Days like a white horse, our work will again be busy in the rich, in the joy of harvest, for this need to write a good work plan. I believe that we are again in the writing of the work plan to worry about it! The following is my help you organize the hospital quality control section work plan, welcome to read and collect.
Hospital quality control section work plan 1
Hospital medical quality management is the lifeline of hospital survival and development, is the core of hospital management. 20xx year quality control section in the hospital leadership and medical department director of the leadership, in accordance with the requirements of the second-class hospital accreditation rules, the quality of medical care for effective management.
First, establish and improve the medical quality control system
The hospital medical quality control system for the hospital medical quality management committee, quality management functions, departmental quality control group and medical personnel at all levels of self-management of the four-level management system.
(a) Medical quality management committee: the hospital set up a medical quality management committee, the president is responsible for, members of the business vice president, quality control section, medical department, nursing department, outpatient and clinical, medical technology, pharmacy and other related departments director.
Responsibilities: mainly responsible for the development of the hospital's medical quality control objectives, tasks, and the establishment and continuous improvement of medical quality control rules and regulations and medical quality assessment standards; organization and implementation of the hospital's medical quality inspection work.
(b) quality management functions: quality control section led by the organization of the Medical Department, Nursing Department, outpatient clinics, hospital infections, such as the quality control of the various departments to carry out timely and comprehensive supervision and management; regular inspection of the quality of health care and put forward awards and penalties; and the quality of health care in the problem, put forward the improvement of the requirements and corrective comments.
(C) departmental quality control group: each clinical, medical and technical departments to set up a quality control team, consisting of the section chief, head nurse, quality control physicians, nurses, pharmacists and other people. The section chief is the first person responsible for the quality of medical care in the section, responsible for the work of the quality control team to guide, supervise.
Responsibilities: to develop practical quality management objectives, tasks, measures and evaluation methods for the department, self-examination of the medical quality of the work of the department, summarize, report; supervise the implementation of various medical regulations, rules and regulations, found that the medical safety hazards in a timely manner to rectify; to improve the department's quality control work records and registration, a variety of quality indicators do a good job of statistics, analysis and evaluation; combined with the characteristics of the specialty and technical level, to develop and revise the department's quality control work, and to improve the quality of the work of the team. The department also has the ability to formulate and revise the diagnosis and treatment routines, technical operation standards, and first aid plans in accordance with the characteristics of the specialty and technical level.
(D) personal quality management: clinicians, nurses, medical technicians and other medical personnel are the specific operators of medical behavior, is the first gateway to quality management, is an important guarantee of quality management.
Responsibilities: standardize the implementation of disease diagnosis and treatment routines and various technical specifications, carefully standardize the filling of a variety of medical instruments, to ensure that the quality of the basic, link quality and the end of the quality, and responsible for this.
Second, clear responsibilities, effectively responsible for the fulfillment of duties and work system
Let all kinds of staff understand their own work content, scope, obligations, rights, authority. The work duties will be distributed to all types of staff in the hands of the organization and study, so that each medical staff to understand what kind of obligations must be done in their own positions, what is the work authority, when the time to ask for instructions, reporting, etc., accurate positioning, will be responsible for the clear to the person.
Three, the establishment, the sound of the rules and regulations
The establishment, the sound of the rules and regulations, especially in order to ensure the quality of medical care, medical safety "core system" to implement, and according to the requirements of the quality management to improve the other related systems.
(A) the first diagnosis is responsible for the system.
(2) The third-level physician checkup system.
(3) Difficult cases discussion system.
(D) consultation system.
(E) critical patient rescue system.
(F) Surgical grading management system.
(7) Preoperative discussion system.
(h) Death case discussion system.
(IX) hierarchical care system.
(x) Checking system.
(xi) Basic writing standards for medical records and case management system.
(xii) Shift handover system.
(xiii) Clinical blood audit system.
(xiv) new technology permits and medical malpractice accountability system.
Four, improve a variety of disease diagnosis and treatment routine technical operation specification and workflow
will be a variety of technical specifications, workflow organized into a booklet, issued to the various related departments, diagnostic and treatment activities should be carried out in accordance with the specific norms to ensure that the various aspects of the quality and efficiency to ensure that the quality of the end.
Fifth, the establishment and improvement of the assessment system
According to the actual hospital, the hospital medical quality management committee will be responsible for the quality of medical care in the whole hospital; the Department of Medical Services on the basis of the quality of the inspection, assessment; quality control section on the quality of the medical quality of the link quality and the end of the quality of the inspection, assessment; the office of the quality of service inspection, assessment. The assessment will take the combination of regular centralized inspection and assessment and irregular sampling. The results of the assessment and the performance of the department's salary is linked to the reward and punishment.
Hospital quality control section work plan 2According to the Ministry of Health, the new version of the "basic specification for medical record writing" and "basic specification for electronic medical records", in accordance with the "three psychiatric hospitals review standards" requirements, seriously carry out the management of quality control of the case, the focus of the work in 2013 is to strengthen the guidance in the spirit of the work of the *** with the learning *** with the improvement of the work of the goal, the comprehensive standardization of our hospital medical personnel Medical record writing behavior, improve the quality of medical record writing, and gradually improve medical quality management. Specific plans are as follows:
First, the organization of the ward physicians on the "basic norms of medical record writing", "medical prescription writing norms", "auxiliary inspection application form writing norms", "prescription writing norms" and "medical record scoring standards" for learning, the organization of all physicians to carry out the relevant norms and standards of the knowledge contest.
Second, highlight the quality control section of the guidance, inspection, assessment, evaluation and supervision functions. Make the whole medical process become a continuous inspection, continuous feedback, continuous adjustment, continuous standardization of the process, from the overall strengthening and promote the standardization of medical records writing, legalization and standardization; to be taken every month in various forms of special inspection of medical records instruments, the organization of quality control personnel at all levels to implement cross-checking, in order to learn from each other, promote each other, **** with the improvement.
Third, with the Ministry of Health, "Medical Quality Miles", "Three Good and One Satisfactory", "antibiotic use of special management activities" and other inspection activities, in the quality of medical documents, the core medical system in the medical record, the quality of the medical record, the quality of the medical record, the quality of the medical record, the quality of the medical record, the quality of the medical record.
Fourth, the quality of the medical record to move forward to strengthen the operation of the medical record of real-time monitoring and management. The key departments, departments to implement early intervention, focusing on monitoring such as outpatient medical records, auxiliary inspection application form, informed consent informational letter, dead patient medical records, difficult and critical patient medical records and other medical instruments, to prevent and reduce the lack of medical records written medical safety hidden trouble. Through the inspection to further strengthen the clinical clinic medical record quality supervision and guidance.
Fifth, to improve the quality of quality control members at all levels of their own business quality construction, to take business training, convene a special discussion meeting and go out to study and visit a variety of forms, to strengthen the writing of medical records and related laws and regulations, the core medical system of training. Improve the quality of medical records management and guidance level.
Sixth, the quality control section of the monthly inspection results, the quality of clinical departments and the existence of problems in the quality of medical records, corrective measures to analyze, summarize, feedback and penalties, and reported to the dean of business. Quarterly medical record quality of the outstanding issues in the medical record review activities, in accordance with the hospital arrangements for medical record evaluation activities to improve the medical staff. Medical record writing level and work enthusiasm.
VII, strengthen cooperation with the information section, improve the information level of quality control management work, strengthen communication and exchange with sister hospitals quality control section and the relevant administrative departments, to the higher hospitals to learn, in order to further improve the management capacity of the quality control section.
Hospital quality control section work plan 3A need to improve the content
(a) medical system, medical technology
1, focus on the implementation of the core medical system: first diagnosis is responsible for the system, the three doctors checking the system, the difficult and critical cases, discuss the system, consulting system, the rescue system for patients with critical illnesses, hierarchical care system, death case discussion system. The system of nursing care, death case discussion system, shift handover system, medical record writing standards, checking system, antibacterial drug classification management system, informed consent talk system.
2. Strengthen the management of key aspects of medical quality.
3, strengthen the quality and safety education of the whole staff, firmly establish the quality and safety awareness, improve the awareness of quality management and improvement of the whole staff and the ability to participate in the strict implementation of the norms and routines of medical technology operations.
4, strengthen the training of all staff, medical staff "basic theory, basic knowledge, basic skills" must be everyone up to standard.
(B) medical record writing
1, "medical record writing specification" re-learning and re-understanding, "hospitalization medical record quality inspection score sheet" explanation and learning;
2, the timeliness and completeness of medical record writing, handwriting clarity;
3, the comprehensiveness of the medical examination and accuracy;
4, the timeliness of the higher doctor's checkup and the standardization of the content of the record;
4, the higher doctor's checkup and the timeliness of the record;
4, the higher doctor's checkup, and the timeliness of the record. The standardization of the content of the record;
5, the timeliness and completeness of the daily medical records (including the medical instructions of the superior doctor, the discussion records of the difficult and critical patients, the rescue records of the critical rescue patients, the records and analysis of important laboratory tests, special tests and pathological results, consultation records, death records and death discussion records, etc.);
6, the standardization of the record of the informed consent to treatment (including hospitalized patients within 72 hours of informed consent conversation record, special examination, treatment of informed consent conversation record, medical insurance patients self-financed drugs and devices informed consent conversation record, etc.);
7, the reasonableness of the treatment (especially antipsychotics and antibiotics, the use of antibiotics, change, discontinuation of records and the adverse effects of the drugs have been reported and documented, the prescription 〈including psychiatric, anesthesia prescription〉, the pass rate, etc.).
8, archived medical records are submitted in a timely manner, whether the project is complete;
(C) Nursing and hospital infection management
1, the implementation of the duties of the class;
2, basic nursing care compliance rate and complication rate;
3, specialty care in place;
4, ward management: Whether quiet, clean, comfortable, safe;
5, the standardization of nursing instrument writing;
6, the management of first aid medicines, equipment;
7, emergency response capacity of hospital infection emergencies;
8, the implementation of hospital infection disseminated medical records report;
9, cleaning, disinfection, sterilization implementation;
10, hand hygiene and self-protection implementation;
11, the rational use of antimicrobial drugs;
12, disposable aseptic items are used in accordance with the norms;
13, the prevention and control of multi-drug-resistant bacteria;
14, the management of medical waste;
15, to enhance the prevention and control of hospital infections in the various tasks.
Second, the improvement measures
1, strict compliance with the laws, regulations, rules and regulations of health care management, diagnostic and treatment practices and routines, to strengthen the quality of the department's management, inspection, evaluation and supervision.
2, the department to implement the whole process of quality management, pay attention to the basic quality, strengthen the link quality, to ensure the quality of the end. Establish quality and safety awareness of the whole staff, strengthen the management and supervision of key aspects of medical quality, key aspects include the management of difficult and critical rescue patients, the management of serious adverse drug reactions, the management of the timeliness and completeness of the medical record writing, the management of the standardization of the treatment of the informed consent record, the management of hospital infections, the reasonableness of the treatment, etc.
3, the implementation of the core system of health care quality and medical safety, the establishment of medical records linking quality and safety. The core system, the establishment of medical records link quality monitoring, evaluation, feedback, each medical record by the resident, deputy chief physician, the director of the three levels of quality control, weekly departmental medical quality management team to carry out quality checks once a month, the departmental medical quality management team of the medical quality of the department to carry out a comprehensive analysis of the situation, assessment, six months to summarize the situation in time to check the processing of the notification.
4, the monthly organization of the "three basic" training, the quarterly organization of skills operation assessment.
5, strengthen the "Medical Record Writing Standards" and "Medical Accident Handling Measures" learning and understanding, strictly in accordance with the provisions of timely, accurate and complete writing of medical documents. The director of the department is the first person responsible for the quality of medical care in the department, and to determine the resident, deputy chief physician, the director of the department is responsible for the department's medical records filed before the three-tier quality inspection, to detect defects in a timely manner feedback and correction.
6, to improve the quality of business learning in the department, to ensure that the number of business learning. Monthly business learning once, difficult cases discussed twice.