I Establishment of a sound medical quality management system
The hospital medical quality management committee regularly organizes quality management system audits and management reviews to check the realization of the hospital's quality policy and objectives, and coordinates the quality management system of all hospital departments and sections at any time to ensure the effective operation of the hospital's quality management system.
Two Continuous Improvement
Continuously check and improve the hospital's quality evaluation standards and supporting the implementation of the program or measures, and timely modification of the hospital's quality control management program.
Three Strictly according to the law
No unqualified personnel shall not be allowed to go on duty alone, cannot issue report cards, and cannot write relevant medical documents. For new graduates and new hospital employees who are not yet qualified to practice, the department should designate senior physicians (nurse practitioners, technicians) to teach them and be responsible for their medical behavior. Strict surgical classification management, tumor diagnosis and treatment, new technology, new project access management.
Four Strengthening basic quality education and training, laying a solid foundation for the end quality
The Department of Medical Education organizes the "Three Fundamentals" education for all staff no less than two times a year, and all clinical and medical departments conduct quarterly education, training and assessment of basic knowledge of the specialties for all undergraduates. The new employees should have a detailed education and training program.
V Strengthening quality control education, legal awareness and quality awareness
Quality control education organized by the Quality Control Department, Medical Education Department, to learn the health laws, regulations, diagnostic and treatment norms, operation norms, workflow. Individual intensive education for personnel who violate healthcare laws and regulations, rules and regulations, and technical operating procedures. Especially for new personnel to work on special pre-service education to establish a good legal, quality awareness.
Six prevention-oriented, the implementation of the whole process of quality control
According to the law of the formation of the quality of medical care, characteristics, and factors affecting the quality of medical care and weaknesses, to take preventive management, the whole process of medical care for the patient from the hospital to the hospital, the implementation of the whole process of quality control.
Seven clear responsibility, refinement, decomposition of indicators, implementation at all levels
Control indicators clearly down to the relevant departments. The hospital will focus on monitoring the quality of the various indicators of refinement, decomposition to the relevant departments, departments can be implemented to the person, monthly statistics on the completion of the indicators, the failure to meet the standard timely notification; quarterly assessment of the indicators.
Eight quality control department to carry out regular and irregular inspection, supervision
(a) running medical records: monthly quality control team of each department to check the running medical records, the number of not less than 30% of the total number of discharged medical records in the same month, the results of the inspection will be carefully documented, and irregularities put forward to improve the method to ensure that unqualified medical records are not out of the department. Every month, the quality control section conducts random checks on the running medical records, and gives timely feedback on the irregularities found in the checks. Final medical records by the case management physician to carry out a unified centralized inspection, scoring, recording, to ensure that the unqualified medical records do not go on the shelf, and will be scored by each department into the department performance assessment.
(2) the quality of medical records: each medical record on the shelves by the case management physician for the initial inspection, the quarterly case management committee to organize clinical experts on the final medical records of all departments to carry out random checks, in accordance with the "quality of inpatient medical records evaluation table" for scoring, "case grade A rate" in the department of the "performance appraisal scores", excellent medical records and grade C medical records, respectively, for individual rewards and penalties. The Quality Control Section writes quarterly reports on the quality of medical records and informs the whole hospital. The medical record inspection of multiple failures or major defects in the department or individual, should be timely feedback, time to correct, and as a key monitoring object, the implementation of key checks, if necessary, obliged to accept the special training arranged by the Department of Medical Education.
(3) outpatient quality: the outpatient department evaluates the outpatient quality every month, including the quality of outpatient medical records, the quality of test and imaging reports (including timeliness and accuracy), the quality of outpatient prescriptions, and the patient satisfaction rate.
(4) application form quality: monthly by the quality control section of the organization of the medical and technical departments of all types of application form inspection, statistics on the application form of the qualification rate of each department and the existence of the main unqualified problems reported to the Department of quality control, monthly feedback departments.
(E) prescription quality: monthly by the quality control section of the organization of the relevant departments of the hospital's prescription inspection, standardized writing of prescriptions, rational use of medication and other reviews, according to the section of the statistics of prescription pass rate, reported to the quality control section, feedback on a monthly basis.
(F) Nursing quality: The Nursing Department conducts inspections and assessments on basic nursing care, health education, nursing documents, basic operations, nursing quality management, etc. through a combination of monthly random inspections and quarterly centralized inspections, and links the assessment results with performance appraisals.
(VII) Comprehensive Inspection: The Medical Quality Management Committee organizes quarterly comprehensive inspections of the basic quality, link quality, and final quality of clinical and medical departments, and links the assessment results to departmental performance appraisals.
Nine quality control accountability
The completion of various quality indicators as the core of the department's work into the performance appraisal system, and linked to personal debriefing, year-end assessment, title promotion. The key quality of the completion of monitoring, for unqualified, non-standard behavior for the appropriate penalties, specific to the section and individual. Has been decomposed to the department, the department of the medical quality indicators quarterly statistics, according to the completion of the corresponding results, the performance of the department, the department's performance appraisal results, and the department, the individual economic income linked.
The quality of work found in the daily inspection of defects, hidden problems, should be the existence of safety hazards by the department, department, analyze the reasons for its occurrence, put forward the rectification method, eliminate the safety hazards, control the medical risk, improve the quality of medical care.
Ten implementation of clinical path management
To the "New Agricultural Cooperative" www.304wsjfm.com单病种控制为基本病种, gradually, in batches, the introduction of common diseases, diseases of a single clinical path management, in order to improve the level of quality management at the same time, the rational use of limited health care resources, improve efficiency, and reduce the cost of basic medical care for patients.