Part 1: Nursing quality control and continuous improvement program (1916 words)
In order to continuously improve the quality of care and ensure patient safety, the Nursing Care Quality Management Committee, after discussion, has re-revised some of the nursing care quality standards and formulated specialty quality standards, adjusted the quality control personnel of each line and improved the quality management program. The details are as follows:
I. Establishment of quality management organization
(a) the establishment of a hospital-wide nursing quality management committee
(b) the establishment of the nursing quality management team in each department, the head of the nurses as the head of the team
(c) Responsibilities
Director: comprehensively responsible for the management of nursing quality, to ensure that the nursing work to achieve the goals.
Team leader: develop nursing quality control program, and constantly revise the nursing quality assessment standards, the whole hospital nursing quality control.
Deputy leader: assist in the development of nursing quality control program, and assist in the revision of the nursing quality assessment standards, from time to time to participate in the nursing quality control meeting of the subdistrict, to guide the nursing unit to complete the unit of nursing quality control.
Group members: according to the division of labor regularly do their own line of nursing quality inspection, evaluation, put forward improvement measures. Responsible for the reasonable quality control of this line.
Second, the daily nursing quality control: the use of the quality control team monthly inspection, assessment and analysis of the causes of the problem, proposed to improve the method of control of the program, as follows:
1. The head of each line of the team for the assessment of the lead, according to the nursing department plan for the content of the responsibility of the team to convene the quality of the assessment of the activities. After the end of the assessment of the information to organize, timely report to the nursing department to assess the situation.
2. Assessment methods: line assessment monthly, the team leader can choose their own assessment time, and reported to the Ministry of Nursing, the Ministry of Nursing according to the situation to send personnel to participate. In order to ensure the fairness and impartiality of the assessment, the key assessment of the content of the Ministry of Nursing, and the assessment of the day to notify the assessment team leader. Members of the assessment team must conduct the assessment according to the required content. Standards for the 20XX newly revised . Content. (Nursing documents: 5 copies of hospital medical records, 5 copies of discharge medical records, mainly critical, death medical records; overall care, health education, nursing procedures monthly medical and surgical each sampling 2 wards in a nurse, health education sampling 5 patients; basic care, first level of care monthly assessment of 3 people in each ward; rescue medicines, equipment, standing medicines in each ward sampling 5 kinds of rescue medicines, 5 kinds of standing medicines, 2 kinds of high-risk medicines, 1 kind of poisonous and narcotic drugs, 2 kinds of drugs, 1 kind of drugs, 2 kinds of drugs, 1 kind of drugs, 2 kinds of drugs, 2 kinds of drugs, 2 kinds of drugs, 2 kinds of drugs, 2 kinds of drugs, 2 kinds of drugs. (1 kind of drugs and anesthesia drugs, 2 kinds of rescue equipment; ward management ward check 5 rooms; ward safety management, high-risk departments must be checked every month).
3. The quality control team in the assessment process, the problems existing in each department, timely feedback to the head nurse of the department or the staff on duty.
4. The quality control team at the end of the assessment, the inspection of the project to carry out a written evaluation, analyze the reasons for the existence of problems, and put forward corrective measures. Summarize the results before the 25th of each month to the Nursing Department.
5. Nursing Department at the end of the regular meeting of the head nurse, according to the quality control team assessment of the existence of the problem of written total feedback, and in the next month before the 5th sent to the hospital briefing.
6. Nursing service satisfaction with the monitoring section issued questionnaires are not accurate.
Third, the night nursing quality control:
1. Night quality inspection using the head nurse on duty daily inspection, the nursing department from time to time to check the way.
2. The head nurse on duty must visit the wards once a day at night to understand the labor discipline of nurses, grooming, etc.; check the environment of the ward, whether the night treatment and nursing work is standardized; to understand the situation of the critically ill patients, and report to the Department of Nursing the next morning if there are any special circumstances.
3. The head nurse on duty should keep her cell phone free during the shift to discover and solve nighttime emergencies in a timely manner and assist in the rescue of critically ill patients.
4. The Nursing Department from time to time to designate the relevant personnel, the quality of nursing care in various wards to check, the results of the inspection and this month's assessment is linked.
Fourth, holiday nursing quality control:
1. Each department during the holidays should be reasonable scheduling, and scheduling shift preparation staff.
2. The head nurse should designate a person to be responsible for the nursing quality of the day in the department during holidays.
3. The head nurse should keep the communication open during the holidays to deal with emergencies in the department in a timely manner.
4. Nursing Department in the holidays from time to time to check the quality of nursing care in various departments and the implementation of various rules and regulations.
Fifth, the quality control of each department
1. Each department set up a nursing quality management team, fully responsible for the quality control of nursing care in the department, the head nurse is the head of the team.
2. Each department in accordance with the hospital-wide nursing quality control program, the development of nursing quality control and continuous improvement program.
3. The quality management team will inspect and evaluate the quality of nursing care in the department every month, and put forward corrective measures for the existing problems, and follow up and check the corrective situation in time.
4. The head nurse should organize a monthly nursing quality analysis meeting, the assessment results to the unit of all nurses feedback, and analysis of existing problems, rectification measures, measures to be effective and easy to implement, and timely rectification of the situation after the inspection.
5. The head nurse will inform the head nurse of the unit of the specific time of the quality analysis meeting, the head nurse of the unit selective participation, each unit at least once a year.
6. The head nurse of each section will record the results of the monthly assessment and save, and send a copy to the nursing department.
Six, continuous improvement methods
1. Nursing Department line quality control team on the monthly existence of the problem to organize, fill out the "** month ** line quality assessment summary sheet", there is a total assessment of the assessment situation, the pass rate, the existence of the problem, the cause of the analysis, corrective measures. There is the previous month's problems to improve the description. According to the existence of a degree of the problem put forward next month's assessment focus.
2. Section of the quality control team to fill out the "** Section ** monthly quality control meeting minutes set of quality continuous improvement single" on the existence of this month's problems with the cause of the analysis, corrective measures, and in the next month's quality control focus on the embodiment. There is a description of the improvement of the problems in the previous month. Nurse manager of the violation of rules and regulations, operational standards of personnel for continuous follow-up, at least 5 times, to urge correction.
3. Nursing department, department head nurse of the weak links in the nursing work, from time to time to check.
4. The Department of Nursing organizes monthly meetings of the hospital's quality control team to provide feedback on problems, assessment standards, assessment methods and corrective action, etc. At the end of the year, the Department of Nursing organizes a conference on continuous quality improvement to listen to the views of all parties and modify the quality control program, quality standards, etc., so as to promote continuous improvement in the quality of nursing care.
The same standard is used for the quality control of nursing care in the whole hospital and in each unit.
Part II: Nursing Quality Management and Continuous Improvement Program (1263 words)
I. Quality Management Objectives
1. Nursing care quality indicators up to the standard requirements of the year of hospital management
2. Patients receive quality service, and the rate of satisfaction with the nursing care reaches more than 85%
3, No violation of law and discipline of nursing staff
4, no nursing accidents
Second, the nursing quality management organization system
Hospital Quality Management Committee - Nursing Quality Management Group - ward management, basic nursing, graded care, holistic care, and nursing care.
The quality of nursing care is controlled at three levels, i.e., the first level is the hospital quality management committee, the second level is the nursing quality management group based on the nursing department, and the third level is the quality control group based on the head nurse of each department.
Third, the quality control method
1, the quality control team is responsible for the quality control of the department, the requirements of the development of practical assessment rules, to achieve the daily quality control, the quality of the nursing work of each class inspection and evaluation of the results of the assessment and bonus linked to the head of the nurses assessment evaluation of one of the contents.
2, the use of "three fixed" "three indefinite" method of quality control
"three fixed" first, every day, the head nurse in accordance with the standards of regular nursing work on the ward to carry out checks; second, the monthly nursing department to check the quality of work. Check; secondly, the monthly nursing department regularly check the nursing work of the whole hospital; thirdly, the quarterly hospital quality management organization to carry out an inspection of the nursing work.
"Three irregularities" First, the head nurse irregularly inspects the nursing work of each class; Second, the Nursing Department irregularly carries out random inspections of the single nursing work of each department; Third, the managing director irregularly monitors the nursing work. Nursing Department often in-depth inspection and supervision of the department found that the problem is corrected in a timely manner, objective and fair evaluation of the nursing unit of the nursing quality level, the establishment of quality data feedback statistical indicators, so that the quality of inspection and control to achieve scientific, data.
3, every six months, a year to do nursing quality evaluation summary, summarize the success and failure of lessons learned, the formation of standards or routines to guide future work.
4, the use of economic leverage to promote the role of the monthly quality assessment results and the distribution of bonuses closely integrated with the ideological education, rules and regulations, quality, economic synergy in full play.
5, according to the overall planning of the hospital, combined with the characteristics of the department and the focus of work to develop annual work plan, monthly work plan and weekly work plan. By the Nursing Department and the head nurse **** with the completion of clinical departments nursing work quality inspection. The results of the inspection will be summarized and fed back to the relevant departments and personnel in a timely manner. For the problems found during the inspection, corrective measures are formulated in a timely manner and all nursing staff are informed of these measures. Nursing work quality inspection results as a reference for further quality improvement of the department, and as a nurse manager management assessment focus.
Fourth, the implementation of the rules
1, the monthly statement at the end of each month to the Department of Nursing.
2, the head nurse assessment information is incomplete in this month's total quality points deducted 1 point.
3, the Department of Nursing can not adhere to the in-depth department, less than two times a month to deduct the bonus for the month.
Fifth, the content of the quality control inspection
1, the content of the nursing quality control inspection, including comprehensive inspection, focus on inspection and night shift inspection, but also includes a number of plus and minus points.
2, the comprehensive inspection includes checking the nursing staff's comprehensive understanding of the patients under their charge, the care of critical patients and technical operations, disinfection and isolation, nursing form writing, drug management, ward norms, health education, labor discipline, grooming and service attitude and so on.
3, key inspection for the monthly arrangement of a key inspection content.
4, the night shift inspection by the night shift nurse to check the night shift nursing work, dealing with emergencies and manpower deployment, and is responsible for the focus of the department of random checks.
5, additional points for the project, including special events praised by the person or thing; satisfaction survey patients named praised nursing staff; medical and nursing errors found in a timely manner to plug the loophole; out of hospital care complications brought about by the careful care of patients recovered.
6, minus points including the occurrence of nursing errors; nursing disputes, complaints verified nursing defects; patient satisfaction survey, such as those who criticized by name.
Shilou County People's Hospital Nursing Department
Part III: Nursing Quality Continuous Improvement Implementation Program (944 words)
In order to embody the concept of "patient-centered" quality nursing services, comprehensively improve the quality of nursing and nursing service level, to provide patients with safe, efficient, and effective nursing care.
In order to reflect the concept of "patient-centered" quality care services, comprehensively improve the quality of care and nursing service level, to provide patients with safe, efficient, high-quality nursing services, to achieve the purpose of continuous improvement of nursing quality, the development of this program.
First, the establishment of the nursing quality management committee and nursing quality management team.
The establishment of the nursing quality management committee composed mainly of the dean in charge, the director of the nursing department, the head nurse, the nursing quality of the implementation of the director of the nursing department, the head nurse of the second level of management, the nursing quality management organization at all levels to ensure the quality of nursing care through the regular and irregular nursing care quality monitoring and inspection.
Nursing Department nursing quality control team from the nursing department and the head nurse of each section of the nursing quality management system, is divided into four groups, group members and management division of labor details see the attached table (Annex 1), the director of the Department of Nursing randomly tracking the nursing quality management team to participate in the quality management team quality assessment work, and nursing quality control work to be managed and guided.
Second, the Department of Nursing nursing quality work objectives
1, basic nursing pass rate ≥ 98% (85 points of the qualifying standard).
2, special, first-class nursing pass rate ≥ 95% (passing standard 85 points).
3, first aid items intact rate of 100%.
4, nursing document writing pass rate ≥ 97% (passing standard is 90 points)
5, nursing "three basic" theory assessment pass rate of 93% (passing standard is 75 points)
6, nursing technical operation assessment pass rate of ≥ 96%
7, disinfection and isolation of the quality of ≥ 98%
7, sterilization and isolation. Qualified rate of ≥ 98%
8, ward management qualified rate of ≥ 98%
9, one person, one needle, one tube, one sterilized qualified rate of 100%
10, the incidence of pressure ulcers in patients after hospitalization 0 (except for the inevitable pressure ulcers)
11, the incidence of nursing accidents 0
Third, the nursing quality management team quality assessment methods.
1, routine quality control: the quality management team, unscheduled quality control 1-2 times a month.
2, single quality control: the nursing department can randomly organize a single quality control according to the nursing work.
3, nursing paperwork quality control: nursing paperwork process quality control by the nursing paperwork management group once a month quality control, section chief nurse of the nursing paperwork of discharged patients for the final quality control.
4, nursing adverse events quality control: the departments reported nursing adverse events, the nursing department according to the reported situation into the quality control management.
5, departmental quality control: departmental nursing quality control team at least once a week to carry out quality checks, quality nursing service demonstration wards, the head nurse every day to ward management and graded nursing quality inspection rounds.
Fourth, the nursing quality of continuous improvement of specific measures
1, the finalization of nursing procedures and standards.
2, revised nursing quality assessment methods and assessment standards.
3, regular and irregular nursing unit of nursing quality assessment of the situation of sampling and evaluation, the responsible person and the person in charge of the responsible department for the existence of problems to analyze the reasons for the development of corrective measures, the Department of Nursing within a week of the existence of the problem of inspection and acceptance.
4, at least once a month to convene a nursing quality analysis meeting to discuss the **** and controversial issues, listen to the views of the analysis of the reasons for the development of corrective measures, the layout of quality control priorities.
January 20XX
Department of Nursing