1. Medical service quality self-examination report
In order to strengthen the quality of medical management, medical safety, combined with the County Health Bureau of the medical quality of the work of the hospital inspection results of the hospital I organized the relevant personnel again on the quality of medical management of the hospital to carry out self-checks, and is now on the existence of the problem and next step
A problem:
1, the new medical quality inspection standards lack of understanding
The hospital in the medical quality management in the quality management is not fully use of quality management tools, PDCA in the medical quality management of the use of the rate is not high, on the statistical analysis of the absence of bar charts, fishbone charts, etc., can not be fully reflected in the data changes.
2, fire to be further strengthened
Fire safety supervision and management department supervision is not in place, part of the dry powder fire extinguishers are not regularly inspected, the inspection is not recorded in a timely manner after the fire, fire knowledge and fire awareness needs to be further improved.
3, medical quality management needs to be further strengthened
(1), the core system and the implementation of medical record writing standards need to be strengthened, part of the staff of the core system to grasp and understand the core system is not enough, can not memorize the core system.
(2), poor surgical management, the lack of unplanned re-operation related knowledge training, lack of emergency surgery management, "three-step verification" is not fully implemented.
(3), the medical department, the nursing department and other relevant departments of the supervision of the traces of insufficient.
(4) The referral process for emergency patients is not clear, and there is a lack of emergency equipment and poor first aid skills among the staff.
(5), did not establish a catalog of high-risk diagnostic and therapeutic items, and insufficient awareness of high-risk items in the hospital. There is no authorization for practitioners engaged in high-risk projects.
4, hospital infection management still needs to be strengthened
(1), hand hygiene training needs to be strengthened, there is no training program, the staff of the seven-step hand washing is not a firm grasp of the hand, hand hygiene publicity map less.
(2), the hospital sensory testing program is not targeted, the key links, key departments of the risk assessment is not perfect.
(3), the lack of laboratory personal protective equipment, no eyewash, incomplete labeling, the risk of occupational exposure, the awareness of occupational exposure follow-up is not in place.
5, clinical drug management still need to be further strengthened
(1), the management of poisonous and anesthetic drugs need to be improved. Poison and anaesthetic prescription is not standardized, not in accordance with the provisions of the registration, poison and anaesthetic drug management personnel are not qualified, poison and anaesthetic drug safekeeping office security facilities are lacking.
(2), the use of antibiotics unreasonable phenomenon is relatively obvious, no antimicrobial graded use of directory; no doctor training, assessment records, no doctor antimicrobial graded use of authorization, perioperative prophylaxis, the use of antimicrobials do not comply with the provisions of the; antimicrobial drug use ratio exceeds the standard.
(3), there are no indications for the use of drugs, prescription transfer audit has missed signatures, the rational use of prescriptions for the lower ability to comment on the use of drugs.
6, auxiliary checks and laboratory tests
(1), laboratory tests can not fully meet the diagnostic needs of critical situations.
(2) The laboratory quality control program is incomplete.
(3), to do invasive tests before the patient did not fully explain, and to obtain the patient's consent answer recognized.
Second, corrective measures
1, the establishment of sound rules and regulations to strengthen hospital management
sound system to strengthen the responsibility to conscientiously implement all levels of the check-up system, reporting system. Clinical departments should strengthen the first physician responsibility system, consultation system, preoperative discussion system, difficult case discussion system, death case discussion and other core system implementation. Further improve the management system to strengthen the standardized management of the hospital.
2, increase the supervision and inspection efforts to ensure the implementation of the core system
(1), to strengthen the health supervision and inspection efforts, and effectively improve the patient's medical environment.
(2), the medical department to further strengthen the quality of inspection and running medical records inspection work, this work to improve the quality of medical care is a very good measure, but focus on the effectiveness, not a formality, the problems found in addition to face-to-face explanations of the repeated offenders must be punished through financial penalties, to give discipline.
(3), to strengthen the three basic training and assessment, we must continue to improve the assessment methods, serious assessment discipline, pay attention to the effectiveness of the assessment, from time to time on the section staff to carry out random checks. The person in charge of the department should pay attention to the three basic training, and often speak to the medical staff about the importance of the three basic learning, to ensure that a monthly assessment of the department, which is essential to improve the technical level of medical staff.
(4), to strengthen the management of the quality of medical records. To further improve the relevant systems and medical records inspection standards, to develop incentives and penalties to ensure the timely filing and safe flow of hospitalized medical records.
(5), to further strengthen the monitoring of hospital infections should be further in the hospital infection case monitoring, sterilization effect monitoring, environmental health monitoring and other work up and down, strict implementation of the hospital infection management system, to do the work in detail, can not cope. It is necessary to further increase the training and publicity of hospital infection knowledge, so that each medical staff should recognize the importance of hospital infection control, consciously abide by the aseptic operation techniques, and do a good job of personal control links. Play the role of departmental hospital infection control team, with the Hospital Infection Office to actively carry out the work, to put an end to the underreporting of hospital infection events.
3, to further strengthen the use of antimicrobial drugs management
(1), according to the Ministry of Health "to further strengthen the management of the clinical application of antimicrobial drugs" notification spirit, to develop the specific implementation of our hospitals, and the system of rewards and penalties, focusing on the monitoring of perioperative prophylactic use of drugs. To further implement the antimicrobial drug hierarchical management system, set prescription authority for doctors to ensure the implementation of the system. To ensure the rational use of antimicrobial drugs.
(2), in strict accordance with the "poisonous and anesthetic drugs management measures" to strengthen the management of poisonous and anesthetic drugs, the Pharmaceutical Affairs Management Committee from time to time to check the management of poisonous and anesthetic drugs.
(3), to strengthen the responsibilities of the Pharmaceutical Affairs Management Committee, to ensure the safety of patients' clinical use of medication hospital pharmacy committee to conscientiously fulfill their responsibilities, strict implementation of the "Interim Regulations on Pharmaceutical Affairs Management in Medical Institutions", to strengthen the training, supervision and management, in order to ensure that clinical use of medication, medical materials and other qualified quality, safety, and in line with the requirements of clinical use. Further improve the monitoring of adverse drug reactions and report them on time. Standardize the construction of the pharmacy, timely inventory and report the near expiration date of drugs.
4, to meet the psychological needs of patients, close doctor-patient relationship, reduce the occurrence of doctor-patient disputes, and create a harmonious environment
Health care workers must be dressed neatly, kindly, energetic, and take the initiative to introduce themselves to the patient is its sub-doctors or nurses, so that the patient gets a good impression of the health care personnel have a sense of trust and a sense of reliance, so that the patient's emotional stability, family satisfaction and peace of mind. The first thing you need to do is to get your hands on a new pair of shoes, and then you'll have a chance to take a look at them.
2. Medical service quality self-examination report
In accordance with the instructions of the Municipal Food and Drug Administration and the provisions of the regulations, in the hospital under the organization of the leadership of the focus on the whole hospital medical equipment, equipment, a comprehensive inspection, the details are now reported as follows:
First, strengthen the management, strengthen the responsibility to strengthen the awareness of the responsibility for quality.
Equipped with medical device quality management personnel, engaged in medical device quality management staff with medical device-related professional knowledge, familiar with the relevant laws and regulations, able to fulfill the medical device quality management responsibilities, effectively assume the responsibility of the hospital's medical device quality management, guidance, supervision and the implementation of the quality management system for inspection, correction and continuous improvement, collection and medical device quality of life. Collect the laws, regulations and product quality information related to the use of medical devices, implement dynamic management, and establish files, supervise the relevant departments and personnel to implement the laws and regulations of medical devices, audit the legal qualifications of medical device suppliers and medical device products, responsible for the acceptance, procurement and maintenance of medical devices, check the quality of medical devices, supervise the treatment of substandard medical devices, organize the investigation and treatment of medical devices, quality complaints and quality accidents, organize the implementation of medical device quality control system. Quality complaints and quality accidents, organize and carry out monitoring and reporting of adverse events of medical devices, and establish a quality management system covering the whole process of quality management.
Second, the procurement of medical equipment, acceptance, warehousing self-check
To ensure the quality of purchased medical equipment and the use of safety, to eliminate the entry of unqualified medical equipment, the hospital has established the "procurement of medical equipment, acceptance, warehousing management system", "large-scale equipment bidding and purchasing system," as well as "medical equipment file management system", in accordance with the "supervision and management of the quality of medical equipment use" provisions, re-organize the "medical equipment use of supervision and management measures", and the "quality of medical equipment use of supervision and management measures". Measures", re-organized the hospital's procurement and acceptance records, and medical equipment related qualification files, and logged into the State Food and Drug Administration website to verify the registration certificate number of medical devices, to eliminate the purchase of unlicensed purchase, purchase of false certificates, purchase of certificates of no qualification, imported medical devices without Chinese manuals, Chinese labeling, Chinese labeling of the purchase of the expiration of the use of medical equipment to ensure the safe and legal use of medical equipment.
Third, the medical equipment without Chinese manuals, Chinese labeling, Chinese labeling purchase, expired use to ensure the safe and legal use of medical equipment.
Third, the medical equipment warehouse storage conditions of self-examination
In order to ensure the quality of medical devices stored in the warehouse, our hospital on the material warehouse warehouse, laboratory warehouse and the library of various departments to carry out inspections, including storage temperature, humidity and the surrounding environment is consistent with the storage conditions of the medical equipment in the warehouse. We also organize special personnel to do a good job of daily maintenance of medical equipment.
Fourth, the self-inspection of Class III medical devices (focusing on implantable medical devices)
Implantable medical devices are high-risk medical devices, in order to ensure that the people use implantable devices safety, effectiveness, the hospital has formulated the "implantable medical device purchase management system. The conditions for the purchase of medical devices and the qualifications of the supplier to make strict provisions for the implantable medical devices submitted to a series of qualifications, in accordance with relevant laws and regulations for strict examination and verification. To strengthen the information management of implantable medical devices, the establishment of a sound implantable medical device procurement, warehousing, warehousing, use, disposal and other review systems, detailed records of product information, all information into the patient's case file for management.
V. Detection and management of suspected adverse events of medical devices
To strengthen the management of unqualified medical devices, to prevent unqualified medical devices from entering the clinic, our hospital has specially formulated the "Medical Device Adverse Event Reporting System". If there is an adverse event of medical devices, the location, time, adverse reaction or basic situation of the adverse event should be investigated and recorded, and promptly reported to the supervision and management of medical devices.
VI. Self-inspection of repair, maintenance and after-sales service of medical equipment
In order to make the medical equipment in a safe state of use, as well as in line with the technical requirements of the standard, the hospital has formulated the "Medical Equipment Maintenance and Repair System", in accordance with the provisions of the production of the "Medical Equipment Repair, Maintenance and Maintenance Records", the cause of the failure of the equipment, the need to replace the spare parts, the state of the maintenance are recorded. The hospital also keeps records of the causes of malfunction, parts to be replaced and the status after repair. Our hospital also emergency medical equipment to do "first aid, life support medical equipment inspection record", requiring each department to do a good job every day to check the first aid equipment, to ensure that the equipment is in a state of readiness.
VII. Self-examination of the problems and the need for improvement
After a period of self-examination and self-correction, the hospital's medical equipment management has become more formalized, but there are some problems, such as: the warehouse expired, unqualified medical equipment can not be destroyed in a timely manner, the library of the classification, partition placement is unreasonable, and the technicians engaged in the maintenance and repair of medical devices are not To carry out training and assessment work.
VIII, the future focus of our medical equipment
Effectively strengthen the safety of hospital medical equipment, medical equipment to prevent the occurrence of safety incidents, to ensure that the majority of patients using medical equipment safety, the future we intend to:
1, to further increase the dissemination of knowledge of the safety of medical devices, the implementation of the relevant systems, to enhance the awareness of the responsibility of the hospital safety of medical equipment.
2, increase the hospital medical device safety work daily inspection, supervision frequency, timely investigation of medical device safety hazards, firmly establish the "safety first" consciousness, regularly engaged in the maintenance of medical equipment and repair of technical personnel to carry out training and assessment work to improve the level of service.
3, continue to cooperate with the higher authorities, consolidate the achievements of the hospital medical equipment safety work, *** with the creation of a good atmosphere for medical equipment, to build a harmonious society to make greater contributions.
3. Medical service quality self-examination report
I. Medical quality management
I hospital pay close attention to the quality of service, to prevent medical errors, according to the law, civilized practice. The hospital set up to Zhang Jiyue, vice president of the leading group of medical quality management, regular sampling of prescriptions, medical records, timely feedback to the relevant responsible person, the whole hospital to monitor the quality of medical care. A variety of single disease quality control to meet the city and district standards.
Second, the medical instruments
Strictly abide by the "basic specification for the writing of medical records" in the requirements for patients to do objectively, truthfully, accurately, timely and complete writing of all medical instruments.
Third, the rules and regulations
Our hospital to improve and implement a series of rules and regulations, improve the management system, including the thirteen core systems, new technology access system, pharmaceutical management system, emergency public **** event management system. For patients who visit the hospital, they are required to present their medical card and ID card when registering, and hospitalized patients are required to submit a copy of both cards during hospitalization, which is carefully checked to prevent impersonation. Strictly grasp the admission criteria, follow the outpatient can be treated. The company's products and services are not only for the hospitalization of patients, but also for the hospitalization of patients who have been hospitalized for a long time.
I strictly abide by the health insurance related systems, the organization of the hospital medical staff repeatedly and seriously study the health insurance related policies, and the assessment work, the assessment results and personal interests of the distribution of links.
Fourth, the basic drug system
For the examination and treatment of patients in the clinic or hospitalized patients, the hospital is strictly in accordance with the provisions of the "Basic Drug List". Each physician is required to strictly abide by the code of ethics of practice, and effectively do
Reasonable examination, reasonable use of medication, reasonable treatment, reasonable fees, can use low-priced drugs do not use high-priced drugs, and effectively reduce the burden of medical costs on farmers. The stock of drugs in the pharmacy reaches more than 90% of the catalog. The amount of medication prescribed is strictly controlled, with no more than 3 days' worth of medication for hospitalized patients and no more than 7 days' worth of medication for discharged patients; large prescriptions, favored prescriptions, and abuse of medication are strictly prohibited, and the number of days of discharged medication shall not exceed the actual number of days of hospitalization. Strictly in accordance with the provisions of the inspection, and resolutely put an end to the phenomenon of one person's health insurance, the whole family medication.
V. Medical cost control
Our hospital in strict accordance with the provincial, municipal and district price, health, finance and other departments jointly formulated the fee standard. Pay close attention to the connotation of construction, improve service quality, shorten the average length of stay of patients, and strictly control hospitalization costs.
Sixth, medical support
This year, the city and district health bureau has increased medical support, the city infectious disease hospitals, district hospitals have experts, professors in the countryside to carry out medical support work to improve the professional knowledge of the front-line medical staff, improve the knowledge structure, update the latest professional dynamics, are of great help.
Seven, the current shortcomings
1, due to insufficient funds, some medical equipment can not be timely maintenance or update, to a certain extent, affecting the in-depth development of related business, professional development of the lack of energy
2, senior Chinese medicine practitioners for the poor grasp of the computer, failed to achieve all the e-prescription for the improvement of outpatient coordination there is a certain degree of resistance.
3, found that individual physicians have outpatient prescription failure phenomenon, including prescription format is not qualified, outpatient antimicrobial drug use ratio is greater than 20%.
Eight, the future direction of efforts
I must take this hospital level review and annual assessment as an opportunity, under the leadership of the higher business administration, strict compliance with the "Regulations on the Management of Medical Institutions", strengthen management measures, optimize the quality of personnel, pragmatic, pioneering and innovative, and constantly improve the quality of health care services and technical service level.
4. Medical service quality self-inspection report
In order to improve the quality of health care, the county hospital of Chinese medicine in accordance with the relevant provisions of the various aspects of the work carried out in the quality of medical supervision and inspection. The hospital office is mainly responsible for coordinating the work of the hospital, is the hospital leadership team leader and the bridge between the staff, the work of the service object both facing the leadership, but also facing the department, but also direct contact with the masses, the work of the task is complicated and arduous. Office of the work style, mental outlook and team quality, are directly related to the image of the hospital. Through this inspection and practice activities, we have a comprehensive understanding of the problems in the work of the hospital office.
First, the office supervision and inspection of the completed work reported as follows:
1, the hospital has carried out double holidays and holidays clinic.
2, to encourage and support the medical staff to primary care institutions to carry out practice activities.
3, the development of measures to shorten the waiting time of patients for examination results and organize the implementation.
4. To establish a system of openness in hospital affairs and organize its implementation.
5, the content of the hospital affairs open to the public in line with the relevant provisions of the effective establishment of the hospital affairs of the hospital open work and feedback.
Second, the current problems and corrective measures:
1, the hospital hospital affairs open a variety of ways, such as bulletin boards, networks, documents, staff congresses have, hospital affairs open information update needs to keep up in a timely manner. Hospital affairs open to the use of a variety of ways to coordinate with each other according to the actual situation.
2, the hospital did not set up a special check results query phone, only the department phone to provide check results query, for the patient to provide check query is limited. To carry out multiple channels of checking inquiries based on the service concept of convenience, it is convenient for different groups of people to know the checking results in a timely manner.
Guizhou 20xx medical quality supervision and inspection of the implementation of the work of the better reflection to the work of the need to improve the place, I believe that through the active efforts of all of us can pass the health care quality supervision and inspection of the requirements, the successful completion of the hospital leadership of the tasks assigned to the hospital office of the work of the benign development of new breakthroughs, the development of the hospital to contribute to the strength of the force.
5. Medical service quality self-inspection report
In order to implement the County Food and Drug Administration on the quality of our hospital medicines, medical equipment quality inspection, to ensure that people use medical equipment safe and effective, standardize the use of drugs and management. The hospital set up a self-inspection team headed by the director in charge, in accordance with the "Drug Administration Law", "Drug Use Quality Management Code", "standardize the standards of the pharmacy" one by one self-check, one by one, the self-inspection team did a lot of detailed self-inspection work, the self-inspection report is as follows:
A, institutions, personnel and systems:
Our hospital has a "license to practice as a health care institution," and other legal qualifications. A drug quality management organization has been set up, consisting of the director in charge, the head of the pharmacy department, the head of the pharmacy, the person in charge of quality, and the purchaser, to clarify the responsibilities of all levels of personnel and institutions. At the same time, the various quality management systems that have been developed, the establishment of continuing education and training programs to improve the quality of personnel, engaged in the work of drugs directly in contact with the drugs of the personnel every year to carry out health checks and establish health records to ensure that the use of drugs in the process of safety and effectiveness.
Second, procurement and acceptance:
Strictly in accordance with the centralized purchasing system of drugs developed by the Health Bureau for the procurement of drugs. We purchase drugs from enterprises with qualifications in drug production and operation; acceptance of drugs in storage is carried out in strict accordance with the standard operating procedures, and the quality of drugs purchased and returned after sale is checked and accepted batch by batch in strict accordance with the statutory quality standards and the quality terms of the contract.
Third, the implementation of standardized pharmacy management system:
Strictly in accordance with the standards of standardized pharmacy, the hospital's pharmacy, pharmacy and outpatient department pharmacy management.
Fourth, drug storage and maintenance:
Warehouse is divided into drug warehouse, medical equipment warehouse, each warehouse are divided into qualified area, pending inspection area, unqualified area, return area, each area in accordance with the provisions of the implementation of the color-coded management, i.e., qualified area is green, pending inspection, return area is yellow, unqualified area is red. After acceptance, drugs are stored in special storage and classification in strict accordance with the drug storage and maintenance system, and are stored in the corresponding storage area according to the storage conditions and requirements of the drugs, and drugs are stored separately from non-drugs, internal and external drugs, prescription drugs and non-prescription drugs, and drugs and hazardous materials that are easy to cascade odor are separated from other drugs. Drugs according to the lot number, the expiration date of centralized stacking, according to the lot number and the validity of the near or near sequential or separate stacking, the near-expiry date of the drugs to fill in the validity of the table every month.
V. Dispensing of drugs:
Pharmacists must dispense drugs with a prescription issued by a registered medical practitioner, non-physician prescription shall not be dispensed with medicines, drug dispensing work in strict accordance with the requirements of the four checking ten pairing for the dispensing of drugs, the issuance of which should be followed by the "first to produce first," "near expiration date first," "the first to produce first," "near expiration date first," "the first to produce first," "the first to produce first," "the first to produce first. "Near-expiry first" and the principle of issuing according to the lot number.
VI. Adverse Reaction Monitoring:
The establishment of the Adverse Drug Reaction (ADR) monitoring and management team, the designation of full-time or part-time personnel responsible for the reporting and monitoring of ADR, the establishment and preservation of ADR monitoring files, the initiative to collect ADR, through the National Adverse Drug Reaction (NADR) monitoring and information network report, the report content should be true, complete and accurate.
VII, special drugs:
Special management of drugs with compliance with the provisions of the safe storage measures, the implementation of double double locks, the account matches the five special management. Purchase of special drugs should be implemented on arrival that is to check, two people open the box, count to the smallest package, and have a special acceptance records, return, expiration, unqualified special management of drugs and waste retrieved in accordance with the provisions of the destruction of health departments under the supervision of the destruction of records should be in line with the to be.
Eight, the problems found in the inspection:
Through the self-inspection team of the hospital use of drugs in all aspects of quality management work on self-inspection, from the personnel and institutions, management system, hardware facilities, management records and other aspects of the comprehensive and detailed self-inspection, basically to meet the requirements of the use of drugs and quality management regulations, but also found some deficiencies, the drugstore, pharmacy, outpatient pharmacy, etc., involving the use of drugs and equipment, individual places, hygiene is relatively low. However, some shortcomings were also found, such as poor hygiene in individual places involving medicines and equipment, untidy arrangement of medicines, lack of standardization of ordering, lack of obvious zoning, and lack of detail in the writing of records. Ordered each station, group, section personnel must be according to the system seriously rectify, and implement to the person.
In the actual work and implementation, there may be some easily overlooked, subtle aspects of the problem, looking to the higher leadership of the work of our hospital to put forward valuable advice. In the future work, we will certainly make persistent efforts to do a better job of our hospital's pharmacy work, to protect the people's drug safety.