1.1 Enhance the awareness of quality management, the establishment of a sound organization and system Our hospital uninterruptedly medical staff for medical quality, medical safety and related laws and regulations and other aspects of education, so that the entire hospital staff fully aware of the quality of medical care is the basis for the survival of the hospital, the basis for development, is the source of competition in the market. The hospital has established and improved three-level quality management organizations at the hospital level, functional departments and departments, *** with the participation of the medical quality of the formation of various aspects of the planning, organization, coordination, control and service guarantee work. Each organization has developed a corresponding work system, responsibilities, assessment programs, etc., the hospital quality management committee by the dean as chairman, extracted from the authorities and the relevant departments experts, the office is located in the quality management section, the basic quality, link quality, the end of the quality of the whole process of effective control; department set up a quality control group, the section chief as the leader, responsible for the section of the daily management of medical quality. The hospital carries out a medical quality inspection and holds a medical quality analysis meeting by system every quarter to check and analyze the existing problems. Improve and perfect the rules and regulations, on the basis of the relevant systems formulated by the state and the army, it has formulated the Regulations on the Management of Medical Cases, Interim Provisions on the Handling of Medical Disputes and Accidents, Interim Provisions on the Management of New Businesses and Technologies, System of Intra-hospital and Extra-hospital Consultation, and Provisions on the Management of Blood Collection and Supply, etc., which provide a policy guarantee for the hospital to strengthen the medical innovation and quality management.
1.2 Grasp the basic medical quality, to lay a good foundation for the development of medical technology
1.2.1 Talent cultivation and discipline construction Talent is the foundation of medical quality, is the most fundamental element, to improve medical quality, first of all, to improve the quality of personnel. Our hospital attaches great importance to talent training, and take it as an important strategic project to grasp, in the introduction of talent at the same time, to take a variety of ways, a variety of ways to grasp the cultivation of young medical personnel, focusing on strengthening the "three basics", "three rigorous" training, annual examination In addition, it encourages young medical staff to write academic papers, participate in academic exchanges within and outside the hospital, and continuously improve the quality of business. Section chiefs, head nurses, not only to have excellent business skills, but also to strengthen the management of knowledge learning, use, and strive to improve the level of management, give full play to the role of quality management at this level. The hospital in accordance with the "small comprehensive, large specialties" model, and actively support the key specialties and advantageous disciplines, so as to drive the overall construction and development of the hospital.
1.2.2 Strengthening the construction of instruments and equipment Instruments and equipment are the basis for carrying out medical work and ensuring medical quality. Over the years, despite the hospital's financial constraints, but still actively find ways to strengthen the hospital's hardware construction, multi-channel introduction of advanced medical equipment. At present, the total value of all kinds of instruments and equipments has reached more than 80 million yuan, which has greatly improved the medical support conditions and the environment for patients. Hospitals give full play to the role of the equipment committee, the instruments, consumables, procurement and supply, use, maintenance, maintenance have a series of systems, so that the instrumentation and equipment intact rate and utilization rate of more than 98%.
1.2.3 Encourage the development of new business, new technology The development of new business, new technology is an important part of the hospital's technological innovation, but also an important way to improve the quality of care. Our hospital in the "Tenth Five-Year Plan" clearly put forward the "science and technology, quality of hospital" strategic policy, and closely integrated with the actual development of the "access provisions", "Evaluation standards", "rewards and punishments", etc., to increase the management and support efforts to carry out an average of more than 30 new businesses, new technologies, the first in the province to carry out the "liver transplantation", The first in the province to carry out "liver transplantation", "laparoscopic rectal cancer radical surgery" and other projects, not only solved the patient's suffering, but also improve the level of medical technology and quality of medical care, enhance the hospital's comprehensive strength and competitiveness.
1.2.4 Strengthening Labor Discipline and Medical Ethics The hospital has issued "Regulations on Strengthening Labor Discipline Management" and "Code of Medical Ethics for Medical Personnel" to regulate the behaviors of all staff and to develop good habits of compliance with rules and regulations. Adhere to the "patient-centered", and actively carry out the "service commitment" activities, enhance service awareness, improve service attitude, the implementation of "high quality, high efficiency, low consumption, convenient" service model
Advancement of the "Service Commitment" activity, enhancement of service awareness, improvement of service attitude, implementation of "quality, efficient, low-cost, convenient" service model, resolutely stopping malpractice in the process of medical activities, the implementation of the price disclosure system, the one-day list system, the public reporting system, increased cost transparency, reduce medical costs, reduce the burden on patients, and improve the patient satisfaction rate.
1.3 Implementation of effective management, strengthen the link quality control
1.3.1 Emphasis on outpatient, emergency work Outpatient, emergency is the front line of medical work, but also the external window of the hospital, is the occurrence of medical disputes and medical accidents. In order to improve the quality of outpatient and emergency work, the hospital has strengthened the technical force, arranged the attending physician or above to attend the clinic, improved the first diagnosis rate of difficult and serious diseases, and reduced the number of patients' re-examination and unnecessary costs. The hospital strictly implements the first diagnosis responsibility system and specialty consultation system to prevent inter-specialty admissions. The quality of outpatient medical records and prescriptions is checked regularly according to the standards, and the hospital rewards the best and penalizes the worst. The hospital has also set up the first aid leading group and first aid detachment, formulated the emergency treatment plan for sudden and major disasters and accidents, and organized regular drills to improve the emergency treatment capability, ensure fast, accurate and effective rescue of patients, and enhance the patients' trust and sense of security. Ensure that the resuscitation instrument intact rate, first aid drug preparation rate of 100%, emergency resuscitation success rate >85%.
1.3.2 Strengthening the management of wards and operating rooms Implementation of regular inspection and random sampling, the combination of functional departmental inspection and departmental self-inspection: (1) to grasp the implementation of the system, such as the three-level physician checking system, the three-checking and seven-checking system, the system of resuscitation and management of the acute and critical patients, the system of discussing difficult cases, the system of preoperative discussion, the system of approval of the surgery, the system of discussing the death of the cases, and the system of post responsibility, Technical access system, etc. (2) To improve the quality of inpatient medical record writing, in strict accordance with the requirements of the Basic Standard for Medical Record Writing, formulate specific scoring standards, rewards and penalties, and insist on reviewing inpatient and outpatient medical records at the departmental and hospital levels to ensure that the rate of Grade A inpatient medical records reaches more than 95%. (3) Strengthening the management and control of nosocomial infection, monitoring and controlling for key departments, key parts and key people, reducing the rate of nosocomial infection and the rate of underreporting. (4) Strengthen the management of the use of poisonous and anesthetic drugs and antibiotics, and ensure that emergency equipment is in good condition. These management, all of which play a role in guaranteeing the quality of all aspects of diagnosis, treatment and rehabilitation of hospitalized patients, and provide a guarantee for the achievement of the expected end quality.
1.3.3 Strengthen the quality control of auxiliary diagnosis To the medical and technical departments, we require timely inspection, standardized operation, accurate results, and high quality reports. The hospital has formulated the "auxiliary diagnosis quality evaluation standard", regular and irregular on the medical and technical departments workflow, operating procedures, report quality, inter-room quality control, consultation system for inspection, the instrument maintenance, medical measurement of random checks. The establishment of clinical experts information feedback, will review the system, the organization of young clinical, medical and technical departments physicians rotate each other, in order to improve the quality of auxiliary diagnosis and differential diagnosis ability.
1.3.4 Grasp the difficult, critical patients diagnosis and treatment The level of diagnosis of difficult diseases and the ability to rescue critically ill patients is a measure of the hospital's overall medical level and quality of the mark. Our hospital firstly strengthens the training of medical personnel, and actively carries out case discussions, academic exchanges and lectures by experts, so as to improve the diagnosis and treatment level of difficult diseases and the ability to rescue critically ill patients. Secondly, in case of difficult cases, the medical office organizes consultation with experts from the whole hospital or invites experts and professors from other hospitals to give guidance, which effectively improves the quality of diagnosis and treatment of difficult diseases; in case of major rescue and major surgery, the vice-president in charge of the hospital is personally present at the scene, the medical office coordinates with all the efforts, and the personnel of the relevant departments work closely with each other, which effectively completes the tasks of rescue and treatment of hospitals and foreign emergencies, ensures the quality of medical treatment and prevents the occurrence of medical accidents.
1.3.5 Strengthening case management The medical record is a factual record of the medical work, is the basis for analyzing and evaluating the quality of medical care, and is also the basis for scientific research and teaching, and will also serve as an important material for the doctors and patients to prove their case in case of medical disputes. Our hospital discharged medical records must be examined and signed by the quality control personnel and the department head and then submitted to the medical records office for screening and registration of discharged medical records, and only those who are qualified can be filed, and the defective medical records are notified to the responsible person for timely modification and improvement. And improve the three-day filing system of medical records, strict implementation of the system of access, borrowing, copying, etc., the damage, loss, and arbitrary alteration of the person was seriously dealt with.
1.4 Give full play to the role of the function, increase quality supervision
1.4.1 Give full play to the role of the management of the Medical Department and the Nursing Department Hospitals to transform the organs of the functional departments of the long-standing passive coping with the situation, for the root causes of the problem of both the "symptomatic" and the "root", and the "root", and the "root", and the "root", and the "root", and the "root". "Improve the management mode, the medical quality indicators included in the annual plan, and will be decomposed to the department, the development of management rules and "medical and nursing quality assessment standards", clear responsibilities, rights and benefits of personnel at all levels in quality management, mobilize all personnel to participate in medical quality management. *** Participating in medical quality management. In addition, the organization also takes the initiative to go to the front line, issue medical and medical technology survey feedback forms to patients, look for obstacles to the improvement of the quality of medical care, and rectify them within a certain period of time, as well as actively coordinating the contradictions between the clinical departments, clinical departments and the medical technology departments; checking and supervising the implementation of the rules and regulations, focusing on investigating and dealing with irregularities and disciplinary incidents, and properly dealing with medical disputes and the relationship between doctors and patients. Adhere to the quality inspection, analysis and evaluation system, regularly in the hospital weekly meeting or the whole hospital general meeting to inform the stage of the quality of the situation, and increase the rewards and punishments.
1.4.2 Give full play to the counseling and supervisory role of the retired second-tier experts The hospital has hired retired second-tier experts as consultants to give full play to their role in helping and supervising by participating in key checkups, major surgeries, medical record reviews, quality monitoring, medical problem analysis, and stage quality evaluations, etc., and to provide the hospital with quality and safety information in a timely manner to provide the basis for setting up quality management goals and decision-making.
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2 Effect and experience
2.1 Improve the overall quality of medical care Due to the improvement of the quality awareness and management level of all staff, the gradual improvement of the rules and regulations, the formation of medical care quality control standards, the formation of a three-level quality control network system of hospitals, functional departments, clinical departments, and the establishment of standardized operation mechanism to follow the rules, according to evidence, so that the management of the hospital into a virtuous circle of track, medical quality indicators obviously Track, the number of medical quality indicators improved significantly, in 2004, 189,500 outpatient visits, 10,607 discharges, bed turnover 26 times, the average number of days in hospital 14 days, outpatient-discharge diagnosis rate of 98.73%, hospitalization resuscitation success rate of 92.08%, the cure rate of 98.34%, the rate of 99.48% of the bed utilization rate, the gross income of more than 60 million yuan of medical care. The number of medical disputes decreased significantly from 23 cases in 2001 to 21 cases in 2002, 14 cases in 2003 and 8 cases in 2004. In the development of "quality service" and "hospital management year" activities and the provincial health department organized by the wind survey were excellent results, for many years in a row was named the province's advanced unit of medical ethics and medical style.
2.2 Enhance the quality of the personnel team by grasping the quality of medical care, pay attention to talent training, the quality of the entire team improved significantly: (1) "Ninth Five-Year Plan", the hospital has trained 30 master's degree students, 5 doctoral students, 14 graduates of the Army Foundation Class, now working for a master's degree 16 people. These people have become the backbone of our clinical work and played an important role in scientific research and teaching; (2) through job training and continuing medical education, more than 90% of the young cadres have been trained at a high level; (3) the hospital has been listed as a non-directly-controlled affiliated hospital of Guiyang Medical College, which undertakes the clinical teaching of undergraduates and the tutoring of master's degree students, and the level of medical staff's professional theories, their teaching and scientific research abilities and comprehensive quality have been significantly improved; (4) the hospital has been able to improve the quality of its medical staff in the past few years. Obviously improved; (4) in the selection and use of talent, breaking the routine, breaking the stereotypes of seniority, dare to introduce and promote outstanding talent, enrich and strengthen the backbone of the team. At present, the average age of the director of the hospital is 40 years old.
2.3 Improved social and economic benefits Due to the improvement of medical and service quality, as well as the troops and soldiers and the people's trust, our hospital patients increased year by year (see Table 1), and become the first provincial and municipal health insurance designated hospitals, and achieved better social and economic benefits. Table 1 Comparison of the number of patients admitted and income from 2002 to 2005
2.4 Enhanced scientific and technological innovation capacity As a result of the improvement of medical quality and increase in medical income, the hospital increased the investment in scientific research, scientific research support conditions have been further improved, and at the same time to strengthen scientific research collaboration with the military academies and colleges and universities, hospitals to broaden the field of research, scientific and technological innovation ability to enhance. Since the "Ninth Five-Year Plan", **** has been awarded 36 projects, of which 6 are for the military and 30 are for the local community, and has been awarded 28 third-class prizes or above, published 250 papers in core journals and 8 medical monographs, and has carried out more than 30 new businesses and technologies on average every year. Hospital ophthalmology, hepatobiliary surgery, trauma surgery, obstetrics and gynecology, geriatrics, the advantages of more prominent, the hospital's overall strength, visibility and influence to further improve.
According to the reality of our hospital, to carry out good clinical research, inseparable from the medical, teaching three interdependent and complementary. Medical quality management is a huge systematic project, is the heavy ground of hospital management, is an uninterrupted work, only to continuously strengthen the management, improve the quality of medical care, in order to continuously improve the hospital's technical innovation ability and service guarantee strength, in order to "adapt to the market to seek development, accelerate the development of the win-win situation", to realize the sustainable development of the hospital. The company's website has been updated with the latest information on the latest developments in the field of medical technology.