Part of a designated medical institution self-examination report
In order to implement the ** Municipal Bureau of Human Resources and Social Security, "on the ** City, the basic medical insurance designated medical institutions and designated retail pharmacy inspection and assessment notice" document spirit, according to the municipal health insurance office on the annual inspection and assessment of the basic medical insurance designated medical institution Requirements, our hospital attaches great importance to the serious arrangement and implementation in place. By the management of the business dean to lead, the medical department is specifically responsible for, in the whole hospital to carry out a special inspection, is now the self-inspection report as follows:
First, attach great importance to improve the responsibility system of medical insurance management
Pit to the notification, the hospital immediately set up a self-inspection of the dean in charge of the leadership group headed by the head of the evaluation of the indicators, and seriously find deficiencies, and actively rectify. Our hospital has always attached great importance to the work of medical insurance, in the daily work, strict compliance with national, provincial and municipal laws and regulations related to health insurance, and seriously implement the health insurance related policies, set up by the business dean in charge of the responsibility of the medical department and nursing part-time health care insurance leading group, sound management system, held several special meetings to study and deploy, and regular training for physicians on health insurance. Medical insurance work at the beginning of the year there is a plan, and regularly summarize the work of medical insurance, analysis of insured patients' medical and cost situation.
Second, strict management, the realization of the standardization of medical management
Quinquennial, in the city of Human Resources and Social Security Bureau and the correct leadership and guidance of the Office of Medical Insurance, our hospital to establish and improve the rules and regulations, set up a "basic medical insurance policy bulletin board" and "complaint boxes The hospital has set up and improved various rules and regulations, set up "Basic Medical Insurance Policy Publicity Board" and "Complaint Box", issued basic medical insurance publicity materials in a timely manner, publicized the telephone number for consultation and complaints, provided consulting services for the insured enthusiastically, and dealt with the complaints of the insured properly. Simplify the process and provide convenient, high-quality medical services.
Strict identification of insured employees during hospitalization is carried out to eliminate the phenomenon of impersonation and hospitalization, and to stop hospitalization of registered beds. The company's website has been updated with the latest information about the company's services, and the company's website has been updated with the latest information about the company's services, and the company's website has been updated with the latest information about the company's services. Outpatient prescriptions are strictly enforced in accordance with the regulations on the amount of medication under the medical insurance, and the amount of outpatient medication prescribed at one time is 7 days, and the amount for chronic diseases is 15 days at most. Hospitalized patients are discharged with no more than a 7-day supply of medication. Implementing the principle of treating patients according to their illnesses, rational examination, rational treatment, and rational medication; there is no falsification or alteration of medical records. Actively cooperate with the Medical Insurance Office to supervise and audit the treatment process and medical expenses, and provide timely access to medical records and related information. The company strictly enforces the fee standards set by the relevant departments, and does not charge for its own programs or raise the fee standards.
Residence strong medical insurance policy propaganda, the department as a unit of regular organization to study the city health insurance issued by the Office of Health Insurance "medical insurance policies and regulations selected", "** City, basic medical insurance and workers' compensation insurance drug directory," and other documents, so that each health care workers are more familiar with the directory, to become a health insurance policy propagandist, explainer, implementer.
Third, strengthen the supervision, to protect the quality and safety of medical services
First, the implementation of the system, strict operating procedures. We continue to strengthen the implementation of the core medical system and the implementation of diagnosis and care procedures, focusing on the first medical responsibility system, the three physician check system, surgical safety check system, medical record writing and prescription review system to ensure medical safety. Continue to carry out in-depth "quality service demonstration wards" to create activities, grasp the basic and hierarchical care, improve the level of comprehensive nursing services.
Secondly, on the basis of strengthening the implementation of the core system, focusing on the improvement of medical quality and continuous improvement. Gradually establish and improve the hospital, section two-level medical quality management system, the implementation of the whole hospital, the whole process of quality control, the implementation of inspection, sampling evaluation system, the results of the public, reward the best and punish the worst, so that the hospital medical work to do a formal, orderly in place.
Third, the medical staff familiar with the core medical system, and in the actual clinical work of strict implementation. Actively learn advanced medical knowledge, improve their professional and technical level, improve the quality of medical care, and serve patients well, while strengthening the humanities knowledge and etiquette knowledge of learning and training, enhance their communication skills.
Fourth, the medical documents as an important part of the control of medical quality and prevention of medical disputes to grasp. The hospitalized medical records are scored, and the chief of the department reviews the initial evaluation, and the hospital quality control is reviewed again. At the same time actively carry out medical record quality inspection and evaluation activities, the quality and operation of medical records have been effectively monitored, the quality of medical care has improved significantly.
Fifth, strengthen the safety awareness, the doctor-patient relationship is becoming more harmonious. We continue to strengthen the medical safety education, improve the awareness of quality responsibility, standardize medical operation procedures, establish and improve the doctor-patient communication system, take a variety of ways to strengthen the communication with the patient, patiently and carefully to the patient to account for or explain the condition. The company's products and services are designed to meet the needs of patients and their families, and to provide them with the best possible service.
Sixth, to further optimize the service process, convenient for patients. By adjusting the layout of the department, simplify the medical links, shorten the waiting time of patients. The outpatient hall set up a medical consulting desk, equipped with wheelchairs and other service facilities, to provide patients with information guidance and medical services, and timely resolution of the various difficulties encountered by the patients during the consultation. Standardized service language, strengthen the training of nursing etiquette, patient care service enthusiasm, nursing care, careful operation, answer patience, put an end to raw, cold, hard, top, push the phenomenon, the patient's praise.
Fourth, strengthen the hospital management, standardize hospitalization procedures and fee management
In order to strengthen the standardized management of health insurance work, so that the provisions of health insurance policies have been fully implemented, according to the requirements of the city health insurance office, our hospital in the hospitalization of patients hospitalized within 48 hours of hospitalization declaration form and to do the admission receipt, discharge certificate registration. At the same time, according to the specified time, type and number of settlement statements, the insured persons of the medical expenses are true and accurate, and the cost details are consistent with the medical records and medical prescriptions.
The doctors in charge of the hospitals are able to provide treatment for the patients, conduct reasonable examinations and use reasonable medication. The company's products and services have been widely used in the medical industry for over a decade, and the company's products and services have been widely used in the medical industry for over a decade, and the company's products and services have been widely used in the medical industry for over a decade, and the company's products and services have been widely used in the medical industry for over a decade, and the company's products and services have been widely used in the medical industry for over a decade. If it is really necessary to use self-financed drugs outside the Drug List and medical materials and related self-financed items that require part of the cost to be borne by the patient due to the condition of the patient, the attending physician shall explain the reasons to the insured person and fill in the "Informed Consent Form", which shall be attached to the inpatient medical record with the consent signature of the patient or his/her family members, and the ratio of the cost of services outside the Drug List to the total cost of the service shall be controlled at less than 5%.
The hospital strictly enforces the charges set by the provincial and municipal price departments, publicizes the prices of medicines, charges for inspections, provides patients with cost lists in a timely manner, and strictly enforces the relevant provisions of the agreement, so that participants can consume in a clear manner.
Fifth, strengthen the system maintenance, safeguard the system operation security
I hospital to strengthen the health insurance information management system maintenance and management, timely exclusion of hospital information management system obstacles to ensure that the system is running normally, according to the requirements of the municipal health insurance office, familiar with the computer technology of the special management personnel responsible for the requirement of health insurance special computer strictly in accordance with the provisions of the special machine, in case of problems with the health insurance office contact, not due to procedural problems, not to be able to contact the health insurance office, but also to ensure the safety and security of the system. In case of any problem, contact with the Medical Insurance Office in a timely manner, so as not to cause medical expenses to be unable to be settled due to problems in the program, and to ensure timely and rapid settlement of the insured. At the same time, to ensure that the information data and information is true, complete, accurate and timely, to eliminate the arbitrary withdrawal of participants hospitalization registration information.
In short, our hospital through strict control of the municipal human resources and social security bureau "basic medical insurance designated hospital evaluation reference index" and other requirements to seriously self-check, and further strengthen the quality management, improve the service awareness and service level, and strengthen the construction of medical ethics and medical style, the successful completion of the work of the medical services to the insured persons, in line with the setup of the basic medical insurance designated hospitals and requirements, and strive for the assessment to achieve the level of A grade.
Part II Self-inspection report of designated medical institutions
Under the correct leadership of the higher authorities, my clinic strictly abide by the relevant national, provincial and municipal health insurance laws and regulations, and conscientiously implement the policy of health insurance:
First, attach great importance to strengthening leadership, and improve the system of responsibility for the management of health insurance
I have always attached great importance to the work of health insurance. I have always attached great importance to the work of medical insurance, held many special meetings to study the deployment of regular medical insurance training for physicians. The work of the medical insurance plan at the beginning of the year, regularly summarize the work of the medical insurance, analysis of the medical care of insured patients and the cost of the situation. We have set up a leading group for medical insurance work with the main leader as the leader and the deputy leader as the deputy leader, and have established and improved the systems of "medical insurance management system", "prescription management system", "medical insurance medical records, prescription audit system", "medical insurance reward report" and strictly observed the implementation of these systems. We know that basic medical care is an important part of the social security system, deepen the basic medical insurance system policy, is the inevitable requirements of the development of the socialist market economy, is to protect the basic medical care of employees, to improve the health of employees is an important measure.
Second, standardize the management, realize the standardization of health insurance services, institutionalization, standardization
In the county health insurance office of the correct leadership and guidance, to establish and improve the rules and regulations, such as the basic medical insurance referral management system, medical insurance work system, fee billing management system, outpatient management system. Setting up the "Basic Medical Insurance Policy Publicity Column" and "Complaints Box"; publicizing the telephone number 6961572 for consultation and complaints; enthusiastically providing consulting services for the insured and properly handling the complaints of the insured patients. Simplifying the process and providing convenient, high-quality medical services. Participants are strictly identified when they visit the clinic, and the phenomenon of visiting the clinic under an impostor's name is eliminated. Reasonable examination, treatment and medication are provided; there is no falsification or alteration of medical records. Actively cooperate with the medical insurance management organization to supervise and audit the treatment process and medical expenses, and provide timely access to medical files and related information. The company strictly enforces the fee standards set by the relevant departments and prohibits the establishment of its own fees or the raising of fees.
Jiuqiang medical insurance policy publicity, so that each patient is more familiar with the catalog. The hospital set up a special person to outpatient and hospitalized patients to implement the telephone return visit, the return visit rate of 81.4%, 98% satisfaction rate with the quality of service, by the majority of participants in the praise of the people.
Third, strengthen the management of the insured to provide quality assurance
First, the strict implementation of diagnosis and treatment and care routines and technical procedures. The first physician is responsible for the implementation of the system, handover system, medical records writing system, technical access system and other core medical systems. Secondly, on the basis of strengthening the implementation of the core system, we focus on the improvement of medical quality and continuous improvement. It has generally improved the medical quality management and control system, assessment and evaluation system and incentive and constraint mechanism, broken down the medical quality management objectives layer by layer and assigned responsibility to each person, moved the checking and supervising gates forward, and penetrated into the front line of clinical work to timely discover and solve the problems and hidden dangers in the medical work. Thirdly, the staff familiarize themselves with the core medical system and strictly implement it in the actual clinical work. They actively learn advanced medical knowledge, improve their professional and technical level, enhance the quality of medical care, and serve patients well, while strengthening the learning and cultivation of humanistic knowledge and etiquette knowledge to enhance their communication skills. Fourthly, medical documents are regarded as an important link in controlling medical quality and preventing medical disputes. Fifth, strengthening safety awareness, the doctor-patient relationship is becoming more and more harmonious. Our hospital continuously strengthens medical safety education, improves the awareness of quality responsibility, standardizes medical operation procedures, establishes and improves the system of doctor-patient communication, adopts a variety of ways to strengthen communication with patients, and patiently and meticulously informs or explains the condition to patients. Standardize the service language, strengthen the training of nursing etiquette, put an end to the phenomenon of raw, cold, hard, top, push phenomenon, patient care service enthusiasm, nursing care, careful operation, answer patience. Through a series of heartfelt service, customer service department in the regular patient satisfaction survey, patient satisfaction has been more than 98%.
Fourth, the maintenance and management of the system
We attach importance to the maintenance and management of the insurance information management system, timely exclusion of obstacles to the information management system to ensure that the system operates normally, in accordance with the requirements of the county health insurance office by the computer technology specialized managers responsible for the requirements of the special health insurance computer strictly in accordance with the provisions of the special machine, in case of problems in a timely manner and the Tianfeng software company and the medical insurance office to contact, can not be due to program problems resulting in the medical insurance. Can not be due to program problems and lead to medical costs can not be settled problems occur, to ensure that participants timely and rapid settlement.
We always adhere to the patient-centered, quality-centered, wholeheartedly for the patient service as the starting point, and strive to do the standardization of the establishment of rules and regulations, the humanization of the concept of service, standardization of quality of medical care, to correct the practice of conscientiousness, and actively provide participants with high-quality, efficient, inexpensive medical care and a warm medical environment, by the majority of the participants of the commendation received a good social and economic benefits. The company has been praised by the majority of participants, and has received good social and economic benefits.
篇三定点医疗机构自查报告
Prefecture and municipal designated medical institutions as an important part of China's health care, for the development of China's medical care, to protect the people's health, plays an important role. However, in the face of the continuous development of the new situation, in the face of the people's new requirements, from the municipal sentinel medical institutions should do their duty and do a good job of medical work, to create the people's satisfaction with the sentinel medical institutions, there are still some problems, some of which are more urgent, and urgently need to be resolved. I as a municipal fixed-point medical institutions, a section director, the municipal fixed-point medical institutions problems and ways to deal with them.
First, the problems and reasons
1, medical services leading organizations do not pay enough attention to
Medical services leading organizations of municipal sentinel medical institutions do not pay enough attention to, in particular, the lack of inspection and supervision of the medical foundation work, resulting in the part of the municipal sentinel medical institutions, "focus on the benefits of the light management; focus on the economic benefits of light social benefits The phenomenon of "focusing on benefits but not management; focusing on economic benefits but not social benefits" still exists in some local and municipal sentinel medical institutions; the assessment indexes of medical insurance management in some local and municipal sentinel medical institutions are not sound; the management of medical insurance is not well combined with the management of quality control of medical care; rewards and punishments are not clear, and there is a lack of incentives to constrain the role of the medical institutions; part of the medical staff is not familiar with and does not understand the medical insurance policy, and the implementation of this policy is not sufficiently publicized, and even the "Instructions for the Insured Patients
2, the medical institutions reform is not in place, there is a "medication for doctors" problem
Medical institutions reform is related to the basic medical insurance system can be successfully promoted the key. China's medical institutions are still pharmaceutical system, the expenditure of the health insurance fund is realized through the services of designated medical institutions and designated pharmacies, but due to the current reform of the medical institutions are not in place, medical institutions, "drugs to feed the doctor" problem is difficult to be resolved fundamentally, in particular, some medical institutions in the medical technology fees increased, the inflated price of drugs is still not in place. The inflated prices of medicines have not yet come down completely. According to relevant information, drug income accounts for about 55% of the total medical income, the profit of medical institutions selling drugs is as high as 28%, the huge profit has formed the situation that the hospital operation is overly dependent on the income from drugs, and it also makes a small number of hospitals and a small number of doctors distort their behaviors, giving patients with medical insurance to do non-targeted examinations, prescribing unreasonable medicines, etc., which results in the sharp increase of medical costs and the burden on individuals, leading to the lack of understanding and grievances of the patients towards the reform of medical insurance. The medical insurance reform does not understand, there are complaints.
3, the heavy burden of medical costs, the average cost is too high
In the medical insurance combined account mode, due to China's social security system is not yet sound, the lack of medical insurance to start the bottom of the fund compensation mechanism, resulting in the insured workers, especially the old workers and retirees personal account funds are small, some frail and sickly, long-term use of medication patients can not afford to pay the high cost of outpatient medical care, individuals pay too much cash, resulting in some of the outpatient medical care patients to pay the cash. Some frail and sick patients with long-term medication cannot afford the high costs of outpatient medical care, and individuals pay too much cash, resulting in some insured workers being afraid or unwilling to go to the doctor, so they have to go to the pharmacy to buy medication to treat their own illness. In the area of inpatient medical care, due to irregularities in the services of designated medical institutions and distortions in the behavior of a few doctors, hospitals use drugs and disposable materials outside the medical insurance drug list, and set up and break down diagnostic and therapeutic items for some illnesses that could have been treated with drugs from the medical insurance drug list. Some patients could not have been examined or could have been examined less, but hospitals or doctors expanded untargeted examinations for the sake of immediate interests, which also directly resulted in the excessive personal burden of various costs outside the directory of the hospitalization costs of the insured, and the out-of-pocket payment ratio increased, on average, up to 35%. Due to the existence of the above reasons, resulting in health insurance patients to the designated medical institutions for treatment, in fact, there is a heavy burden of medical costs, the average cost is too high, the degree of benefit is low, can be reported to the ratio of low and single disease over the standard problem.
4, the implementation of the health insurance system is lax, irregularities occur from time to time
Part of the local municipal sentinel medical institutions on the use of self-financed medicines, diagnostic and therapeutic items and medical service facilities range of items signing system and the implementation of the one-day list system is not in place; some of the sentinel medical institutions to verify the hospitalization procedures are not rigorous gatekeeper; clinical examination, the use of medication is not clear indications of the existence of irrational examination, treatment, and the writing of prescriptions for patients. ; insured patients prescription writing is not standardized, the project is missing, the drugs prescribed and the treatment of disease does not match; fraudulent prescribing, not symptomatic treatment, outpatient special chronic disease personnel and retirees, large prescriptions, patients discharged from the hospital over the dose of medication and other phenomena occur from time to time, and individual hospitals and even the existence of a nominal, fraudulent hospitalization, fabrication and forgery of illegal acts to seize the health insurance fund.
5, dealing with designated medical institutions in violation of the provisions of the difficulty
1999 by the Ministry of Labor and Social Security, the Ministry of Health, the State Administration of Traditional Chinese Medicine issued by the Interim Measures for the Management of Urban Employees' Basic Medical Insurance Designated Medical Institutions, it is clearly stipulated in the Interim Measures for the Management of Urban Employees' Basic Medical Insurance Designated Medical Institutions, the labor security administrative department may, depending on the circumstances, ordered to make corrections in the limited term, or notify the health administrative department to give criticism, or cancel the designated medical institutions. Depending on the circumstances, the labor security administrative department may order the institution to make corrections within a certain period of time, or inform the health department to criticize it, or cancel the qualification of designated medical institutions. This provision is difficult to implement in some municipal health insurance areas. Because there are not many municipal general hospitals, most of the insured hospitalization is concentrated here, such hospitals, such as violation of the provisions of the act or even fraud, the Ministry of Labor and Social Security is very difficult to cancel the qualification of its designated, dealing with violations of the provisions of the difficulty.
Second, to solve the problem of the `processing approach
1, deepen the reform of medical institutions, the establishment of a benign, healthy operating mechanism
We must adhere to the "three reforms", deepen the reform of health care institutions, accelerate the pace of institutional reforms, reversing the operating mechanism of the health care institutions to medicines to feed the medical, the implementation of medicine, the implementation of separate accounting, separate management. The company's business is to provide a wide range of products and services to the public. Adjustment of the price of medical services, on the premise of reducing the total cost of medical care, the embodiment of the knowledge and skills of medical personnel to raise the price of services to a more reasonable level, reduce the proportion of drug revenues in the total income of hospitals, the establishment of a benign, healthy operating mechanism.
2, strengthen the management, strict implementation of the agreement of the designated medical institutions
The current agreement of the designated medical institutions to strictly improve the implementation of the provisions of the basic medical insurance service management, improve the settlement of costs, control the personal burden of the insured, and to strengthen the assessment and supervision of the designated services and other content. To develop and control the basic medical insurance drug catalog preparation rate, utilization rate and the proportion of out-of-pocket drug costs to the total cost of medication for the insured. The management of diagnosis and treatment programs should be strengthened, with a focus on controlling the use of new diagnosis and treatment programs, large-scale equipment inspections and disposable medical materials. The basic medical insurance fee settlement method should be continuously improved, and the fee control and medical service quality assurance mechanism should be sound. Medical insurance management organizations should strengthen assessment and supervision in accordance with the indicators and assessment methods stipulated in the agreement, and the results of the assessment should be announced to the public and linked to the standard of settlement of medical expenses. A credit rating system for designated medical institutions should be explored, and the credit rating of designated medical institutions should be assessed annually on the basis of the assessment. For those designated medical institutions with excellent assessment results and high satisfaction rate of the insured, the agency may simplify the auditing and settlement procedures and notify the public in an appropriate form; for those designated medical institutions with more problems found in the assessment and low satisfaction rate of the insured, strict auditing shall be carried out, and their management and supervision shall be strengthened; for those designated medical institutions with serious problems, poor assessment results and low satisfaction rate of the insured, the agency shall pursue their responsibility for breach of contract or even terminate their agreements in accordance with the agreement. The agency should pursue its responsibility for breach of contract or even terminate the agreement, and if necessary, report to the administrative department of labor security to cancel its fixed-point qualification.
3, strengthen the inspection, to solve the heavy burden of medical costs
Health, finance, price, drug supervision and other departments to strengthen the supervision and inspection of the designated medical institutions, standardize their medical behavior, strict implementation of the designated agreement, and consciously provide high-quality services for the insured patients; develop and improve the relevant policies, to eliminate the doctor's large prescriptions, duplication of tests and other irregularities in the diagnostic and therapeutic behavior, to guide the reasonable examination, rational use of medication, and the treatment of patients with medical conditions. Reasonable use of medication, treatment of disease, the proportion of individual out-of-pocket payments of insured persons to control within a reasonable range, and strive to solve the problem of heavy burden of medical costs of insured persons, the average cost is too high, the beneficiary degree of low, can be reported than the low ratio and a single disease exceeds the standard.
4, standardized health insurance fund payment management, strict treatment of sentinel medical institutions in violation of the provisions
To strict treatment of sentinel medical institutions in violation of the provisions of the provisions, we must standardize the management of the payment of health insurance fund. First, to strengthen the daily supervision of the designated medical institutions, in addition to regular checks, the implementation of surprise inspections to combat violations. Establish and improve the letter and report system, investigate and deal with fraudulent use of medical insurance card, false invoicing, medicine for medicine and other violations of the health insurance fund. Secondly, payment policies, payment standards and payment ranges are strictly enforced, and reimbursement for Class A and Class B drugs is categorized; the fund's payment auditing and anti-fraud work is strengthened, and payment for over-scope medical expenditures and irregularities is refused, and the parties involved are strictly investigated and held responsible. Third, strengthening management and plugging the loopholes in medical expenses. Adhere to the list of reimbursement of hospitalization expenses, settlement of audits and reviews, and referral and transfer of hospitals to strictly implement the approval system. Fourth, the strict audit of medical expenses, allocation procedures, clear work responsibility, the implementation of fault accountability system.
The establishment of designated medical institutions, the purpose is to develop our medical career, to meet the needs of insured persons to seek medical treatment, to maintain the health of the people, the establishment of a harmonious society. I as a municipal sentinel medical institutions, a department director, to recognize the state set up a sentinel medical institutions purpose and role, to hold the country, responsible for the people's attitude, seriously do a good job in the sentinel medical institutions, in the quality of medical care, to protect the people's health on the basis of the more emphasis on the sentinel medical institutions of the social benefits of the reputation to maintain the sentinel medical institutions. Here, I want to do a good job of taking the lead, with their own superb medical skills and good medical style to play an exemplary role in guiding the whole department to strictly implement the agreement of the designated medical institutions, to eliminate large prescriptions, repeat checks and other irregularities in the diagnosis and treatment of behavior, the patient reasonable examination, rational use of medication, treatment of disease, resolutely stop the violation of the provisions of the act, and strive to be a doctor of the people's satisfaction.