The quality control section is under the leadership of the president and business dean, based on national laws and regulations and the quality management requirements of the health industry, through the operation of the hospital in the process of the overall quality of the overall quality of the status of the all-round quality supervision, inspection, analysis and evaluation of the overall quality of the hospital to improve the overall quality of the hospital to put forward the views and recommendations, in order to promote the quality of hospitals and continuous improvement of the function of the management department. The following is my annual report on the work of the quality control section brought to you , welcome to read.
20** year we quality control section in the hospital party, political leadership under the correct leadership, in the hospital under the strong cooperation of the comrades of the various departments, hard to learn, active work, bold management, dare to innovate, serious and responsible, leading the comrades of the section to develop and innovate, and strive to complete the hospital to the work of the various tasks. According to the health administrative departments and hospital quality management requirements, the quality control section conscientiously fulfill their duties, strict system, high standards, strict requirements for medical records, prescriptions for regular and occasional inspections, comprehensive reviews. To do the work seriously have a record, the existence of problems have analyzed, have commented on the timely communication with the section director and responsible for feedback, to be rectified, and regularly analyze the results of the evaluation reported to the dean in charge.
I. Work responsibilities
1, quality control section under the leadership of the President, the Dean in charge, the hospital's quality of care for the entire monitoring; according to the overall development of the hospital, our section of the hospital's medical records, prescriptions for strict quality control, and the review of prescriptions to summarize and assess the situation. And put forward quarterly, quarterly stage of quality control focus on the goal of medical quality management to be summarized, put forward suggestions for rectification, and promote continuous improvement.
2, the development of the hospital's medical management of rules and regulations, planning, standards and major measures, is responsible for organizing and coordinating the implementation of hospital quality management, supervision, inspection, analysis and evaluation.
3, quality control section in charge of the leadership of the President, the specific organization and implementation of the hospital's clinical medical, nursing quality management. Responsible for the development of the hospital's medical quality management implementation program, and often supervise and inspect, summarize and report on time. In-depth understanding of the medical quality of each department, urging each department against the medical quality standards of self-examination, the development of the standard program. Responsible for the organization of prescription, medical record writing, clinical medication, preventive medicine, outpatient, emergency quality inspection work,
Regular analysis and summary of timely report to the dean. Completion of other related work assigned by the hospital leadership. The staff of this department carefully and meticulously check the medical record homepage, antimicrobial drug approval list, surgical nursing records, medical prescription records, surgical laboratory orders, etc., to keep the quality control, and to find out the problems and correct them in a timely manner. We go deep into the outpatient clinics and departments and urge the doctors in charge of each department to write carefully. In order to strengthen medical quality control and medical quality and safety management. And in the following areas have increased efforts: the writing of medical records, the third level of physician visits, the approval of surgery, the grading management of surgery, the approval of antimicrobial drugs and grading management, prescription writing, talking about difficult cases, doctor-patient communication, and so on.
Second, the collective efforts
1, the hospital: in order to further strengthen the hospital rational use of medication guidance, supervision and management of standardized clinician medication behavior, to reduce and avoid the occurrence of adverse drug reactions, to reduce or alleviate the emergence of bacterial resistance, to ensure that the clinical use of medication is safe, effective and economically appropriate to improve the quality of medical care maximized. To minimize the cost of medicines, the following measures have been developed:
(a) strict implementation of the principle of graded use of antimicrobial drugs management, the hospital limited varieties are divided into non-restricted use, restricted use and special use of three categories, fill in the antimicrobial drug application for approval of the single development
(b) the establishment of antimicrobial drugs special rectification leading group and members of the antimicrobial drug use steering review, by the Quality control personnel weekday review of the work record daily assessment of the situation is summarized, into the hospital performance of the integrated quality assessment, rewards and penalties.
(C) the daily microcomputer database of the hospital's sales of antimicrobial drugs in the amount of the top ten drugs level prescribing antimicrobial drugs in the amount of the top ten doctors ranked public, the use of antimicrobial drugs to analyze and report to the dean in charge of the Department of Medical Sciences for scientific treatment
(D) the amount of the top ten physicians to prescribe antimicrobial drugs to take a scientific treatment
(E) strengthen the knowledge training on the rational application of antimicrobial drugs, the use of antimicrobial drugs to improve the quality of life. Rational application of antimicrobial drugs knowledge training
Circular drug news, the introduction of new drugs, pre-service training, kitchen standardized writing training and typical medical records issued in the form of education and training organized by the Department of Medical Services, each time the content of the self-defined, the examination test, to guide the rational use of clinical medication in order to improve the hospital's various types of personnel to improve the rational use of antimicrobial drugs of the comprehensive quality.
2, the departments: in the hospital. Vigorous control, the use of antimicrobial drugs in various departments has also been controlled, especially cefmenoxime, cefoxitin sodium dosage has been controlled, and now physicians in various departments basically do according to the indications for the use of drugs, such as the application of antimicrobial drugs, if necessary, but also the use of the use of the level by level. But occasionally there are individual physicians still use high-grade antimicrobials, expect physicians from the fundamental interests of the masses, from the people's health.
3, quality control section: quality control section mainly from the following aspects of the inspection, quality control
(1) the use of antimicrobial drugs indicated
(2) preventive medicine selection time
(3) the choice of antimicrobial drug varieties
(4) the use of antimicrobial drugs dosage, cycle, pathway, frequency
(5) the antimicrobial drugs Classification management
(6) replacement of antimicrobial drugs with or without medical records and whether the medical advice is consistent
(7) rationality of the combination of drugs
At the same time, a review of typical medical records. Feedback circulars are issued, and a combination of intervention and feedback methods are used for testing, reviewing antimicrobial prescriptions or medical prescriptions in advance, and directly intervening in doctors' prescriptions or medical records for rectification
In this year, the whole hospital **** checked all kinds of prescriptions of 4,585, of which 3,986 were qualified, and 554 unqualified prescriptions, with a reasonable rate of 87% (not up to the standard of 95%), and an intensity of antimicrobial drug use of 45 (the prescribed range does not exceed 40), outpatient antimicrobial drug ratio of 13% to meet the standard, inpatient antimicrobial drug use rate of 54.5% to meet the standard, the above data in the rectification of a lot of irregularities before, do not meet the standard, now there has been a significant improvement and enhancement.
Three, the goal
In the whole hospital medical staff *** with the efforts of our medical quality has improved greatly, our department will continue to work hard, for the hospital's medical quality improvement to dedicate their own strength.
Quality Control Section 20**-12-17