I. Single-disease clinical path refers to the patient care plan with scientific (or rational) and chronological order developed by medical, nursing and related personnel for a certain disease or a certain surgery after the diagnosis of the disease is clear.
Second, all departments in the hospital to carry out single disease clinical pathway are required to comply with this system.
Three, the departments of single disease clinical pathway should follow the scientific, safe, standardized, effective, economic, ethical principles, and with the department's functional tasks, need to have qualified professionals and technicians, the corresponding equipment, facilities and quality control system; medical staff at all levels to strictly implement the relevant disease diagnosis and treatment norms, routines, optimize the quality of quality control of the diagnosis and treatment of disease. The quality of the link.
Four, the establishment of the organization, strengthen supervision under the leadership of the President, the President in charge of the establishment of a three-tier medical control system is responsible for carrying out the quality of a single disease and clinical pathway work, and is responsible for the management of the work, supervision. The hospital has set up the Single Disease Quality and Clinical Path Management Leading Group, which is subordinate to the Medical Quality Management Committee of the hospital and is mainly responsible for formulating the rules and regulations related to the single disease quality and clinical path management, guiding, monitoring and evaluating the quality of the single disease quality and clinical path management of the hospital and coordinating the problems encountered in the process of the implementation of the clinical path. The relevant departments set up a single disease quality and clinical path implementation team, headed by the director of the clinical department, medical and nursing staff as members, the physician in charge of the implementation of the clinical path is mainly responsible for the implementation of the clinical path, clinical path of the implementation of the process of evaluation and analysis of the effect of the Department of Medical Services is responsible for the collection of related materials, records and collation and reporting of information.
Fifth, quality control, assessment and improvement (a) into the path of the selection of medical records required: 1. diagnosis is clear; 2. no other comorbidities, complications and concomitant diseases; 3. patient voluntary (signed informed consent); 4. diagnosis and treatment process did not appear in other obvious complications, comorbidities. (ii) Implementation of process control and variation analysis; (iii) single disease quality control indicators 1. Diagnostic quality indicators: diagnostic compliance rate in and out of the hospital, pre- and post-operative diagnostic compliance rate, clinical and pathological diagnostic compliance rate. 2. Treatment quality indicators: cure rate, improvement rate, failure to cure rate, complication rate, antibiotic use rate, morbidity and mortality, re-hospitalization rate in one week. 3. Hospitalization indicators: average hospitalization day, average hospitalization day before surgery. 4. Cost indicators: average hospitalization day, average hospitalization day before surgery, average hospitalization day before surgery, average hospitalization day before surgery, average hospitalization day before surgery, average hospitalization day after operation. 5. Cost indicators: average hospitalization cost, hospitalization cost per bed day, operation cost, drug cost, examination cost. (D) the main measures for quality control of single disease 1. according to the clinical pathway management requirements formulated by the Ministry of Health, strict implementation of diagnostic and treatment routines and technical procedures; 2. sound implementation of the diagnosis, treatment, care system; 3. reasonable examination, the use of appropriate technology, to improve the level of diagnosis and treatment; 4. rational use of medication, control of nosocomial infections; 5. to strengthen the management of critically ill patients and perioperative patients; 6. to adjust the service flow of the medical department to control ineffective hospitalization days. The process of adjusting the medical and technical department services, control invalid hospitalization days.
Sixth, the clinical departments should attach great importance to the quality of single disease management and control work, refine the work program, determine the specific objectives and implementation steps, the establishment of information reporting system, the completion of a single case of each case of diagnosis and treatment of cases to be registered, fill out a single case of quality control statistics, and effectively implement the work of the responsibility for the responsibility of the person to the person, the target to the person, to ensure that the clinical quality of the single case of the quality of clinical pathway management work successfully carried out. The management of the work is carried out smoothly.
Seven, the provisions of this regulation since the date of issuance of the implementation of the single disease quality and clinical path management leading group is responsible for the interpretation, explanation.