Part I hospital self-examination report
My county since June 1, 20xx in the county gradually implemented the standardized management of township health hospitals. Through the convening of a mobilization meeting, issued an implementation plan, clear work objectives and tasks, the development of work measures and other work methods, the first part of the township health center pilot as a guide, and gradually pushed out in the county. So far, this work has been fully implemented in the county 13 township health centers. According to the requirements of the higher level, now the county township health hospitals standardized management of the progress of the pilot work of self-examination reported as follows:
First, the work achievements
1, through the medical aspects of the health hospitals of the various clinical departments and public **** health aspects of the standardization of the construction of the vaccination clinic as well as the environmental construction, and further improve the infrastructure of the township health hospitals, including the configuration of the department, the provision of medical equipment and the use of professional and technical personnel, such as the appointment of posts The township health center infrastructure construction.
2, through the unified management of township health centers people, talent, and materials, so that the health center of the unit and the subordinate jurisdiction of the village health center of the deployment of technical personnel, qualification access, funding, asset management, as well as business guidance and work co-ordination, public **** health, health care market supervision, and so on, to rationalize the township health centers of the management system.
3, completed the township health center personnel distribution system reform, in the implementation of the director of the tenure of the target responsibility system and improve the basis of the management system, the township health center section set up into two parts of the public **** health and medical care, clear township health centers to the public **** health services, the center of the health center to be on the premise of this, to further improve the level of medical technology, guidance around the general The function of the business work of the health center. The establishment of a strict 'performance appraisal system, the allocation of personnel wages linked to the services they provide and labor contributions, to improve the internal vitality of the township health centers, to stimulate the work of the majority of cadres and workers enthusiasm.
4, in the health center of the administrative and operational aspects of both the implementation of institutionalized management. Set the hospital leaders and department heads of the rank and file target tasks. The implementation of responsibility, rights and benefits of the combination of job responsibility system, the establishment of a sound system of medical care work, including the clinical departments, shift handover, standardized writing of medical documents, error and accident registration, disinfection and isolation, to prevent medical disputes, and to eliminate the occurrence of medical liability accidents.
5, actively carry out rural health institutions to support the work of counterparts, the arrangement of five county-level medical and health institutions to support the 13 township health centers, arranged for 13 township health centers in accordance with its regional division, responsible for the county's 248 village health clinics of the packet system of responsibility, the practical establishment of a sound rural three-tier health care network of infrastructure, the limit to play its due role. Through the signing of the form of counterpart support agreement clearly defines the work objectives, tasks, mode of work, time, and the responsibility and power of both sides, improve the management and service capacity of primary health care institutions at all levels, so that the recipient township health centers and village health rooms in the environment, the connotation of the construction has changed significantly.
6, strengthened the township health center accounting, health prevention specialists, maternal and child specialists, co-therapy specialists and other specialists in management, the development of the specialists in the employment and assessment of the management approach, the employment of all specialists must be declared by the health center, the Health Bureau for approval of the employment, without the permission of the competent authorities at the higher level, the health center is not allowed to arbitrarily change to ensure the stability of the health center specialists team, and effectively promote the financial and public ***** health and other various measures. and public **** health and other work is carried out smoothly.
7, the development and issuance of the "Huaxian township health center director norms ten", strengthened the management of health center director. Clearly require the director of the health center in accordance with relevant state laws and regulations to carry out the work, subject to the management of the Health Bureau, to ensure the smooth flow of government, in accordance with the "Huaxian township health center director norms of the ten" requirements of self-discipline, to complete the work on schedule.
Second, there are problems
1, due to historical reasons, individual township health centers shortage of technical personnel, small scale, existing medical equipment can not play its due role. Solution: is being solved through temporary secondment, commissioned training and other ways to be resolved.
2, uneven distribution of medical equipment resources. Solution: The Health Bureau through the survey mapping statistics, the county township health centers all damaged, idle medical equipment for unified registration, repair, maintenance, debugging, redeployment of the use. In order to improve the utilization of equipment, to facilitate the masses to seek medical treatment.
3, the village health center standardized construction, township health center standardized management and rural health services integrated management of the three inherent *** the same point of effective combination, Qiqi grasp *** management, scientific and reasonable arrangements for the deployment of a substantial increase in work efficiency.
Part II hospital self-examination report
In order to strengthen the quality of their own work, exemplary medical actions, remove the stability of the hidden dangers, the insurance of the patient rescue stability, I according to the pediatrics according to the disruption of this and the detailed environment of the Department of the work of the self-correction work of the rigorous self-examination.
2. Legal awareness is thin.
3. The doctor and patient do not have enough skills.
4. Teamwork is not strong.
5. The degree of professional skill needs to be further improved.
For the above points we should do:
1. In the work must strictly obey the health care handling laws, administrative standards, part of the rules and regulations and diagnosis and treatment of nurses model, the old, adhere to the medical service professional behavior.
2. Repeatedly study health care laws, standards, rules and regulations and diagnosis and treatment of nurses to help nurses model, example, to improve their own legal awareness, model to help nurses practice action.
3. In the medical care nurse activities, should be the patient's condition, medical treatment (medical or surgical program, check items, types of drugs, etc.), medical risks (complications, accidents, drug side effects, etc.) to inform the patient, timely answers to their inquiries, is strictly prohibited to use stimulating speech or the patient's `disease treatment and healing of the adverse effects of the speech, pay attention to the method of speech, The method and skill.
4. Accurate use of patients or relatives informed notification and authorization request.
5. Accurate transcription of nursing documents, must be objective, true, accurate, timely and complete. Do not take scraping, sticking, painting and other methods to whitewash or remove the original handwriting.
6. Strengthen the team spirit of mutual assistance, internal to collaborate with the medical | education network to collect and organize.
7. To automatically study the progress of medical knowledge, improve their professional skills, improve the quality of medical care, good service for patients, and at the same time should enhance the humanities knowledge and etiquette knowledge of the training and cultivation, to strengthen their skills in the same.
8. Patients should have a sense of responsibility and benevolence; familiarize themselves with the core medical track system, and fulfill it strictly in the actual clinical work.
9. In the practice of activities to do:
Speak to pay attention; account to understand.
The examination should be meticulous; the record should be complete.
The system should be strict; skills should be proficient.
Manipulation should be exemplary; relief should be in place.
Part III hospital self-inspection report
In order to do a good job of hospital safety, according to the Department of Health and other higher departments of the spirit of the document, our hospital production safety leading group seriously organized to learn the spirit of the document, strictly in accordance with the requirements of the investigation, and seriously solve the existing problems. Now the self-inspection report is as follows:
First, our hospital safety production leading group to organize the relevant personnel to x key safety requirements of the scope of self-inspection, has on the distribution room, water and sewage facilities, pressure vessels and other facilities and equipment and outpatient clinics, wards, x information network facilities, canteens, and other places where people gather, the Finance Department, warehouses, pharmacies, and other key parts of the inventory, in particular, the whole hospital water, electrical circuits and other key equipment and facilities The first time I saw this, I was able to get a good look at it.
Second, x safety leadership group is well organized, the establishment of a safety team in each section, the head of each section for the section safety officer, divided into clear responsibilities, the establishment of production safety management regulations, as well as production safety systems, outpatient clinics, wards, and other places of gathering of people safety, fire hydrant and other firefighting facilities, fire extinguishing equipment check intact, evacuation routes are smooth; convene a whole hospital staff batches of "fire knowledge" for The fire knowledge of the "special education," a detailed account of the use of fire extinguishers, fire how to guide patients to escape, to improve the fire awareness of the staff.
Third, the organization drew x each section of the backbone of the force led by the director in charge of the team, and actively participate in x District Health Bureau organized fire drills, as a representative of the hospital to further improve the staff's fire fighting fire fighting ability.
Fourth, the organization of the relevant personnel to carry out the work of the hospital disputes, and actively resolve the factors of instability, x to the production safety self-examination of the work as an opportunity to timely detection of potential safety hazards, and effectively curb the occurrence of accidents.
V. Grasp medical safety. The hospital leadership convened a timely meeting of section chiefs, head nurses, around the theme of "patient-centered" medical safety special activities, unify thinking, raise awareness, organize and carry out the whole medical quality education, improve medical safety awareness, hospital leadership in the hospital to carry out extensive inspections, the implementation of health care management system and operating procedures norms, the implementation of the control of x infection regulations and rules. Implement the rules and regulations for the control of x-infections, strict hand hygiene standards, strict sterilization and isolation system implementation. The management of poisonous and anesthetic drugs, autoclave sterilization and disinfection management, biomonitoring and environmental monitoring, strict inspection of the quality of the link, to remove the hidden danger of security, to provide people with a harmonious, safe medical environment.
Through self-examination, all hospital staff to improve the awareness of production safety, clear responsibility. Ensure that production safety is implemented into the daily work.
Part IV Hospital Self-Inspection Report
Fire protection is an important daily work of the unit, related to property safety, personal safety, social stability and economic development. Currently is a period of high incidence of fire, all kinds of insecurity factors increase, very easy to induce fire accidents. In compliance with the Chengdu Public Security Fire Bureau of fire safety training instructions, in line with the unit is responsible for the medical staff is responsible for the patient is responsible for the attitude of responsibility and social responsibility, the hospital on May 20, the hospital's fire facilities for the whole hospital carried out a comprehensive. Inspection. Now the inspection and rectification report is as follows:
First, self-inspection
(a) the hospital floors and the various wards, office areas, safety channel indicator signs are complete and clear. Emergency lights are not damaged, the power supply is good, and can meet the evacuation requirements.
(b) The hospital **** is equipped with 14 dry powder fire extinguishers and 4 fire hydrants. Fire hydrant 1 per floor, fire extinguishers average 4 per floor. After checking are available for normal use.
(C) the hospital's electrical wiring line last year for the overall transformation, wires, switches, sockets, electric switches are re-purchased in accordance with the relevant standards installed. The wards prohibit patients from boiling water for cooking, and now the wires and lines are in good condition.
(d) Each floor of the fire pipeline is smooth, there is sufficient water, pipeline layout, can work properly, to meet the requirements of fire safety.
(E) hospital fire prevention system is not yet sound.
Second, the current fire situation assessment
Through this inspection found that the hospital fire prevention work is generally better, but still exposed a lot of deficiencies, there are some fire safety hazards. The most prominent is the number of fire extinguishers is not enough, in the key parts are not equipped, can not be used without timely replacement. Furthermore, the fire safety prevention system is incomplete, some staff fire safety general knowledge is insufficient, fire awareness is not strong, self-protection ability is lacking.
Third, corrective measures
(a) the fire safety work as an important work to grasp, the main leader personally deployed, business dean personally grasp. Key parts of the responsibility to a person. Outpatient clinic by the Department of Internal Surgery and Radiology is responsible for; inpatient department by the inpatient department doctor is responsible for; office area and staff canteen by the hospital affairs director is responsible for.
(b) the hospital to establish a fire inspection, disposal system, the first person found fire hazards must be dealt with in a timely manner, reported. Fire fighting and disaster relief should be all hands, cooperation, *** with the disaster relief.
(C) equipped with 14 dry powder fire extinguishers, placed in the key layout. The first floor placed 4, the second floor of the hospitalization department 4, the third floor of the hospitalization department 4, the staff cafeteria 2. Existing able to use 12 fire extinguishers, ready to buy 2.
(D) from time to time in the whole hospital fire safety inspection activities, found that the safety of hidden danger in a timely manner to deal with, to capture the first signs of hidden danger.
Part V Hospital Self-inspection Report
According to the "Office of the State Administration of Traditional Chinese Medicine, the Office of the National Health Planning Commission on the issuance of the national medical institutions of traditional Chinese medicine tablets management special inspection program> notice" and the provincial Health Planning Commission, the provincial Bureau of Traditional Chinese Medicine, "on the issuance of the Jiangsu Provincial Medical Institutions of traditional Chinese medicine tablet management special inspection program>" and "on the issuance of Jiangsu Provincial Medical Institutions of traditional Chinese medicine tablets management special inspection program>". Inspection of the implementation of the program> notice" requirements, in response to the city will be organized to carry out the city's medical and health institutions special inspection of the management of Chinese medicine tablets call, the recent quality management of Chinese medicine tablets leading group of our hospital on the purchase of Chinese medicine tablets, storage, deployment, decoctions, prescription management and review of the work of a comprehensive self-inspection, is now self-inspection report is as follows:
First, the management of Chinese medicine tablets of my hospital The current situation
1, set up a management organization. Our hospital has set up a leading group for the quality management of traditional Chinese medicine tablets, and President Liu Jinghong personally served as the head of the group, from the purchase of tablets, storage, deployment, decoction prescription management and review of the strict management, so as to ensure the quality of traditional Chinese medicine tablets, to ensure that the clinical use of medication is safe and effective.
2, the purchase and acceptance management of Chinese medicine tablets. We can strictly follow the regulations to purchase Chinese medicine tablets from Chinese medicine tablets manufacturing enterprises with "Drug Production License" or Chinese medicine tablets operating enterprises with "Drug Operation License". When purchasing Chinese medicine tablets, the acceptance is carried out in strict accordance with the national drug standards and the standards and norms set by the provincial drug supervision and management departments, including the quality, specifications, quantity, packaging, labeling, certificate of conformity, etc., which must meet the requirements, and each Chinese medicine tablet must be accompanied by the quality inspection report of the drug supervision department and the acceptance and signature of the Chinese medicine tablets by the personnel who have intermediate professional and technical titles and experience in identifying the tablets, and they shall be considered to be qualified only.
3. Storage, custody and maintenance of Chinese medicine tablets. Our hospital has set up an independent Chinese medicine tablets warehouse with perfect ventilation, temperature, humidity, moisture, insects, rodents, anti-theft and other conditions and facilities, which is managed by specialists and inspected every day. This completely prevents the occurrence of moldy and deteriorating Chinese medicine tablets, discoloration, insect infestation, rodent infestation and other problems.
4, Chinese medicine drinks transfer management. The Chinese medicine dispensary dispensers strictly implement the management system for the dispensing of Chinese medicine, and resolutely refuse to dispense prescriptions that may cause medication safety problems such as the existence of "eighteen anti-", "nineteen", pregnancy contraindications, and exceeding the dosage stipulated in the Chinese People's Pharmacopoeia, and require the prescribing doctor to confirm (double) that the prescriptions are safe for the patient. And ask the prescribing doctor to confirm (double signature) or re-issue the prescription before giving the deployment, the prescription requires first decoction, after the next, the package decoction and other special decoction methods can be indicated in the service bag and give a clear explanation to the patient, the inspection did not find worms, mildew, oil, discoloration and tampering with the bucket and other phenomena.
5, Chinese medicine decoction management. Our hospital decoction room is equipped with two multifunctional automatic decoction machines, which can basically meet the requirements of soaking, second decoction, stirring, first decoction, second decoction, etc. We have established relatively perfect operation procedures of Chinese medicine decoction machines and scientific and reasonable decoction process of Chinese medicine soup, and we can operate according to the requirements or doctor's instructions for the Chinese medicine tablets which are indicated to have the special requirements of first decoction, second decoction, second decoction, other decoction, melting, packet decoction and decoction of water with water, etc, which ensure the quality of decoction and safety of medicines. This ensures the quality of decoction and ensures the safety and effectiveness of medication.
Second, there are problems
1, our hospital decoction room equipment is less, can only ensure that patients on the basic requirements of Chinese medicine decoction. At the same time, due to the small number of staff in the Chinese medicine room, it fails to play a perfect work efficiency.
2, our hospital prescription review working group personnel professional direction limitations, failed to establish a perfect Chinese medicine prescription special review system, also failed to successfully carry out Chinese medicine prescription review related work.
Third, corrective measures
1, our hospital on the composition of the Chinese medicine room staff to carry out a reasonable distribution of adjustments to ensure that the smooth completion of the Chinese medicine tablets dispensing, decoction and other related work, to ensure efficiency, to ensure that the patient's use of medication in a timely manner, safe and reasonable.
2, strengthen the prescription management review team staff business training, the timely establishment of a perfect Chinese medicine prescription special review system, to ensure the smooth development of Chinese medicine prescription review work.
In this self-examination action, we found that there are still some problems and deficiencies in the work, our unit will strictly comply with the requirements of the Department of Pharmaceutical Supervision, and actively carry out business learning and self-examination, to ensure that the patient's medication is reasonable and safe.
Part VI hospital self-examination report
In order to implement the implementation of the Ministry of Health, "hospital management year activities program", the implementation of the unified layout of the hospital department, the medical technology section through the study, combined with the base situation of the department, in accordance with the implementation of the "hospital management year activities program". "Hospital Management Year Activity Program" activity requirements, clear to strengthen the connotation of medical institutions and internal management, improve the quality of medical services, to ensure the people's health and safety of life, to promote the healthy development of health care undertakings, through the study of the comparison, the implementation of self-checking and self-correction, to solve the existing problems.
The development of the hospital does have the problem of medical safety hazards. The main reason behind these problems is that the department of the various systems are not fully implemented, security awareness is weak, management and supervision of the work of lax, ignoring the connotation of the construction, in the context of the current reform of the medical and health system, to effectively strengthen the industry management, stabilize the medical order, to ensure that medical safety is particularly important. Under the theme of "patient-centeredness and improvement of medical quality", we have carried out the search and organization of medical diagnostic techniques and taken targeted measures to eliminate various hidden dangers that are unfavorable to patients. Establishment of long-term management mechanism. Thoroughly implement the core system and standardize the operation procedures of various examinations. The report was written carefully and carefully to provide the clinic with effective diagnostic opinions of the patients' examination.
The establishment of an orderly workflow, b ultrasound, ultrasound in the case of many patients, the inspection process is chaotic, some patients waiting time is too long, family members have opinions, quarrels, in this regard, we must set up the inspection and registration window, according to the order of the number of inspection, (except for emergencies). To prevent the first to induce conflicts. b ultrasound examination of the number of patients increased significantly, the current two units do not meet the needs of the development of the situation, must increase the number of units, supporting the computer print report, standardize the checklist 'report form, check the results of the report to be examined by the physician's signature review is issued. b ultrasound medical and technical staff shortages should be resolved urgently. To solve the duty regulations, post implementation to the person, the implementation of 24 hours on duty system.
Endoscopy room, most people are late for work, anesthesiologists are not in place on time, and patients often wait too long. Check according to the principle of first-come-first-served, gastroscopy nurses gastroscopy equipment to be strictly disinfected, the preparation of disinfectant pay attention to the concentration, effective time, to prevent the occurrence of hospital-acquired infections, the quality of medical diagnosis, to do the inspection to be careful, the work should be recognized, the attitude should be heart, all in accordance with the operating specifications, to prevent the occurrence of errors. Enteroscopy in the morning and afternoon, do a good job of cleaning and cleansing before the examination. All everything should be for the sake of the patient, to solve the problem of difficult and expensive to see the patient, to do sincerely for the patient service noble ideas.
The new equipment 16-row spiral ct has been carried out more than half a year, since the development of the basic perfect with the need for clinical examination, but still do not play the 16-row spiral ct full function of the examination, and gradually the scope of the examination of the development of the broad and deep aspects of the development and development of new projects. Although the current achievement of a large number of performance, but there are still many problems.
System implementation is not in place, the operating procedures are not standardized, especially in the abdominal examination, not in accordance with the normative requirements for patients to do a good job before the examination, affecting the quality of the image, resulting in ambiguous diagnostic quality.
Diagnostic quality control is not strict, the phenomenon of misdiagnosis and misdiagnosis exists, in terms of the need to step up efforts to put a good quality, the implementation of the three-tier review and audit system, in the quality of control to put more effort.
Provide for the time to take the film and report the results of the time, emergency within half an hour to take the film, an hour to take the results, non-emergency examination, head examination in the morning, 4:00 pm to take the results of the chest, abdominal examination at 10:00 pm to take the results of the next day, abdominal examination of the patient should be swept plus enhancement, a one-time payment, to reduce the patient back and forth to the trouble of the payment.
Accelerate the new project to carry out business knowledge learning to vascular imaging parts of the examination as the future work of the main topics, image three-dimensional reconstruction processing, more importantly, to accelerate the development of ct diagnostic technology, through short-term training, participation in online exchanges and discussions, and gradually improve the professional and technical diagnostic level.
Troubled case discussion is not standardized. There is no perfect system established, the physician expresses his opinion without record and considerable information archives, case tracking feedback, lack of serious summary. In this regard, we must begin to improve the establishment of a long-term mechanism, the development of effective measures to focus on reading the program, case discussion and analysis, report review and verification, case tracking records archives, and constantly summarize, and strive to learn new technologies, to open up new projects, give full play to the function of the 16-row helical ct, put a good quality, speed up the angiographic, imitation endoscopy, three-dimensional reconstruction of the technical knowledge to learn, and to improve the diagnostic level of the ct imaging profession. The company's technical level is also very good at improving the diagnostic level of ct imaging.
Labor discipline is too poor, late for work, the implementation of the rules and regulations of the Ministry of hospitals is not in place, duty is not on duty, sometimes leading to the patient's family have opinions. At present b ultrasound, ultrasound, ct has been implemented 24 hours on duty system. The solution to the emergency patients with the arrival of the investigation.
Through the study and implementation of the hospital management year activities program, to further recognize that all medical personnel should be all for the sake of the patient concept, to solve the problem of difficult and expensive to see a doctor, to do sincerely for the noble idea of patient service. For the majority of patients to provide quality services, to accelerate the development of the hospital master plan a better future, *** with efforts.