In order to y implement the spirit of the 18th CPC National Congress and the Sixth Plenary Session of the 18th CPC Central Committee, to reform and innovation to lead the work, accelerate the pace of development of the hospital, to play the leading role of traditional Chinese medicine in the region, and to actively build a modernized traditional Chinese medicine hospital with traditional Chinese medicine characteristics, Western medicine has the ability to combine the advantages of traditional Chinese medicine with the advantages of the combination of the East and the West, according to the district *** and the Municipal Bureau of Health "Thirteenth Five-Year "planning and the hospital" 13th Five-Year "development goals, after study, decided to officially start the creation of a third-level Chinese medicine hospital. In order to ensure that the creation of a solid, orderly progress, combined with the actual work, the development of this creation of the implementation of the program.
First, the guiding ideology:
(a) the implementation of comprehensive quality management and full quality control. The establishment of patient care from admission to discharge, including outpatient medical, ward medical activities throughout the quality control process and the whole quality management system. Define the quality content and incorporate it into the daily work of the medical management department, the implementation of dynamic monitoring and combined with the departmental target responsibility system to ensure the implementation of quality control measures.
(b) Based on various laws and regulations, rules and regulations and medical operating procedures, and constantly revise and improve the quality of the examination system, examination standards.
(3) Strengthen the implementation of various medical core systems, such as the third-level physician room system, consultation system and case discussion system and other core systems of medical quality in the hospital, the single medical behavior of each medical staff to maximize the guide to the correct diagnosis and treatment plan.
(d) The quality control department has planned and targeted interventions, and conducts specialized research and develops comprehensive interventions for quality problems that are influenced by multiple factors or synergistic effects of multiple diagnostic and treatment activities.
Second, the management system:
(a) the first level of management: hospital medical quality management committee, including: dean and medical quality control office, pharmacy management committee, hospital infection management committee, blood transfusion management committee, nursing quality management committee, case management committee and other organizations.
(ii) secondary management: the dean of each division.
(c) Third-level management: the relevant functional departments. Medical Department, Nursing Department, Hospital Sensory Department, Pharmacy Department, Equipment Department, Information Department, General Department.
(d) Fourth-level management: the head of each department and departmental medical quality controller.
Their duties are described as follows:
(a) the first level of management duties:
1, the Medical Quality Management Committee duties:
(1) education of medical personnel at all levels to establish a wholeheartedly for the patients, the implementation of "patient-centered" measures to improve medical style, improve service attitude, enhance the quality of medical services, and to improve the quality of medical care. The company's mission is to improve the quality of medical care, improve the service attitude, enhance the quality consciousness, ensure medical safety, and strictly prevent errors and accidents.
(2) Reviewing the rules and regulations of medical and nursing care in the hospital, and formulating the requirements for quality assessment and the system of rewards and punishments.
(3) grasp the diagnosis, treatment, nursing and other medical quality of each department. Timely development of measures to continuously improve the quality of medical care.
(4) Identification of major medical and nursing quality problems, problems in the quality of medical care, put forward rectification requirements.
(5) Regularly inform the whole hospital of major medical, nursing quality, hospital infection quality and treatment decisions.
(6) to the hospital about medical management of the system changes, quality measures of the revision of the discussion, put forward proposals, submitted to the President of the Office for consideration.
2, medical quality control office responsibilities:
(1) accept the leadership of the dean in charge and the Medical Quality Management Committee, the hospital throughout the monitoring of medical quality.
(2) regularly organize meetings to collect feedback from department directors and quality control group medical quality issues
(3) randomly check the quality of inpatient sessions in each department, report to the dean in charge or the hospital medical quality management committee to put forward interventions
(4) collection of outpatient and case quality control group feedback from the departments of the final quality of health care statistics, analysis, confirmation, notification of the corresponding The departmental staff and put forward corrective advice.
(5) monthly to the hospital to put forward the whole medical quality quantitative examination results, in order to link with performance pay.
3, the hospital infection management committee responsibilities:
(1) conscientiously implement the hospital infection management laws and regulations and technical specifications, standards, the development of the hospital rules and regulations for the prevention and control of hospital infections, the diagnosis of hospital infections and supervise the implementation of standards.
(2) According to the prevention of hospital infections and hygiene requirements, the hospital's architectural design, the construction of key departments of the basic standards, basic facilities and workflow review and comments.
(3) study and determine the hospital infection management program in this hospital, and the implementation of the program for examination and evaluation.
(4) Study and determine the hospital infection key departments, key links, key processes, risk factors and interventions to be taken, and clarify the responsibilities of all relevant departments and personnel in the prevention and control of hospital infections.
(5) study and develop the hospital outbreaks of hospital infections and the emergence of unexplained infectious diseases or special pathogens infection cases and other events when the control plan.
(6) the establishment of a meeting system to regularly study, coordinate and solve problems related to hospital infection management.
(7) According to the characteristics of pathogens in this hospital and the current status of drug resistance, with the Pharmacy Management Committee to put forward the rational use of antimicrobial drugs guidance.
(8) Other important matters related to hospital infection management.
4, nursing quality management committee responsibilities:
(1) according to laws and regulations to revise and improve the nursing management of all kinds of rules and regulations, operating standards.
(2) review the nursing department of nursing staff continuing education, research and teaching planning and implementation.
(3) Review of the hospital nursing duties at all levels.
(4) Determine the hospital nursing quality assessment standards and implementation programs.
(5) Quarterly nursing quality supervision and inspection of the whole hospital, to determine the nursing quality management of major problems.
5, Pharmaceutical Management Committee responsibilities:
(1) implementation of the "People's Republic of China *** and the State Drug Administration Law" and other relevant laws and regulations, the organization of the development of the hospital's response to the rules and regulations, the implementation of measures, and supervision of the implementation of the various departments
(2) based on the national basic drug directory in conjunction with the urban workers' and workers' health insurance drug directory to develop a hospital drug directory, and regularly revise the directory. Revision of the catalog.
(3) According to the hospital drug catalog, check and validate the hospital drug plan; review the purchase of new drugs in the hospital.
(4) Supervise the rational use of drugs in hospitals, focusing on the use of antibiotics in hospitals, serious adverse drug reactions and the handling of drug-borne accidents.
(5) Organize inspections of the use and management of medical toxic drugs, *** products, *** and radiopharmaceuticals in hospitals, and find timely correction of problems.
6, the case management committee responsibilities:
(1) implementation of the Ministry of Health on the writing of medical records of the regulations, the development of hospital medical records, quality control management measures.
(2) Regularly organize the medical staff to learn about the standard requirements for the quality of medical record writing.
(3) Regular quality checks on medical records.
(4) According to the quality of medical records feedback problems put forward specific measures of quality control.
(5) According to the quality of hospital medical records in conjunction with visiting other hospitals to propose a perfect revision program.
(6) Supervision and inspection of the safety management of hospital medical records.
7, blood transfusion management committee responsibilities:
(1) organization and implementation of the "People's Republic of China *** and the State Blood Donation Law" and other relevant laws and regulations.
(2) Develop and revise the hospital management system of blood transfusion management.
(3) Review the operating procedures of the hospital blood transfusion room.
(4) To guide the rational use of blood, blood components and blood products in clinical practice
(5) To investigate and deal with serious clinical transfusion reactions
(6) To organize the relevant personnel from time to time to solve the problems that need to be coordinated and solved in a timely manner in clinical blood transfusion.
(2) the duties of the second level of management:
Responsible for the organization and leadership of the management of the quality of medical care in each sub-discipline, to assist the President to do a good job in the coordination of the quality of medical care management in the hospital, supervision and other work.
(C) three management department responsibilities:
1, put forward the preliminary views of the management measures and programs discussed and adopted by the committees.
2, to complete the departmental provisions of the various work plans, work arrangements.
3, regularly complete the arrangements of the committees.
4, regularly complete the monthly quality inspection and analysis of quality problems and take measures.
5, supervision and inspection of hospital management laws and regulations, operating procedures, work systems and other hospital management norms.
6, monthly in the medical management committee under the coordination of the timely completion of the quality examination.
7, based on the hospital management evaluation system to establish a modern hospital management in line with the detailed departmental assessment rules, and at any time to amend the assessment rules.
8, the medical quality of the problems in the analysis and summary, proposed intervention measures.
9, the quality of the results of the examination of each functional department to analyze the reasons for the adoption of practical and feasible interventions.
(D) four management department responsibilities:
1, combined with the characteristics of the profession and the development trend, the development and revision of the department's disease diagnosis and treatment routines, drug use norms and organize the implementation of the responsibility for implementation to the individual, linked to performance pay.
2, regularly organize the department staff to learn medical and nursing routines, and strengthen the quality consciousness.
3, on time to participate in the meetings of the Office of Medical Quality Control, reflecting the problem.
4, collect medical quality problems related to the department, and put forward corrective measures.
Third, strengthen the individual self-management is to achieve the source of hospital quality control power:
Medical personnel self-management in the process of medical activities, medical personnel's personal behavior has a greater degree of independence, and their personal qualities, the level of medical technology on the quality of medical care has a greater impact on the quality of the quality of the quality of the major factors of instability, is the quality of control of the Basic point. In the process of quality control, special emphasis should be placed on the third-level physician responsibility system, consultation system and case discussion and other core systems to ensure the correct implementation of medical quality control.
(a) The requirements for doctors at all levels are as follows:
1. Outpatient physicians:
(1) Strictly implement the first physician responsibility system and consultation system.
(2) Ask for a detailed history, physical examination carefully, to have a preliminary diagnosis.
(3) Outpatient medical record writing is complete, standardized and accurate.
(4) Reasonable examination and standardized writing of application form.
(5) Specific medications are documented in the medical record.
(6) Drug usage, dosage, duration and compounding are reasonable.
(7) Prescription writing is qualified.
(8) the second visit to the diagnosis is not clear, the receiving physician should: a, recommended specialist consultation; b, please ask the superior physician treatment; c, hospitalization.
(9) the third visit diagnosis is still not clear, the receiving physician should: a, hospitalization; b, the patient refused to hospitalization need to perform the signature procedure.
(10) Admission of patients by specialty.
(11) According to the needs of the condition, indicate the special mode of admission: car or escort.
Quality indicators:
(1) According to the hospitalization orders issued by the outpatient doctors as the basis for the statistics of each doctor's outpatient diagnosis and the final diagnosis of the rate of conformity;
(2) According to the ratio of each type of daily outpatient doctors (chief of department, attending doctors, senior or junior doctors) to the statistics, and do a good job of accumulating the usual statistics.
2. Residents:
(1) Examination and initial treatment of patients within 30 minutes of admission.
(2) Emergency, critical and serious patients should be handled immediately and reported to the superior physician.
(3) According to the specified time to complete the medical record writing (24 hours for general patients, critical patients within 6 hours; the first medical record completed on the shift, emergency patients completed before surgery).
(4) medical record writing is complete, standardized, not missing items.
(5) Complete blood, urine and stool tests within 24 hours, and complete liver and kidney function, chest X-ray and other required specialty tests as soon as possible according to the condition.
(6) According to the specialty diagnosis and treatment routine to formulate a perfect diagnosis and treatment plan.
(7) For the patients under his/her care, he/she must make rounds once a day in the morning and once in the afternoon.
(8) According to the specified time and requirements to complete the medical record (rescue records, consultation, preoperative discussion, preoperative section, transfer and transfer, special treatment, patient family conversation and signature, discharge section and death discussion of all medical activities should be a detailed record).
(9) Changes in the condition of the patients under their care should be reported to the supervising physician in a timely manner.
(10) The process of diagnosis and treatment should comply with the provisions of disinfection and isolation, strict aseptic operation, to prevent the occurrence of hospital-acquired infections. If there is a case of hospital infection, fill in the form and report in time.
(11) Patients should be discharged with the approval of the supervising physician, who should indicate the discharge instructions and explain the precautions.