The summary is a product of the review of their own social practices, it is their own work practices as material, the use of the first person to write, which the achievements, practices, experiences, lessons learned, etc., have self-referential characteristics. I organized the "medical quality and safety management work summary" for reference only, I hope to help you!
Part I: medical quality and safety management work summary20xx year is our xx city xxxx hospital to create an important year of the third-class hospital. In one year, we have a comprehensive, new, more profound understanding of the understanding and experience of medical quality and safety, summarize the Department of Neurology in 20xx medical quality and safety work as follows:
First, we in the beginning of 20xx that is in January and February to develop a work plan , on the 20xx January-December Work priorities have a co-ordinated arrangement, the specific work of the implementation of people, responsibility for the implementation of the implementation of the core system of the implementation of the situation on a regular basis or from time to time to check, put forward the corresponding corrective measures. Under the leadership of all relevant functional departments of the hospital, we have continued to learn in our work, improved the doctor-patient communication system (including the first communication after admission, the doctor-patient communication before discharge, and the communication at any time when the condition changes), assessed the condition of patients hospitalized for more than 30 days, formulated the Neurology Clinical Diagnosis and Treatment Guidelines, operation norms, and operation procedures, improved the department's medication management (especially for the management of antimicrobials), the supervision of multi-resistant medications
The implementation of quality control of medical records. In 20xx years ago, the supervision of the quality of medical cases in my department is mainly for regular or irregular random inspection of medical records, in the shelves of medical records, the results of the inspection is recorded in the quality of medical records self-examination register, found that the problem in the morning meeting, in order to achieve the improvement of the *** with the improvement of the 20xx years later, according to the medical department were issued by the new quality of inpatient medical records scoring standards for the quality of the department of the case scoring. During the year, *** sampled more than 100 in-shelf medical records, with no grade B or C records. ****Checked 577 archived medical records from January to June 20xx, and found that the third-level physician checking system was implemented, but the implementation was not in place, there were scribbles in the medical records, the communication between doctors and patients was not signed, and the quality of the writing of medical records was not high. Such as changes in the development of the condition, prognosis, differential diagnosis too little **** sexual problems, and in July 20xx after the gradual rectification.
three, antimicrobial drug regulation. According to the situation of our department, in order to achieve the relevant objectives issued by the hospital, we strictly implement the graded management of antimicrobial drugs, many times to organize the department to study and assess the strict implementation of the use of antimicrobials applicable, our department successfully completed the objectives of the hospital that is the intensity of antimicrobials used in the 20DDD below. Over the past year, the intensity of antimicrobial use in our department has been 9-12DDD, and the standardization and process of using antimicrobials at the restricted level have been strictly implemented. The use of special grade antimicrobials are selected according to the results of drug sensitivity, and apply for a consultation organized by the pharmacy department before use. However, due to the lack of understanding of this work, there was one case in which no consultation was requested and the drug was selected based on the drug sensitivity results only. During the year, the inpatient department of neurology registered the use of antimicrobial drugs (including dosage, dosage form, and usage) in discharged patients. The total number of outpatients using antimicrobials was counted daily, and less than 20% of outpatients used antimicrobials.
The above work exists in the use of antimicrobial drugs before the failure to send microbiological examination in a timely manner, analyze the reason is mainly due to the presence of infections in patients after admission to the hospital, send the examination may affect and delay the diagnosis and treatment of the patient's timing.
Four, the implementation of the three basic three strict training . Since July 20xx since the development of the three basic three strict training program, the development of training standards, and training in the department of unarmed cardiopulmonary resuscitation process, lumbar puncture process, physical examination of the scoring standards.
Fifth, single disease and clinical pathway quality control work. So far my department *** have acute cerebral infarction, viral encephalitis, epilepsy persistent state of three kinds of diseases into the management of single disease and clinical pathway. Summarize 20xx, our department *** have 91 cases of acute cerebral infarction, enrolled in the single disease management, the average hospitalization cost of 14,100 yuan, the average number of days of hospitalization 14.2 days. Viral encephalitis 7 patients were enrolled in clinical pathway management and 0 cases of persistent status epilepticus. To summarize the above data, the persistent status epilepticus and viral encephalitis were enrolled in fewer cases. The small number of single disease network direct reporting is related to the installation of computers in our department only in March and our physicians do not pay enough attention to network direct reporting.
Sixth, teaching quality control summary . 20xx year I *** accept interns 72 people, including general practitioners transfer training 4 people, xx medical college 2 people, xx medical school 1 people, xx Chinese medicine college 34 people, xx medical college 31 people. *** Organized 16 lectures in the department on neurological physical examination, anatomy of the nervous system, diagnosis and treatment of cerebral hemorrhage, cerebral infarction, subarachnoid hemorrhage, epilepsy.
VII, hand hygiene, nosocomial sensation, multi-drug resistance work summary . 20xx since June, the department to carry out and participate in the hospital on hand hygiene, nosocomial sensation, multi-drug resistance related knowledge training for many times so far has been in the department of self-checking, hand hygiene and related knowledge, multi-drug resistance of the assessment has reached the standard.
eight, blood transfusion system of learning, implementation . 20xx year I seriously organized to participate in the hospital blood transfusion knowledge training once, the department *** with the study of nearly 10 times, serious study of the indications for blood transfusion, serious completion of blood transfusion application form filling, before and after the assessment of transfusion and transfusion of the implementation of the doctor's orders. 20xx year I *** two patients transfusion of autologous blood, after self-examination of transfusion of blood, and the patient's blood transfusion of the patient's own blood. In 20xx, two patients in our department **** were transfused with autologous blood, and the self-examination of the transfusion history scored more than 90 points.
Nine, the implementation of the system of intra-departmental discussion . My department has always insisted on difficult medical record discussion, critical case discussion, death case discussion, this year, the establishment and improvement of hospitalization more than 30 days assessment and discussion system. 20xx year my department **** there is a death case 1 person, the department organized discussions and records. Difficult cases were discussed five times, one critical case was discussed, and 70 patients were hospitalized for more than 30 days, which were written and recorded in a timely manner in strict accordance with the case discussion system. Among them, 10 statements were filled out for hospitalization over 30 days.
Ten, the implementation of critical value reporting system. Since May 20xx, **** receive critical value report 36 times, by the hospital and departmental self-check, July 22, 20xx missed registration once, the critical value of the patient Li Huaxiang (236417) blood culture detected G + positive bacteria, has been in the department for learning, and the parties involved in the punishment, has been formulated to rectify the measures.
XI, the establishment and improvement of multi-drug resistant bacteria (category II) register and related systems . Hospitalized patients transfer register *** transferred to 51 patients (since June 21, 20xx began to register). 20xx I *** reported multi-drug-resistant bacteria (Class II) 1 case, sputum culture detected Klebsiella, has taken bedside isolation, special instrument, strict hand hygiene and other appropriate measures. The patient is currently admitted to the hospital.
XII, the establishment and improvement of unplanned admission and re-entry registration and assessment system . Since May 20xx, **** there are two cases of unplanned return, Zhao Guoshu (245318) diagnosis of cerebral infarction recovery, 8 days after discharge to return to, return to the reason for the patient hopes that the limb function recovery is better, vascular disease did not reoccur. Xiao Huaixue diagnosed intracranial multiple occupying lesions (brain metastases?). The patient went to the XX clinic, but there were no beds in the upper department so he returned.
thirteen, improve the patient discharge follow-up system and further implementation . Among them by the nursing staff follow-up more than 70 cases, by the doctor follow-up patients 15 cases, at present the number of cases of physician follow-up less, analyze the reasons are: follow-up awareness of the lack of part of the follow-up patients have omitted to register the situation. At present, our department has a public cell phone, to further strengthen and implement the follow-up system for discharged patients.
XIV, improve the adverse event reporting system. 20xx I **** reported 14 cases of adverse events, including 1 case of water and electricity adverse events, 1 case of wall contamination, 3 cases of nursing adverse events, 9 cases of adverse drug events, analyze the reasons are: high-risk patients fell out of bed, fall events. Adverse drug events involving drugs: carbamazepine, ampicillin, amoxicillin flucloxacillin, cefmetazole, etc., analyzed mainly for the side effects of drugs, the main symptoms occurring are: rash, itchy skin, gastrointestinal tract adverse reactions, after stopping the drug to give anti-allergy treatment are cured.
Fifteen, the development of the perfect section of the complaint and management mechanism . 20xx year I *** have 2 cases of patient complaints, 20xx September 4, patient xxx family complaints discharged from the hospital with the needle water error, I take the implementation of self-examination of the situation, reported to the Department of Nursing and Medical Branch. After the implementation of the situation on the parties involved in the criticism and education and punishment. 20xx October 7, patient xxx complained of unsatisfactory blood pressure control, cerebral infarction foci have not disappeared, cough did not get better, the department to organize the whole group of physicians checkup, analysis of the reasons for the adjustment of the treatment plan, and to explain to the patient infarction foci can not be disappeared, please respiratory xxx director of the consulting to help diagnose respiratory lesions, the patient was discharged after the improvement.
Summarizing the above, we work in 20xx, the number of beds increased significantly, the workload increased in the case of medical quality control in the hospital under the leadership of the leadership of the hospital leadership and the relevant departments, through the **** with the efforts of all health care workers, did a lot of work. However, to summarize, there are many aspects of the implementation is not in place, there are many details are still lacking, such as the knowledge rate of the core system and the implementation of the relevant systems still need to make further efforts, the next year, we will strive to follow up with discharged patients in a single patient management, hand hygiene, medical advice review, case quality supervision to do more work, and strive to make the Department of the quality of medical care on a higher level.
Part II: Summary of medical quality and safety management20xx, according to the hospital medical quality and medical safety management committee work plan, developed a number of goals, and one by one implementation. However, there are still many shortcomings, in the future work still need to continue to improve and perfect, now the 20xx medical quality and medical safety management work is summarized as follows:
First, according to the law practice management
In order to further strengthen the implementation of the implementation of the practice of the law and the implementation of the safeguard of medical safety, the Medical Department to strengthen the hospital's practice of the law to carry out Check, supervision, implementation, feedback, organization and implementation of learning. The company's main goal is to provide the best possible service to its customers, and to provide the best possible service to its clients.
Second, the system construction, continue to improve the system
In the implementation of the medical regulations and operating standards at the same time, the hospital revised the medical, pharmaceutical, technical management standards and clinical specialty diagnosis and treatment standards.
Three, regular medical quality inspection, continuous improvement of medical quality: Medical Department of the whole hospital clinical departments to carry out quality inspection. Strictly in accordance with the "basic specification for the writing of medical records" requirements, the organization of at least one monthly supervision and inspection of the quality of medical records.
Fourth, the main deficiencies
1, the quality of medical care:
(1) the quality of medical documents in some departments is poor: mainly in the superior physician's examination records are exactly the same, the routine inspection is not perfect, the medical record appears in many logical errors (such as the patient's name, gender, age, entry and exit diagnosis is inconsistent, etc.), the important abnormal examination results without analysis, the patient's name, sex, age and diagnosis.
(2) The use of antibiotics in some departments is not standardized
(3) The work of the medical quality control team in some departments has not been implemented.
Fifth, the next stage of medical quality and medical safety management work focus:
1, to strengthen the study of laws and regulations, to strengthen the supervision, strictly good access to practice, so that medical personnel at all levels consciously according to the law, according to the practice.
2, to strengthen the study of various types of quality management system, to improve the quality of medical care, so that the diagnosis of a standard, the treatment has a basis.
3, do a good job in the "basic specification for medical record writing" (20xx version) training, improve the quality of medical record writing. Strengthen the "three basic and three strict", and constantly improve the quality of medical staff and practice level, and continuously improve the quality of medical services.
4, improve and unify the hospital medical quality evaluation standards.
5, further improve the hospital and departmental management organization, the implementation of hospital and departmental medical quality management system and responsibility.
6, now running medical records by the Medical Section of the regular organization and inspection; archived cases by the Medical Section and the case room organization of the relevant department director or quality control physicians regularly or irregularly supervise the inspection of medical records, at least once a month.
Article 3: Medical quality and safety management work summaryThe ultimate goal of health care reform is to provide patients with better quality medical services at lower cost. In recent years, our hospital and other municipal general hospitals, the same as the city's health care work as a basic part of the city, but also the formation of a unique maternal and child health care system, in the region for women and children to provide high-quality and inexpensive medicine and health care services, inheritance of the development of medical science and medicine and training of medical personnel have made unremitting efforts. In 20xx, our hospital adhere to the patient-centered service concept, to improve the quality of medical care, reasonable charges, reduce medical costs as the starting point, and strive to provide quality medical services for the majority of patients.
First, strengthen the quality of medical management, to ensure and improve the quality of medical services
(a) Medical quality management is the core of hospital management, improve medical quality is the management of the fundamental purpose of the hospital. The quality of medical care is the lifeblood of the hospital, the level of medical care, the quality of medical care is directly related to the survival and development of the hospital. In recent years, on the basis of medical quality service, our hospital has taken reducing medical quality defects, timely investigation and elimination of medical safety hazards, reducing medical malpractice disputes and eliminating medical accidents as the top priority. Our hospital strictly control the medical quality, each department strictly implement the rules and regulations, standardize the diagnosis and treatment behavior, adhere to the first diagnosis and responsibility system, three-level check-up system, difficult patient consultation, critical patients and pre-operative and post-operative discussion system. Enhance the sense of responsibility, pay attention to the dynamic analysis of medical activities, and take all kinds of precautionary measures, so as to prevent the danger from occurring in the first place. In order to improve the current demand for patients' right to medical information, improve the notification system.
Strengthen the quality control management.
(B) optimize the medical service process to improve the basis of medical quality. The service process is the structure and mode of operation of the medical institution. On the basis of not increasing the number of wards and health and technical personnel, the optimized medical service process determines the efficiency and competitiveness of the medical institution, which enhances the long-term viability of the hospital to a large extent, so that the available resources of the hospital can reduce duplication and waste by balancing the components of the process, and so that the existing hardware and software of the hospital can achieve a higher utilization rate and better utilization level, give full play to the abilities of professional and technical staff as much as possible, meet the needs of patients as much as possible, and achieve high economic and social benefits. Our hospital adheres to the patient-centered approach, makes efforts to optimize the medical process, facilitates patients' access to medical treatment, seeks for practical effects, enhances the service consciousness, optimizes the development environment, and strives to provide patients with warm and convenient, high-quality medical services. The introduction of various measures to facilitate the people, such as charging the registration window networking, to reduce the long queues for registration, some experts set up a special registration window, the introduction of telephone booking registration and other measures. The medical and technical departments have introduced time-limited commitments for the issuance of report forms. Nursing department in the implementation of star nurses selection activities emerged a number of advanced nurses, nurses and patients to build a bridge, the introduction of convenient measures to find ways to solve practical problems for patients, hospitalized patients on the nursing work satisfaction rate of 98%.
(C) the implementation of medical quality, medical safety education, is to strengthen the foundation of medical quality. How to improve the quality of the managers themselves and strengthen the quality of the whole hospital medical staff education is the basis of quality management. Improvement of medical quality can not be achieved solely by the efforts of a few managers or some of the medical staff, but the need for all hospital workers have a correct outlook on life, values, professional ethics; the need for a strong sense of responsibility, professionalism, compassion; the need to set up a solid awareness of the quality of medical care, medical safety; in the hospital to carry out a full range of high-quality service and "safety"
Safety is the biggest savings, accidents are the biggest problems. The hospital comprehensively carry out quality service and "safety is the biggest savings, accidents are the biggest waste" activities, stimulate the staff than learning, dedication to the spirit of professionalism, the formation of a better than, learn, catch up with, and surpass the good atmosphere.
(4) the establishment of a perfect quality management system, standardize medical behavior is the core. In recent years, our hospital from the strengthening of system construction, combined with the nature of the work of each post, the work content, the development of job responsibilities, medical ethics, personnel management, meetings, learning, attendance, safety and security, logistics management, financial and property management, management of statistical reports, management of medical documents and archives, awards, punishments, etc. *** five parts of the 241 management system; the development of the administrative management, medical quality management, nursing quality management, drug management, hospital infections, and the development of a new system to ensure the quality of life of the people. Management, medical quality management, drug management, hospital infection control management, financial management, as well as ideological and political work and medical ethics management and other 26 quality control assessment rules; the development of functional sections, business sections of the comprehensive goal of responsibility to achieve the first level of management, the first level to the first level of responsibility pattern. Clear responsibility to ensure that the function, so that the responsibility, power, clear, moderate interest, so that the management of the chapter to follow, the chapter must follow, and gradually improve the management of the legalization, institutionalization, standardization, standardization.
The establishment of a quality management system in line with the actual hospital, the hospital set up a president, vice president, medical department and clinical departments as members of the quality management, quality control assessment leading group, responsible for the quality management of the hospital. The whole hospital formed a main leader personally grasp; the leaders in charge of specific grasp; functional departments daily grasp; clinical departments when to grasp the medical quality, medical safety management pattern.
Strengthen the medical quality management adhere to the usual inspection and monthly, quarterly, annual quality control combined, strict link quality, to ensure that the end of the quality gate. "The three basics", "promote the three strict", the implementation of the "three doctors" check-up system. The Medical Department often organizes the hospital staff to study health laws, regulations, systems, operating procedures and operating routines, and recorded in the personal business records. In recent years, through the development of medical business management, efforts to improve the quality of medical care, to ensure medical safety as the goal of the full range of quality management, so that the hospital's work to achieve the expected purpose of the integrated target responsibility system, medical quality gradually improved, the gradual reduction of safety hazards, no medical accidents, medical disputes are also relatively few, improve the quality of medical care, to ensure medical safety for the next year, the second class A maternity and child health care hospital review and reassessment work to prepare for The hospital review and reassessment work to prepare.
Second, improve the quality of care, reduce medical costs, is the most fundamental goal of the hospital
Improve the quality of care, reduce the cost of medical care, so that the people with less money to enjoy the more excellent health care is the fundamental goal of the reform of the health care system. Reduce medical costs, improve economic efficiency is also every dean, patients, social people, medical staff, etc. *** with the concern of social issues, it is the nature of society and the direct reflection of the purpose of the service. As a hospital administrator to strengthen the quality of scientific management, reduce management costs to start from improving the quality of service and business quality, highlighting the "technology" to win rather than "fee" to win.
(a) This year, our hospital strictly implement the drugs, large medical equipment and equipment procurement tender
bidding policy and drug "Shunga price" policy, the implementation of separate accounting for medicine, respectively, management, adjustment of medical service prices, to reduce the total cost of medical care, reduce the proportion of drug revenue in the total income of the hospital. The economic burden on patients has been reduced in real terms. To realize the goal of "reducing patient costs", the first thing is to solve the problem of ideological understanding and improve medical ethics, to adhere to the "serve the people" purpose, correctly deal with the relationship between social benefits and economic gains, the social benefits in the first place, to prevent the one-sided pursuit of economic gains and prevent We should adhere to the principle of "serving the people", correctly handle the relationship between social benefits and economic benefits, put social benefits in the first place, and prevent the tendency of one-sidedly pursuing economic benefits and neglecting social benefits. "Patient-centered", with the interests of the majority of patients as the prerequisite, effectively treating medical and nursing work as a noble profession, dealing with the interests of hospitals, individuals and patients; effectively achieving reasonable inspection, rational use of medication, and providing high-quality services at low prices, and practicing the "Three Represents" in the medical work. "Three Represents" important thought.
Part IV: Summary of medical quality and safety managementOver the past year, our hospital in the Health Bureau under the direct and correct leadership, seriously study the Ministry of Health, the Bureau on the reform of the health care system of the relevant spirit of the reform of the health care system, into the reform of the medical and health system, open up the health care market, and actively participate in the market competition. Adhere to the patient-centered, all for the patient service, and constantly improve the quality of medical services, improve service attitude. Strictly grasp a variety of medical quality control indicators, improve the overall level of medical effectively reduce medical disputes, to eliminate the occurrence of medical errors.
Now on this year's medical treatment and medical safety work summary
First, effectively improve medical services
Strengthen the medical ethics and medical laws and regulations, rules and regulations of education, so that the majority of staff to further establish the wholeheartedly for the patient's services, adhere to the "patient-centered" service concept. The service concept of "patient-centered", seriously carried out the content of "good service, good quality, good medical ethics, public satisfaction" of the "three good and one satisfied" activities, and constantly improve the level of medical services. Innovative service process, optimize the diagnosis and treatment environment. We have enriched the outpatient physicians, rationalized the working hours, and insisted on opening the clinic on time to ensure that the patients are treated in a timely manner. The establishment of an open and transparent system of medical expenses, the implementation of a one-day list system for hospitalized patients, patients can always query the price of drugs, hospitalization costs and other details, by the patient's praise.
Strengthen doctor-patient communication, improve the content of communication, improve communication, focus on the effect of communication, and effectively strengthen the basic management of the hospital, the establishment of a sound medical safety management organization, the implementation of the core medical work system and safety measures, to ensure that medical instruments and equipment are legal, reasonable, and safe to use, to avoid the occurrence of medical errors and accidents. Strict technical access system, standardize medical practice behavior. Seriously implement the "Drug Administration Law", "Medical Devices Supervision and Administration Regulations", and strengthen the supervision and management of the purchase, storage and use of drugs and medical devices.
Two, effectively improve the quality of medical services
Medical quality and safety is related to the health of the masses, is the lifeline of medical services, is the core content of hospital management and eternal theme. Medical safety is carried out first to improve the quality of medical care, enhance the level of service. Strengthen medical quality management, pay close attention to the implementation of rules and regulations, always adhere to the "patient-centered", quality as the core, quality and safety as the theme, seriously implement the rules and regulations, job responsibilities, strict implementation of diagnosis and treatment of technical routines, the implementation of the various systems to the various links.
The establishment of xx town health hospital medical quality management group, strengthen the quality management of medical documents, strict implementation of the "basic norms of medical record writing", the quality of the case implementation of the whole monitoring and management. The development of xx town health hospital professional and technical personnel assessment program, in order to implement the reward and punishment mechanism, to ensure that the rewards and punishments in place, the quality of medical services assessment of the outstanding results of the department or individual to give praise and material incentives; the quality of medical services assessment of the results of substandard department or individual in addition to financial penalties and hospital-wide notification of the criticism, to strengthen the "three basics and three strict" training, held from time to time at all levels and types of personnel. The company's main goal is to provide the best possible service to its customers, and to provide the best possible service to its customers in the future.
Three, the establishment of a perfect quality management system, standardize medical behavior is the core
This year, our hospital from the strengthening of the system construction, combined with the nature of the work of the job, the work content, the formulation of the relevant management system and assessment rules, and the development of the functional departments, business departments, the comprehensive goal of the book of responsibility to achieve the first level, one level to one level, one level to one level, the pattern of responsibility. The pattern of one level being responsible to one level. Clearly responsible for ensuring that the function, so that the responsibility, the right to clear, moderate interest, so that the management of the chapter to follow, the chapter must follow, and gradually improve the management of the legal system, institutionalization, standardization, standardization.
Four, the proper disposal of disputes between doctors and patients in accordance with the law
According to the relevant laws and regulations, the disposal of disputes between doctors and patients into the legal system, standardized track, to safeguard the legitimate rights and interests of doctors and patients. According to the "Medical Accident Handling Regulations" set up xx township health hospital medical dispute coordination and handling group, according to law properly deal with the medical disputes. Adhere to the principle of prevention in the first, found at an early stage, disposed of in the small, establish and improve the prevention and disposal mechanism of doctor-patient disputes, the careful implementation of relevant preventive and control measures, and strive to resolve various types of doctor-patient disputes, to prevent the doctor-patient disputes triggered by mass incidents and vicious incidents.
V. Strengthen security measures to ensure the safety of the hospital
Regularly organize key positions staff learning and training, the implementation of various internal security measures. Regularly and irregularly on the fire safety to carry out a comprehensive inspection, easy to cause fire, the storage of dangerous goods and the concentration of people to focus on the inspection (such as the drugstore, outpatient, wards, etc.), on the fire facilities to carry out regular maintenance and replacement to ensure that the fire equipment is in good condition. Our hospital implements the general duty system of hospital leaders, clearly defines each person's time period division of labor, and conducts hospital-wide inspections during the duty period, so as to effectively implement the security precautionary measures of fire prevention, anti-theft, and anti-sabotage into practice. Strictly implement the security responsibility system, to improve the destabilizing factors investigation, found that the problem is immediately rectified. The development of human defense, material defense, technical defense emergency measures to ensure that the hospital does not appear major security incidents.