(I) Medical quality management
1. It should strengthen the management of medical services and standardize the behavior of medical services in accordance with the requirements of the Basic Medical Care, Health Care and Health Promotion Law, the Regulations on the Administration of Healthcare Institutions and the Measures for the Management of Healthcare Quality and other laws and regulations.
2. Should be set up in accordance with the relevant provisions of the medical quality management of specialized departments or working groups, or designate a full-time (part-time) staff responsible for the specific management of medical quality.
3. Follow the relevant clinical diagnosis and treatment guidelines, clinical technical specifications, industry standards and clinical paths and other relevant requirements to carry out diagnosis and treatment, strict compliance with the core system of medical quality and safety.
4. Improve the medical safety management related work system, emergency plans and workflow, strengthen the medical quality of key departments and key aspects of safety and risk management, improve the awareness of medical safety, the implementation of the organization's safety goals for the elderly.
5. Establishing quality objectives in line with the quality management requirements of medical institutions, and implementing the requirements of medical services related to safety assurance and controllable quality. Regular monitoring, early warning, analysis, assessment, evaluation and continuous improvement of the quality of medical care within the institution.
II) medical care service management
1. Should carry out geriatric medical care needs assessment work, the establishment of nursing assessment system and process. The specific assessment work refers to the Notice on the Assessment of Elderly Nursing Care Needs and Standardization of Services (State Healthcare Medical Development [2019] No. 48).
2. It should carry out relevant work in accordance with the relevant requirements of nationally issued or recognized diagnostic and treatment technical specifications and operating procedures such as the "Basic Nursing Care Service Work Specification", "Common Clinical Nursing Care Technical Service Specification", and "Chinese Medicine Nursing Routine Technical Operating Procedures", and establish a hierarchical nursing care management system, develop a reasonable and standardized diagnostic and treatment and nursing care service process, and establish a nursing care goal management responsibility system to set up nursing care The nursing management objectives are set out in a system of accountability.
3. It should strengthen nursing quality management, develop and implement nursing-related work systems, technical specifications and guidelines with reference to the "Elderly Nursing Practice Guidelines (Trial)", strengthen the training, assessment and service improvement of the nursing workforce, and continuously improve the quality of nursing care.
(3) Management of Medical Rehabilitation Services
1. Our hospital is a combined medical and nursing institution that carries out rehabilitation services, and should be equipped with appropriate facilities and equipment according to the scale of our hospital and the demand situation of the elderly, and should strictly carry out the rules and regulations of rehabilitation, personnel duties and technical operation norms. Our hospital set up rehabilitation medicine department, with reference to the "Rehabilitation Medical Center Management Standards (Trial)" for management.
2. Organizations carrying out rehabilitation services should assess the physical and mental conditions, daily living activities and social functions of the elderly on a need basis, and formulate and implement the quality evaluation standards for rehabilitation services, the process of evaluating the effects and the risk prevention and control plans.
3. Institutions carrying out rehabilitation aids fitting services should establish a rehabilitation aids management system, specify the organization's configuration of the rehabilitation aids catalog, dedicated management, regular inspection, maintenance and related records, and guide the elderly in the scientific use of aids.
D) hospice service management
1. Hospice services to carry out the combination of medical institutions, should refer to the national and local requirements on the management of hospice-related work to establish a relevant system, with full-time staff.
2. The quality management of hospice services should be strengthened, with reference to the "Hospice Practice Guidelines (Trial)" to develop and implement the relevant work system, technical specifications and service guidelines; to strengthen the training of professional and technical personnel, assessment and service improvement, and continuous improvement of service quality.
3. Establishing a good communication mechanism with the elderly and their families, strengthening positive communication with the elderly and their families, focusing on humanistic care, safeguarding the legitimate rights and interests of the elderly and the dignity of life, and protecting the privacy of the elderly and their families. The religious beliefs of the elderly or the customs and habits of ethnic minorities should be respected.
(E) infection prevention and control management
1. Should be in accordance with the "Hospital Infection Management Measures" "Chinese medicine medical technology-related infection prevention and control guidelines (for trial implementation)" and the hospital infection control and disinfection industry standards, to strengthen the prevention and control of infection within the organization, the development and implementation of relevant rules and regulations and work norms, set up a scientific workflow, so that the layout of a reasonable, clear partition, clean and dirty separate, clearly marked. In order to achieve reasonable layout, clear partition, clean and dirty separate, clearly marked, effective prevention and control of hospital infections.
2. Regular training for institutional staff to enable them to master the prevention and control of nosocomial infection disinfection and isolation of knowledge, and in the work of the correct application, improve the prevention and control of nosocomial infection awareness and ability.
3. Establishment of institutional nosocomial infection management responsibility system, clear responsibility departments and personnel, the establishment of an effective institutional nosocomial infection monitoring system, timely detection of institutional nosocomial infection cases and infection outbreaks, to take proactive and effective measures, and timely reporting as required.
4. Should be in accordance with the "Regulations on the Management of Medical Waste" "medical waste management in health care institutions," the development and implementation of medical waste management rules and regulations, workflow, according to the provisions of the classification and collection of medical waste, transportation and temporary storage and personnel training, occupational safety and protection work.
(F) management of infectious diseases
1. In accordance with the "Prevention and Control of Infectious Diseases Act" and other relevant laws and regulations, the establishment of a system for the management of infectious diseases, according to infectious disease season, cycle and trend of infectious diseases to do a good job in the pre-screening and triage of infectious diseases, diagnosis and referral work.
2. The establishment of public **** health emergencies and infectious disease outbreaks monitoring information reporting system, clear responsibility for the department and personnel, to undertake infectious disease outbreaks reporting, prevention and control of infectious diseases and other work. Should establish and improve the normalization of infectious disease outbreak prevention and control mechanism, conditional institutions can set up medical observation isolation place, only to provide services within the institution. The discovery of infectious diseases confirmed patients or suspected patients, should be in accordance with the principle of territorial management, within the prescribed time to the local county (district) level disease prevention and control institutions report.
3. Should strictly implement the relevant management system, operating standards, to prevent infectious diseases and nosocomial infections of medical infections.
4. Infectious disease outbreaks should be under the leadership of the local health and health administrative departments to carry out the prevention and control of infectious diseases and outbreaks and other work. With the ability to provide medical treatment, can provide medical treatment to confirmed patients or suspected patients work. If they do not have the ability to provide treatment, they should be reported and referred immediately and records should be kept. During the epidemic, the nursing region should establish an external visitation management system, strengthen the management of personnel in and out of the institution to prevent external imported infections, if necessary, can take closed management measures.
(VII) medication management.
1. Multiple medication safety assessment should be carried out, with reference to drug instructions, according to the specific situation of elderly patients to develop individualized drug delivery program. Follow the guidelines for the clinical application of drugs, clinical diagnosis and treatment guidelines and drug instructions for the rational use of drugs, respect the patient's right to information on the use of drugs.
2. Establish a daily drug administration management system, including medical advice confirmation and audit requirements, drug verification and inventory process and requirements, antibacterial drug classification and management requirements, drug storage and placement process and requirements, daily drug issuance process and requirements, drug issuance and taking records, etc.; for the self-administration of drugs for the elderly, the establishment of a regular check of the supply of medicines, storage, expiration date and so on to assist them.
3. It should clearly explain to the elderly and their family members the storage method of the drugs used, the process of drug administration and precautions, guide the elderly to use the drugs rationally at the right time and through the right way, inform them of possible adverse reactions, and observe and deal with them in a timely manner in case of adverse drug reactions.
(viii) management of medical records
1. Patient registration and medical record management system should be established in accordance with the Regulations on the Administration of Medical Institutions, Regulations on the Management of Medical Records in Medical Institutions, Basic Standard for the Writing of Medical Records, Basic Standard for the Writing of Medical Records of Traditional Chinese Medicine and other regulations, and the writing and management of medical records should be in line with the relevant provisions of the administrative departments of health and wellness.
2. The management of medical records shall be strictly controlled, and no one shall alter medical records at will, and it is strictly prohibited to forge, conceal, destroy, seize or steal medical records.
3. In addition to provide patients with diagnosis and treatment services for medical personnel, as well as by the administrative department of health or medical institutions authorized by the department or personnel responsible for case management, medical management, any other institutions and individuals shall not be unauthorized access to the patient's medical records. The patient or his proxy to the medical institution to submit an application for copying or access to medical records and provide relevant supporting materials, the medical institution shall, in accordance with the provisions of the medical record copying or access services.
4. Institutions for the elderly in the medical beds and beds for the elderly between the transition and the elderly out of hospitalization should have records and information available, the relevant medical records should be properly preserved.