Medical institutions annual self-inspection report (selected 5)
Time in a hurry, a period of time has come to an end, looking back at this period of time, there are surprises, there are also problems, for which we must do a good job of summarizing, write a good self-inspection report. So how to write a detailed self-examination report? The following is my annual inspection of medical institutions for you to organize the self-inspection report (selected 5), welcome to learn and reference, I hope to help you.
Self-inspection report on the annual inspection of medical institutions 1
According to the work requirements of the xxxxx City Health Bureau, "xxxxx City 20xx years of primary health care institutions focused on rectification of the work of the implementation of the program" (Wei medical hair [20xx] No. 15), in accordance with the rectification of the xxxxx County Health Bureau on the xxxxx health hospital special inspection of the problems found in the rectification of the opinion, xxxxx health hospital attaches great importance to the first person personally grasping
First, the leadership attaches great importance to the establishment of a self-checking leading group
On April 19, held a conference on the rectification of medical institutions, study and implementation of the "× × × × × × City 20xx years of primary health care institutions to focus on the rectification of the work of the implementation of the program," the hospital medical staff to carry out the medical and health care laws and regulations to learn the "Practicing Physicians Act," "the Regulations on the Management of Medical Institutions", "Nurses Regulations", "Prescription Management Measures", "Medical Record Writing Standards" and other norms and learning included in the performance appraisal of staff. The establishment of the president as the leader, vice president for the vice president, the head of each department as a member of the leadership group, on the health hospital standardization of legal practice to enhance the level of hospital management to carry out self-examination and self-correction.
Second, adhere to the law, standardize the scope of practice
1, the hospital departments strictly in accordance with the "scope of the license for medical institutions" engaged in the practice of activities, no more than the phenomenon of diagnostic subjects practicing medicine.
2, the existing staff of the health center 48 people, practicing physicians, practicing physician 13 people, practicing nurses 14 people, pharmacists 6 people, medical imaging technicians 2 people, test technicians 1 people, strictly unlicensed and non-health technicians engaged in medical activities alone.
3, health center consultation strictly in accordance with the "Interim Provisions for the Management of Medical Outpatient Consultation".
4. There is no illegal and irregular release of medical advertisements.
5, outlawed the opening of unauthorized stomatology clinics.
6, standardize the writing and management of medical documents, medical documents timely, accurate, complete and standardized. Medical records, prescriptions, nursing records must be developed according to the Ministry of Health, "the basic rules of writing medical records, and in the specified time to complete, shall not arbitrarily change the format or simplify the project, content, and shall not be delayed in the completion of time.
Four, the implementation of disinfection and isolation system, to prevent the occurrence of infection accident
Strict implementation of the injection operating procedures, to achieve "one person, one needle, one tube, one use, one disinfection," to eliminate the reuse of medical supplies. The company's products and services have been widely used in the field of medical technology, and the company has been able to provide a wide range of products and services to the public. Strictly implement the hospital infection and infectious disease reporting system. All single-use medical supplies after use to do soak disinfection, destruction of the type of harmless disinfection, incineration treatment, and have a detailed medical waste handover records, no resale, gift and so on.
In short, the health center attaches great importance to the standardization of practice, pay close attention to the implementation of further standardization of practice behavior, in order to improve the quality of medical care to lay a solid foundation.
Medical institutions annual self-inspection report 2
The outpatient department is a private for-profit medical institutions, in order to do a good job of qualified pharmacy, we are based on the "Regulations for the Implementation of the Drug Administration Law", "Drug Business Quality Management Specification" and other relevant documents required to seriously carry out a self-inspection, and now report on the relevant status as follows:
A, the basic business
Outpatient clinic since its inception, that is, adhering to all patient-centered service concept. Adhere to the integrity-based, according to the law, the operation of drugs without quality accidents. The pharmacy is staffed by three practitioners, one pharmacist and two other professional and technical personnel, who are engaged in the quality management, acceptance and daily maintenance of drugs. The pharmacy has an area of ten square meters and a warehouse of fifteen square meters, which is reasonably laid out and well-equipped to meet the requirements of classified storage of medicines. And there is a person in charge of management.
Second, the main implementation process and self-examination
Strengthen education and training to improve the overall quality management quality of pharmaceutical practitioners.
(1) In order to improve the overall quality of all staff, our hospital, in addition to actively participating in the various training organized by the higher-level pharmaceutical administrative departments, but also adhere to the internal job training. These include training in laws and regulations, the clinic system, work procedures, accountability training, job skills training, drug classification knowledge training and practitioner moral education. All trainings are assessed and have achieved more obvious training effects. The clinic regularly arranges medical checkups for practitioners who are in direct contact with medicines.
(B) Facilities and equipment
Our clinic strives to further increase its efforts on the basis of the existing, in accordance with the relevant requirements, to upgrade and remodel the pharmacy. Equipped with and replaced thermometers. Drug shelves, refrigerated boxes. Replacement or repair of the Chinese medicine cabinet, the purchase of the necessary Chinese medicine pulverizer. Improve the ventilation and thermostatic facilities of the pharmacy. To achieve a bright, clean environment, reasonable layout, and equipped with the necessary modern office equipment, the purchase and sale of inventory computerized management. Treasury to achieve a reasonable layout, the ground level, doors and windows tight, no source of pollution, with dust, moisture, mold, pollution, insects, rodents, birds, equipment, facilities, with fire safety facilities to meet the requirements.
(C) purchase management
Strictly the purchase of drugs. Seriously implement the first enterprise, the first varieties of audit system and its procedures, drug purchase system and its procedures, pay attention to the supply unit quality assurance system survey, to ensure that the supply unit and the purchase of drugs 100% legitimacy. The company implements the quality policy of "quality first, standardized operation", the drug purchase vouchers are complete and true, and the quality of drug purchases is strictly controlled. Receiving and inspection personnel in accordance with legal standards for the purchase of drugs in accordance with the prescribed ratio of drug quality acceptance batch by batch, the first varieties, injections, a variety of dosage forms of the first purchase of drugs are the acceptance of the appearance of the drug properties of the acceptance inspection, to ensure that the acceptance of drugs in the warehouse acceptance rate of 100% of the unqualified drugs and counterfeit and shoddy drugs resolutely be rejected.
(D) storage in the maintenance
Strictly in accordance with the requirements of the storage of drugs stored, first of all, in accordance with the storage conditions required by the drugs were stored in the room temperature library, cool storage and refrigerated storage, and secondly, will be close to the expiration date of the drug statement every month in accordance with the time required to fill in, to ensure that in the library of the drugs in good quality.
Three, self-examination summary and the existence of problems. Emancipation program
has been in the city council's care and guidance, after all the staff's *** with efforts to improve the quality management system, to strengthen their own construction. After self-examination that: basically meet the conditions set by the drug authorities.
1, outpatient pharmacy in strict accordance with the relevant laws and regulations and the hospital's quality management system for sales activities, carefully check the physician's prescription, the specifications of the drug, the expiration date, the method of taking, precautions and the patient's name, and other necessary information, to ensure that the drugs are accurately paid.
2, adhere to the law, do not have business relationships with units and individuals without drug business qualifications.
3, to do the drug payment are in line with the relevant provisions. Preserve the physician's prescription and establish a complete sales record.
4, with a valid business license.
5, no illegal operation of fake and shoddy drugs.
6, the person in charge of quality and quality management are licensed.
7, in order to facilitate the establishment of long-term monitoring mechanism for the use of drugs, my clinic has set up a computerized management information system to achieve the purchase of drugs, storage, sales and other operational aspects of the whole process of quality control. The purchase and sale of units, operating varieties and sales personnel to establish a database, its legal qualifications and operating authority for automatic correlation control, effective management of the dynamic inventory of drugs.
8. Improvement of drug storage conditions and temperature regulation facilities to meet the drug storage temperature requirements. At the same time, we found some problems and deficiencies will take effective measures to seriously rectify. The main performance: First, the training of staff to be further strengthened; Second, the positions of quality management work on self-examination of the conscientiousness and ability to be strengthened; Third, after-sales service work needs to be strengthened to further improve the quality of drugs query work.
I clinic will certainly be based on the self-examination and internal audit of the problems found in the process, the implementation of one by one, continuous inspection, rectification, so that the clinic's quality management of drug management is more standardized, standardized I clinic against the relevant provisions of the self-examination of the internal audit, that is, basically in line with the requirements of the Department of Pharmacovigilance.
Self-inspection report on the annual inspection of medical institutions3In order to improve the quality of medical services and technical service level, my service station against the "Regulations for the Implementation of Medical Institutions" carried out a rigorous self-examination and self-correction work. Now the relevant self-inspection report is as follows:
First, the leadership attaches importance to the strict organization
I held a meeting of the service station, the self-inspection of the work of strict deployment. At the meeting, the establishment of a self-check by the head of the leading group, strictly against the "Rules for the Implementation of the Regulations for the Management of Medical Institutions" carried out a serious and detailed self-check and self-correction work, and achieved significant results.
Second, the basic situation of self-check
(a) institutional self-check: unit full name "Keyuan Street Feng Yuan Community Health Service Station", the nature of the private non-enterprise, located in; legal representative:; the main person in charge of the District Health Bureau issued a "medical institutions Practice Permit", Practice Permit No. December 23, 20xx. I service station of the "medical institutions practice license" has implemented strict management, has never been altered, trading, transfer, rent. Existing 6 beds, diagnosis and treatment subjects are preventive health care, general medicine; business room area of 320 square meters.
(b) personnel self-examination: I service station existing attending physician 1, a licensed physician, physician assistant 2 Ming, 3 nurses. My service station has never been registered to carry out a wide range of licensing activities; never used without a licensed physician qualification, nurse practitioner qualification of the personnel or a certificate of multi-location registration of physicians engaged in medical activities, belonging to the medical personnel are licensed, and set up in the hall of the supervision column open to the public.
(C) improve the quality of service: in accordance with the relevant provisions of the health administrative departments, standards to strengthen the quality of medical management, the implementation of medical quality assurance program; regular inspection, assessment of the rules and regulations and all levels and types of personnel job responsibility system implementation and implementation, to ensure medical safety and quality of service, and constantly improve the level of service.
(D) hospital cross-infection management: the establishment of a service station within the cross-infection management leading group, composed of etc.. Frequent education and training of relevant personnel, the establishment and improvement of the management of medical waste disposal, nosocomial infection and disinfection management, waste leakage treatment program and other relevant rules and regulations, there is a person on the source of medical waste, type, quantity and so on complete records, regular disinfection of key departments and parts of the disinfection effect of the monitoring, preparation of disinfectant labels marked clear, complete and standardized.
(E) solid medical waste treatment: all medical waste is classified and collected, according to the provisions of the time of temporary storage of dirt with warning signs, dirt containers are sealed, anti-puncture, temporary storage of dirt to do the "five preventive", the transportation of medical waste transfer for the person in charge of and have a signature record.
(F) the handling of single-use medical supplies: all single-use medical supplies after use to do the soaking disinfection, destruction of the type of medical waste collected by the treatment station.
(VII) drug management self-examination: the investigation of my service station has never used counterfeit, expired, expired and prohibited drugs. Strictly implement the provisions of the antibacterial drug system.
Third, there are shortcomings
First, due to the lack of funds, some medical equipment can not be maintained or updated in a timely manner, to a certain extent, affecting the in-depth implementation of related business, the development of the lack of energy; second, by the establishment of the limitations of the staff, staff tension, the workload is large, the opportunity to provincial medical institutions for further training is not much, the knowledge of the cycle of updating is long! The first is the fact that the company's business has been in a state of flux for a long time, and that has affected its ability to improve its service level to a higher level.
Fourth, the direction of future efforts
I service station must take this self-examination as an opportunity, under the leadership of the higher business administration, conscientiously implement the spirit of the meeting of the higher level, strict compliance with the "Regulations on the Management of Medical Institutions", strengthen management measures, optimize the quality of personnel, pragmatic and pioneering, and constantly improve the quality of medical services and technical service level. and technical service level.
Self-inspection report on the annual inspection of medical institutions4To protect the lives of the people, improve the quality of life of the people, in line with: "people-oriented, patient first" principle, we are for the spirit of the higher documents, under the guidance of the High-tech Zone Health Bureau, the organization of the relevant personnel focused on the hospital medical equipment, equipment for a comprehensive inspection, now report the specific situation. Comprehensive inspection, the specifics are reported as follows:
First, strengthen the leadership, strengthen the responsibility, enhance the awareness of quality responsibility.
The hospital first set up a dean as the leader, the director of each department as a member of the safety management organization, the management of medical equipment safety into the hospital's top priority. The company's management of the safety of medical equipment is one of the most important aspects of the hospital's work. The hospital has established and improved a series of medical device-related systems to ensure the safe and smooth implementation of the hospital's clinical work.
Second, in order to ensure the purchase of medical equipment, equipment quality and use of safety, to prevent the entry of unqualified medical equipment, the hospital specially formulated medical equipment purchase management system. The conditions for the purchase of medical equipment and the qualifications of the supplier have made strict provisions.
Third, in order to ensure that the entry of medical equipment, equipment, legal and quality, and seriously implement the medical equipment warehousing system, to ensure the safe use of medical equipment.
Fourth, in order to accurately and safely use medical equipment, our hospital regularly organizes business studies, and invites professional and technical personnel to conduct training in the use of equipment, and has achieved good results.
Fifth, do a good job of daily storage, some of the hospital's medical equipment is more valuable, in my hospital technicians regularly self-check maintenance at the same time, regularly ask the manufacturer's technicians to check the calibration.
Six, to strengthen the management of unqualified medical devices, to prevent unqualified medical devices into the clinic, the hospital specially formulated adverse event reporting system. If there is an adverse event of medical devices, we should find out the location, time, adverse reaction or basic situation of the adverse event, and make a good record, and quickly report to the District Drugs and Medical Devices Supervision and Administration Bureau.
VII, the focus of our future work on medical devices
Effectively strengthen the hospital's medical device safety work, to eliminate the occurrence of medical device safety incidents, to ensure that the majority of patients using medical devices safety, in the future work, we intend to:
1, further increase the knowledge of medical device safety publicity, the implementation of the relevant systems to improve the hospital's medical device safety awareness of responsibility. safety responsibility awareness.
2, increase the hospital medical device safety work daily inspection, supervision frequency, timely investigation of medical device safety risks, firmly establish the "safety first consciousness, service to patients, and continue to build the people satisfied with the hospital.
3, continue to cooperate actively with the higher authorities, consolidate the hospital medical device safety achievements, *** with the creation of a good atmosphere for medical devices, to build a harmonious society to make greater contributions.
Medical institutions annual self-inspection report 5Municipal Health Bureau:
In order to further strengthen the management of our region's new rural cooperative designated medical institutions, standardize the behavior of diagnostic and treatment services, control the unreasonable growth of medical costs, to protect the safety of the new rural cooperative fund, to promote the new rural cooperative fine management, and to promote the health system evaluation work, according to the "Office of the Provincial Department of Health on the implementation of the new rural cooperative service behavior of the designated medical institutions Inspection activities of the notice" document spirit, the District Health Bureau issued the "on the implementation of the designated medical institutions of the new rural cooperative service behavior inspection activities of the notice" (point health hair 20xx55) document, the designated medical institutions of our region of the new rural cooperative service behavior checking activities for the arrangements and deployment of the medical institutions of the self-check, the District Health Bureau organized a special team, from September 5 to 9, the jurisdiction of all levels of health care institutions to carry out a Specialized inspection. Now the inspection situation activities are summarized as follows:
First, the achievements
District People's Hospital, the township health centers attach great importance to the work of the new rural cooperative, strengthen the internal management, the strict implementation of the new rural cooperative policy, the full service of the participating masses to ensure that the work of the new rural cooperative is smoothly promoted to ensure that the participating masses to benefit from level Improvement, to ensure the safety of the new rural co-operation fund. The main performance is as follows:
(a) the basic establishment of internal control mechanisms
The township health centers have established a new rural health management system, a clear division of responsibilities; strengthen the basic management, improve the rules and regulations, and strict assessment of rewards and punishments, to ensure that the provisions of the system to the letter.
(B) hospitalization costs are steadily declining
After the implementation of hospitalization pay per bed day reform, the township health centers to strengthen cost control, strengthen medical services, to achieve a decline in costs, the service does not discount the good results. 20xx January-August, Lianpeng Township Health Center hospitalization average cost of 1200 yuan, down 272 yuan compared with the same period last year, a decline of 18.48%. The average cost of a hospitalization case was 1,200 yuan, down 272 yuan from the same period last year, a decline of 18.48%.
(C) outpatient total prepaid remarkable results
After the implementation of outpatient total prepaid payment method reform, the township health centers have strengthened outpatient integrated management, the development of the management program, and strengthen the day-to-day management, strict supervision and assessment, to ensure that the benefits of the masses participating in the clinic, outpatient fund security. Qiaobian Township Health Center to strengthen the system of supervision, quarterly assessment, household audit, January-August **** reduction of village health room irregularities subsidy funds 4140.80 yuan, effectively curbing the phenomenon of fictitious diagnosis and treatment of arbitrage fund, to ensure that the total amount of outpatient prepaid fund use safe and effective.
Second, there are problems
(a) District People's Hospital
First, the internal management system of the New Agricultural Cooperative still need to be further improved. Due to the integration of the District People's Hospital into the management of the Yichang City Central Hospital, the District People's Hospital does not have an independent and perfect new rural cooperative level management organization, the medical insurance office of the new rural cooperative management function needs to be further strengthened, the internal control and assessment mechanism needs to be further improved.
Secondly, the implementation of admission standards is not strict. District People's Hospital in the implementation of the "community first", "cascade referral" system there is the phenomenon of the first admitted, after the referral; admission standards are not strict, there are outpatient hospitalization, the phenomenon of the big treatment of minor illnesses.
Third, the rational use of drugs to be strengthened. District People's Hospital is using the third-level hospital drug catalog, the overall drug prices are high, the use of antimicrobial drugs do not strictly implement the provisions of the management of graded use.
Fourth, the rational examination to be standardized. District People's Hospital has strengthened the ultrasound, CT and other large-scale inspection management, inspection of the target, rationality has been improved, but there are still non-conventional requirements of the main disease has nothing to do with the inspection, the diagnosis and treatment of the significance of the unnecessary inspection and other excessive inspection behavior.
(2) Township health centers
The township health centers of the new rural cooperative outpatient management of the basic norms, the implementation of the basic drug policy, the compensation in place in a timely manner, no fictitious medical services to seize the phenomenon of the fund, the participants in the masses of high satisfaction, the community has a good response.
The township health centers in the new rural cooperative hospitalization management, there are mainly the following problems:
First, the proportion of individual health centers of acute and critical patients is too high. 1-8 months, xx health centers according to the acute and critical management of the proportion of patients amounted to 28.78%, higher than the average level of the whole region of nearly 10 percentage points.
Second, the overall service capacity of township health centers is insufficient. Due to the influence of talent, equipment, technology, management and other factors, the township health center's medical service capacity is declining, some of the common rural diseases, frequent diseases can not be treated in primary health care institutions, the proportion of patient outflow is rising, affecting the level of benefit to the participating farmers and the safety of the New Agricultural Cooperative Fund.
Third, the average cost of some township health centers is high. Compared with the same period last year, the average cost of Aijia Township Health Center, Lianpeng Township Health Center, the average cost of a significant decline in the NPC pay per bed day reform is more effective. xx Township Health Center, the average cost of 1,583 yuan, relatively high.
Fourth, the reasonable examination still need to be standardized. Some tests are not related to the main diseases, and some tests (such as blood glucose) are repeated too often.
(C) village health center
First, the implementation of the basic drug policy is not in place. Non-basic drugs still exist in village health centers, which affects the benefit of participating farmers because they cannot be included in the compensation.
Secondly, some village health centers are not included in the reimbursement of traditional Chinese medicine.
Third, some townships have a low utilization rate of the total prepaid fund for outpatient services. 72.93% of the fund in Aijia Township and 70.25% in Lianpeng Township in the January-August period, which is too much of a fund sinking, and the rate of benefit for the participating farmers is low.
Fourth, the phenomenon of fictitious medical services still exists to varying degrees. Some of the village health center did not implement the small ticket signature system, arbitrary arbitrary charges; less make up more than reported, fictitious person times and other arbitrage fund phenomenon is difficult to fundamentally eliminate.
Three, rectification requirements
(a) strengthen the leadership, the implementation of responsibility. District People's Hospital to correctly handle the relationship between hospital development and the interests of the masses, and effectively strengthen the management of the new rural cooperative duties, rationalize the relationship, establish and improve the internal control mechanism, the responsibility for cost control to the department, the implementation of the doctor. The township health centers should further implement the president's overall responsibility, the director of the leadership of the implementation of the system, the management of the responsibility for the implementation of the department, extended to the village health room, and strict accountability system.
(B) establish rules and regulations, standardize behavior. District People's Hospital, the township health centers to start from the construction of the system, the implementation of fine management, standardize the behavior of the new rural cooperative services, improve the level of benefit to participating farmers. District People's Hospital shall establish a relevant management system that conforms to the actual situation of Jiangnan Hospital District and highlights the responsibilities of the District People's Hospital, and strengthen the system management in terms of admission (discharge) standards, standardized diagnosis and treatment, and reasonable fee control, etc., so as to include the average cost of the case, the average cost per day, the ratio of the composition of the drugs, the positive rate of large-scale examination, the actual compensation ratio, the utilization rate of the extra-catalog drugs, and the average hospitalization day in the assessment content. The township health centers should establish systems that are compatible with the payment method reform to ensure that the reform achieves the expected results.
(C) strengthen supervision, serious discipline. New Agricultural Cooperative Fund is to participate in the masses of life-saving money, it is strictly prohibited at all levels of medical institutions and medical personnel illegal cheating, taking, misappropriation, squeezing. The district co-management office to perform the duties of supervision, carefully review the relevant compensation information, strengthen online supervision, on-site supervision, telephone follow-up, household verification, the discovery of irregularities and violations of discipline to be reduced costs, notification and criticism, etc., on the problem of outstanding, serious, social repercussions of the violations of discipline cases should be reported to the District Health Bureau to deal with. The township health center to strengthen the dynamic supervision of the village health room under the jurisdiction of the implementation of daily supervision, quarterly assessment, to further standardize the diagnosis and treatment reimbursement behavior, to ensure that the medical services are not discounted, the level of farmers to benefit from the level is not reduced.
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