Quality management standards in accordance with the Ministry of Health, quality management and business development on many years!
Department of quality management can be done, is very standardized
Medical institutions to strictly implement the quality of medical care and medical safety of the core system of construction, standardize the relevant departments of the medical institutions, the implementation of hospital affairs. Focus on the requirements:
1. Strict implementation of the system of responsibility for the first diagnosis, physician room visits, difficult case discussion, critically ill patients in emergency situations, counseling, preoperative discussion, death discussion? , handover and other core systems are implemented to ensure medical quality and medical safety.
2. Implementation of the basic norms of medical record writing, standardize medical record writing, strengthen the connotation construction of medical records, improve? High-quality medical records.
Implementation of the "basic norms of electronic medical records, clinical application of standardized electronic medical record system construction and electronic medical records. Emergency Department and management guidelines (for trial implementation)" construction in accordance with the requirements of the document, the construction of key emergency medicine and management guidelines (for trial implementation)", to further strengthen the Emergency Department, Emergency Medicine, Pathology, Neonatal Unit
4. and other key departments and key areas of the construction and management, so that the personnel, equipment, facilities, their functions, tasks and carry out scientific, rational, and quality medical records. and mission and to carry out scientific, rational and standardized medical services.
According to the basic standards for hemodialysis units in medical institutions, the rules, equipment, and personnel to do hemodialysis units meet the basic standards.
6. Comprehensive implementation of the hospital affairs open system, and further implementation of the requirements of the hospital affairs openness, as well as medical institutions hospital affairs openness supervision and evaluation methods (for trial implementation) "to enhance the awareness of the hospital affairs openness of medical institutions, and to promote the medical institutions to further optimize the service process and the internal democratic management decision-making.
(E) to further strengthen nursing care, the implementation of basic care, improve nursing services, improve the quality of care.
1. Further implement the "Nurses Regulations", establish and improve the nursing regulations, disease care routine nursing norms, standards, the establishment of the nurse post responsibility system, standardize the practice of nurses, safeguard the legitimate rights and interests of workers nurses, contract nurses and the preparation of nurses with equal pay for equal work and equal equality.
2. Implementation of the Ministry of Health to strengthen clinical care in hospitals "(work on the road to health medical government issued [2010] No. 7) and normative documents to improve medical services and strengthen nursing management.
Hospitals are graded according to the "General Hospital Nursing Guidelines (Trial)" and inpatient basic nursing services (Trial) "document requirements, refine the content of graded care services, services, and into the hospital affairs open to the patients announced and the community. Hospitals, effectively strengthen the organizational leadership, improve and implement the rules and regulations to strengthen clinical care, mobilization of forces, provide the facilitating conditions for the effective implementation of the work and a strong guarantee, and gradually reverse the situation by the family of self-employed patients or their family caregivers to assume the care of patients' lives.
3. Solidly carry out "quality nursing service demonstration project activities, do 16 priorities. In particular, the establishment of the nurse performance appraisal system, clinical nurses nursing patients to implement the accountability system, the hospital clinical front-line nurses accounted for the proportion of nurses totaling no less than 95%, according to the clinical nursing workload rational allocation of nursing human resources, encouraging the use of various forms of health care instrument, the hospital invested more funds to improve the treatment of nurses, clinical front-line inclined to the incentives, to create an atmosphere of good practice.
(f) the implementation of the clinical application of medical technology management approach", continue to do a good job in the clinical application of medical technology management.
Conscientiously implement the "management of the clinical application of medical technology", the management of cardiovascular intervention", "gynecological endoscopy treatment technology management specification" and other normative documents, medical technology and management system. In order to promote the development of medical science and the rational application of medical technology clinical. The main requirements:
1. provincial health administrative departments in this regard? Medical technology access and audit of the organization and implementation of medical institutions, in this regard has developed and released the second category of medical technology directory to guide the medical institutions in the second category, the third category of medical technology before the clinical application of third-party technical audit work in the application of key cell therapy technology management, in conjunction with the provincial food and drug supervision? Cell therapy products or technologies related to the management of the field of combing, mapping, immediately stop the unauthorized cell therapy products or technologies of clinical research and clinical application.
2. Provincial health administrative departments of medical institutions in the area to carry out cardiovascular interventional technology and gynecological endoscopy treatment technology, in accordance with the provisions of the implementation of the access management, guidance, supervision of medical institutions, the clinical application of medical technology management norms.
3. The main person in charge of the medical institution as the primary responsibility for the management of medical technology and clinical application of this institution, is responsible for the establishment of rules and regulations, the establishment of a sound management of medical technology and medical technology management of this institution's clinical application of the document for technical audit. Carry out the first category of medical technology, strict management, the second and third category of medical technology clinical application of the third party to conduct technical audits, in strict accordance with the provisions of the application work before the clinical application of medical technology.
4. Medical institutions to establish a surgical grading management system, the development of specific implementation rules and management methods, the development of institutional surgical grading directory, in strict accordance with the provisions of the professional and technical capabilities of the physician review and through the corresponding surgical privileges can be granted only after the implementation of dynamic management.
5. medical technology and medical institutions to establish a risk warning mechanism, develop and improve the disposal plan, and organize the implementation of medical technology damage.
(VII) the Chinese people **** and the State of China "," Narcotic Drugs and Psychotropic Substances Administration Regulations "" prescription management approach "," Drug Administration Act "Implementation of the "Interim Provisions" of the Medical Institutions, Drug Administration, "Guiding Principles for the Clinical Application of Antimicrobial Drugs, Rational Use of Drugs Monitoring in the Nation, "National Prescription Set and the General Office of the Ministry of Health on the Management of Clinical Antibiotic Use Notice on relevant issues" (Department of Health Medical Government issued [2009] No. 38), and actively promote the clinical use of drugs and other laws, regulations, rules and normative documents main requirements:
1. Establishment of the institutional pharmacy management organization, improve the work management system, seriously. BR /> 2. Implement the "National Formulary", the development of institutional formulary, and conscientiously organize training, implementation and evaluation work to promote the rational use of clinical drugs.
3. Seriously implement the "prescription review system, and implementation of dynamic monitoring of prescriptions and extraordinary warnings, the irrational use of drugs, timely intervention.
4, the establishment of a sound antimicrobial drug hierarchy management system, clear prescription authority for physicians at all levels to use antimicrobial drugs according to the provisions of the guiding principles for the clinical application of antimicrobial drugs, to take practical measures to promote the rational use of antibiotics.
5. incision surgery prevention strict control of class I focus, to further strengthen the management of perioperative prophylactic application of antimicrobial drugs, strengthen the clinical microbiology testing, clinical use of antibiotics and bacterial resistance monitoring, clinical application of antibiotics and bacterial resistance to the establishment of early warning mechanisms.
6. Practical and reasonable drug use monitoring, according to the monitoring requirements to establish and improve the program, serious, timely, accurate and good data collection and reporting.
7. Drugs, anesthesia, essence, put special drugs, seriously implement the safety management system.
8. Establishment of clinical pharmacist system, there is a clear clinical pharmacist job responsibilities and the corresponding clinical pharmacist work with the management system, clear responsibilities and tasks in the medical quality management system, seriously.
(viii) Further strengthen the safety management of key aspects of medical services, to ensure medical safety.
1. Continue to promote the realization of patient safety goals.
2. The implementation of the surgical safety verification system, effective surgical safety verification.
3. Implementation of the hospital system, "blood for clinical medical institutions management approach (for trial implementation)", clinical blood transfusion technical specifications and hospital operating room (room) management norms (for trial implementation) "normative documents, check the implementation of the system, and do a good job in verifying the safety of blood transfusion, medication, testing and other medical services. The safety of the key links.
(IX) the implementation of hospital infection management practices and technical specifications, to strengthen the key sectors, key departments, key aspects of hospital infection control.
1. Establish and improve the organization of control of hospital infections, hospital infection management department with clear responsibilities, reasonable part-time staff, the development and implementation of relevant rules and regulations, compliance with the actual court.
Actively carry out the monitoring of hospital-acquired infections, hospital infection reporting system, so that the problem is detected in time, timely treatment to reduce hospital-acquired infections, resulting in harm to patients.
3. Implementation of the hospital operating department (room) norms (for trial implementation) "normative documents, to strengthen the operating room, hemodialysis room of the key industries, intensive care wards, neonatal wards, disinfection and supply room and other hospital infection prevention and control, medical equipment cleaning, disinfection, sterilization and other key aspects of the prevention and control of hospital infections up to standard.
4. Implementation of medical institutions hemodialysis room management norms ", to strengthen the management of hemodialysis room. Hemodialysis room, quality control and hospital infection prevention and control measures to meet the regulatory requirements of the organization and management.
5. To carry out hospital infection control and part-time personnel and hospitals focusing on departmental infection, medical staff of the hospital infection prevention and control of knowledge training of key aspects of hospital infection prevention and control, to strengthen the awareness of the prevention and control of hospital infections, to improve the level of prevention and control of hospital infections.
(j) of the pathogenic microorganisms laboratory biosafety regulations ", people to people infected with highly pathogenic microorganisms laboratory and experimental activities biosafety approval and management methods", "medical institutions clinical laboratory management approach" and other relevant regulations. Regulations, conduct a comprehensive inspection of medical institutions within the laboratory biosafety, quality control and management, focusing on inspection system construction, hardware facilities, personnel management, emergency response, and implementation.
(11) in the People's Republic of China **** and the implementation of the "Blood Donation Law", "blood for clinical medical institutions management approach (for trial implementation)", "clinical blood transfusion technical specifications, the General Office of the Ministry of Health on the Further strengthen the blood management work of the notice" and county-level blood station staff should know the 100 questions and answers to strengthen the focus of the clinical management of blood to further standardize the clinical management of blood to promote clinical science, the rational use of blood to protect the safety of blood for clinical use. Key requirements:
Medical institutions should comply with the relevant provisions of China's "Chinese People's Republic of China *** and the State Blood Donation Law, strictly prohibit the illegal collection of blood.
The clinical blood transfusion management committee of the second-level hospitals should develop a clear responsibility for the use of blood according to the "blood, good blood for clinical use of standardized management and technical guidance, and actively carry out clinical rational use of blood, blood, science, education, training and inspection work.
3. Medical personnel of medical institutions, for clinical medical institutions management approach (for trial implementation) "clinical blood transfusion technical specifications and guidelines, scientific and rational use of blood.
4. Clinical departments of medical institutions, should be based on the "blood for clinical medical institutions management (for trial implementation)", clinical blood transfusion technical specifications, and in the actual work of the blood for clinical use plan, formulate weekly, monthly, and carry out an assessment of the medical staff blood use.
5. Medical institutions Department of reasonable technicians, equipment and facilities for blood transfusion (blood bank), blood transfusion department (blood bank) should establish a quality management system, develop a blood reserve plan to do the clinical use of blood storage, testing and release.
6. Medical institutions should establish a scientific and effective transfusion of adverse reactions and emergency response plan, there is blood, seriously implement.
(xii) establish regular inspection of the existence of production safety infrastructure, technical equipment, operating environment, prevention and control devices, safety risk work mechanism, focusing on strengthening the construction system of production safety, safety management organization system, responsibility for the implementation of labor discipline, site management, accident investigation and other weak links in the rectification work. The main requirements:
1. Perfect safety organization, leadership, management bodies, regulations, rules, standards, carefully organized, and carried out a clear manpower needs.
2. Strengthen the daily routine management, maintenance of safe production of important facilities, equipment, key equipment and installation, maintenance and protection of safe operation and prevention of leakage, leakage, leakage, perfect match and use of labor protective equipment. BR /> 3. Ensure smooth fire escapes, no obstacles, complete fire fighting equipment, visible signs, manned management, fire alarm system.
4. Strengthen emergency management, improve the development of a variety of emergency plans, emergency relief supplies and maintenance, regular emergency drills.
5. To strengthen the management of important departments radiology, medical oxygen isotope room, oxygen supply room, hazardous materials warehouse safety, power distribution room, pressure vessels, elevators.
(M) continue, the national blood bank blood safety activities, the Ministry of Medical Affairs separately defined program of activities to carry out special inspections.
(XIV) 3 in the national general hospitals to continue to carry out activities to assess the quality of medical records, program of activities issued separately by the Ministry of Medical Affairs.
(xv) to carry out the national tertiary general hospital quality of service advanced unit assessment activities, the program of activities issued separately by the Ministry of Medical Affairs.
(xvi) to carry out the supervision and inspection of the national medical institutions radiological work of the program of activities issued separately by the Ministry of Supervision.