Quality management you can based on the Ministry of Health quality management year of the standard set, business development content is a lot!
Now section quality management you can do these is very standardized:
Medical institutions should strictly implement the core system of medical quality and medical safety, standardize the construction of medical institutions related to the section, the implementation of hospital affairs. Key requirements:
1. Strict implementation of the first diagnosis is responsible for the implementation of the core system of the three physician room, difficult cases, critical patient rescue, consultation, pre-operative discussion, death case discussion, handover and other core systems, to protect the quality of medical care and medical safety.
2. Implement the "Basic Standard for Medical Record Writing", standardize the behavior of medical record writing, strengthen the connotation construction of medical records, and improve the quality of medical records.
3. Implement the Basic Standard for Electronic Medical Records, standardize the construction of electronic medical record system and the clinical application of electronic medical records.
4. In accordance with the requirements of the "Guidelines for the Construction and Management of the Emergency Department (Trial)" and "Guidelines for the Construction and Management of the Department of Critical Care Medicine (Trial)" and other documents, further strengthen the construction and management of the emergency department, the department of critical care medicine, the department of pathology, the neonatal ward and other key departments and key departments, so that the personnel, equipment, facilities equipped with their functions and tasks, to carry out scientific, rational and standardized medical services.
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5. In accordance with the "Basic Standards for Hemodialysis Units in Medical Institutions", the rules and regulations of hemodialysis units, equipment and personnel are in accordance with the basic standards.
6. comprehensively implement the system of hospital affairs disclosure in hospitals, further implement the requirements of hospital affairs disclosure as well as the Measures for Supervision and Evaluation of Hospital Affairs Disclosure in Medical Institutions (for Trial Implementation), enhance the awareness of hospital affairs disclosure in medical institutions, and promote the further optimization of the service process and the internal democratic management of medical institutions in decision-making.
(E) to further strengthen nursing care, the implementation of basic care, improve nursing services, improve the quality of care.
1. Further implement the Nurses Regulations. The establishment of sound nursing regulations, disease care routine and nursing service norms and standards, the establishment of the nurse post responsibility system, standardize the practice of nurses; safeguard the legitimate rights and interests of nurses, contract nurses and the establishment of nurses with equal pay for equal work.
2. Implement the "Notice of the Ministry of Health on Strengthening Clinical Nursing Work in Hospitals" (Wei Medical Government Development [2010] No. 7) and related normative documents, improve nursing services, and strengthen nursing management.
Hospitals should refine the service connotation and service items of graded care according to the requirements of the "Guiding Principles of Graded Care in General Hospitals (Trial)" and "Basic Nursing Care Service Items for Inpatients (Trial)" and other documents, and incorporate them into the public affairs of hospitals to be announced to patients and the society. Hospitals should effectively strengthen the organizational leadership, improve and implement the strengthening of clinical care work of the rules and regulations, to mobilize all aspects of strength for the effective implementation of the work to provide convenient conditions and strong protection, and gradually reverse the situation by the patient's family or family members of the self-employed caregiver to undertake the patient's life care.
3. Solidly carry out the "quality nursing service demonstration project" activities, do a good job of 16 key tasks. In particular, the establishment of the performance appraisal system for nurses, clinical nurses nursing patients to implement the accountability system, the hospital clinical front-line nurses accounted for no less than 95% of the total number of nurses, according to the workload of clinical care and reasonable deployment of nurses manpower to encourage the use of forms of nursing instruments, hospitals to increase funding, improve the treatment of nurses, tilted to the clinical front-line, the establishment of incentives to create a good atmosphere for practicing.
(F) implement the "management of clinical application of medical technology", continue to do a good job in the management of clinical application of medical technology.
Conscientiously carry out the implementation of the "management of clinical application of medical technology", "cardiovascular interventional diagnostic and treatment technology management norms", "gynecological endoscopy diagnostic and treatment technology management norms" and other normative documents, the establishment of the medical technology access and management system, to promote the development of medical science and the rational application of medical technology clinical. Key requirements:
1. Provincial health administrative departments to do a good job in the jurisdiction of the medical institutions of medical technology access and audit of the organization and implementation of the work, the development and issuance of the jurisdiction of the second category of medical technology directory, to guide the medical institutions to carry out the second category, the third category of medical technology before the clinical application of the third-party technology audit of the application work. Focusing on strengthening the management of cell therapy technology, it will work with provincial food and drug supervision and management departments to comprehensively sort out the situation related to cell therapy products or technologies in this jurisdiction, get a clear picture of the bottom line, and immediately stop the clinical research and clinical application of unapproved cell therapy products or technologies.
2. Provincial health administrative departments in accordance with the provisions of the jurisdiction to carry out cardiovascular interventional diagnostic and treatment technology and gynecological endoscopy diagnostic and treatment technology of medical institutions to implement access management, guidance and supervision of medical institutions on the clinical application of medical technology standardized management.
3. Medical institutions as the main person in charge of the organization's clinical application of medical technology management of the first responsible person, responsible for the establishment of the organization's clinical application of medical technology to establish and improve the management of the relevant rules and regulations, the establishment of medical technology management files. The first category of medical technology to carry out technical audits, strict management; at the same time to do a good job in the second and third category of medical technology before the clinical application of third-party technical audit of the application, in strict accordance with the provisions of the clinical application of the relevant medical technology.
4. Medical institutions to establish a surgical grading management system, the development of specific implementation rules and management methods, the development of the institution's surgical grading catalog, in strict accordance with the provisions of the physician's professional and technical capabilities of the audit and pass before granting the appropriate surgical privileges, and the implementation of dynamic management.
5. Medical institutions to establish medical technology risk warning mechanism, develop and improve the medical technology damage disposal plan and organization and implementation.
(7) the implementation of the "Chinese People's **** and the State Drug Administration Law", "Regulations on the Administration of Narcotic Drugs and Psychotropic Substances", "prescription management", "Interim Provisions on Pharmaceutical Management in Healthcare Institutions", "the guiding principles for the clinical application of antimicrobial drugs", "Notice on Strengthening the Monitoring of the National Rational Use of Drugs", "China's National Prescription Set" and "Notice on Issues Relating to the Management of Clinical Application of Antimicrobials" of the General Office of the Ministry of Health. Notice on Relevant Issues of Clinical Application Management of Antimicrobial Drugs (Health Office of the Ministry of Health Medical Affairs [2009] No. 38) and other laws, regulations, rules and normative documents, and actively promote the rational use of medicines in clinical practice. Key requirements:
1. Establishment of the institution's pharmacy management organization, improve the relevant work and management system and conscientiously implement.
2. Implement the China National Formulary, formulate the institution's formulary, and seriously organize training, implementation and evaluation to promote the rational use of medication in the clinic.
3. Seriously implement the prescription review system, implement dynamic monitoring of prescriptions and over-warning, and intervene in irrational use of medication in a timely manner.
4. In accordance with the provisions of the Guiding Principles for the Clinical Application of Antimicrobial Drugs, establish and improve the hierarchical management system of antimicrobial drugs, clarify the prescription authority of physicians at all levels for the use of antimicrobial drugs, and take practical measures to promote the rational application of antimicrobial drugs.
5. Focusing on the strict control of prophylactic use of drugs in Class I incision surgery, the management of prophylactic application of perioperative antimicrobial drugs will be further strengthened. Strengthen the clinical microbiological testing, clinical application of antibacterial drugs and bacterial drug resistance monitoring work, the establishment of clinical application of antibacterial drugs and bacterial drug resistance early warning mechanism.
6. Do a good job of monitoring the rational use of medication, and collect and report data carefully, timely and accurately in accordance with the requirements of the monitoring work program.
7. To establish and improve the safety management system of poison, anesthesia, essence, discharge and other special drugs and earnestly implement it.
8. Establishment of clinical pharmacist system, there are clear clinical pharmacist job responsibilities and corresponding clinical pharmacist work and management system, clear their responsibilities and tasks in the medical quality management system and conscientiously implement.
(H) to further strengthen the safety management of key aspects of medical services to ensure medical safety.
1. Continue to promote and implement the "Patient Safety Goals".
2. Implement the "Surgical Safety Verification System" and do a good job in surgical safety verification.
3. Implement the "Hospital Work System", "Measures for the Management of Clinical Blood Use in Medical Institutions (Trial)", "Technical Specifications for Clinical Blood Transfusion", and "Management Specifications for Hospital Surgical Departments (Rooms) (Trial)" and other normative documents, and implement the checking system, and do a good job of safety verification of key aspects of medical services such as blood transfusion, medication, and testing.
(ix) implement the "Hospital Infection Management Measures" and related technical specifications, and strengthen the key departments, key departments, key aspects of hospital infection control.
1. Establish and improve the hospital infection management organization, hospital infection management department with clear responsibilities, reasonably equipped with full-time and part-time personnel, develop and implement the relevant rules and regulations in line with the actual hospital.
2. Actively carry out monitoring of hospital infections, the establishment of hospital infection information reporting system, to achieve timely detection of problems, timely treatment, and minimize the harm caused by hospital-acquired infections to patients.
3. Implement the "Hospital Operating Department (Room) Management Code (Trial)" and other relevant normative documents to strengthen the operating room, hemodialysis, intensive care unit, neonatal wards, disinfection and supply room and other key departments of the prevention and control of hospital infection. Medical equipment cleaning, disinfection, sterilization and other key aspects of hospital infection prevention and control in line with the norms.
4. Implement the "Code for the Management of Hemodialysis Units in Medical Institutions" and strengthen the management of hemodialysis units. The organization and management of hemodialysis room, quality control and hospital infection prevention and control measures are in line with the standard requirements.
5. Carry out hospital infection management of full-time and part-time personnel and hospital infection key departments, key links of medical staff of hospital infection prevention and control knowledge training, strengthen the awareness of hospital infection prevention and control, improve the level of hospital infection prevention and control.
(10) according to the "Pathogenic Microorganisms Laboratory Biosafety Regulations", "highly pathogenic pathogenic microorganisms infected with human beings laboratory and experimental activities biosafety approval and management methods", "clinical laboratory management methods in health care institutions" and other relevant provisions of the laboratory within the medical institutions to carry out a comprehensive inspection of biosafety, quality control and management, focusing on the inspection of system construction, hardware and facilities, Personnel management, emergency response, implementation of the implementation and other aspects of the situation.
(xi) Implementing the Chinese People's Blood Donation Law, Measures for the Administration of Clinical Blood Use in Medical Institutions (for Trial Implementation), Technical Specifications for Clinical Blood Transfusion, Circular of the General Office of the Ministry of Health on Further Strengthening the Management of Blood, and One Hundred Questions and Answers to be Known and Understood by the County Blood Bank Personnel to further standardize the management of clinical blood use by strengthening clinical blood use management, promoting scientific and rational use of clinical blood, and safeguarding the safety of clinical blood use by the public. Clinical science, rational use of blood, to protect the safety of clinical blood. Key requirements:
1. Medical institutions should comply with the relevant provisions of the People's Republic of China Blood Donation Law, and illegal collection of blood is strictly prohibited.
2. Hospitals above the second level should establish clinical blood transfusion management committees with clear responsibilities, do a good job in standardized management and technical guidance of clinical blood use, and actively carry out education, training and inspection of rational and scientific clinical blood use.
3. Medical personnel of medical institutions shall use blood in a scientific and reasonable manner according to the "Measures for the Management of Clinical Blood Use in Medical Institutions (for Trial Implementation)", "Clinical Blood Transfusion Technical Specifications" and guidelines.
4. Clinical departments of medical institutions should formulate weekly and monthly clinical blood use plans according to "Measures for the Management of Clinical Blood Use in Medical Institutions (Trial Implementation)", "Technical Specifications for Clinical Blood Transfusion" and the actual work situation, and carry out assessment of the medical staff's use of blood.
5. Medical institutions should equip the blood transfusion department (blood bank) with reasonable technical personnel, equipment and facilities, and the blood transfusion department (blood bank) should establish a quality management system, formulate a blood reserve plan, and do a good job in storing, testing, and distributing clinical blood.
6. Medical institutions should establish scientific and effective response plans for adverse reactions to blood transfusion and emergency use of blood, and implement them conscientiously.
(xii) establish a working mechanism to regularly investigate the safety of production safety infrastructure, technical equipment, operating environment, prevention and control means and other aspects of the existence of potential safety hazards, focusing on strengthening for the construction of production safety systems, safety management organization system, responsibility implementation, labor discipline, site management, accident investigation and handling of the work of rectification and other aspects of the weak links. Key requirements:
1. Establishment of a perfect production safety organization and leadership, management bodies, rules and regulations, operating procedures, standards, etc., clear staffing requirements, and seriously organize the implementation.
2. Strengthen the safety of production of important facilities, equipment, key equipment and devices of daily management and maintenance, maintenance and to ensure safe operation, to prevent leakage of electricity, gas, water; improve the labor protection supplies and the use of equipment.
3. Ensure that the fire fighting channel is smooth, no obstacles, complete fire fighting equipment, signs, special management, with fire warning system.
4. Strengthen emergency management, improve the development of various types of emergency plans, emergency rescue materials, equipment and maintenance, regular emergency drills.
5. Strengthen the safety management of important departments such as radiology, medical oxygen chamber, isotope room, oxygen supply room, dangerous goods warehouse, power distribution room, pressure vessel and elevator.
(xiii) continue to carry out the national blood collection and supply institutions special supervision and inspection of blood safety activities, activities by the Ministry of Medical Affairs issued separately.
(xiv) continue to carry out the national tertiary hospital medical records quality assessment activities, activity program issued separately by the Ministry of Medical Affairs.
(xv) to carry out the national tertiary hospitals advanced units of quality service evaluation activities, the program issued separately by the Ministry of Medical Affairs.
(16) to carry out the national medical institutions to supervise the work of radiotherapy inspection, activity program issued separately by the Ministry of Supervision Bureau.