In order to comprehensively promote the deepening of the reform of the medical and health system and the reform of public hospitals, and to gradually establish China's hospital accreditation and evaluation system, and to promote the strengthening of medical institutions to strengthen their own construction and management, and to continuously improve the quality of medical care to ensure the medical safety, improve medical services, and better fulfill their social responsibilities. medical safety, improve medical services, better fulfill their social responsibilities and obligations, improve the overall service level and service capacity of the medical industry, and meet the people's multi-level demand for medical services, the standards are formulated on the basis of summarizing the experience of the first cycle of hospital accreditation in China and the activities of the Year of Hospital Management.
This standard applies to the second level of general hospitals, other types of second-level hospitals for reference.
This standard *** set 7 chapters 69 sections 356 standards and monitoring indicators.
Chapter I to Chapter VI *** 63 sections 321 standards for hospital self-evaluation and improvement, and as a field review of the second level of general hospitals.
Chapter VII***6 section 35 monitoring indicators for the daily operation of level II general hospitals, monitoring of healthcare quality and safety indicators and tracking and evaluation after accreditation.
Instructions:
1. Level II hospitals are regional medical institutions that provide medical care to areas containing multiple communities (with populations generally in the hundreds of thousands), taking into account preventive, health care and rehabilitative medical services and undertaking certain teaching and scientific research tasks in a comprehensive or specialized manner; in this standard, "county hospitals" are In this standard, "county hospital" is the medical and health center within the county organized by the government, which should combine the characteristics of the local disease spectrum, focusing on strengthening the ability to rescue and treat difficult diseases and critically ill patients, which seriously endanger the health of the local people. At the same time, it shall undertake operational and technical guidance for township health centers and village health offices and further training for health personnel.
2. The names of diseases cited in this standard and ICD-10 code using the International Statistical Classification of Diseases and Related Health Problems, People's Health Publishing House, the tenth revision of the second edition (Peking Union Medical College Hospital, the World Health Organization, the International Classification of Families Collaborating Center for the compilation).
3. The name of the operation cited in this standard and ICD-9-CM-3 code using the International Classification of Diseases Surgery and Operations, People's Army Medical Press, the ninth edition of the clinical revision of the 2008 edition (Liu Aimin compiler).
Chapter I Hospital Functions and Tasks
I. Hospital settings, functions and tasks in line with the positioning and requirements of the regional health planning and medical institution setup planning
(a) The functions, tasks and positioning of the hospital are clearly defined, and the hospital is maintained at a moderate scale.
(2) It is mainly responsible for the diagnosis and treatment of common and frequent diseases and some difficult diseases, taking into account the functions of prevention, health care and rehabilitation, and it can provide 24-hour diagnosis and treatment services for acute and critical illnesses.
(3) Clinical departments set up diagnostic and treatment subjects, personnel echelon and diagnostic and treatment technology capacity to meet the provincial health administrative department of the second level hospital standards.
(D) medical and technical department services to meet the needs of clinical departments, project settings, staff echelon and technical capacity to meet the provincial health administrative department of the second level hospital standards.
Scientific and standardized internal management mechanism
(a) adhere to the public hospital public welfare, the maintenance of people's health rights and interests in the first place.
(B) in accordance with the provincial health administrative departments, the implementation of standardized training of residents.
(3) the promotion of standardized diagnosis and treatment, clinical path management and quality control of single diseases, as a key project to promote the continuous improvement of medical quality.
(4) Improving work performance, optimizing medical service systems and processes, and shortening average hospitalization days and patients' waiting time for medical treatment.
(5) In accordance with the National Guidelines for Clinical Application of Essential Medicines, the National Essential Medicines Formulary, and relevant regulations on the use of medicines in medical institutions, physicians' prescribing behavior is regulated to ensure that essential medicines are given priority and rational use.
(F) strictly control public hospitals to carry out special services.
Three, undertake government directive tasks
(a) According to the government directive to undertake the work of counterpart support for primary health care institutions, included in the dean's target responsibility system and the hospital's annual work plan, with the implementation of the program, a person in charge.
(2) according to the "Chinese people's *** and the State of infectious disease prevention and control law" and "public *** health emergency regulations" and other relevant laws and regulations to undertake infectious disease discovery, reporting, treatment, prevention and other tasks.
(3) To carry out health education, health counseling and other forms of public welfare social activities.
(4) according to the "Statistics Law" and the health administrative department, complete the basic operating conditions of the hospital, medical technology, diagnosis and treatment information and clinical medication monitoring information and other related data reporting work, the data is true and reliable.
Four, emergency management
(a) comply with national laws and regulations, and strictly implement the emergency plans formulated by governments at all levels. Obey the command and control, undertake the county's emergency medical rescue tasks and cooperate with the prevention and control of public **** health emergencies.
(2) the establishment of the hospital emergency work leading group, the implementation of responsibilities, the establishment and continuous improvement of the hospital emergency management mechanism.
(3) The hospital has a clear strategy for dealing with major emergencies, establishes a hospital emergency command system, develops and improves various types of emergency plans, and improves the ability to respond quickly.
(4) carry out emergency training and exercises to improve the quality of emergency response at all levels and types of personnel and the hospital's overall emergency response capability.
(E) reasonable emergency supplies and equipment reserves.
V. Clinical medical education and scientific research
(1) to undertake the government-assigned directive task of cultivating talents in primary health care institutions (township health centers, village health offices), to develop relevant systems, training programs, and have specific measures to protect.
(2) Undertake clinical teaching and internship tasks for medical students in medical schools or undertake the task of training general practitioners in the region.
(3) There are systems in place to ensure that the continuing medical education of health professionals.
(iv) There is a system to support and encourage the participation of medical personnel to carry out investigations and research related to common and frequent diseases in the region, and to provide appropriate funding, conditions and facilities to achieve results.
VI. Ability and resources to undertake the functions and tasks of public medical and health centers (optional, county hospitals are mandatory)
(a) Undertake the functions and tasks of public medical and health centers.
(ii) Under the organization of the competent authorities, undertake to establish and improve the three-tier rural medical and health service network based on township health hospitals and village health offices.
(3) The specialty settings and diagnostic and treatment technology capabilities have obvious advantages among hospitals of the same level.
(4) according to government directives, the hospital to receive the city's three hospitals to support the hospital, and strive to achieve the level of second class A, should be "up to the standard work" task as the director of the target responsibility system and the hospital's annual work plan, with the implementation of the program, a person in charge.
Chapter II Hospital Services
I. Appointment service (optional, county hospitals are mandatory)
(a) the implementation of a variety of forms of appointments and time-slots of services, outpatient and discharge patients to implement the outpatient and follow-up in the medium and long term appointments.
(b) have a booking system and norms, operational procedures, and gradually increase the proportion of patients with appointments.
(3) There are performance appraisal and allocation policies to improve outpatient services and facilitate patients' access to medical care, and medical staff are supported to engage in evening outpatient services and holiday outpatient services.
(4) Establishment of appointment referral services with higher-level counterpart hospitals and primary medical institutions linked to cooperation.
II. Outpatient process management
(1) Optimize the layout and structure of outpatient clinics, improve the outpatient management system, implement convenient measures to reduce the waiting time for medical treatment, and improve the experience of patients in medical treatment.
(2) Publicize outpatient information, ensure that medical staff attend outpatient clinics on time, and notify patients in advance of any change in the time of medical staff attendance. Provide counseling services to help patients to effectively seek treatment.
(3) Deploying medical resources according to the flow of outpatients, and coordinating between outpatients and auxiliary departments.
(d) According to outpatient patient flow supporting medical resources. There are performance evaluation and allocation policies to improve outpatient services and facilitate patients' access to medical care. Support for medical staff to engage in evening outpatient clinics and holiday outpatient clinics.
Three, emergency green channel management
(1) Reasonable allocation of emergency resources, equipped with professionally trained and competent emergency medical staff, emergency equipment and medicines, in line with the basic requirements of the "Guidelines for the Construction and Management of Emergency Departments (for Trial Implementation)".
(2) Implementing the system of responsibility for the first diagnosis, and establishing a system of emergency and first aid transfer services with primary medical institutions.
(3) Strengthening the examination and triage of emergency cases, dividing patients with acute and critical illnesses from those with general emergencies, treating patients with acute and critical illnesses in a timely manner, and effectively triaging patients with non-acute and critical illnesses.
(4) the establishment of emergency hospitalization and surgery "green channel", the establishment of trauma, pesticide poisoning, acute myocardial infarction, stroke, high-risk pregnancy and maternity and other key types of emergency service procedures and norms, the need for emergency resuscitation of critically ill patients can be resuscitated first and then pay, to ensure that the patient to obtain coherent medical services.
(E) to carry out first aid technical operating procedures of full training, the implementation of qualified induction system.
(6) The director of the department, the head nurse and qualified personnel to form a quality and safety management team, can use the core system, job responsibilities, diagnostic and treatment norms and quality and safety indicators to strengthen the quality of emergency medicine throughout the monitoring and management and regular evaluation, and promote continuous improvement.
Four, hospitalization, referral, transfer service flow management
(a) Improve the patient admission, discharge, transfer service management system and standards, improve the service flow, and facilitate the patients.
(2) To develop a reasonable and convenient income hospital system and procedures for emergency patients' admission. Critical patients should be rescued and admitted in a timely manner.
(3) Within the framework of the national basic medical insurance system and under the organization of the competent authorities, the hospital shall establish and implement a two-way referral system.
(4) Strengthening the handover management of patients who are referred to the hospital or department, timely transmission of patients' medical records and related information, and provision of continuous medical services for patients.
(E) Strengthen the management of health education and follow-up appointments for discharged patients, and improve patients' health knowledge and awareness of post-discharge medical, nursing and rehabilitation measures.
V. Management of basic medical security services
(1) There are management systems and corresponding safeguards for various types of basic medical security services, and the management of service fees is strictly enforced to facilitate patients' access to medical care.
(2) The fees and charges for medical services are made public, and the basic medical insurance payment programs are announced.
(3) Protecting the rights and interests of all types of participants in the basic medical insurance system, and strengthening the informed consent of insured patients.
VI. Protecting the legitimate rights and interests of patients
(1) The hospital has a relevant system to ensure that patients and their families are fully aware of their rights.
(2) The physician in charge shall take appropriate ways and use easy-to-understand language to explain to the patient, his family or proxy the condition of the patient and treatment, special treatment and disposal, and to obtain his consent, the content of the explanation should be recorded, and to fulfill the written informed consent procedures.
(C) to carry out experimental clinical care (clinical human trials) should strictly comply with national laws, regulations and departmental rules, audit management procedures, and obtain written consent from patients.
(D) to protect the patient's right to privacy, respect for national customs and religious beliefs.
(v) the hospital for medical staff to protect the legitimate rights and interests of patients, doctor-patient communication and other training, the relevant medical staff can know and follow.
VII. Complaint Management
(1) Implement the "Hospital Complaints Management Measures (Trial)", the implementation of the "first complaint system", the establishment or designation of a special department to accept and deal with the complaints of patients and medical personnel, and timely processing and reply to the complainant.
(2) Announcement of the complaint management department, location, reception time and its contact information, and at the same time announced the higher departments of the complaint telephone. It establishes sound complaint files and standardizes complaint handling procedures.
(3) Continuous improvement of medical services based on complaints from patients and medical staff.
(iv) Specialized training for all staff on dispute prevention and handling.
VIII. Consultation Environment Management
(1) Provide patients with consultation reception, guidance and counseling services.
(2) Emergency and outpatient waiting area, medical and technical departments, inpatient wards, etc. have obvious, easy to understand signs.
(3) The environment for consultation and hospitalization is clean, comfortable and safe.
(4) There are facilities and management measures to protect patients' privacy.
(v) Implementing the "Standards for Smoke-free Medical Institutions (Trial)" and the "Decision on a Total Ban on Smoking in the National Healthcare System from 2011".
(F) Implementation of measures to create a "safe hospital", to build a harmonious doctor-patient relationship, optimize the medical practice environment has been effective.
Chapter III Patient Safety Goals
I. Establishment of a checking system to identify patients
(a) the implementation of the unique identification of patients (such as health insurance cards, new rural cooperative medical card number, ID card number, medical record number, etc.) management.
(2) in the diagnosis and treatment activities, the strict implementation of the "checking system", at least at the same time using the name, age, bed number, etc. 2 check the patient's identity, to ensure that the correct patient to carry out the correct operation.
(3) Improve patient identification measures in key processes (emergency, ward, operating room, ICU, labor and delivery room, neonatal room processes), and establish a complete transfer handover registration system.
(4) The use of "wristbands" as identification of patients, mainly for ICU, neonatology (room), operating room, emergency room and other key departments, as well as unconsciousness, rescue, blood transfusion, language communication barriers in different languages, infectious diseases, drug allergies and other patients.
Two, to establish the procedures and steps for effective communication between medical staff in special circumstances
(a) In the routine diagnostic and treatment activities of hospitalized patients, medical advice should be given in writing.
(2) in the implementation of emergency rescue, if necessary, oral temporary medical advice; nurses should be oral temporary medical advice complete restatement of confirmation, in the implementation of two-person verification; after the timely addendum.
(C) receive non-written patient "critical value" or other important examination (test) results, the receiver must be standardized, complete and accurate record of patient identification information, examination (test) results and the information reported by the person, review and confirm the correctness of the physician can be provided only after the use.
Three, the establishment of a surgical safety verification system to prevent errors in surgical patients, surgical sites and surgical procedures
(a) Elective surgery of the various preoperative examination and assessment work is completed in its entirety before surgical orders can be issued.
(2) There is a system for identifying and labeling surgical sites and workflow.
(3) There is a system and workflow for surgical safety verification and surgical risk assessment.
Four, the implementation of hand hygiene standards, the implementation of the basic requirements of hospital infection control
(a) In accordance with the "Code of Hand Hygiene for Medical Personnel", the correct configuration of effective and convenient hand hygiene equipment and facilities, to implement hand hygiene to provide the necessary safeguards and effective regulatory measures.
(2) Medical personnel should strictly follow the requirements related to hand hygiene in clinical diagnosis and treatment activities.
V. Strengthening the management of special drugs to improve drug safety
(1) high concentration of electrolytes, confusing (drug name similarity, similar drug appearance) drugs have strict storage requirements, to strictly implement the use of narcotic drugs, psychotropic drugs, radioactive drugs, toxic drugs for medical use and drugs and pharmaceuticals and other drugs and other special management of the use of drug management rules and regulations; high concentration of electrolytes, confusing (drug name similarity, similar drug appearance) drugs have strict storage requirements; high concentration of electrolytes, confusing (drug name similarity, similar drug appearance) drugs should be strictly enforced. Electrolytes, easy to confuse (sounds like, looks like) drugs should have strict storage requirements, high-risk drugs such as storage in the hospital district, it must be done in a special cabinet with locks, with high-risk drug labeling.
(ii) prescriptions or medication orders in the transcription and implementation of strict verification procedures, and by the transcription and implementation of the signature confirmation.
VI. Clinical "critical value" reporting system
(a) There is a clinical "critical value" reporting system and process to determine the "critical value" of the project.
(2) Establishment of "critical value" evaluation system.
VII. Preventing and reducing patient falls, bed falls and other accidents
(1) Assessing high-risk patients who are at risk of falls and bed falls, we should take the initiative to inform them of the dangers of falls and bed falls, and take measures to prevent the occurrence of accidents.
(b) There are falls, bed falls and other accidents reporting system, treatment plan with the workflow.
Eight, to prevent and reduce the occurrence of pressure ulcers in patients
(a) There is a pressure ulcer risk assessment and reporting system, pressure ulcer diagnosis and treatment and nursing care norms.
(b) Implementation of nursing measures to prevent pressure ulcers.
IX. Proper handling and reporting of medical safety (adverse) events
(1) There is a system and enforceable workflow for proactive reporting of medical safety (adverse) events and hidden defects, and the medical staff is fully informed.
(2) There are incentives to encourage medical staff to report online through the Medical Safety (Adverse) Incident Reporting System.
(3) There should be root cause analysis of major unsafe events, combining safety information with the actual situation of the hospital, and making targeted and continuous improvements in the hospital's management system, operation mechanism and regulations.
X. Patient participation in medical safety
(1) for the patient's disease diagnosis and treatment, for patients and their families to provide relevant health knowledge education, to help patients make a correct understanding of the diagnosis and treatment program and choice.
(2) To take the initiative to invite patients to participate in medical safety activities, such as identification, confirmation of surgical site, use of drugs.
Chapter IV Medical Quality and Safety Management and Continuous Improvement
I. Medical Quality Management Organization
(1) There is a medical quality management responsibility system for hospitals and departments, and the dean is the first person responsible for medical quality management, responsible for the development of medical quality and medical safety management and continuous improvement programs, and regular thematic studies of medical quality and medical safety, and the head of the department is fully responsible for the medical quality management of the department, and the implementation of medical quality management. The director of the department is fully responsible for the medical quality management of the department, and carries out the tasks related to the management and continuous improvement of medical quality and medical safety.
(2) The hospital has appropriate quality management organizations, including medical quality management, pharmacy management, nursing management, hospital infection management, case management, blood transfusion management and other organizations, which regularly study medical quality management and other related issues, record the process of quality management activities, and provide support for the dean's decision-making.
(3) medical, nursing and other functional departments are responsible for the organization and implementation of hospital medical quality and medical safety management, and the implementation of continuous improvement programs, undertake guidance, inspection, assessment and evaluation of medical quality management, strict records, regular analysis, timely feedback, implementation of rectification, and the establishment of multi-sectoral quality management coordination mechanism.
Two, medical quality management and continuous improvement
(a) have medical quality management and continuous improvement program, and organization and implementation.
(2) The establishment and implementation of medical quality management system, operating standards, diagnosis and treatment guidelines.
(3) adhere to the "strict requirements, strict organization, rigorous attitude", strengthen the "basic theory, basic knowledge, basic skills" training and assessment; once every two years, the organization of health personnel assessment.
(4) to establish a medical risk prevention mechanism to ensure patient safety, in accordance with the provisions of the report of medical safety (adverse) events and hidden defects, do not conceal the report, slow report and omission.
(5) The quality management personnel of the hospital's leadership team, functional departments, clinical and medical departments are able to apply the principles of total quality management, and carry out continuous quality improvement activities through appropriate quality management improvement methods and quality management technology tools, and evaluate the effects of quality improvement.
(6) Regular education on medical quality and safety is conducted for all staff, medical quality and safety awareness is firmly established, and the ability of all staff to participate in medical quality management and improvement is improved.
(vii) Establishment of a database of medical quality control and safety management information to provide a basis for formulating the goals of continuous improvement in quality management and evaluating the effects of improvement.
Three, medical technology management
(a) hospitals to provide medical technology services appropriate to the function and mission, in line with laws, regulations, departmental regulations and industry norms, in line with the scope of the hospital's diagnostic and treatment subjects, in line with the principles of medical ethics, the application of technology is safe and effective.
(2) The management of medical technology is in line with the provisions of the Measures for the Administration of Clinical Application of Medical Technology, and does not apply unapproved or abolished and eliminated technologies. The establishment of medical technology catalog, and according to the hospital to carry out the state of medical technology to implement dynamic management, grading and classification management, supervision and evaluation and file management system, clinical application of new technologies should be approved in accordance with the provisions of the report.
(3) have medical technology risk warning mechanism and medical technology damage disposal plan, and organization and implementation. The safety, quality, efficacy and economy of the new medical technology to carry out full tracking management and evaluation, timely detection and reduction of medical technology risks.
(4) The scientific research projects are in compliance with laws, regulations and medical ethics principles, and are approved according to regulations. In the process of scientific research, the company implements full quality management, fully respects the patients' right to information and right to choose, signs informed consent, and protects the safety of patients.
(5) the implementation of "hierarchical management" and "access system" for health technicians performing surgery, intervention, anesthesia and other high-risk technical operations, and regular technical competence evaluation and "re-authorization The "re-authorization" mechanism.
Four, clinical pathway, single disease quality management and continuous improvement (optional, county hospitals are mandatory)
(a) in accordance with the "surgical 10 diseases county hospital version of the clinical pathway" requirements to carry out clinical pathway, single disease quality management, as a key project to promote continuous improvement of medical quality, one of the important elements of standardizing clinical diagnosis and treatment; have the necessary organizational system to carry out work With clear responsibilities, the establishment of departmental coordination mechanism.
(2) According to the hospital's medical resources, focusing on common and frequent diseases, with reference to the clinical pathway management documents issued by the Ministry of Health, and in accordance with the principles of evidence-based medicine, the development of hospital implementation of the documents, and the implementation of education and training.
(3) Establishing a real-time monitoring platform in the hospital's information system to monitor the application and variation of clinical pathways.
(4) Establishing a clinical pathway statistical work system, and regularly conducting statistical analysis of quality and safety indicators, such as average hospitalization days, hospitalization costs, drug costs, discharge rate within 30 days of discharge, unanticipated reoperation rate, complications and comorbidities, and mortality rate, of patients who enter the clinical pathway.
(E) The hospital regularly conducts clinical pathway management-related medical staff and patient satisfaction surveys. Summarize and analyze the factors affecting the implementation of clinical pathway, and constantly improve and refine the pathway standards.
(F) the development of relevant systems and procedures to ensure that the Ministry of Health documents to report the quality of the single disease indicator information, to be correct, reliable and timely.
V. Inpatient Treatment Management and Continuous Improvement
(1) Legally qualified physicians and nurses provide standardized and homogeneous services to patients in accordance with the system, procedures, and the results of the assessment of their conditions.
(2) The application of disease diagnosis and treatment norms and guidelines for the clinical application of medicines, and the standardization of clinical examination, diagnosis, treatment, and the use of medicines and implantable (intermediary) medical devices.
(3) The supervising physician is responsible for evaluating and approving the appropriateness of inpatient treatment plans/programs (examinations, drug therapy, surgery/interventional therapy, etc.) and recording them in the medical record.
(4) The management of in-hospital consultation is standardized, the responsibilities of in-hospital consultation are clarified, and the quality and efficiency of consultation are improved.
(e) Provide more detailed discharge instructions and rehabilitation guidance for discharged patients.
(vi) The department director, head nurse and qualified personnel form a departmental quality and safety management team, using the core system of quality and safety management, job responsibilities, diagnostic and treatment guidelines and quality and safety indicators, to manage and evaluate patients with a length of stay of more than 30 days, and to optimize the process of medical services.
(VII) For hospitals that carry out neonatal inpatient diagnostic and treatment activities, they should establish a neonatal ward that meets the specifications in accordance with the requirements of the Guidelines for the Construction and Management of Neonatal Wards (Trial).
(viii) shall regulate oncology diagnosis and treatment activities in accordance with the requirements of the Guidelines for Standardized Diagnosis and Treatment of Common Tumors in Municipal and County Hospitals (Trial Implementation).
VI. Management and Continuous Improvement of Surgical Treatment
(I) The qualification access system of surgeons and the management system of graded authorization for surgery are implemented, and there is a mechanism for regular evaluation and reauthorization of surgeons' qualification and competence.
(2) The implementation of the system of evaluation of patients' conditions and preoperative discussion, following the diagnostic and treatment standards to formulate diagnostic and treatment and surgical programs, and adjusting diagnostic and treatment programs based on changes in the patient's condition and the results of reassessment should be documented in the medical record.
(3) the patient's informed consent before surgery, including preoperative diagnosis, the purpose and risk of surgery, the use and selection of high-value consumables, as well as other optional diagnostic and therapeutic methods.
(4) The hospital has established an approval system for major surgery reports and has emergency surgery management measures to ensure timely and safe emergency surgery.
(5) In accordance with the requirements of the "Technical Guidelines for the Prevention and Control of Surgical Site Infections (Trial)", the hospital guides and standardizes the prevention and control of surgical site infections, and the selection of surgical prophylactic antimicrobial drugs and the timing of their use are in line with the norms.
(6) The whole process of surgery and postoperative precautions are timely and accurately recorded in the medical record; the surgically removed tissues must be pathologically examined to clarify the postoperative diagnosis.
(7) Doing a good job of post-surgical treatment, observation and care of patients, and recorded in the appropriate medical instruments.
(viii) the director of the department, the head nurse and qualified personnel to form a quality and safety management team, there are applicable quality and safety management of core systems, job responsibilities, operational standards and quality and safety indicators, to strengthen the management of the perioperative period, to protect the safety of patients, and the establishment of the "unplanned re-operation" monitoring, cause analysis, The company has established a monitoring, cause analysis, feedback, improvement and control system for "unplanned reoperation".
VII. Anesthesia Management and Continuous Improvement
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VII.