In order to strengthen the "patient-centered, quality-centered" service concept, consolidate the results of the creation of the second hospital, and constantly improve and improve the quality of nursing care and safety management, highlighting the quality of nursing services, focusing on the continuous improvement of the quality of nursing care, the implementation of pdca's quality management methods, the adoption of the target-oriented, data management to promote the hospital nursing technology level, management level of continuous improvement, we hereby formulate this year's nursing quality and safety management plan. The management to promote the hospital nursing technology level, management level and constantly improve, especially the development of this year's nursing quality and safety management work plan.
First, improve the nursing quality management system, develop a good nursing quality management team
1, constantly improve the nursing quality and safety management committee under the leadership of the director of
The establishment of the nursing department, the special quality control group, the department of quality control group composed of three-level quality control system.
2, nursing quality and safety
Management Committee according to the Ministry of Health 2012 version of the "second-class general hospital accreditation standards for the implementation of the rules", in 2013, based on the nursing quality evaluation standards, to revise and improve the special quality control group and nursing quality evaluation standards. Each quality standard is oriented to goal management and focuses on the evaluation of nursing effect. The Department of Nursing should revise the inspection standards of each group in a timely manner and solve the problem of too many special quality control items that are not combined with reality.
3. Nursing quality and safety
The members of the management committee have clear work responsibilities and implement the work content. The Nursing Department is responsible for comprehensive and integrated inspection, and the special quality control group is divided into nine groups: ward management, hierarchical care, quality care, health education, disinfection and isolation, nursing document writing, emergency medicines and instruments, special nursing unit, and nursing technical operation. The departmental quality control team is divided into different specialties and specialists. The head nurse is the first person responsible for the management of nursing quality in the department, organizing and carrying out the work of the nursing quality control team in the department, clear responsibilities and implementation in place, and requires a quality control record can be checked.
4, the implementation of each specialty nursing
The responsibility of the technical guidance of the group, specialty nursing team is divided into pressure ulcer nursing team, pipeline nursing team, bruise nursing team, intravenous infusion nursing team, intravenous blood transfusion nursing team. Each group provides technical guidance, carries out relevant knowledge training and assessment, and standardizes nursing behavior. Continuously improve the nursing staff's awareness of risk assessment of high-risk patients, strengthen the nursing management of high-risk patients to ensure nursing safety and reduce the incidence of adverse events.
5, continuously improve the quality of care
Quality and safety management committee members to check the quality, improve the inspection method, optimize the process, tracking is effective, reflecting the effect of continuous improvement.
Second, take pdca's quality management methods, the implementation of multi-dimensional quality control
1, quarterly nursing quality comprehensive inspection and occasional supervision. The focus of the inspection is to supervise the care of critically ill patients, departmental management, nursing safety, nurses standardized practice, etc., after the inspection of the scene feedback on the existence of problems, give targeted guidance, the nursing department from time to time to supervise the implementation of key issues.
2, monthly nursing quality inspection. Nursing Department special quality control team according to the nursing quality assessment and evaluation standards on the strict supervision and inspection of the departments, and the outstanding problems that existed last month, tracking inspection and rectification. It also exchanges the inspection situation with the Nursing Department, informs the inspection results at the regular meeting of the head nurse, and puts forward the corrective measures and the next work idea. And the problems found in the monthly supervisory inspection as the main content of the next month's quality inspection tracking, check the actual rectification effect. And inspection records, analysis, evaluation and improvement measures records.
3, the implementation and improvement of departmental quality self-control. The department set up a quality control team, clear responsibilities, and give full play to the role of quality control personnel. Monthly self-examination of the department, the existence of problems put forward practical rectification proposals, and timely feedback on the effect of rectification. The department held monthly quality analysis meeting, quality control personnel should have the appropriate 'speech' at the meeting, to improve the quality of nursing care in the department to come up with ideas. Usually nursing staff found in the work of the problem can be verbalized in a timely manner to notify the parties or report to the head nurse.
4, the head nurse night inspection. The Department of Nursing arranges for the head nurse to take turns conducting the head nurse's night checkup every week, focusing on supervising the implementation of the core system, the completion of work duties, the quality and safety of nursing care for critically ill patients, etc.,.
5, the departments actively carry out inpatient nursing work satisfaction survey, through the inpatient satisfaction survey, found that there are deficiencies in nursing work, targeted to strengthen management, improve the quality of nursing services, and will be reported to the Department of Nursing, for the questionnaire responded to the problem of serious analysis, continuous improvement.
6, the implementation of continuous improvement of nursing quality. The role of the department monitoring group and nursing backbone, focusing on link quality control and key issues of rectification effect tracking. The implementation of the department's usual inspection and nursing supervision combined with the combination of key and comprehensive inspection of the principle. The Nursing Department held a regular meeting with the head nurse to analyze the causes, put forward corrective comments, and track the effect of rectification.
7, adhere to the quarterly inpatient work break symposium, face-to-face communication with patients and their families, free speech, heart-to-heart exchanges, closer to the doctor-patient relationship; continuous improvement of nursing work, improve patient satisfaction.
8, conscientiously implement the "non-punitive nursing adverse event reporting system," the department on time to report to the Department of Nursing, the Department of Nursing will be organized by the head nurse of each department on each adverse event to discuss, analyze and summarize the lessons learned and will be a typical case notification to alert the nursing staff to the strict implementation of the rules and regulations and operating procedures.
9, the nurses who have not obtained the license shall not work independently must be implemented to teach. This year, the new nurses for pre-service theoretical and operational training and assessment, requiring everyone to pass. To strengthen the management of nursing internship teaching, in July to the interns before the warning education to avoid errors.
10. Strengthen the management of nursing defects, nursing disputes, adhere to the strict supervision of the quality of the work link, found that the safety hazards, take timely measures to nip nursing errors in the bud. The Nursing Department of nursing defects errors in a timely manner to discuss and analyze.
11, strengthen the nurse business skills training. According to the training plan formulated at the beginning of the year, the whole hospital nurses were organized theoretical examination, operational assessment.
12. Strengthen the training of specialized nurses and nurses for further training. Developed 10 nursing backbone to the provincial and state hospitals for further training, involving critical care, hemodialysis, neonatal, operating room, orthopedics and other specialties.
Third, the development of quality control objectives
1, ward management qualified rate of ≥ 90%
2, graded care qualified rate of ≥ 90%
3, quality care qualified rate of ≥ 90%
4, health promotion coverage of 100%
5, nursing instruments written qualified rate of ≥95%
6, first aid items intact rate of 100%
7, nursing "three basic" examination pass rate of 100%
8, the number of cases of nursing accidents occurred in the year 0
9, pressure ulcer risk assessment rate of 100%, falls, falling out of bed risk assessment rate of 100% of the county people's hospital. Hospital Nursing Department February 10, 2014 10 xx