Public health service management part (160 points)
Strict implementation of * * province * * township hospitals public * * health service management regulations.
I. Establishment of Public Health Office (10 score)
According to the requirements of the allocation of public health office staff, business premises and related equipment and facilities, the implementation of the treatment of public health personnel.
Two, infectious disease epidemic report and management (20 points)
1 set up an infectious disease clinic to receive and treat patients with infectious diseases and suspected infectious diseases. (5 points)
2. Establish a register of infectious diseases and a register of laboratory examination results (including X-ray examination of tuberculosis), and fill in all items clearly and completely. (3 points)
Collect, register and verify the epidemic information in time, and report directly to the network according to the legal time limit. (5 points)
In accordance with the division of responsibilities, the implementation of cholera, tuberculosis, AIDS, schistosomiasis and other key infectious diseases prevention and control measures. (7 points)
Three, immunization program (40 points)
1 The vaccination clinic has a seed waiting room and a vaccination room, and each room is clearly marked. (5 points)
2. Implement information management for children's vaccination. The computer input and management rate of vaccination related information of target children in the jurisdiction is 100%. (10)
In accordance with the requirements of the Regulations on the Administration of Vaccine Circulation and Vaccination, do a good job in receiving, storing, transporting, distributing and using vaccines. Refrigerators and freezers are managed by special personnel, and the vaccines are released according to varieties, batch numbers and expiration dates, and the temperature records are complete. (15)
4 vaccination cards, certificates and books are complete, and the whole vaccination rate of children's immunization program vaccine is over 90% in the township. (10)
Four, public health emergencies emergency treatment (10)
1 Establish and implement the reporting system for public health emergencies, and keep complete records on duty and work. (5 points)
Assist county-level health administrative departments and disease prevention and control institutions to carry out investigations and implement relevant prevention and control measures at sampling points. (5 points)
Five, maternal and child health care work (50 points)
1 hold a regular meeting of village-level health care personnel once a month, master the basic situation of maternal and child health care in the township, work full-time at the grassroots level for no less than 15 days a month, establish a maternal health care manual within the jurisdiction in time, correctly and completely fill in work-related tables, cards and books, and report the information report of maternal and child health care work regularly. ( 1 1)
2. Complete pregnancy control, prenatal examination and postpartum visit according to regulations, and implement tasks such as setting up a file for high-risk pregnant women, tracking management and guiding the selection of delivery places. Responsible for 42-56 days postpartum health examination. The pregnancy mastery rate is over 95%, and the management rate of high-risk pregnant women is 100%. (12)
3 Do a good job in visiting newborns. Children under 7 years old should have a regular physical examination of "4,2, 1" or monitor their growth and development. Project management of frail children found in physical examination. The project management rate is over 60%. (10)
There are 4 township hospitals that provide technical services for in-hospital delivery, and the guiding standards for obstetric construction of township hospitals in * * province. (6 points)
5. Implement classified management for pregnant women to prevent interception of high-risk pregnant women. The cesarean section rate of township hospitals approved to carry out cesarean section is controlled within 25%. (6 points)
6 publicity and mobilization and assistance in neonatal disease screening, prenatal screening and diagnosis. Specification for the issuance and management of Birth Medical Certificate. (5 points)
Six, rural health education (10)
1 Use rural cable broadcasting, publicity windows, farmers' technical schools, popular science fairs and traditional ethnic programs to carry out health education. (3 points)
2 to carry out the prevention and control of infectious diseases, parasitic diseases, chronic non-communicable diseases, endemic diseases and occupational diseases. (4 points)
Seven, village clinic management (10)
1 Implement the integration of rural health service management focusing on public health services, strengthen the supervision of rural doctors within their jurisdiction, hold regular meetings of rural doctors, and make overall arrangements for work tasks. (5 points)
2. According to the requirements of * * * Province's Measures for Labor Subsidies for Rural Doctors in Public Health Services, do a good job in performance evaluation and labor subsidies for rural doctors in public health services. (5 points)
Eight, public health management (10)
1. Grasp the background of catering units and employees in the jurisdiction, guide rural doctors to establish a rural dinner information registration system and report it in time, and inspect and guide rural dinner activities. (5 points)
2. According to the requirements of the Regulations on the Management of Medical Wastes, supervise the disposal of medical wastes in village clinics within their jurisdiction. (5 points)
Clinical diagnosis and treatment service management part (300 points)
(a) establish and improve the post responsibility system for all kinds of personnel (15 points)
1. According to the actual situation of our hospital, establish the post responsibilities of all kinds of personnel, and check the information. (15)
2. All kinds of personnel are familiar with their respective job responsibilities and earnestly perform their duties. The correct answer rate of random medical personnel is 100%. (5 points)
3. Establish a post performance appraisal system for all kinds of personnel and put it in place with records. (5 points)
(two) improve and implement the rules and regulations (35 points)
1. Establish and focus on the core systems of medical quality and safety management, such as doctor's rounds system, difficult case discussion system, consultation system, critically ill patient rescue system, bookmark discussion system, death case discussion system, check system, handover system, conversation notification system, etc., and keep records. (6 points)
2. Strictly implement the "Regulations on the Writing of Medical Documents in Rural Medical Institutions" in Hunan Province. The writing of medical records is timely, accurate, complete and standardized. The qualified rate of random medical records 100%, the excellent and good rate of medical records ≥90%, and the coincidence rate of admission and discharge diagnosis ≥90%. (10)
3. Make prescriptions in strict accordance with prescription writing requirements, and randomly check outpatient prescriptions and medical records: the qualified rate of prescriptions is greater than or equal to 90%, and the proportion of clinical diagnosis records is 100%. (8 points)
4. Strengthen the medical quality management of surgical cases. The coincidence rate of diagnosis before and after operation was ≥90%, the primary healing rate of aseptic incision was ≥90%, and the infection rate of aseptic incision was ≤ 65438 0%. (5 points)
5. Strictly abide by the diagnosis and treatment of nursing routine and operating procedures. Strengthen the management of outpatient (emergency) diagnosis and treatment, complete the commonly used first-aid drugs and equipment, and maintain a good standby state to ensure timely and effective outpatient (emergency) diagnosis and treatment. Standardize the referral guidelines and referral procedures for referred patients. This is recorded. (6 points)
(three) the establishment of medical quality management system (25 points)
1. It is clear that the dean is the first person in charge of medical quality management and is fully responsible for medical quality work. (5 points)
2. According to the scale of the hospital, combined with the actual situation, it is clear that 1 full-time or part-time managers are specifically responsible for medical quality supervision and exercise the functions of guidance, inspection, assessment, evaluation and supervision. (5 points)
3. Formulate and implement medical quality supervision and management, inspection and evaluation, analysis and evaluation, information notification and other systems. Regularly carry out quality inspection, evaluation and notification of medical links, and implement rectification measures. This is recorded. (10)
4. Formulate and implement medical quality management measures, plans for continuous improvement of medical quality and standards for inspection and evaluation of medical quality. This is recorded. (5 points)
(four) to strengthen the safety management of medical services (20 points)
1. According to the requirements of relevant laws and regulations, combined with the weak links of medical safety in our hospital, we regularly carry out medical service safety education, and regularly carry out medical quality and medical service safety analysis (once a quarter). (5 points)
2. Strengthen medical safety management, formulate and implement the system of acceptance, investigation, handling and feedback of medical disputes and complaints, and clarify that a part-time employee is specifically responsible, and does not transfer contradictions or shirk responsibilities. This is recorded. (5 points)
3 hospitals and individuals signed a medical quality and medical safety liability form, responsibility decomposition to people, the implementation of medical quality and medical safety responsibility system and accountability system, accountability to people. This is recorded. (5 points)
Formulate and implement the medical accident prevention plan and treatment plan, and have the data to check. Timely report medical disputes, medical accidents and major medical negligence. The reporting rate of major medical negligence and medical accidents is 100%. (5 points)
(five) to strengthen the "three basics" training, master and apply appropriate rural health technology (35 points)
In accordance with the "three strictness" requirements and the "three basics" training guide for medical staff in township hospitals "by the Provincial Health Department, strengthen the" three basics "training for medical staff in township hospitals.
1. Establish the "three basics" training system and assessment, reward and punishment measures, formulate the "three basics" training plan, and have specific training arrangements and training records. (5 points)
2. The hospital organizes a "three basics" theoretical examination every quarter and a "three basics" skill assessment every six months, with papers and records. (6 points)
3. During the supervision and inspection, the qualified rate of the "three basics" theoretical examination for medical staff is greater than or equal to 80%. (7 points)
4. According to the requirements of the Training Manual of Appropriate Technologies for Rural and Community Health in * * Province, each doctor can master and use 10 many appropriate technologies in rural areas. (10)
(six) to strengthen nursing management and improve the quality of nursing (80 points)
1. Improve the nursing management system. According to the scale of the hospital, the head of nursing management or nursing department is set up, and the nurse or director of nursing department is responsible for nursing management under the leadership of the dean. The allocation of nursing manpower conforms to the relevant regulations and can meet the clinical needs. (10)
2. According to the requirements of the "Standard for Nursing Work in Township Hospitals" compiled by the Health Department of Hunan Province, establish and implement various nursing work systems, nurses' job responsibilities and work standards, common and frequently-occurring diseases nursing routines, and common nursing technology operating procedures. There are records and materials to check. (20 points)
3. Change the nursing work mode, strengthen clinical basic nursing, implement the service tenet of "patient-centered" and humanized nursing service measures, and provide rehabilitation and health guidance. The qualified rate of basic nursing is ≥90%. (5 points)
4. Establish the evaluation standard of nursing quality, regularly check and evaluate the quality of nursing, enhance the quality consciousness of nursing staff in township hospitals, and improve the quality of nursing and the level of nursing service. (15)
5. Strengthen the management of operating room, delivery room and supply room. The service building, equipment configuration and functional requirements, room layout and workflow are reasonable, which meet the requirements of preventing and controlling hospital infection. (10)
6. Strengthen on-the-job training and continuing medical education of nursing staff. Make a training plan for nursing staff, including in-hospital training, academic education, further study in higher hospitals, study abroad, etc., to improve the overall level of nursing team. This is recorded. (10)
(seven) Chinese medicine service management (35 points)
1. Strictly implement the Basic Standards for the Management of Traditional Chinese Medicine Services in Township Health Centers issued by the Ministry of Health and state administration of traditional chinese medicine and the Standards for the Construction of Traditional Chinese Medicine in Township Health Centers issued by the Provincial Health Department, strengthen the construction and management of traditional Chinese medicine pharmacies, and meet the requirements in the establishment, equipment and professionals of traditional Chinese medicine pharmacies. (10)
2. Provide basic medical services of traditional Chinese medicine, and apply the theory of traditional Chinese medicine to deal with more than 35 kinds of common diseases, frequently-occurring diseases and chronic diseases in outpatient clinics, wards and home visits; Chinese medicine services should account for more than 25% of the total medical services in hospitals. (8 points)
3. More than five kinds of Chinese traditional medicines and appropriate technologies such as acupuncture, massage, cupping, application, scraping, fumigation and washing, acupoint injection and hot ironing are used in medical clinics and rehabilitation health care services. It can provide 100 kinds of Chinese patent medicines and more than 300 kinds of Chinese herbal pieces to meet the clinical drug demand, and the sales of Chinese medicines account for more than 30% of the total drug sales. (7 points)
4. Strictly abide by the principles, technical standards and operating specifications of the state on diagnosis and treatment of traditional Chinese medicine. (5 points)
5. Make full use of the knowledge of traditional Chinese medicine to prevent various infectious diseases, carry out more than two comprehensive services using traditional Chinese medicine technology to prevent and treat diseases, and participate in health guidance and behavioral intervention using traditional Chinese medicine theory and technology; Take various forms to publicize the knowledge of Chinese medicine for disease prevention and health care. (5 points)
(eight) clinical medication management (30 points)
1. Strengthen the management of antibacterial drug use (*** 13 points).
Strictly implement the Guiding Principles for Clinical Application of Antibacterials of the Ministry of Health, and establish and improve the management system for rational drug use. To formulate and implement the grading management system of clinical application of antibacterial drugs in our hospital. There is information to check. (2 points)
Outpatient prescriptions and hospitalization orders strictly control the unreasonable combination of antibacterial drugs, advocate single use, use more than two with caution, and prohibit more than three. For patients who use tertiary antibacterial drugs, there must be a record of expert consultation in the superior hospital or doctor consultation and discussion in our hospital. Five hospitalized medical records, five discharged medical records and 1 death medical records were randomly selected. In-patient medical records must record the selection, switching and discontinuation of antibacterial drugs (5 points each, *** 10).
Perioperative drug use must be strictly in accordance with the Guiding Principles for Clinical Rational Use of Antibacterials, and special circumstances must be signed by the department director and recorded in the medical record (1).