Tertiary General Hospital Accreditation Standards
I. Hospital Functions and Tasks (50 Points)
(A) Medical Services (20 Points)
Can provide comprehensive and continuous medical care, preventive health care, and rehabilitative medical services.
1. Provide a high level of specialized services based on high-quality comprehensive medical services. It undertakes the task of diagnosis and treatment of critical and difficult diseases, and carries out two-way referral.
2. It has sufficient medical service radiation capacity, and a certain proportion of the annual discharged patients should come from regions or provinces other than the hospital's location.
3. According to the relevant provisions of the State, to participate in the local emergency medical network, under the leadership of the administrative department of health, can cooperate with the emergency center to make a rapid emergency response, to undertake the emergency rescue mission of the disaster, and can accept batches of sick and wounded for the hospital emergency.
4. To carry out mental health, genetic finding outpatient services and support and guidance for community medical, nursing and rehabilitation medical services.
(2) teaching and research (15 points)
1. Undertake clinical teaching and internship in higher medical schools, and can train senior clinical medical personnel. It also undertakes the task of further training of clinical specialties for technical backbones of secondary hospitals.
2. Undertake national, provincial (autonomous regions, municipalities directly under the Central Government) scientific research projects.
(C) business and technical guidance (10 points)
To fulfill the technical guidance of lower-level medical institutions is the hospital's duties and obligations, the establishment of regular technical guidance and cooperation, to help carry out new technologies, new projects, to solve difficult problems, and to train health technology and management personnel. To fulfill the health or agricultural support work of the local health administrative department.
(D) preventive health care (5 points)
1. Carry out health education
2. Undertake the local health administrative department assigned to preventive health care, the main chronic non-communicable diseases (cardiovascular and cerebrovascular diseases, malignant tumors), clinical epidemiological investigations and prevention and treatment work.
3. Participate in urban primary health care.
Two, departmental settings (30 points)
Hospital departments should be set up with their functions, tasks and scale. Functional departments should be set up in line with the principle of streamlining, efficiency and adapt to the needs of management. Business departments should be under the guidance of the "Medical Institutions Setting Plan" and the overall development of the basis to strengthen the construction of specialties, part of the first-level departments to implement the second level of sub-specialties, highlighting the advantages of specialties.
(I) Clinical departments (20 points)
1. The first-level specialized departments
should be in line with the "Basic Standards for Medical Institutions" and the local "Medical Setup Planning".
2. Second-level specialized departments
Internal medicine: there should be at least seven departments, the following departments in the ground for the mandatory departments :cardiovascular, digestive, respiratory, hematology, neurology, nephrology, endocrinology and other specialized departments.
Surgery: general surgery, cardiothoracic surgery, neurosurgery, urology, orthopedics and other specialized departments.
Obstetrics and gynecology:There shall be specialized departments such as gynecology, obstetrics, family planning, and so on.
Pediatrics:There shall be specialized departments such as pediatrics, neonatology, and so on.
3. Key Specialties
The key specialties shall be set up according to the "Medical Institutions Establishment Plan".
The hospital should have more than three key specialties.
Each key specialty has 20 beds.
4 should have a comprehensive intensive care intensive care unit (ICU or integrated intensive care unit) or specialized intensive care intensive care unit (or specialized intensive care unit)
(ii) medical and technical departments and other operational departments (10 points)
In addition to conforming to the other, there should also be a library of information and statistics room (room)
Third, staffing (30 points)
The hospital should be equipped with its functions, tasks and scale of health professionals and other professional and technical personnel, in addition to citing should be in line with the "Basic Standards for Medical Institutions", should also meet the following conditions:
(a) actually engaged in the clinical nursing nursing number of on-board nursing not less than 50% of the total number of health professionals, beds beds and ward nurses than not less than 1:0.4, the number of nurses in the hospital is not less than 50% of the total number of health personnel, beds and ward nurses. Those who have graduated with a college diploma or above in nursing should be not less than 20% of the total number of nurses. The director and deputy director of the nursing department, and the head nurses of the internal medicine, external medicine, gynecology, pediatrics, emergency department, operating room and key departments should have the technical position of deputy chief nurse or above, and the structure of the competent nurses and nurses is reasonable(10 points)
(ii) The director, deputy director, attending physician, and resident are reasonable in the organization. (6 points)
(c) The director of each first-level department and key second-level departments should have the technical position of chief physician, and the director of general second-level departments should have the technical position of deputy chief physician or above. (7 points)
(iv) The ratio of nutrition personnel (personnel with technical position of dietician or above) to beds is 1:200 (4 points)
(v) The professional staff of blood transfusion department is determined according to the number of hospital beds, the number of surgical cases, the amount of blood used, and the actual work situation. (3 points)
Hospitals affiliated with medical schools and teaching hospitals, an appropriate increase in the proportion of personnel
Four, hospital management (140 points)
(a) Organization and management (25 points)
1. Hospitals should have a sound scientific management system, the management of the work of all the full-time or part-time personnel responsible.
2. Seriously implement the relevant national laws, regulations and the State Council issued the "Regulations on the Management of Medical Institutions" and the Ministry of Health issued the "Regulations on the Management of Medical Institutions," the "National Hospital Work Regulations," "Hospital Work System" and "Hospital Staff Responsibilities," and combined with the hospital's actuality, the hospital to seriously develop and continuously
improve the hospital work system, all levels of service category Personnel job duties and pre-service education system, and organize and implement, and strengthen the standardized management.
3. Hospitals implement target management, should be developed in the medium and long term development planning and annual plan. Do a good job of implementing the progress of hair coordination, inspection, assessment and evaluation.
4. Establishment of a sound internal and external supervision system, regular evaluation of the hospital's work and quality of medical services.
5. The director should have a comprehensive grasp of the knowledge and skills of hospital management, understanding of the dynamics of domestic hospital management, strengthen the awareness of scientific management; hospital leaders must accept the national, provincial (autonomous regions and municipalities directly under the Central Government) health administrative department of the management of the professional post training and obtain training certificates. Can only section of the leadership should also receive job training
6. There are in-house training programs and funding
7. Hospital employees on the hospital leadership team structure, cooperation and job satisfaction ≥ 80%.
(II) Information Management (22 points)
1. There is a sound information management organization and related work system
2. The library of Chinese and foreign language medical books and periodicals can meet the needs of medical education and research
3. The archive management is carried out in accordance with the "scientific and technological institutions, archive management upgrading methods" (national level 2) standards.
4. Electronic computerized management of medical, case statistics, finance, personnel, pharmacy, and library information.
5. All kinds of statistics, analysis, coding and information must wipe out the national and ministerial standards.
6. Hospital information must be true, complete, accurate and timely analysis, feedback and utilization.
(C) financial management (15 points)
1. Strict implementation of the state's relevant financial system, strengthen the financial law.
2. Strict implementation of fee standards, the implementation of the main service items marked price.
3. Implementing the policy of "running the hospital diligently and thriftily", strengthening management and gradually carry out cost accounting.
(D) equipment management (19 points)
1. There is a sound equipment management and maintenance organization, with a certain number of engineers and technicians.
2. Hospital equipment to implement program management, the establishment of a sound system of regular procurement, maintenance, repair and renewal of medical equipment. Ensure that medical work needs. Ensure that the equipment is in good condition, improve the efficiency of use, to avoid repeated purchases.
3. Hospitals should focus on ensuring that the "basic standards for medical institutions" to achieve the equipment and other basic equipment, first aid equipment, guardianship equipment, the purchase of valuable instruments and equipment to be demonstrated. The relevant large-scale equipment in accordance with the relevant provisions of the Ministry of Health.
4. Valuable equipment to establish a file, specialized management.
(E) general management (19 points)
1, a sound general management system, job responsibilities and work system
2. General material quota management, a sound procurement, acceptance, storage, distribution, scrapping and other systems
3. proactive, timely service for the medical teaching and research and staff life. Do down three (under the receipt, under the delivery, under the repair), to ensure that three through (water, electricity, gas), timely treatment of three leaks (water, electricity, gas), do down two satisfied (workers, patients).
4. Unexpected power supply measures to ensure that emergency needs
(F) building management (8 points)
1. Hospital construction to have a master plan, new construction, alteration, expansion to carry out feasibility studies, information preservation is complete, in line with the Ministry of Health, "General Hospital Building Standards," and other building codes.
2. The hospital's outpatient department, inpatient department, medical and technical departments, operating rooms, disinfection and supply room, emergency department and other departments of the building layout and people, logistics direction is reasonable. Indoor lighting, color design in line with hygiene requirements.
3. There is a regular maintenance program for old hospital buildings, and no medical activities shall be conducted in dangerous buildings.
(VII) safety management (15 points)
1. There is a sound hospital safety and security management organization.
2. There is a sound hospital safety and security management system, measures and implementation records and regular evaluation of safety management.
3, easy to hazardous equipment and departments have special management measures, such as high pressure system, hyperbaric oxygen supply room dangerous goods warehouse isotope room power distribution room operating room bacterial room, etc.
Fire fighting equipment is complete, clearly marked, regular inspection and replacement, easy to use.
Strictly enforcing the management system of toxic drugs for medical use, narcotic drugs and psychotropic drugs.
(H) environmental management (17 points)
1, to keep the hospital clean and sanitary]
2, outpatient clinics, wards and other medical treatment to go smoking is prohibited; to keep clean and quiet.
3, to improve the hospital greening, landscaping and road hardening.
4, sewage and radioactive substances, such as treatment, toxic gas emissions and smoke should be in line with the relevant provisions
V. Medical management and technical level (480 points)
(a), medical management (105 points)
1. Establishment of a sound medical management organization, staffing is reasonable, and there is a corresponding work system. There is a vice president in charge of business work.
2. To develop a practical medical business construction of the hospital planning and work plan, and organization and implementation.
3. Establish and improve the medical work system diagnosis and treatment technical specifications, operating procedures and medical quality standards, and organize the implementation of
4. Establish and improve the medical quality management organization, formulate the quality management program, improve the quality management of internal constraints on the mechanism for quality management, quality education for the whole staff to improve the quality of consciousness, and regularly monitor and inspect the quality management of healthcare, medical technology and pharmaceuticals and medical records, Evaluate and propose improvement suggestions. The necessary medical quality management organizations are: medical quality management committee, case management committee (can be merged with the medical quality management committee), pharmacy management committee, hospital infection management committee, blood transfusion management committee.
5. Adhere to the third-level physician room visits and various case discussion system. Establish and improve the quality of medical records inspection and assessment system to strengthen the hospital, department, attending physician three-level inspection and assessment. Medical record writing requirements clear, standardized, complete, correct, timely, key points, analysis, pay attention to the quality of connotation, complete records of all levels of physician visits, rescue consultation, discussion of the views shall not be false.
6. Attaching great importance to medical safety, enhance the awareness of medical safety of all hospital personnel. Strengthen the management of medical defects, develop measures to prevent, timely occurrence and correction of errors and accidents. The errors and accidents that have been found should be reported in a timely manner, correctly dealt with, lessons learned, summarize the experience and improve the work.
The technical training and assessment of the management personnel, and the establishment of technical files of medical personnel.
Outpatient management, improve service attitude, simplify procedures, convenient for the masses, and strive to eliminate the "three long and one short" (registration, charging, medicine collection time is long, short consultation time) phenomenon, and have corresponding measures, internal and external gynecology and pediatrics should be an associate physician or above outpatient clinic every day, of which the internal medicine and surgical clinic should be guaranteed every day two Among them, the internal medicine and surgery outpatient clinics should ensure that two associate chief physicians or above are on duty every day, and they should undertake the task of guiding junior physicians to help them solve difficult problems. The number of physicians attending outpatient clinics should account for more than 65% of the total number of physicians on duty.
Strengthening the construction of the emergency department, the implementation of emergency first-responsibility system, in accordance with the Ministry of Health and the provinces, autonomous regions and municipalities directly under the Central Government, in the organization and leadership, the layout and personnel, beds, equipment, medicines, equipment, communications equipment and vehicles equipped to implement, to ensure that the medical treatment, rescue and transfer of patients need.
10. Adhere to the bedside shift system of critical rescue patients, closely observe the changes in the condition, and stand fast at their posts.
11. Medical and technical departments to establish and adhere to the idea of the first line of clinical services, strengthen management, quality assurance, improve work efficiency. Shorten the appointment and send the report time. Laboratory must establish an indoor quality control system, and participate in the Ministry of Health Clinical Laboratory Center or the region's Clinical Laboratory Center of the inter-room quality assessment activities (Class A hospitals must participate in the Ministry of Health Clinical Laboratory Center of the inter-room quality assessment activities).
Supervision and guidance of bedside research and clinical use of drugs.
(B), nursing management (75 points)
1, the implementation of the Ministry of Health on strengthening the management of nursing work of the relevant provisions of the Ministry of Health, the establishment of a sound nursing management system.
2, the implementation of hospital nursing under the leadership of the director of the Department of Nursing responsibility system. Drugs actively create conditions for the establishment of nursing vice president, the implementation of three or two management.
3, the effective implementation of the Ministry of Health, "hospital staff duties" of the relevant provisions of the Ministry of Health, to give full play to the role of intermediate and above technical positions in nursing, all levels of personnel in accordance with the technical position.
4, to carry out holistic care, there is a holistic nursing implementation program, through the model wards gradually to the whole hospital to promote.
5. Establishment of the overall care medical records, and constantly improve.
6, improve the disease care routine and nursing technical operation procedures, and seriously implement.
7, designate and improve the nursing quality management program, strengthen nursing quality management.
8, the Department of Nursing should be specifically responsible for education and continuing education of the deputy director, the wards should be responsible for teaching nursing staff.
9, strengthen the training of nursing staff, assessment, the establishment of business and technical files, the annual training rate of not less than 15%; graded training objectives, training programs, and organization and implementation; the training of nursing graduates from tertiary institutions, the use of the plan to implement the drug to the individual.
10, strengthen the training of nursing managers. Nurse manager or more managers must accept the national and provincial (autonomous regions, municipalities directly under the Central Government) health administrative departments organized by the management of professional post training and obtain a certificate of completion.
(C), "three basic", "three strict" training and management (45 points)
1, the hospital should adhere to the basic theory of health professionals, basic knowledge, basic skills (referred to as the "three basic"). "Three Fundamentals") training, cultivate strict requirements, strict organization, rigorous attitude (referred to as "three strict").
2, "three basic" training must be full participation, "three basic" assessment must be everyone up to standard.
3, the "three strict" style should be implemented into the medical business activities and management at all times.
4. Medical personnel mastered the first aid of cardiovascular resuscitation.
(D), hospital infection management (40 points)
1, the implementation of the Ministry of Health on strengthening the relevant provisions of the hospital infection, improve the hospital infection management organization, strict control of hospital infections.
2. There are hospital infection control program and management system, off the monitoring records, effects, evaluation and improvement facilities.
3. Establishment of strict sterilization, isolation and legal reporting of infectious diseases registration and reporting system.
4. There is a hospital infection education and training system, health care workers must establish the concept of asepsis, and strictly carry out the correct aseptic technology operation.
5. Rational use of antibiotics management.
6, the management of special areas should meet the requirements of the Ministry of Health "Hospital Infection Management Code.
7, disinfection supply room should meet the Ministry of Health "hospital disinfection supply room acceptance criteria (for trial implementation) requirements.
8, disinfected items, object surfaces, hands, air sampling and testing on-site to meet the specified requirements.
(E), blood transfusion management (15 points)
1. Strict implementation of the Ministry of Health, "blood collection and supply institutions and blood management methods" and related regulations, blood transfusion work into the region's blood three unified management. May not find their own blood source, self-picked and self-supplied blood source.
2. Establish and improve the blood transfusion work system, technical operation procedures and quality standards, and set up quality assessment indicators and quality management information feedback system.
3, clinical blood transfusion to strictly implement the blood registration system and blood approval procedures, blood transfusion must be implemented before the pre-transfusion testing and verification system.
4. Strictly grasp the indications for blood transfusion, rational use of blood and component blood transfusion management.
5, there is strict control of blood transfusion infection program and management system, the establishment of blood transfusion reaction and transfusion of infected disease registration report and investigation and treatment system.
6. The blood transfusion department should meet the requirements of the relevant regulations of the Ministry of Health.
(6) Technical level (200 points)
The hospital should have the level of medical technology appropriate to its functions and tasks, and be able to accept referrals from secondary and some tertiary hospitals. Can properly handle complex and difficult cases.
1. Clinical departments (see Annex I) (60 points)
2. Medical and technical departments (see Annex II) (60 points)
3. Key specialties (60 points)
(1), can carry out the "Annex I" listed in the key specialties of diagnostic and therapeutic techniques, each key specialty to reach the domestic or provincial advanced ranks. Domestic or provincial advanced ranks.
(2) The head of the department or subject leader should have the technical position of deputy chief physician, and have a certain degree of visibility in the domestic academic field of this specialty.
(3), the formation of professional talent echelon.
(4), can carry out experimental research corresponding to the focus.
(5), the Ministry (Commission) provincial scientific research results.
(6) International academic exchanges.
(7), ≥ 2 papers published in national (core journals in the field of specialty) or provincial academic journals each year.
4, Nursing (20 points)
(1), the key specialties of nursing to reach the domestic advanced level.
(2), to carry out holistic care, and can provide technical guidance to lower hospitals.
(3), able to undertake clinical teaching of mutually beneficial specialties in secondary and higher health schools.
(4), to carry out nursing research ≥ 2 nursing research or innovation projects per year.
(5), ≥ 3 papers published in provincial and above journals each year.
Six, teaching, research management and level (105 points)
(a), teaching and research management (45 points)
1. There are functions and tasks to adapt to the sound teaching and research management organization, the hospital leadership should be responsible for teaching and research management.
2. There are practical teaching and research planning and work plan, and the organization of implementation and evaluation.
3, there is a sound teaching and research work regulations, supervision, inspection and evaluation.
4, there is a relatively stable team of teachers and the establishment of the preparation, assessment, evaluation and inspection of the classroom system.
5. Teaching materials (e-learning materials, self-editing, etc.), teaching equipment (instrumentation, charts, specimens
this model, experimental animals, etc.) and the classroom, classroom, the number of diseases, patients can meet the needs of clinical teaching.
6, the implementation of the Ministry of Health on the "teaching hospital" management regulations.
(B), teaching, research level (60 points)
The hospital should have its functions and tasks appropriate level of teaching and research.
1 、Completion of clinical internships in higher medical schools and colleges
2. Independent training of master's or doctoral students.
3. Post-graduation education and continuing education and refresher education formal and rigorous effect.
4. Undertake ≥2 scientific research projects at the provincial level or above every year.
5. In the statistical year, in the national academic journals (core journals in the field of expertise) published ≥ 20 papers; participate in international academic exchanges ≥ 1.
6. According to the evaluation of the first three years of statistics, there are provincial scientific and technological progress (results) ≥ 1; ministries and provincial scientific and technological progress (results) ≥ 2 awards.
Seven, ideological and political work and medical ethics (65 points)
(a), the implementation of the Party's line policy, policy adhere to the socialist approach to hospitals, adhere to the purpose of serving the people, and put the social benefits in the first place. (10 points)
(ii), there is a corresponding management system and education body system. (5 points)
(C), adhere to patriotism, socialism, collectivism education, professional ethics education and legal education. (5 points)
(4), to strengthen the construction of medical ethics and medical style, through the "code of medical ethics of medical personnel and the implementation of measures", the establishment of sound measures for the clean practice of medicine, resolutely resist unethical practices, rewards and penalties are clearly defined. (13 points)
(E), patient-centered, quality service. (13 points)
(F), promote professionalism. Excellence in technology, serious and responsible for work. (6 points)
(VII), the establishment of a sound system of supervision of the public and society, patients, contracted units of the hospital's satisfaction ≥ 85%. (13 points)
VIII. Statistical indicators (100 points)
1. Admission diagnosis and discharge diagnosis compliance rate ≥ 95%.
2. Pre- and post-operative compliance rate ≥90%.
3. ≥50% compliance rate between primary clinical diagnosis and pathology.
4. Positive rate of X-ray computerized tomography (CT) examination ≥60% (without CT, this does not account for points).
5. Magnetic **** vibration imaging device (MRI) ≥ 70% positive rate (no MRI, this does not account for points).
6. Positive rate of large X-ray ≥50%.
7. The rate of X-ray radiography ≥40%.
8. Passing average of clinical chemistry inter-room quality assessment for the year (VIS ≤ 120).
9. Annual average pass in blood inter-unit quality assessment (improvement deviation index DI≤2).
10. The average score for the year on the Inter-Room Quality Assessment for Immunization is above the national average.
11. ≥80% correct national identification rate on bacterial inter-room quality assessment.
12. Autopsy rate ≥10% (except neonatal autopsy).
13. Emergency critical care patients resuscitation success rate ≥ 80%.
14. Ward critical patients resuscitation success rate of ≥ 84%.
15. Aseptic surgical incision healing rate of grade A ≥ 97%.
16. The rate of re-hospitalization of the same case within one week (determined at the time of examination of the disease, compared with peer hospitals) is at a lower level in peer hospitals.
17. The hospitalized maternal mortality rate is ≤0.02%.
18. Neonatal mortality rate of live births ≤ 0.5%.
19. Anesthesia mortality rate ≤ 0.02%.
20. Outpatient prescription rate ≥ 95%.
21. Outpatient medical record writing format pass rate ≥ 90%.
22. Grade A case rate ≥ 90% (no grade C cases).
23. Accompanying rate of ≤ 5% (excluding baby-friendly hospital obstetrics wards)
24. One person, one needle, one tube, one sterilization implementation rate of 100%
25. 100% inpatient therapeutic dietary meals
26. Inpatient meal rate of ≥ 80%
27. Hospital-acquired infections rate of ≤ 10%
28. Hospital infection underreporting rate of ≤20%
29. sterile surgical incision infection rate of ≤0.5%
30. bed occupancy rate appropriate range of 85%-93%
31. average hospitalization days ≤18 days
32. bed turnover ≥17 times/year
33. more than 10,000 yuan of medical equipment, instrumentation, ≥95% of the rate of perfection
34. 100% completion of directive tasks
35. 100% passing rate of the "Three Fundamentals" assessment of health technicians (passing standard is 80 points)
36. 100% passing rate of nursing technical operation (passing standard is 90 points)
37. 100% passing rate of basic nursing care (passing standard is 90 points)
37. Nursing care pass rate (passing standard is 90 points) 100%
38. intensive care first level of care pass rate (passing standard is 80 points) 90%
39. Nursing document writing pass rate (passing standard is 80 points) ≥95% (according to the needs of the reform of the nursing model of nursing documents by the local self determination).
40. The number of wards to carry out holistic care ≥ 20%
41. First aid items intact rate of 100%
42. Routine instrument disinfection and sterilization rate of 100%
43. Disposable syringes, transfusion (blood) after the use of disfigurement of the rate of 100%
44. Annual bedsore number of 0 (except in special circumstances)
45. Component blood transfusion utilization rate of 70% formula:
Annual use of various components of blood (bags) = annual use of various components of blood (bags) + annual use of whole blood (bags) × 100%
46. Cure and improvement rate of single diseases up to the standards of quality control of diseases issued by the Ministry of Health.
47. The death rate of single disease type is lower than the quality control standard of disease type issued by the Ministry of Health.
48. The postoperative ten-day mortality rate per unit of disease is lower than the quality standard of disease issued by the Ministry of Health.
49. The rate of underreporting of legally reported infections is zero.
50. The number of medical responsibility accidents is zero.