.
First, the departmental settings
Departments are established in accordance with the functions of the hospital, the actual work and the needs of the community.
Clinical sciences: medicine, surgery, obstetrics and gynecology, emergency room should be set up. Conditional settings, pediatrics, Chinese traditional medicine, the five palaces, family beds section (group) Division.
Medical and technical departments: should be set up in the pharmacy (including the deployment room), laboratory (testing center of the unified arrangement, may not be required), radiology room, operating room, treatment room, supply room, medical records and statistics office, library.
Management: set up the hospital office (responsible for medical, nursing, personnel, secretarial, security, finance, logistics, etc.).
4. Preventive health care (section): set up rooms for health prevention and epidemiology, maternal and child health room (including family planning technical guidance).
Two, staffing
The ratio of beds and staff in the hospital to meet the basic requirements. The following table shows the ratio of all personnel:
Talent of all kinds
% of managers and service personnel
? % of health workers
their respective health technicians
?
Central and Western medical practitioners (doctors) %
? Nursing %
? Examination %
Radiation %
? Pharmacy %
? %
?
15-20
?80-85
?38
?38
?4
?4
?8
?8
?
This division has more than 25 percent of its health workers in preventive care.
Three, the technical level of
Technical establishment from a practical point of view, to carry out community thematic critical patient diagnosis and treatment of common diseases, general ambulance service. Basic requirements:
(A) Medical
1. Emergency medical care:
24-hour community emergency clinic (which includes visits).
2. Internal Medicine, Pediatrics:
Correct treatment of common, frequent and difficult diseases, appropriate treatment and referral.
Circulatory, urinary, and respiratory failure, acute poisoning and shock, and other general emergency and critical patients with early diagnosis and treatment of life-sustaining rescues.
Mastery of treatment of local infectious diseases and sterilization and isolation techniques.
Surgery, Gynecology, Obstetrics:
The clinical diagnosis and timely and correct treatment of surgical acute abdomen.
Ability to perform general upper abdominal surgery.
To perform surgical hemostasis, suturing and bandaging, fracture and other management.
To complete common pathologic obstetrical management in physiologic obstetrics and part of a cesarean section.
4 Pentacenter:
To be able to diagnose the common diseases of the department, the most common diseases and some acute treatments.
To carry out work on prevention of blindness, caries and deafness.
Chinese traditional medicine:
Squidding, surgery, gynecology, pediatrics common some difficult cases.
Conducting acupuncture, massage and so on.
6. Nursing
Skilled in caring for a variety of diseases in the technical operation, strictly executed.
To do ward management and hierarchical care, correctly write 5 kinds of nursing forms (temperature?). Single doctor's advice sheet, your doctor's record, nurse shift, nursing record).
7 medical and technical departments:
Electrocardiogram, ultrasound work.
Ability to perform routine blood, urine, stool tests and some biochemistry.
(The area of the testing center where the arrangement must be contracted)
Ability to perform fluoroscopy, radiography, general gastrointestinal imaging, and other tests.
(B) Preventive health care
Technical guidance for immunization programs and five shifts in epidemic management.
2Parents can carry out perinatal health care, children's systematic health care main four technical program.
3. Community prevention and control of chronic non-communicable diseases, geriatric care, mental health and the development of community-based rehabilitation medicine.
(C) Teaching
1. Training of village doctors, health workers and midwives.
2. Acceptance of students from the College of Traditional Chinese Medicine as part of their clinical studies.
Fourth, the management of the hospital
The director should be familiar with hospital management, hospital management, professional short-term training.
The hospital has a long-term development plan and specific implementation steps.
Hospital staff, hospital leadership job satisfaction ≥ 80%.
Social and hospitalization satisfaction of the contracted unit ≥ 80%.
5, information management:
To grasp the population of various infectious diseases, the establishment and improvement of the registration and reporting system infectious diseases. Registration pass rate ≥ 95%, false negative rate ≤ 0.5%.
Good hospital statistics, statisticians in a community's population, life, disease (disease, chronic disease, endemic disease) dynamics, timely analysis, proposed solutions, the need to timely and accurately complete a variety of health statistics report.
Creating a medical record management system, hand or part-time staff responsible for management, step by step according to the International Classification of Diseases (ICD), outpatient medical records, inpatient preparation of complete medical records, writing, in accordance with the standard level of a rate of ≥ 80% of the medical records, eliminating the C class medical records.
The main part of the basic equipment (Annex VII).
Six, statistical indicators
Admission diagnosis and discharge diagnosis compliance rate of ≥ 85%
Pre-operative and post-operative, the diagnosis rate of ≥ 95%
3 outpatient referral rate of ≤ 20%
4 single-disease cure and improvement rate: compared with peer hospitals, on average
5 single-disease mortality rate: compared with peer hospitals, on average
6 single disease mortality rate: compared with peer hospitals, on average
6 single disease mortality rate: compared with peer hospitals, on average
6 single disease mortality rate: compared with peer hospitals, on average, the average
6. average single disease critical patient success rate: compared with peer hospitals
7. hospitalization referral rate ≤ 3%
8 nursing technology operation pass rate ≥ 85%
9. coma, paralyzed patients with decubitus ulcers: 0
10 nosocomial infection incidence of ≤ 3%
11 aseptic surgical injury? Incidence of mouth infection ≤ 1%
A 12-needle execution rate of 100%.
13 routine instrument sterilization bacterial pass rate of 100%
14 bed occupancy rate of ≥ 60%
15 bed turnover rate of ≥ 32 times
16 the average number of days of hospitalization is 6 days
17 outpatient prescription ≥ 98% pass rate
18 outpatient medical record writing pass rate of ≥ 90%
19. Inpatient medical record writing pass rate of ≥ 98%
20 level of X-ray rate of ≥ 40%
≥ 85% pass rate 21. nursing five forms of writing
22 more than two medical liability accidents number 0
23. equipment utilization rate of ≥ 80%
24 special diagnostic equipment to check the positivity of the rate of ≥ 20% (mainly refers to B-)
25.0 to 7-year-old children to establish the rural urban card rate of ≥ 98%, ≥ 100%
26 Measles live vaccination coverage in rural areas ≥ 90% and ≥ 95% in urban
27 Polio vaccination rate of live vaccines, rural urban ≥ 90% and ≥ 95%
28 White Pertussis Vaccine Vaccination Rate ≥95% and ≥90% in rural areas in urban
29 BCG vaccination rate in rural areas ≥90% and ≥95% in urban
Urban full coverage of 30 four vaccines in rural areas ≥85% and ≥92.5%
31 detection and treatment of diseases in women in rural areas ≥60% and ≥90% in urban
32 . Perinatal mortality rate in rural areas ≤ 20% ≤ 90% in urban
33 prenatal checkups, rural urban ≥ 95% ≥ 80%
34 adoption? Adoption of modern midwifery rate ≥ 95%
35. post-partum visit rate of ≥ 80% and ≥ 70% in rural areas of urban
36, health technicians of the three basic assessment pass rate of 100%
37 first-aid items are in good condition 100%
38 basic nursing care pass rate of ≥ 80%
39 levels of Nursing care pass rate ≥ 80%
A hospital grading standards
Hospital construction, management, technical level, quality of work, civilized service, regular self-assessment of the cost-effectiveness, and the development of improvement measures. County (city) hospitals? Accreditation Committee in the hospital outside the hospital quality evaluation criteria. Based on the results of the review, a hospital is categorized into A, B, C three grades.
First, the first-class hospital
Hospital construction results are remarkable, departmental settings, staffing, management level, technical level, quality of work and the hospital's infrastructure comprehensive level of more than 900 points, after evaluation.
Secondly, Hospital B
Hospital construction achievements are good, its departmental settings, staffing, management level, technical level, quality of work and the hospital's infrastructure integrated level of 750-899 points after the evaluation of the exam.
Third, C-level hospitals
have a certain degree of achievement, the examination passed the basic standards, but there is also a large gap between the requirements of hospital construction and grading standards. After a comprehensive assessment and inspection (including 749 points to 749 points). Class C hospitals should have a practical plan for improvement and development.
Criteria for Level II Hospitals
Multiple communities (with a radius population of more than 100,000), two hospitals, providing medical, preventive, health care, and rehabilitation services and health care facilities, and a tertiary health system at the intermediate level.
In particular, the higher level - the three main "appeared above the tertiary level! Approved by the State Ministry of Health, it seems to be difficult to be in the top 3 hospitals with the country's leading specialized clinics to apply, it is. Some hospitals in Beijing reached the "three specialties", such as: Peking Union Medical College Hospital, Xie? The General Hospital of the People's Liberation Army (301 Hospital), the three PL is the best hospital!
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