The quality of medical care is fundamental to the survival and development of a hospital, and is a reflection of the level of a hospital, medical safety management is an important aspect of medical quality. I have organized the medical quality and safety management year-end work summary for you, I hope it will help you.
Medical quality and safety management year-end summary of the work of a20xx year I seriously study, to "take the initiative to create a first-class" activities as an opportunity to create a "second-class" Chinese medicine hospital as the goal, closely around the "patient-centered," the "first-class," the "second-class" Chinese medicine hospital. "Patient-centered, quality-centered" purpose, to play the advantages of Chinese medicine, improve the quality of medical care. At the same time, constantly strengthen the medical safety management, investigate medical safety hidden danger, protect the quality of medical care and medical safety, and strive to achieve for the people to provide safe, effective, convenient and inexpensive medical services.
A medical quality and safety management
(a) strict implementation of the core system of medical care, strengthen the management of medical business
The hospital established a medical quality management committee, the president is the first responsible person. The establishment of the hospital two-level medical quality management organization quality assurance system, the director is responsible for the medical quality management of this section, the medical department organization and implementation of the overall medical quality management, guidance, supervision, inspection, assessment and evaluation of medical quality management, regular medical quality and safety education, medical quality management and continuous improvement program, and the establishment of the quality management goals, targets, plans, measures, results The hospital has also established quality management goals, targets, plans, measures, effects, evaluations and information feedbacks.
The hospital has established and improved the accountability system for medical quality management, strengthened the basic quality, link quality and end quality management, and standardized diagnosis and treatment behaviors with the Diagnostic and Treatment Routine and Clinical Path. Strict implementation of the weekly business review, a monthly administrative review and holidays dean, functional departments, section chief inspection system, timely detection of problems to solve the problem. The annual volume of medical services: outpatient emergency __, up __%, hospitalization __, up __%, bed utilization rate __%, various types of surgery __, up __%. The hospitalization cure and improvement rate was __%, and all kinds of critically ill patients were rescued __ times, with the success rate of rescue __%. Throughout the year, medical checkups were completed for some county-level leading cadres and enterprise employees of some units, *** counting __ person-times. The county's chronic disease physical examination __ times, the disabled physical examination __ times.
(2) optimize the medical service process, improve the quality of medical services
I adhere to the "patient-centered" service concept, to "three good and one satisfaction" as the goal. The company has improved the medical service measures to achieve a reasonable arrangement, warm service, smooth flow, strengthen the communication between doctors and patients, promote the harmonious relationship between doctors and patients, and improve patient satisfaction; actively improve the medical environment, keep the hospital clean and orderly. Solidly carry out the "quality nursing service demonstration project" activities, effectively strengthen nursing management, standardize practice behavior, solid basic nursing services, fully mobilize the enthusiasm of the majority of nursing workers, and strive to provide patients with safe, high-quality, satisfactory nursing services.
(C) carried out a quality assessment of medical records writing activities
In accordance with the State Administration of Traditional Chinese Medicine, "the basic norms of Chinese medical records writing" and "medical institutions, medical records management regulations", to further standardize the management of medical records. The establishment of the assessment mechanism, monthly outpatient prescriptions, inpatient medical records for a random review activities to strengthen the medical record writing assessment. Inpatient medical records of Class A medical records rate _%, no Class C medical records.
(4) strengthened the hospital infection management
In accordance with the "Hospital Infection Management Measures" and the second level of Chinese medicine hospital accreditation standards related to the requirements of the development of a variety of contingency plans, the stomatology, operating room, emergency department, endoscopy and laboratory and other key departments of infection management to strengthen the management and monitoring. Developed the "Hospital Infection Management Manual", "Department of Hospital Infection Quality Self-Inspection Book", set up a hospital infection quality control committee, to strengthen the hospital infection prevention and control of infection management, in the biomonitoring, disinfection, medical waste recycling, destruction and other aspects of the strict implementation of the relevant systems, the rate of medical waste disposal of ___%, the rate of hospital infections of ___%, carried out the year the rate of the current patient ___ times, the actual rate of ___%, to carry out biomonitoring of ___, the qualification rate of __%, quarterly training in hospital-acquired diseases related knowledge ___ times, the participation rate of __%, the year ___ hospital-acquired diseases theoretical knowledge examination, the pass rate of __%, the year no large hospital-acquired infections occur.
(E) to strengthen the emergency, first aid work
The establishment of the first aid team based on Chinese medicine personnel to strengthen the basic skills of medical personnel training in first aid, medical staff can skillfully and correctly use a variety of resuscitation equipment, mastery of a variety of first aid techniques. Strengthen our hospital inter-departmental coordination capacity, in order to adapt to the needs of emergency rescue work in complex situations.
(F) to strengthen the management of clinical blood transfusion
to strengthen the management of blood transfusion, the strict implementation of the "Clinical Blood Transfusion Technical Specification" and "medical use of blood management methods" and other systems, the strict implementation of blood transfusion technology operating procedures, grasp the indications for blood transfusion, scientific and rational use of blood, the development and implementation of the control of transfusion of infected programs. The annual blood transfusion ___ person times, blood transfusion volume ___ ml, component blood transfusion 100%, no violation of blood use and blood transfusion errors occurred.
(VII) strengthened the quality control of clinical testing
According to the "Pathogenic Microorganisms Laboratory Biosafety Regulations", "Department of Clinical Laboratory Management Measures" and other relevant provisions, to comprehensively strengthen the laboratory biosafety, quality control and management work; to provide a 24-hour emergency testing services to meet the clinical The company also provides 24-hour emergency testing services to meet clinical needs, and conducts indoor quality control and inter-room quality evaluation of clinical testing programs.
(H) infectious disease management
According to the relevant requirements, regulations and timely reporting of various types of infectious diseases, the year *** reported all types of infectious diseases _ _, deaths _ _, no omission, late reporting and false reporting of cases. Epidemic information network is running normally.
(IX) to strengthen the regular assessment of physicians
According to the Ministry of Health, every two years on the regular assessment of physicians, the establishment of adverse medical behavior, tainted record file on the physician, the requirement for physicians to have good professional ethics, medical ethics. Continuing education credits are up to standard. 20xx in 20xx on ___ licensed physicians, physician assistants to carry out the examination, all qualified.
(10) clinical path management
In view of the actual hospital, the medical department developed the hospital's Chinese medicine clinical path management regulations, and took the lead in the development of ___ pilot specialties, ___ pilot diseases of the clinical path of the implementation of the program, the year into the path of the ___ cases, the rate of entry ___%, variation ___ cases, the number of cases out of the path of the number of cases of clinical path Percentage of all discharged cases _%. Average hospitalization days _ days.
(XI) Chinese medicine guidance
In the county medical association with the assistance of the county, held ___ times the county township health centers and rural doctors in Chinese medicine appropriate technology training will be training rural doctors *** counting ___, teaching ___ hours, not only so that the rural doctors are able to skillfully grasp and application of appropriate technology of traditional Chinese medicine, but also the farmers can also have the appropriate technology of traditional Chinese medicine, and the farmers can also have the appropriate technology of traditional Chinese medicine. For the Chinese medicine appropriate technology can also have a deep understanding and understanding, fully enjoy the "less money, cure" benefit.
Second, the quality of care and safety management
Nursing work to the patient-centered, improve the quality of care, deepen the quality of care services, to ensure that nursing safety as the goal. Seriously implement the rules and regulations and strictly enforced. Through quality control to block and change certain bad state, so that the quality of care is always in line with the quality standard requirements. Adhere to the regular monthly meeting of the head nurse; quarterly nursing quality management meeting; nursing adverse event analysis and discussion of the special meeting; nursing, medical, logistics multi-departmental coordination meeting, etc., strictly according to the work plan to complete the key work, summarize the strengths and weaknesses of the previous month's work, and put forward the corresponding corrective measures. The core system of nursing is seriously implemented, and the work of quarterly room visits and difficult case discussions is adhered to.
Continuing to carry out in the inpatient department "quality nursing service demonstration ward" activities, inpatient satisfaction is __%. Annual completion of business indicators: rescue of critically ill patients ___ times, rescue success rate __%, the number of hospitalized patients ___ times, outpatient observation of patients ___ times, intravenous infusion ___ times, blood transfusion ___ times, intravenous injection ___ times, intramuscular injections and various types of skin tests ___ times, catheterization ___ times, oral care ___ times, gastric lavage ___ times, oxygen inhalation ___ times, ultrasound nebulization ___ times, the number of surgical procedures ___ times, traditional Chinese medicine nursing ( fire cupping, moxibustion strips, external application of traditional Chinese medicine, fumigation of traditional Chinese medicine, functional exercise, fracture healing instrument, auricular acupoint bean burrowing, TDP, etc.) ____ times. Nursing instrument writing qualification rate __%, first aid items intact rate __%, routine instrument disinfection and sterilization qualification rate __%, the number of bedsores occurred ___, patient satisfaction rate of __%.
Three, logistics and safety management
To adhere to the "strengthen the quality, improve management, make the best use of things, service clinical" principle, to protect the logistics supply. Strengthened medical equipment, instruments, water, electricity, vehicles, and hospital fire facilities, channel management, to provide protection for the hospital's work.
Four, medical quality and safety incident management
Carry out the whole medical quality and safety education, improve the awareness of medical safety. Seriously implement the "Interim Provisions for Reporting Medical Quality and Safety Incidents", "Interim Measures for Medical Quality and Safety Cautions and Talks System", our hospital has formulated a major medical safety incident, medical accident prevention plan and handling procedures. It further improves the organizational leadership, management institutions, regulations, operating procedures and standards of production safety, clarifies the staffing requirements, and puts measures in place; it adopts special management and measures for key areas and departments. The hospital regularly reported medical quality and safety incidents, and reported ___ cases for the whole year***. No medical accidents occurred throughout the year. No medical disputes throughout the year.
Medical quality and safety management year-end work summary sample twoThe quality of medical care is the fundamental survival and development of a hospital, is a hospital level embodied in high and low, medical safety management is an important aspect of medical quality. Over the past year, our hospital in the Health Bureau under the direct and correct leadership, seriously study the Ministry of Health, the Bureau of the relevant spirit of the reform of the health care system, to join the reform of the health care system, open up the health care market, and actively participate in the market competition. Adhere to the patient-centered, all for the patient service, and constantly improve the quality of medical services, improve service attitude. Strictly grasp a variety of medical quality control indicators, improve the overall level of medical effectively reduce medical disputes, to eliminate the occurrence of medical errors.
Now on this year's medical treatment and medical safety work is summarized as follows:
First, effectively improve medical services
Strengthen the medical ethics and medical laws and regulations, rules and regulations of education, so that the majority of staff to further establish a wholeheartedly for the patient's services, adhere to the idea of "patient-centered". Patient-centered" service concept, seriously carried out the content of the "good service, good quality, good medical ethics, public satisfaction" of the "three good and one satisfied" activities, and constantly improve the level of medical services. Innovative service process, optimize the diagnosis and treatment environment. We have enriched the outpatient physicians, rationalized the working hours, and insisted on opening the clinic on time to ensure that the patients are treated in a timely manner. The establishment of an open and transparent system of medical costs, the implementation of a one-day list system for hospitalized patients, patients can always inquire about the price of drugs, hospitalization costs and other details, by the patient's praise.
Strengthen doctor-patient communication, improve the content of communication, improve communication, focus on the effect of communication, and effectively strengthen the basic management of the hospital, the establishment of a sound medical safety management organization, the implementation of the core medical work system and safety measures, to ensure that medical instruments and equipment are legal, reasonable, and safe to use, to avoid the occurrence of medical errors and accidents. Strict technical access system, standardize medical practice behavior. To conscientiously implement the "Drug Administration Law", "Medical Device Supervision and Administration Regulations", to strengthen the drugs, medical equipment procurement, storage, use of supervision and management.
Second, effectively improve the quality of medical services
Medical quality and safety is related to the public's health and safety, is the lifeblood of medical services, is the core content of hospital management and eternal theme. Medical safety is carried out first to improve the quality of medical care, enhance the level of service. Strengthen medical quality management, pay close attention to the implementation of rules and regulations, always adhere to the "patient-centered", quality as the core, quality and safety as the theme, and seriously implement the rules and regulations, job responsibilities, strict implementation of diagnostic and treatment technology routines, and the implementation of the various systems in all aspects.
The establishment of Yao town health center medical quality management group, strengthen the quality management of medical documents, strict implementation of the "basic specification for medical record writing", the quality of the case of the implementation of the whole monitoring and management. The development of Yao town health hospital professional and technical personnel assessment program to implement the reward and punishment mechanism, to ensure that rewards and punishments in place, the quality of medical services assessment of outstanding results of the department or individual to give praise and material rewards; quality of medical services assessment results do not meet the standard of the department or individual in addition to financial penalties and hospital-wide notification of the criticism, to strengthen the "three basics and three strict" training, held from time to time at all levels and types of personnel, the quality of medical services assessment results of the Department of Health. The company's main goal is to provide the best possible service to its customers, and to provide the best possible service to its customers in the future.
Three, the establishment of a perfect quality management system, standardize medical behavior is the core
This year, our hospital from the strengthening of the system construction, combined with the nature of the work of the job, the work content, the formulation of the relevant management system and assessment rules, and the development of the functional departments, business departments, the comprehensive goal of the book of responsibility to achieve the first level, one level to one level, one level to one level, the pattern of responsibility. The pattern of one level being responsible to one level. Clearly responsible for ensuring that the function, so that the responsibility, the right to clear, moderate interest, so that the management of the chapter to follow, the chapter must follow, and gradually improve the management of the legal system, institutionalization, standardization, standardization.
Four, the proper disposal of disputes between doctors and patients in accordance with the law
According to the relevant laws and regulations, the disposal of disputes between doctors and patients into the legal system, standardized track, to safeguard the legitimate rights and interests of doctors and patients. According to the "Medical Accident Handling Regulations" set up Yao Township Health Center Medical Dispute Coordination and Handling Group, according to the law properly deal with medical disputes. Adhere to the principle of prevention in the first, found in the early, disposed of in the small, establish and improve the prevention and disposal mechanism of doctor-patient disputes, the careful implementation of the relevant preventive and control measures, and strive to resolve various types of doctor-patient disputes, to prevent doctor-patient disputes triggered by the group of 'events and vicious events.
V. Strengthen security measures to ensure hospital safety
Regularly organize key positions for staff to learn and train, and implement various internal security measures. Regularly and irregularly on the fire safety to carry out a comprehensive inspection, easy to cause a fire, the storage of dangerous goods and the concentration of people to focus on the inspection (such as the drugstore, outpatient clinics, wards, etc.), the fire facilities for regular maintenance and replacement, to ensure that the fire equipment is intact. Our hospital implements the general duty system of hospital leaders, clearly defines each person's time period division of labor, and conducts hospital-wide inspections during the duty period, so as to effectively implement the security precautionary measures of fire prevention, anti-theft, and anti-sabotage into practice. Strictly implement the security responsibility system, to improve the destabilizing factors investigation, found that the problem is immediately rectified. The development of human defense, material defense, technical defense emergency measures to ensure that the hospital does not have a major security incidents.
Medical quality and safety management year-end work summary sample threeThe ultimate goal of health care reform is to provide patients with better quality medical services at a cheaper cost. In recent years, our hospital, like other municipal general hospitals, has become a basic part of the city's medical and health care work, and has formed a unique system of maternal and child medical and health care work, and has made unremitting efforts to provide high-quality and inexpensive medicine and health care services for women and children throughout the region, inherit the development of medicine and medicine academics and cultivate medical talents. In 20xx, our hospital adhere to the patient-centered service concept, in order to improve the quality of medical care, reasonable charges, reduce medical costs as the starting point, and strive to provide quality medical services for the majority of patients.
First, to strengthen the management of medical quality, to ensure and improve the quality of medical services
(a) Medical quality management is the core of hospital management, to improve the quality of medical care is the management of the fundamental purpose of the hospital. The quality of medical care is the lifeblood of the hospital, the level of medical care, the quality of medical care is directly related to the survival and development of the hospital. In recent years, on the basis of medical quality service, our hospital has taken reducing medical quality defects, timely investigation and elimination of medical safety hazards, reducing medical malpractice disputes and eliminating medical accidents as the top priority. Our hospital strictly control the medical quality, each department strictly implement the rules and regulations, standardize the diagnosis and treatment behavior, adhere to the first diagnosis and responsibility system, three-level check-up system, difficult patient consultation, critical patients and pre-operative and post-operative discussion system. Enhance the sense of responsibility, pay attention to the dynamic analysis of medical activities, and take all kinds of precautionary measures, so as to prevent the danger from occurring in the first place. In order to improve the current demand for patients' right to medical information, improve the notification system.
(B) optimize the medical service process to improve the basis of medical quality. The service process is the structure and mode of operation of the medical institutions, on the basis of not increasing the number of wards, health and technical personnel, optimized medical service process determines the efficiency and competitiveness of the medical institutions, which to a large extent enhances the long-term viability of the hospital, so that the available resources of the hospital through the balance of the process of the various components to reduce duplication and waste, so that the hospital's existing hardware and software to achieve a higher rate of utilization and a better utilization level, give full play to the abilities of professional and technical staff as much as possible, meet the needs of patients as much as possible, and achieve high economic and social benefits. Our hospital adheres to the patient-centered approach, makes efforts to optimize the medical process, facilitates patients' access to medical treatment, seeks for practical effects, enhances the service consciousness, optimizes the development environment, and strives to provide patients with warm and convenient, high-quality medical services. The introduction of various measures to facilitate the people, such as charging the registration window networking, to reduce the long queues for registration, some experts set up a special registration window, the introduction of telephone booking registration and other measures. The medical and technical departments have introduced time-limited commitments for the issuance of report forms. Nursing department in the implementation of star nurses selection activities emerged a number of advanced nurses, nurses and patients to build a bridge, the introduction of convenient measures to find ways to solve practical problems for patients, hospitalized patients on the nursing work satisfaction rate of 98%.
(C) the implementation of medical quality, medical safety education, is to strengthen the foundation of medical quality. How to improve the quality of the managers themselves and strengthen the quality of the whole hospital medical staff education is the basis of quality management. Improve the quality of medical care can not rely solely on the efforts of a few managers or some of the medical staff can be realized, but the need for all hospital workers have the correct outlook on life, values, professional ethics; the need for a strong sense of responsibility, dedication, empathy; the need to set up a solid awareness of the quality of medical care, medical safety; the hospital to carry out a full range of high-quality service and "safety is the biggest savings, accidents are the biggest waste". The company has also launched a comprehensive quality service and "safety is the biggest savings, accidents are the biggest waste" activities to stimulate the staff than learning, dedication to the spirit of professionalism, the formation of a better atmosphere than, learn, catch up, and surpass.
(D) the establishment of a perfect quality management system, standardize medical behavior is the core. In recent years, our hospital from strengthening system construction, combined with the nature of the work of each post, the work content, the development of job duties, medical ethics, personnel management, meetings, learning, attendance, safety and security, logistics management, financial and property management, management of statistical reports, management of medical documents and archives, awards, punishments, etc. *** five parts of the 241 management system; the development of the administrative management, medical quality management, nursing quality management, drug management, hospital infections, and the development of a new system to ensure the quality of life. Management, medical quality management, drug management, hospital infection control management, financial management, as well as ideological and political work and medical ethics management and other 26 quality control assessment rules; the development of functional sections, business sections of the comprehensive goal of responsibility to achieve the first level of management, the first level to the first level of responsibility pattern. Clear responsibility to ensure that the function, so that the responsibility, power, clear, moderate interest, so that the management of the chapter to follow, the chapter must follow, and gradually improve the management of the legalization, institutionalization, standardization, standardization.
The establishment of a quality management system in line with the actual hospital, the hospital set up a president, vice president, medical department and clinical departments as members of the quality management, quality control assessment leading group, responsible for the quality management of the hospital. The whole hospital formed a main leader personally grasp; the leaders in charge of specific grasp; functional departments daily grasp; clinical departments when to grasp the medical quality, medical safety management pattern.
Strengthen the medical quality management adhere to the usual inspection and monthly, quarterly, annual quality control combined, strict link quality, to ensure that the end of the quality gate. "The three basics", "promote the three strict", the implementation of the "three doctors" check-up system. The medical department often organizes the hospital staff to study health laws, regulations, systems, operating procedures and operating routines, and recorded in the personal business records. In recent years, through the development of medical business management, efforts to improve the quality of medical care, to ensure medical safety as the goal of the full range of quality management, so that the hospital's work to achieve the expected purpose of the integrated target responsibility system, medical quality gradually improved, the gradual reduction of safety hazards, no medical accidents, medical disputes are also relatively few, improve the quality of medical care, to ensure medical safety for the next year, the second class A maternity and child health care hospital review and reassessment work to prepare for The company is also preparing for the review and reassessment of the hospital.
The most fundamental goal of the hospital is to improve medical quality and reduce medical costs
Improving the quality of medical care, reducing medical costs, and allowing the public to enjoy better medical care for less money is the fundamental goal of the reform of the health care system. Reduce medical costs, improve economic efficiency is also every dean, patients, social people, medical staff, etc. *** with the concern of social issues, it is the nature of society and the direct reflection of the purpose of the service. As a hospital administrator to strengthen the quality of scientific management, reduce management costs to start from improving the quality of service and business quality, highlighting the "technology" to win rather than "fee" to win.
Standard policy and drug "Shunga pricing" policy, the implementation of separate accounting, separate management of medicine, adjusting the price of medical services, reduce the total cost of medical care, reduce the proportion of drug revenue in the total income of the hospital. The economic burden on patients has been reduced in real terms. To realize the goal of "reducing patient costs", the first thing is to solve the problem of ideological understanding and improve medical ethics, to adhere to the "serve the people" purpose, correctly deal with the relationship between social benefits and economic gains, the social benefits in the first place, to prevent the one-sided pursuit of economic gains and prevent We should adhere to the principle of "serving the people", correctly handle the relationship between social benefits and economic benefits, put social benefits in the first place, and prevent the tendency of one-sidedly pursuing economic benefits and neglecting social benefits. "Patient-centered" to the interests of the majority of patients as a prerequisite, the effective health care work as a noble profession, to deal with the interests of hospitals, individuals and patients; effectively achieve reasonable inspection, rational use of medication, to provide quality services at low prices.