In order to implement the medical core system, to ensure the improvement of the quality and safety of medical care in my department, to ensure the quality of medical records written within the quality and completion of medical indicators, to draw up the quality of medical care and safety of this year's work plan.?
One, strengthen the ideological understanding, sustained development:
Hospital head of leadership, continue to grasp the quality management work, the implementation of the rules and regulations. Monthly supervision of the department held a quality management committee meeting, medical records quality control group meeting, hospital sensory group meeting, nursing management group meeting, medical safety group meeting, etc., standardize the management, standardize medical behavior, and promote the sustainable development of our hospital departments.
Two, clear section medical, the main work indicators.
1, bed occupancy rate ≥ 92%
2, the average hospitalization ≤ 14 days
3, three days after admission to confirm the diagnosis of the rate of ≥ 90%
4, the average preoperative hospitalization ≤ 3
5, admission and discharge diagnosis of conformity ≥ 95%
6, hospitalized critically ill patients resuscitation success rate of ≥ 85%
7, surgery Before and after the diagnosis of the rate of compliance ≥ 90%
8, clinical and pathological diagnosis of the rate of compliance ≥ 90%
9, the three basic assessment pass rate?100%?80/100
10, outpatient medical record writing rate of ≥ 90%?90/100 points or more?
11, Grade A medical records rate ≥ 90%? No grade C medical records
12, medical equipment? Instruments intact rate ≥ 90%
13, first aid instruments? Drug intact rate?100%
14, antimicrobial use range & lt;60%?DDD & lt;40%, drug sensitivity & gt;80%, antimicrobial restrictions on the use of the rate of & lt;50%
15, 250 surgical procedures
Three, to improve the department of health care quality assessment work, the implementation of standardized quality management, the development of assessment standards, monthly by the Quality controllers to check, do a good job summarizing feedback.
1, with reference to the third-level hospital accreditation standards and three good and one satisfied with the accreditation standards, the monthly work of the department, carefully scoring? The results are linked to the bonus.
2, sound, the implementation of a variety of medical systems, requiring a variety of systems to implement records standardized, complete project. Medical team strictly implement the three-stage check-up system, 48 hours after admission to the attending physician check-up, within a week the director of the check-up, pre-operative, post-operative check-up of the superior physician, serious patients at any time to ask the superior physician check-up, the sick automatically discharged to ask the superior check-up, serious patients on duty physician check-ups after a good record of the course of the disease. Strengthen the management of informed conversation system, non-surgical patients within 72 hours of admission to talk, talk before, during and after surgery, implantation talk, talk at any time in critical condition, special diagnostic and therapeutic operations, treatment, medication talk, blood transfusion consent talk, anesthesia before consent talk, strict implementation