Medical quality management and control system:
I. Establishment of hospital and departmental quality management and control system
1. Quality management and control at the hospital level, with the dean as the first responsible person.
(1) the establishment of the hospital quality management committee and related committees, is responsible for in accordance with the requirements of the national medical quality management, the development of the institution's medical quality management system, training system, as well as the introduction and application of technology management system and organization and implementation. Responsible for the development of the hospital's quality continuous improvement plan, implementation of the program and organize the implementation and evaluation.
(2) The Medical Department, Nursing Department and other functional departments are responsible for the quality and safety management in their respective areas. They are responsible for the implementation of medical quality management system and quality improvement plan, regular supervision and analysis and evaluation of the results, and continuous improvement of medical quality.
(3) The Quality Supervision Section, as the office of the Hospital Quality Management Committee, is responsible for performing the functions of auditing, evaluating and supervising the quality and safety of the whole hospital.
2. Quality management and control at the departmental level, with the department head as the first responsible person.
The establishment of departmental quality management and control group, referred to as the quality control group, composed of the department director, head nurse, medical and nursing key personnel. It is responsible for implementing laws, regulations, rules and normative documents related to medical quality management, formulating the quality management system of the department as well as quality improvement plans and programs and organizing training and implementation. Regularly analyzes and evaluates the quality and safety of the department, proposes corrective measures for weak links in medical quality and organizes their implementation.
II. Regularly organize training, education and assessment of quality management personnel, and correctly use quality management tools to carry out quality improvement activities. Regular training and assessment of medical staff on the "three basic and three strict" and quality management system standards, training and qualification rate of 100%.
Third, the medical staff obtains practicing qualification according to the law, and practices according to the diagnosis and treatment subjects approved and registered by the higher health administrative department. Strictly follow the clinical diagnosis and treatment guidelines, technical operation standards, industry standards and clinical pathway requirements to carry out diagnosis and treatment, strict compliance with the core system of medical quality and safety, so that the rational examination, rational use of medication, rational treatment.
Four, the establishment of a perfect single disease indicator system, the development of single disease quality reference standards, and promote the fine management of medical quality.
V. Establishing and improving the social evaluation system, continuously improving the satisfaction monitoring indexes, regularly carrying out patient and staff satisfaction monitoring, and continuously improving the patient's experience of medical treatment and the staff's feeling of practicing medicine.
VI. Establishing and improving the basic database of quality and safety indicators, collecting and reporting relevant information in a timely manner, analyzing and evaluating using quality management tools, and continuously improving medical work.
Seven, the establishment of a perfect adverse event reporting management system, the use of information in the continuous improvement of medical quality, and in accordance with the relevant provisions of the State reported drugs, consumables, equipment and medical safety events.
VIII, the establishment of medical safety and risk management system, improve medical safety management system, emergency plans and workflow. Strengthen the safety and risk management of key medical departments and key links, and implement patient safety objectives. Improve complaint
management, timely resolution and proper handling of medical disputes.
Nine, the quality management department regularly conducts on-site inspections and spot checks on the quality of each department, which are publicized or notified on 0A, and the results are used as an important indicator for performance evaluation as well as appraisal, appointment and promotion.
X. Quality Supervision Department regularly assesses the implementation of quality management requirements in the hospital, timely analyzes and gives feedback on the collected medical quality and safety information, provides early warning and intervention on medical quality problems and safety risks, and evaluates the effect on a regular basis.