20xx in the hospital leadership of the strong support of the medical department in the quality of medical care, quality of service, medical safety and other aspects have achieved greater improvement, 20xx year medical department will, as always, in the hospital committee under the leadership of the scientific outlook on development to lead the development of the whole situation of the medical work, routinely enhance the ability of independent innovation, and continue to carry out in-depth "hospital management year" and "two years". "and" two good and one satisfaction "activity practice, and constantly push the work of the medical department to the depth.
First, to prevent medical accidents to ensure medical safety
Seriously do a good job of medical quality assessment work, strictly an hospital developed management norms, work systems and assessment rules, to carry out management work, the strict implementation of medical precautionary measures and medical accidents handling plan, the implementation of medical defects accountability system, strictly according to the standard of medical procedures to carry out medical activities. We organize the staff of the hospital to study the relevant medical laws and regulations. Strengthening the quality management of key links and departments, and expanding the focus of medical quality management from the evaluation of end-of-care quality to the inspection and supervision of the quality of each link in the whole process of medical care. The focus includes: (1) Emphasizing the standardized and complete writing of admission notification, authorization, and informed consent for various treatments. (2) To truly and accurately do a good job in the "death case discussion", "critical case discussion", "rescue of critically ill patients discussion" of various records and physician handover; (3) to organize the department to strengthen the diagnostic and treatment standards and related laws and regulations. (3) Organize the department to strengthen the study and assessment of diagnosis and treatment standard and relevant laws and regulations. (4) to further change the style of work to strengthen the sense of service, to do "more explanation, more comfort, more understanding, more warmth, more help", so that the quality of hospital services to a higher level; (5) to strengthen the diagnosis and treatment plan, the safety of medication inspection efforts.
Second, medical quality management
1, strengthen the department's own construction
According to the city's work in 2008 inspection of the deficiencies proposed for my department, we will continue to strengthen their own quality and system construction in 20xx, mainly including: improving and updating the activities of various committees, minutes of the meeting; to strengthen the management of departmental archives; to change the style of work, strengthen the sense of service, from empirical management gradually to scientific management, and to improve the quality of service.
2, to participate in the hospital quality control management committee for the examination every Thursday morning to a regular department for the whole examination, all clinical departments of the hospital rotation cycle. The contents of the inspection include: physician handover, including the actual handover of the department to carry out the status and written records; department three-stage inspection, focusing on the supervision of the department teaching inspection and the director of the inspection of the implementation of the norms; the quality of hospitalization medical records; the implementation of the department's five discussion system, including the discussion of critical cases, difficult cases, the death of the discussion, a detailed understanding of the records and the implementation of its situation; listen to the director of the department of medical operation, quality management, scientific research and teaching, the implementation of the system, the implementation of the system, the implementation of the system, the implementation of the system, and the implementation of the system. The company's website has been updated with the latest information on the company's website, including its website and the website's website.
3, case quality management
(1) link quality every Monday and Tuesday to the clinical department to check 4-6 points link medical records, in strict accordance with the "Shandong Province Medical Document Writing Standards" in the medical records of the three-stage checkups, the five discussions, consultation (intra-disciplinary consultation, in-hospital consultation and out-of-hospital consultation), the doctor's orders to the condition of the check and so on; in addition to the strict standardization of the physician's shift handover, random checking In addition, they strictly regulate the handover of physicians, randomly check the monthly quality education analysis of the department, help the department to identify the problems and put forward improvement programs, and supervise the records of the three basic and three strict learning and political learning records.
(2) final medical records Monthly to the case room sampling of 10 discharged medical records of various departments, every six months on the sampling of the final case for the exhibition, and strictly according to the "Lingshian People's Hospital medical documents quality assessment of the rewards and penalties," awards and penalties.
4, the focus of the department supervision
(1) for the quality of the icu monitoring, weekly from time to time on the icu spot check, focusing on the spot check content: strict standardization of critical patient medical record writing and medical personnel shift records; department of the actual check-up situation; the implementation of the system of critical patient reporting; actually watch the medical staff on the critical patients of the proficiency of various technical operations, standardization;
(2) monitoring of the anesthesiology department, regular monthly inspections to the anesthesiology department, the main content includes: preoperative anesthesia visits actually carried out; improve the signing of various anesthesia agreements; strict checking system and the implementation of the management of narcotic drugs.
The monitoring of the key departments, the medical department will strictly do check some records, check some right, and each time the content of the difference will be summarized, compared, evaluation, *** with the discussion of the corresponding improvement measures, in order to improve the quality of the department at the same time to eliminate the safety hazards.
Third, continuing medical education
1, strengthen the training of new personnel for the last year, the new personnel in the medical record writing is not standardized, legal knowledge is weak, the work of the idea of lack of correctness and other shortcomings, the Medical Department in 2009 will further increase the training of new personnel, training is divided into the writing of the medical record, the law of the licensed physician, how to do a good job as a clinician three major sections, through the staged lectures In the form of staged lectures, the medical section of the whole monitoring, and randomly check the learning records of training personnel, and in the stage of learning after the field questions and written form of assessment, unqualified people are not allowed to work.
2, to strengthen the scientific research work of each section in the completion of the daily work, to have a plan, targeted organization of 1-2 scientific research topics, attending physician or more than the staff to write and publish scientific research papers shall not be less than two, the medical department in the supervision of scientific research work at the same time, and make every effort to create favourable conditions for the department.
3, strict out-of-hospital training, internship management in the acceptance of Texas Health School, Modern Medical College, Xinglin Medical College, Tai'an Medical College and other colleges and universities interns, as well as township health hospitals to further strengthen the management of the organization and discipline, and emphasize its basic knowledge, basic theory and basic skills training.
4, strengthen the professional and technical personnel business training According to our hospital situation, in the principle of training on demand and hospital economic conditions allow, select and send medical personnel to higher hospitals to learn, absorb advanced technology, improve the technical level. Intermediate title of professional and technical personnel should be closely related to their own specialties, encourage self-study through self-study, off-the-job learning consciously and rigorously supplemented, the growth of new theories, new technologies, new methods of professional technology, and mastery of cross-disciplinary and related disciplines of knowledge. Junior title of professional and technical personnel should be combined with their own positions, professional and technical knowledge and skills of the job training, proficiency in professional and technical, participate in scientific research, able to solve the more complex and difficult diseases, and strive to invite in, send out, the principle of their own learning to find ways to improve the professional team's professional qualities, in the hospital committee's approval and support of inviting experts from higher levels of professional and technical guidance of the hospital, in the form of room visits, surgery, lectures and other forms of continuous improvement of our professional and technical guidance. The hospital has been able to continuously improve its business level in the form of room visits, surgeries, lectures, etc., and has supported various departments in inviting experts to guide the development of new technologies and new businesses.
5, continue to strengthen the management of business learning Strictly Monday, weekly business learning in each department, the Medical Department from time to time to randomly check the actual learning situation in each department and combined with the learning record for the scene of the question. In addition, every Thursday to arrange a professional lecture specifically for young doctors, by the section chiefs take turns teaching, the medical department to participate in the whole process and make a good record, from time to time to carry out on-site assessment.
6, emphasizing the importance of academic lectures both inside and outside the hospital, the higher hospital professor source lectures, etc. is to the medical department even if the arrangement of the relevant work, to ensure that the relevant professionals are able to participate.
7, every six months to organize a "three basic and three strict" theoretical assessment, and with the September formal practical skills assessment of the hospital, the "three basic and three strict" training work in quarters, specifically: the first quarter, the whole staff of the low seniority The first quarter, the whole staff of junior doctors CPR, ventilator, defibrillation application training; the second quarter, urinary catheterization, a variety of puncture, intubation and other commonly used clinical skills training and the first theoretical examination; the third quarter, the whole staff of knowledge training of narcotic drugs, antibacterial drugs; the fourth quarter, the second theoretical examination and practical skills assessment, and for the weaknesses of the special training.
20xx hospital reform is also very necessary, as long as there are unreasonable things exist, must be reformed, this is something we have to look good, the road ahead, we will gradually and slowly adapt to the current work, only to the direction of the forward, this is what we have been to do well, we must do a good job, our work to do!