Part I Market Special Supervision Self-inspection Report
In order to improve the quality of medical services and technical services, our hospital against the "Medical Institutions Management Regulations Implementing Rules" carried out a rigorous self-inspection work. Now the relevant self-examination report is as follows:
First, the leadership attaches importance to the strict organization
Our hospital held a meeting on the self-examination of the work of strict deployment. At the meeting, the establishment of the Wang Bin as head of the relevant business departments responsible for the members of the self-examination of the leading group, the business departments in accordance with their respective division of labor, strictly against the "Rules for the Implementation of the Regulations for the Administration of Medical Institutions" carried out a serious and meticulous self-examination and self-correction work, and achieved a significant effect.
Second, the basic situation of self-check
(a) institutional self-check: the full name of the unit is "Kunming Tangchi Hospital", xx nature of the private sector, located in Kunming Yangzonghai Scenic Area Management Committee, Tangchi Town; legal representative: Gao Kaihong; the main person in charge of: xx. with the xx Bureau of Health issued the "Medical Practice License", the practice of the license, and the "medical institutions". License to Practice as a Medical Institution" issued by XX Health Bureau, License No.: xx, valid until xx, xx, xx, xx. The hospital has implemented strict management of the Medical Institution Practice License and has never altered, traded, transferred or rented it. Existing beds xx, diagnosis and treatment subjects are surgery, internal medicine, traditional Chinese medicine, obstetrics and gynecology, laboratory, imaging; business room area of xx square meters.
(b) personnel self-examination: I have never been registered to carry out a wide range of licensing activities or the illegal issuance of "medical certificates"; never used without the qualification of licensed physicians, nurses licensed personnel or a certificate of a number of locations registered physicians engaged in medical activities, the affiliated health care personnel are licensed, and set up in the hall of the supervision of the bar open to the public.
(C) improve the quality of service: in accordance with the relevant provisions of the health administrative departments, standards to strengthen the quality of medical management, the implementation of medical quality assurance program; regular inspection, assessment of the rules and regulations and all levels and types of personnel job responsibility system implementation and implementation, to ensure medical safety and quality of service, and constantly improve the level of service.
(4) hospital cross-infection management: the establishment of a hospital cross-infection management leading group, consisting of ...... and so on, the leading group of personnel have obtained the induction certificate. Frequent education and training of relevant personnel, the establishment and improvement of the management of medical waste disposal, nosocomial infection and disinfection management, waste leakage treatment program and other relevant rules and regulations, there is a person on the source of medical waste, type, quantity and so on complete records, regular disinfection of key departments and parts of the disinfection effect of the monitoring, prepared disinfectant labels marked clear, complete and standardized.
(E) solid medical waste treatment: all medical waste is classified and collected, according to the provisions of the time of temporary storage of dirt with warning signs, dirt containers are sealed, anti-puncture, temporary storage of dirt to do the "five preventive" xx, medical waste transportation and transfer to a person responsible for and have signed the record.
(F) the handling of single-use medical supplies: all single-use medical supplies after use to do the soaking disinfection, destruction of the type by the medical waste disposal station collection, harmless disinfection, incineration treatment, and have a detailed record of the handover of medical waste, no resale, give away, etc. All operators have been trained. All operators are trained and have specialized protective facilities and equipment.
(VII) epidemic management and reporting: Our hospital has established a strict epidemic management and reporting system, which provides for a person in charge of epidemic management, epidemic register is complete, the epidemic report card fill in standardized, epidemic report a monthly self-check processing, no omission or late reporting occurs.
(H) drug management self-examination: the hospital has never been found to have used counterfeit, expired, invalid and prohibited drugs.
Third, there are shortcomings
First, due to the lack of funds, some medical equipment can not be maintained or updated in a timely manner, to a certain extent, affecting the in-depth implementation of related business, the development of the lack of energy.
Second, by the establishment of the limitations of the personnel, tight, heavy workload, to the provincial medical institutions to further training opportunities are not much, the knowledge of the long cycle of updating, to a certain extent, affecting the level of service to a higher level, etc.
Fourth, the medical equipment is not timely maintenance or updating.
Fourth, the direction of future efforts
I must take this self-examination as an opportunity, under the leadership of the higher business administration, seriously implement the spirit of the meeting of the higher level, strict compliance with the "Regulations on the Management of Medical Institutions", strengthen management measures, optimize the quality of personnel, pragmatic, pioneering and innovative, and constantly improve the quality of health care services and technical service level.
Part II Market Special Supervision Self-inspection Report
In order to further strengthen the supervision of the medical industry, rectify and standardize the practice of medical institutions, and safeguard the people's health rights and interests, according to the Provincial Health and Family Planning Commission, Provincial Bureau of Traditional Chinese Medicine, "on the development of medical institutions according to law to carry out the work of the special supervision and inspection of the notice of the work of the notice" (Su Wei supervision [20XX] 13) requirements. 20XX] No. 13) requirements, the Municipal Health Planning Commission is scheduled from September 20XX to July 20XX in the city to carry out special supervision and inspection of medical institutions in accordance with the law.
First, the work objectives
To serve the people's health for the purpose of focusing on the social concerns of hot spots, adhere to the problem-oriented, innovative supervision and law enforcement means to strengthen the supervision and inspection of medical institutions practice, according to law and seriously investigate and deal with violations of the law, and strive to solve the current stage of medical services in the field of the outstanding problems, and to further consolidate and standardize the medical service Market order, and effectively safeguard the people's health rights and interests.
Second, the work of the task
(a) a comprehensive self-examination, conscientiously implement corrective measures (September 20XX October). All levels of health care administration should quickly deploy the jurisdiction of the medical institutions to carry out a comprehensive self-examination and self-correction of the practice of law, the problems found in the self-examination should be comprehensive and conscientious implementation of the corrective measures, and will be self-examination and rectification of the situation as well as the practice of law book (book templates see Annex 1) submitted to the registration of the administrative department of health and family planning.
(B) supervision and inspection, serious investigation and punishment of illegal acts (November 20XX 20xx July). Health planning administrative departments at all levels and health supervision agencies should be based on the self-correction of medical institutions, for different types of medical institutions, focusing on supervision and sampling or "double random" inspection, and found violations of the law, according to the law, serious investigations and punishments.
1, two, three hospitals (including maternal and child health institutions, the same below). Focusing on whether there is a rental contract department, over the scope of diagnostic and treatment activities, the employment of non-health personnel, violations of the ban on the clinical application of medical technology, without the record to carry out the restriction of the clinical application of medical technology, and whether to carry out a clear clinical research management of the clinical application of medical technology.
2, first-class hospitals (including unclassified), outpatient clinics and clinics. Focus on checking whether there is the issuance of false medical documents, rental loan "medical institutions practice permit", not according to the public standard charges, over the scope of diagnostic and treatment activities, the employment of non-health professionals and other violations, and whether the violation of medical beauty, maternal and child health, family planning and other technologies and urology, skin and venereal diseases and other diagnostic and treatment activities.
3, stem cell clinical application. First, the provisions of the record has been carried out in accordance with the provisions of the stem cell clinical research medical institutions, focusing on checking whether the scope of the project in accordance with the record to carry out stem cell clinical research, as well as the existence of unauthorized clinical research projects carried out by the stem cell directly into the clinical application. Secondly, for medical institutions that have not filed a record of complaints and reports and medical advertisements as a clue, seriously investigate and deal with the unauthorized conduct of stem cell clinical research and clinical application.
Each region should be in the city's basic standards of medical institutions and medical technology on the basis of the action of the large-scale investigation, the violation of the release of medical advertisements, complaints and reports of concentrated, has been repeatedly punished by the medical institutions focusing on the inspection.
Third, the work requirements
(a) to strengthen organizational leadership. Health planning administrative departments at all levels, health supervision agencies and medical institutions to effectively safeguard the health rights and interests of the general public from the height of the strengthening of leadership, clear responsibility, to ensure that the special supervision and inspection work in practice, to achieve results. The supervision and inspection to take the medical institutions comprehensive self-inspection, the jurisdiction of the health and family planning administrative departments comprehensive supervision and inspection, provincial and municipal health and family planning administrative departments to supervise the way. During the special inspection, the municipal health supervision institute to strengthen the supervision of the work of health supervision institutions at all levels, the municipal health and family planning commission listed to supervise major typical cases of violations, and in due course to organize the supervision of the localities. Self-examination and rectification is not serious, supervision responsibility is not implemented, the case is not in place, will be in accordance with the relevant provisions of the party discipline, seriously investigate the responsibility of the relevant personnel.
(B) the implementation of work responsibility. Various types of medical institutions at all levels to effectively implement the main responsibility of practicing according to law, seriously against the laws and regulations, and comprehensively carry out self-examination and rectification of the situation of practicing according to law. Health planning administrative departments at all levels, health supervision agencies to conscientiously implement the regulatory responsibility, combined with the actual jurisdiction, innovative supervision and inspection methods, and actively explore the adoption of "double random", flight inspection and other ways to strengthen supervision and inspection. To the public complaints and reports and media exposure. Case clues, to be investigated and verified one by one to deal with, real-name reports should be timely feedback, so that everything has been investigated, and every piece has a reply. Medical institutions and medical personnel found to be illegal and irregular practice, should be seriously investigated and dealt with in place according to the law, and must not be uninvestigated, harboring connivance. For serious violations, resolutely revoke the medical institutions related diagnosis and treatment subjects or "medical institutions license" or "maternal and child health technology service license", revoke the relevant personnel practice certificate.
(C) Strengthen coordination. Local supervision and inspection results and medical institutions, accreditation, malpractice points management, etc., to explore the establishment of a "blacklist" system, the occurrence of major violations of the medical institutions and related personnel, according to the law into the social credit system, to increase the penalties for violations of the law. Strengthen departmental communication and collaboration, not belonging to the jurisdiction of the administrative department of health and family planning of medical advertising, medical service prices and other violations of the law, should be based on the relevant laws and regulations in a timely manner to inform or transfer to the relevant departments. Suspected of committing a crime, the timely transfer of judicial organs to investigate criminal responsibility, strictly prohibit the "punishment instead of punishment" or "have a case not to transfer" behavior.
(D) play social supervision. All areas to open up the complaint and reporting channels, take the initiative to publicize the complaint and reporting phone (Wuxi City Health Supervision complaint and reporting phone: 82827110), to encourage the public to provide illegal cases of clues. Effectively strengthen communication with the media, actively publicize the progress of the work, increase the exposure of typical cases, investigate and deal with major cases can be invited to the media tracking reports, to increase the deterrent effect on criminals. Pay close attention to the recent changes in public opinion, carefully sort out and analyze the research and judgment, and respond to social concerns in a timely manner, in order to create a good social atmosphere for the special supervision and inspection.
Annex: Slight
Part III Market Special Supervision Self-inspection Report
According to the work requirements of the ×××× Municipal Bureau of Health, "××× Municipal Primary Healthcare Institutions in 20XX Focused Rectification Work Implementation Program" (Health Medical Development 〔20XX〕 No. 15), in accordance with the work requirements of the ×××× County Bureau of Health on the ×××× Health Center special inspection of the problems found in the rectification of opinions, × × × × Health Center attaches great importance to the first hand personally, the total responsibility for carrying out a rigorous self-examination and self-correction work.
First, the leadership attaches great importance to the establishment of self-checking leading group
On April 19, held a meeting of the rectification of medical institutions, study and implementation of the "xxxxx City, the implementation of the centralized rectification of primary health care institutions," the entire hospital medical staff to carry out medical and health care laws and regulations to learn, put the "Medical Practitioners Act", "Regulations on the Management of Medical Institutions", "Nurses Regulations", "Prescription Management Measures", The Code for the Writing of Medical Records" and other norms and learning included in the performance appraisal of staff. The establishment of the dean as the leader, vice president for the vice president, the head of each department as a member of the leadership group, on the health hospital standardization of legal practice to enhance the level of hospital management to carry out self-examination and self-correction.
Second, adhere to the law, standardize the scope of practice
1, the hospital departments strictly in accordance with the "scope of the license to practice medical institutions" engaged in business activities, no more than the phenomenon of diagnostic and treatment subjects practicing medicine.
2, the hospital's existing staff of 48 people, practicing physicians, practicing physician assistant 13 people, practicing nurses 14 people, pharmacists 6 people, medical imaging technicians 2 people, test technicians 1 people, strictly unlicensed and non-health professionals engaged in medical activities alone.
3, health center consultation strictly in accordance with the "Interim Provisions for the Management of Medical Outpatient Consultation".
4. There is no illegal and irregular release of medical advertisements.
5, outlawed the opening of unauthorized stomatology clinics.
6, standardize the writing and management of medical documents, medical documents timely, accurate, complete and standardized. Medical records, prescriptions, nursing records must be developed according to the Ministry of Health, "the basic norms of Chinese medical records writing", "prescription management approach" and other standardized book.
Third, conscientiously implement the basic drug system
× × × × × × health center all drugs for the national basic drugs, the jurisdiction of the service station and the village health center drug supply by the hospital unified online procurement and distribution, the implementation of zero-differential rate sales, no fake, expired, invalid drugs.
Fourth, the implementation of disinfection and isolation system to prevent the occurrence of infections
Strict implementation of injection procedures, to achieve "one person, one needle, one tube, one use, one disinfection", to eliminate the reuse of medical supplies. The company has been carrying out regular testing of the effectiveness of disinfection and sterilization, and has established records. Strictly implement the hospital infection and infectious disease reporting system. All single-use medical supplies after use to do soak disinfection, destruction of the type of harmless disinfection, incineration treatment, and have a detailed medical waste handover records, no resale, gift and so on.
In short, the health center attaches great importance to the standardization of practice, pay close attention to the implementation of further standardization of practice behavior, in order to improve the quality of medical care to lay a solid foundation.