Chapter 1 General Rules
Article 1 purpose of the assessment
To further strengthen the management of the hospital's clinical departments, standardize their workflow, mobilize the enthusiasm of the clinical departments, strengthen the responsibility of the managers and employees, enhance the effectiveness of the staff to enhance the overall capacity of the hospital and the overall quality of the hospital, the development of this assessment system.
Article 2 appraisal principles
1. The assessment of the clinical departments should follow the "just, fair and open" principle, to ensure that the assessment is objective and fair.
2. The assessment should follow the principle of concise standardization and easy to operate, do not make the assessment a formality.
Article 3 of the assessment basis
The assessment of the clinical departments based on: national health, medical, pharmaceutical, medical insurance and other laws and regulations; the hospital's policies and regulations; the hospital's rules and regulations; the clinical departments of the work of the summary; the hospital's work inspection records.
Article 4 assessment results
The results of quantitative assessment are mainly used for the issuance of departmental performance pay, training and education, honor evaluation, reward and punishment management.
Chapter 2 appraisal organization and responsibilities
Article 5 appraisal organization
The hospital has set up the Appraisal Committee, which is mainly responsible for the appraisal of each clinical department.
Article 6 Main Duties of Appraisal Organization
1. The Appraisal Committee of the hospital is responsible for the specific appraisal work of each clinical department.
2. The work undertaken by the Department of Human Resources includes: organization, training, guidance and service of performance appraisal; supervision, inspection and coordination of performance appraisal; punishment for violation of regulations and acceptance of departmental or individual complaints; aggregation, analysis, summarization and notification of the appraisal results; filing and application of the results.
Chapter 3 appraisal cycle and procedures
Article 7 appraisal cycle
1. Quarterly appraisal. Completion of the previous quarter's appraisal within the first 10 working days of the next quarter.
2. Annual appraisal. Completion of the previous year's appraisal within the first 10 working days of the following year.
Article 8 Appraisal Procedures
1. The Human Resources Department of the hospital will hold an appraisal meeting at the beginning of the quarter, which is responsible for the organization and deployment of the appraisal.
2. Each clinical department provides the work report of the previous quarter.
3. The hospital's appraisal committee evaluates each department.
4. The Human Resources Department statistically summarizes the results of the assessment and reports them to the hospital's Hospital Management Committee for review, and the results of the review are fed back to the departments by the Human Resources Department.
5. If there is no objection from the clinical departments, the Human Resources Department will report the assessment results to the Finance Center, which will initiate the performance pay and bonus procedures in accordance with the relevant hospital regulations.
6. If there is no objection from the clinical departments, the Human Resources Department will communicate with them to mediate or go through the performance complaint procedure.
Chapter 4 assessment content and standards
Article 9 assessment content and standards
The assessment of the hospital's clinical departments, the assessment project mainly includes work efficiency, management effectiveness, medical quality, medical safety, quality of service, labor discipline and medical ethics*** seven aspects, the specific indicators and standards are shown in the attached table.
Chapter 5 appraisal discipline
Article 10 of the appraisal department has hindered the investigation or falsified to provide false information, depending on the severity of the situation to be punished.
Article 11 of the assessment team members should consciously seek truth from facts, fairness and decency, can objectively and accurately reflect the situation and opinions of the investigation, on time and high quality to form the assessment materials.
Article 12 of the deliberate disruption of the order of the assessment, deliberately disturbing people, once found to be dealt with severely.
Chapter 6 Supplementary Provisions
Article 13 of this system refers to the hospital's other assessment system to deal with the outstanding matters.
Article 14 of this system of final interpretation of the hospital's Human Resources Department.
Chapter 7 Required Forms
Contents and Standards for Quantitative Assessment of Clinical Departments
Assessment Items Quantitative Indicators Scoring Standards
Work Efficiency Workload Plan Completion Rate Workload plan completion rate up to ____%, for every drop of ____%, minus points
Bed Utilization Rate Bed utilization rate not less than ____%, for every drop of ____% , minus points
Average hospitalization days Average hospitalization days less than days, for each extension of 1 day, minus ____ points
Management effectiveness Departmental cost to medical income ratio Departmental cost to medical income ratio control at ____, for each higher ____, minus points
Drugs cost ratio Drug cost ratio of less than %, for each higher ____%, minus points
=Cure rate Cure rate up to ____%, minus ____ points for each decrease in ____%
Diagnostic Compliance RateDiagnostic Compliance Rate up to ____%, minus points for each decrease in ____%
Number of Violations of Diagnostic and Medical CodesMinus points for each violation of diagnostic and medical codes detected
Aseptic Surgical Incision Infection RateAseptic surgical incision infection rate less than %, minus points for each increase in ____%
Medical record qualification rate 1. Grade A medical record qualification rate up to %, for every decrease ____%, minus points 2. Grade B medical record qualification rate up to %, for every decrease ____%, minus points 3. For every case of Grade C medical record, minus points
Focused Case Discussion RateFocused Case Discussion Rate up to 100%, for every decrease ____%, minus points
Medical Quality Comprehensive Score to the quality management section inspection scoring The comprehensive score of medical quality is based on the inspection score of the Quality Management Department. For every decrease of ____, points will be deducted
Medical Safety Medical Dispute Incidence Rate The incidence rate of medical disputes is controlled at less than %, and for every increase of ____, points will be deducted
The Number of Medical Accident Incidents The number of medical accident incidents will be deducted by points for every occurrence of medical accidents
First-aid Goods Intactness Rate First-aid goods intactness rate is up to ____%, and for every decrease of ____, points will be deducted. ____ points
Service QualityNumber of valid patient complaintsEvery 1 valid patient complaint, minus points
Patient SatisfactionPatient Satisfaction %, for every drop ____%, minus points
Labor DisciplineNumber of Days of AbsenteeismAccumulated absenteeism of departmental employees is controlled to be within days, and for every day in excess of 1 day, minus points
The Number of Violations of Work DisciplineFor every 1 violation of work discipline by departmental employees, minus points
Work Discipline Violations Violation of work discipline, minus points
Medical ethics in accordance with the hospital's "medical ethics assessment of reward and punishment system" to implement the assessment
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