Dear leaders and comrades:
2005 is a critical year for the hospital to deepen its reform. This year, we have closely focused on the overall goals set by the hospital at the beginning of the year and adhered to the scientific principle of "people-oriented" The concept of development, focusing on the hospital management year work theme of "putting patients at the center to improve the quality of medical services", insists on putting the pursuit of social benefits, safeguarding the interests of the masses, and building a harmonious doctor-patient relationship in the first place, and actively explores the long-term development of scientific management. Effective mechanism ensures the sustainable development of the hospital and comprehensively improves the hospital’s medical quality. As the business dean in charge of medical work, I will now report the work done in the past six months to the leaders of Renji Company and the hospital as follows:
1. Review of the work in the first half of the year
(1 ), implement the work related to the Hospital Management Year activities
Hospital Management Year activities, as one of the members of the leadership group and the director of the Hospital Management Year Office, according to the "Hospital Management Year" of *** Province and *** City In the spirit of "Notice on Activity Assessment Rules", the contents and tasks of the Hospital Management Year activities were decomposed, and the hospital's "Hospital Management Year Activity Plan", "Hospital Management Year Activities Work Plan" and the hospital's "Hospital Management Year Activity Assessment Rules" were formulated 》, which includes quality indicators and other aspects related to quality and safety requirements, is in the process of being organized and implemented.
(2) Medical management work
1. Continuously improve and implement the medical work system
Revised and improved the compilation of the medical work system of our hospital. It can be sent to the medical staff of our hospital after proofreading. This system covers various key medical systems and commonly used medical work systems, medical accidents, dispute prevention and handling plans, emergency public health incident handling plans, and Implementation rules for the application of anti-infective drugs in our hospital, etc. At the same time, the key medical system has been strengthened in link management, combining weekly regular inspections with unscheduled inspections, unifying eight registration books in the implementation of the hospital's key medical system, standardizing record requirements, and making the hospital The implementation of various systems is progressing toward standardization and has achieved certain results.
2. Strengthen basic quality management and improve the overall quality of medical staff
Comprehensively improving the "three basics" level of medical staff in the hospital is one of the keys to strengthening basic quality. This year, we will focus on To grasp learning, we must first grasp the style of study and the implementation of the learning system, especially focusing on the improvement of the actual work level of medical staff and the improvement of the comprehensive quality of emergency response capabilities; the second is to grasp the implementation of the learning system, stipulating that every Tuesday is for the hospital Business study day; the third is to focus on the content of learning, including relevant laws and regulations, technical operation routines, various rules and regulations and norms, as well as professional related professional theories and medical progress; the fourth is to focus on learning methods, including the whole hospital and departments Business lectures, case discussions, distance education, going out to participate in academic activities, and sending them to higher-level hospitals for further study and short-term training. In order to overcome difficulties in the face of staff shortages, dozens of medical staff were selected to go to higher-level hospitals for further study and short-term training. The current situation, especially the issue of continuing education for senior professional personnel; fifth, promoting learning through examination, focusing on the practicality of the examination, as well as the depth and breadth of the examination. Strengthening the "Three Basics and Three Stricts" training, the Three Basics Examination was held twice for on-the-job medical and technical personnel under the age of 45 in the hospital. The number of references reached 268. 83 people were randomly selected from the reference staff to take the exam again, and the results were both the same. Up to good.
3. Focus on improving the quality of medical records and prescriptions.
The Medical Record Management Committee held three meetings in the first half of the year to discuss how to improve the quality of medical record writing in our hospital. At the same time, we reviewed the archived medical records and prescription quality review results of each department, summarized and sorted them out in a timely manner, and analyzed existing problems. Provide timely feedback on problems, require each department to make rectifications within a time limit, and organize a review of the rectification situation. In addition to the monthly self-examination of medical records and prescriptions organized in the hospital, in the first half of the year, 315 archived medical records were selected and sent to **** People's Hospital for review based on self-examination. Among a total of 315 medical records submitted for review, there were 284 Class A medical records, 28 Class B medical records, 1 unclassified medical record, and 2 Class C medical records, with a Class A rate of 90%.
Individuals with Class C medical records were severely dealt with: 1. Waiting for two months; 2. Withholding RMB 1,000; 3. Notifying the whole hospital of criticism. At the same time, the department where the person is working will deduct 5 points from the quarterly performance appraisal. The public exposure of poor-quality medical records and prescriptions in the hospital in the form of "Medical Bulletin" has played a certain warning and promotion role.
In the first half of the year, we carried out the re-identification of prescriptions in our hospital, identified 218 doctors with the right to prescribe, implemented the Ministry of Health's "Prescription Management Measures (Trial)", and organized medical staff, Pharmacy staff learned the requirements of the "Prescription Management Measures" and took implementation measures. The new prescriptions were officially put into use on April 1. The following measures have also been taken to improve the quality of medical records and prescriptions: ① Increase the sample size of archived medical records; ② Check current inpatient medical records once a week, and the wards checked include all current inpatient medical records; ③ From previous years, we have learned This year, the director of the written notification department has so far reported directly to the medical department at the morning meeting of the department on the second day of the inspection, forming written information on the existing problems, and each doctor has a copy; ④ Prescription quality inspection was carried out every year in previous years. Improved from once a quarter to once a month, to the current three inspections per month; ⑤ The requirements must be strictly implemented according to the specifications, and the inspectors are not allowed to have good-natured ideas. The seriousness, rigor, and standardization of the inspection process have been strengthened, and the quality of the inspection has been emphasized. By taking the above measures, although there are still certain problems with the quality of our medical records and prescriptions, the overall quality has been significantly improved.
4. Standardize management and adhere to reasonable inspections, rational use of drugs, and treatment according to illness.
In order to further strengthen the "patient-centered" service concept, correct the unhealthy practices in the industry, and reduce the unreasonable burden on patients, according to the Provincial Department of Health's "Notice on Further Standardizing Medical Service Behaviors to Correct Improper Practices" (*Health Office [2004] **) and the Provincial Department of Health and the Provincial Department of Finance's "Notice on Issuing the Implementation Opinions on Controlling the Proportion of Drug Revenue in Medical* Institutions", formulated the **** People's Hospital Department Drug Proportion Control index. This year, we will focus on the use of antibacterial drugs as a breakthrough and strive to reduce the proportion of drug revenue in total business revenue. The maximum prescription limit for outpatients has been introduced, and our hospital's "Guiding Principles for Clinical Application of Antimicrobial Drugs" has been formulated. At present, most departments in our hospital have implemented the principle of graded use of antibiotics, and relevant measures have been taken recently for a few departments that have not implemented it.
5. Continuously improve the medical safety awareness and preventive measures of medical staff.
In the first half of the year, all hospital staff were organized to further study the "Regulations on Handling Medical Accidents", "Law of Practicing Physicians", "Measures for the Management of Prescriptions" and other relevant laws and regulations, enhance legal awareness and medical safety awareness, and strengthen work responsibility , standardizing various diagnostic and treatment behaviors. Strengthen medical quality supervision and organize weekly medical safety inspections. Convened 5 hospital-wide doctor meetings; organized 1 exam on knowledge of relevant laws and regulations; organized 1 special lecture on "Standardized Writing of Medical Records and Prevention of Medical Accidents" to further enhance all medical staff's understanding of the importance of medical records, and provide guidance on how to use medical records from a legal perspective Understand the importance of medical record writing and discuss how to adapt medical record writing to the needs of the current situation; invite relevant experts from the ***** Municipal Health Bureau to give lectures on "Medical Safety and Prevention of Medical Disputes" and "Confirmation of Medical Accidents and Legal Liability" "Special lectures, arrange for each department to discuss how to prevent medical disputes and accidents, investigate hidden dangers that cause disputes and accidents, formulate rectification measures, communicate at middle-level cadre meetings, and form written materials for submission; comprehensively strengthen basic quality and links Management and control of quality and final quality, strengthen safety supervision of high-risk groups, high-risk departments, and high-risk periods, provide assessment data every quarter according to hospital performance assessment requirements; organize relevant surgical departments to study the "Jiangsu Provincial Surgical Graded Management Standards" (Trial), further improved the surgical approval filing and registration system, and conducted special inspections of surgical approval filing. The Ministry of Health issued the "Interim Regulations on the Management of Physicians' Outgoing Consultation" and organized learning to standardize the management of consultations from July 1; further standardize the writing of various consent forms and urge clinical health technicians to conscientiously fulfill their notification obligations. Overall, the incidence of medical disputes in the first half of the year dropped compared with previous years.
6. Pay attention to discipline construction and enhance the development potential of the hospital
With the rapid development of modern medicine, the division of labor in disciplines and specialties has become both more refined and more comprehensive. Traditional disciplines and specialties have continued to evolve. Differentiation, integration and recombination have led to more and more interdisciplinary and interdepartmental technical issues in medical treatment, teaching and scientific research in medical units. Therefore, strengthening discipline construction is an important issue in hospital management. This year the hospital has identified six key disciplines for training and development. Based on the needs of discipline development, the hospital held two special meetings for key discipline leaders in the first half of the year to organize the study of the "Hospital Discipline Construction Requirements" and formulate discipline development plans for each discipline. It was gradually implemented as planned in April. During this period, we successively established a children's asthma diagnosis and treatment center, a urinary disease diagnosis and treatment center and a biliary disease diagnosis and treatment center. The Department of Gastroenterology has launched a number of new technologies and new projects this year. The cardiovascular disease diagnosis and treatment center has not yet been officially listed due to equipment factors, but its basic work is already underway, and it intends to jointly establish a cardiovascular disease diagnosis and treatment center with ****. The construction of key disciplines can produce talents, achievements, and brands, exert good social and economic benefits, and drive the development of other disciplines. /
7. Formulate a medical quality management plan and assessment rules
In the first half of the year, according to the requirements of medical quality management and hospital performance salary assessment rules, the "Medical Quality Control Plan", "Patient Quality Control Plan" and "Patient Management Plan" were formulated. District Medical Quality Assessment Standards", "Outpatient Medical Quality Assessment Standards", "Emergency and First Aid Quality Assessment Standards", "Pharmaceutical Department Quality Assessment Standards", "Surgical Management Work Points", etc.
8. Other work
① At the beginning of the year, *** Municipal Health Bureau’s 2004 year-end inspection, family planning qualification inspection, and baby-friendly hospital inspection; ② The establishment of comprehensive wards, ③ Assisting in the payment of newly introduced performance-based wages; ④ The staffing and adjustment of doctors for the merger of the two hospitals at the beginning of the year; ⑤ Assisting in the recruitment of all employees; ⑥ Presiding over the formulation of the EMSS (Emergency Medical Rescue System) construction plan (to be discussed and implemented); ⑦ Business work and surgery; ⑧ Responsible for the rescue of critically ill patients and the treatment of sudden batches of injured people.
(3) Prevention and protection work
1. Infectious disease management
Working with the Prevention and Protection Department, the medical staff in the hospital were educated on the prevention and control of meningitis in batches. Training and cholera prevention and control knowledge training and the implementation of related work.
Supervise the reporting of infectious disease epidemics in the headquarters and branches. Improvement of the general infectious disease register and tuberculosis referral register.
2. Health education
On "4.7 World Health Day", "5.31 World No Tobacco Day" and "6.6 Eye Care Day", medical staff will be organized to carry out health education knowledge 3 times, went to the streets and went to community free clinics 3 times, and received a total of more than 560 free clinics and health consultations. According to the requirements of Chuangwei, we have compiled health education materials in recent years and conducted centralized training for branches.
(4) Pharmacy management
1. Further strengthen service awareness, establish a good window service image, and insist on stand-up service.
2. Pay close attention to the quality of drugs and adhere to the "three checks" system for drug quality, that is, acceptance, drug receipt, and drug distribution. No incidents of counterfeit and substandard drugs have occurred.
3. Adhere to the double review and deployment system, and there were no errors or accidents in the first half of the year.
4. Convene a general staff meeting to put an end to unhealthy trends in the purchasing and selling field. Pharmacy personnel are strictly prohibited from participating in any business activities of drug suppliers. Outpatient prescriptions are bound together by two persons, and the same prescription is strictly prohibited.
5. Actively prepare for the work of the Municipal Food and Drug Administration and the Municipal Health Bureau on the establishment of star-rated pharmacies and successfully passed the preliminary inspection of the Municipal Food and Drug Administration.
6. Completed the purification design and decoration of the preparation room, the purification monitoring of the clean room and the preliminary preparations before the preparation room certificate renewal.
7. Actively cooperate with the unified bidding and distribution of ***** drugs, and coordinate and handle related matters in the distribution process.
(5) Medical insurance work
1. Organized the study of relevant laws and regulations, reiterated the specific requirements of medical insurance patients, randomly checked more than 280 medical insurance medical records, and re-examined and checked reasonably. Medication status.
2. In view of existing problems in medical insurance, such as: high grade of medication, large quantity of medication, unreasonable or unindicated use of some medications, excessive dosage of medication when discharged, long hospitalization time, and medication without medical advice Issues such as these were communicated at mid-level cadre meetings and hospital-wide doctor meetings respectively, and the frequency and intensity of supervision were strengthened. At present, the above phenomena have been effectively controlled, and all medical insurance expenses from January to July have been settled.
2. Existing problems and improvement measures
Since I am both a leader and a doctor, it is often difficult to correctly align management and business relationships. To some extent, due to the operation Factors such as this affect the management work, and because our hospital has seriously lacked a complete set of management plans, systems and assessment rules in the past. In the first half of this year, there was a lot of reading and writing to develop software materials, so the implementation of some issues has not been fully implemented. Due to historical reasons, there was a lot of "debt" in past management. Faced with a lot of problems, sometimes it is inevitable If you are afraid of difficulties, the work intensity is not strong enough. In the future, you should pay attention to improving the work in the following aspects:
1. Further strengthen the intensity of medical management work
Eliminate external interference and make reasonable arrangements In terms of business work and management work, the main time and energy should be focused on management, and at the same time, management should be further strengthened to solve key and difficult problems one by one, so that the management level and medical quality can be improved simultaneously.
2. Further strengthen scientific and standardized management
Strive to learn domestic and advanced management concepts and management experience, study the "Modern Hospital Management Evaluation Guide", and combine it with the specific requirements of hospital management activities , to improve their management concepts and management level, and to put management on a scientific and standardized track.
3. Further strengthen the "implementation" issue in management.
So far, it should be said that its software materials have been initially improved. To keep the work of the entire hospital on the right track, the key point is to focus on the word "implementation" and ensure that there are rules and regulations that must be followed. We must abide by and insist on doing everything according to the system, norms and operating routines. At the same time, we must regularly go deep into the clinical front line to conduct investigations and supervise inspections, because many tasks in medical management must be carried out over and over again in order to complete all aspects. The work is implemented.
3. Main points of work in the second half of the year
1. Further improve and revise the outpatient and emergency work system.
2. Establish a complete medical quality management network system.
3. Further strengthen medical quality inspection and assessment, with special emphasis on the implementation of key medical systems.
4. Further improve the quality of medical records and prescriptions, check once a week, provide timely feedback on the inspection situation, and provide suggestions for rectification.
5. Pay close attention to medical safety and prevent and reduce the occurrence of medical accidents and medical disputes, especially in surgical departments.
6. Strengthen supervision of the off-line use and rational use of antibiotics.
7. Strictly implement the surgical graded management system and formulate specific requirements based on the situation of the hospital.
8. Actively participate in the hospital management year activities and implement all tasks.
9. Organize a discussion on the EMSS construction plan and implement it step by step according to the situation.
10. Do a good job in standardizing the construction and acceptance of downward extension points.
11. Summary of the stages of key discipline construction.
12. Prevention and protection work.
13. Community service work.
14. Equipment management and equipment demonstration and procurement work.
15. Actively cooperate with hospital center work and other related work.
16. Carry out work on new technologies and new projects.