(1) Medical Services (20 points)
The ability to provide a comprehensive continuum of 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, there are enough medical services radiation capacity, a certain percentage of annual discharges should come from regions or provinces outside the hospital.
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 rapid emergency response, to undertake emergency rescue tasks in disasters and accidents, and can accept batches of sick and wounded for in-hospital emergency.
4, to carry out mental health, genetic finding outpatient services and support, guidance community medical, nursing, rehabilitation medical services.
(2) teaching and research (15 points)
1, undertake clinical teaching and internship in higher medical schools, can train senior clinical medical personnel. It also undertakes the task of clinical specialty training for technical backbones of secondary hospitals.
2. Undertake national, provincial (autonomous regions, municipalities directly under the Central Government) 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, to carry out health education
2, undertake the local health administrative department assigned to preventive health care, the main chronic non-communicable diseases (cardiac, cerebrovascular diseases, malignant tumors) clinical epidemiological investigations and prevention and treatment work.
3, participate in urban primary health care. Hospital departments should be set up in accordance with their functions, tasks and scale. Functional departments should be set up in accordance with the principle of streamlining and efficiency, and adapt to the needs of management. Business departments should be under the guidance of the "Medical Institution Setting Plan" and on the basis of overall development, to strengthen the construction of specialties, and 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 of specialized departments
should be in line with the "Basic Standards for Medical Institutions" and the local <medical setup planning>.
2, the second level of professional departments
Internal medicine: there should be at least seven departments, the following departments in the ground for the mandatory departments: cardiovascular, gastroenterology, respiratory, hematology, neurology, nephrology, endocrinology and other professional 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 and family planning.
Pediatrics:There should be pediatrics, neonatal and other specialized departments.
3. Key Specialties
The key specialties shall be established 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 & lt; medical institution standards & gt; in addition to the information and statistics room should be set up library (room) hospitals 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 clinical nursing work in the number of nurses not less than 50% of the total number of health professionals, beds beds and ward nurses of the ratio of not less than 1:0.4, with a college graduate diploma in nursing not less than the total number of nurses Graduation diploma of not less than 20% of the total number of nurses, nursing department director, deputy director, internal, external, gynecology, pediatrics, emergency department, operating room and key departments, the head nurse should have the technical position of deputy director of nursing or above, the nurse in charge of nurses, nurses structure is reasonable (10 points)
(2), director, deputy director of the medical doctor, attending physician, resident physician institution is reasonable. (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)
(d), nutrition personnel (personnel with the technical position of dietician or above) to bed ratio of 1:200 (4 points)
(e), blood transfusion department professionals 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 (a), organization and management (25 points)
1, the hospital should have a sound scientific management system, the management of the work of a full-time or part-time personnel responsible for.
2, conscientiously 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's work system, all levels of service category Personnel job duties and pre-service education system, and organize and implement, and strengthen the standardization of management.
3, the hospital to implement the target management, should be formulated in the medium and long term development planning and annual plan. Good implementation of the progress of hair coordination, inspection, assessment and evaluation.
4, the 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, to understand the domestic dynamics of hospital management, strengthen the sense 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 staff on the leadership team structure, cooperation and job satisfaction ≥ 80%.
(2), information management (22 points)
1, there is a sound information management organization and the relevant work system
2, the library of Chinese and foreign language medical books and periodicals to meet the needs of medical education and research
3, archives management in accordance with the "scientific and technological institutions, archives management and upgrading methods" (the national second level) standards.
4, the medical, case statistics, finance, personnel, drugstore, and library information such as the implementation of electronic computer management.
5, all kinds of statistics, analysis, coding and information must be erased from the national and ministerial standards.
6, the hospital's information must be true, complete, accurate and timely analysis, feedback and utilization.
(C) financial management (15 points)
1, the strict implementation of the state's relevant financial system, strengthen the financial law.
2, the strict implementation of fees and charges, the implementation of the main service items marked price.
3, the implementation of the "thrifty hospital" policy, strengthen business management and gradually carry out cost accounting.
(D) equipment management (19 points)
1, there is a sound equipment management and maintenance organization, equipped with a certain number of engineers and technicians.
2, the hospital equipment 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, the hospital should focus on ensuring that the "basic standards for medical institutions" to achieve the equipment and other basic equipment, first aid equipment, monitoring equipment, the acquisition 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, special management.
(E) general management (19 points)
1, a sound general management system, job duties and work system
2, general material quota management, there is a sound procurement, receiving, 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 the three through (water, electricity, gas), timely treatment of three leaks (leakage of water, electricity, gas), to do down two satisfied (workers, patients).
4, there are unforeseen circumstances of the power supply measures to ensure emergency needs
(F), building management (8 points)
1, the hospital construction to have a master plan, new construction, alteration, expansion to the feasibility of the demonstration, the preservation of information 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 the direction of the people, logistics is reasonable. Indoor lighting, color design in line with hygiene requirements.
3, the old hospital buildings have a regular maintenance program, shall not engage in medical activities 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 chamber oxygen supply room dangerous goods warehouse isotope room power distribution room operating room bacterial room, etc.
Fire fighting equipment is complete, signs are conspicuous, regular inspection and replacement, and easy to use.
Strictly enforcing the management system of toxic drugs for medical use, narcotic drugs, and psychotropic drugs.
(VIII) environmental management (17 points)
1, keep the hospital clean and sanitary]
2, outpatient clinics, wards, and other medical treatment to prohibit smoking; keep clean and quiet.
3, to improve the hospital greening, landscaping and road hardening.
4, sewage, effluent, radioactive substances and other treatment, toxic gas emissions and smoke should be in line with the relevant provisions (a) medical management (105 points)
1, the 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, the development of practical medical business construction of the hospital's planning and work plan, and organization and implementation.
3, the establishment of a sound medical work system diagnosis and treatment technical specifications, operating procedures and medical quality standards, and organize the implementation of
4, the establishment of a sound medical quality management organization, the development of quality management program, improve the quality of management of the internal constraints on the mechanism for quality management, quality education of the whole staff to improve the quality of awareness, and regularly monitor and inspect the quality management of medical care, medical technology and drug case management, 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. Establishment of a sound quality inspection and assessment system of medical records Strengthen the hospital, department, attending physician three-level inspection and assessment. Medical record writing requirements clear, standardized, complete, correct, timely, key points, analysis, focusing on the quality of connotation, complete records of all levels of physician visits, rescue consultation, discussion of the views shall not be false.
6, attaches 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 handled, 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 critical rescue patients bedside shift system, closely observe the changes in the condition, and stand fast at their posts
11, medical and technical departments to set up and adhere to the idea of the first line of service for the clinic, to strengthen the management, to ensure the quality of the work to improve 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 responsible 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 technical positions.
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, the establishment of 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 ""). Three basic") training, training strict requirements, strict organization, rigorous attitude (referred to as "three strict").
2, "three basic" training must be full participation, "three basic" assessment must be up to standard.
3, the "three strict" style should be implemented into the medical business activities and management of the whole process.
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 with monitoring records, effects, evaluation and improvement facilities.
3, the 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, strictly carry out the correct aseptic technology operation.
5, there is a 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 and supply room should meet the Ministry of Health "hospital disinfection and 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. It is not allowed to find its 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 and reporting and investigation system.
6, blood transfusion department should meet the requirements of the relevant provisions of the Ministry of Health.
(6) Technical level (200 points)
The hospital shall have a level of medical technology appropriate to its functions and tasks, and be able to accept referrals from secondary and some tertiary hospitals. It can correctly 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 diagnosis and treatment technology, each key specialty to reach the domestic or provincial advanced ranks. Advanced domestic or provincial level.
(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 specialty nursing to reach the domestic advanced level.
(2), to carry out holistic care, and can provide technical guidance to lower hospitals.
(3) It is capable of undertaking clinical teaching of mutually beneficial specialties in secondary and higher health schools.
(4), nursing research nursing research or innovation projects ≥ 2 per year.
(5) ≥ 3 papers published in provincial or above journals every year. (A) teaching Scientific research management (45 points)
1, with the function and mission to adapt to the sound teaching and scientific research management organization, hospital leaders should be responsible for teaching, scientific 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, evaluation, 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 、Completing clinical internships in higher medical schools
2 、Independently training master's or doctoral students.
3, post-graduation education Continuing education and refresher education formal and strict effect.
4. Undertake ≥ 2 scientific research projects at the ministry, provincial or above level every year.
5, in the statistical year, in the national academic journals (core journals in this field) 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. (A), the implementation of the Party's line policy, policy adhere to the socialist approach to running the hospital, adhere to the purpose of serving the people, 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 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) 1, admission diagnosis and discharge diagnosis compliance rate ≥ 95%.
2, before and after surgery compliance rate ≥ 90%.
3, Clinical main diagnosis and pathology compliance rate ≥50%.
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 examination ≥50%.
7. The rate of X-ray nail photography ≥40%.
8, Clinical chemistry inter-room quality assessment of the year average pass (VIS ≤ 120).
9, blood inter-room quality assessment of the annual average pass (improved deviation index DI ≤ 2).
10, Immunization Inter-Room Quality Assessment yearly average above the national average.
11. Bacterial interlaboratory quality assessment national identification correct rate ≥ 80%.
12, autopsy rate ≥ 10% (except neonatal autopsy).
13, emergency critical patient resuscitation success rate ≥ 80%.
14, ward critical patient resuscitation success rate ≥ 84%.
15, aseptic surgical incision grade A healing rate of ≥ 97%.
16, the same case within a week of re-hospitalization rate (check to determine the type of disease, compared with peer hospitals) is at a lower level of peer hospitals.
17. The hospitalized maternal mortality rate is less than 0.02%.
18. Neonatal mortality rate of live births is ≤0.5%.
19, anesthesia mortality rate ≤ 0.02%.
20, outpatient prescription pass rate ≥ 95%.
21, outpatient medical record writing format pass rate ≥ 90%.
22, the rate of grade A cases ≥ 90% (no grade C cases).
23, accompanied by the rate of ≤ 5% (excluding baby-friendly hospital obstetrics wards)
24, one person, one needle, one tube, one sterilization implementation rate of 100%
25, inpatient therapeutic diet dining rate of 100%
26, inpatient dining 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, the appropriate range of bed utilization rate of 85%-93%
31, the average hospitalization day ≤ 18 days
32, the number of beds turnover ≥ 17 times a year
33, more than 10,000 yuan of medical equipment, instrumentation, ≥ 95% intact rate
34, 100% completion of directive tasks
35, health professionals "three basic" assessment pass rate (passing standard is 80 points) 100%
36, nursing technical operation pass rate (passing standard is 90 points) 100%
37, basic Nursing care pass rate (passing standard is 90 points) 100%
38, intensive care First-degree nursing 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 care model, nursing documents are determined by each region).
40, the number of overall care wards ≥ 20%
41, first aid items intact rate of 100%
42, routine instrument disinfection and sterilization rate of 100%
43, disposable syringes, transfusion (blood) device after the use of the disfigurement rate of 100%
44, the annual number of bedsore occurrence of 0 (except in special circumstances)
45. Calculation formula for 70% utilization rate of component blood transfusion:
Annual usage of various components of blood (bags) sub
Annual usage of various components of blood (bags) + annual usage of whole blood (bags) × 100%
46. Cure and improvement rate of single disease reaches the quality control standard of disease 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 standards for diseases issued by the Ministry of Health.
49. The rate of omission of statutory reporting of infections is 0
50. The number of medical liability accidents is 0