Inadvertently, a period of time has come to an end, turn your eyes to review this period of time, there are gains and losses, for this reason must do a good job of summarizing, write a good self-inspection report喔. Are you still struggling to write a self-examination report? Here are three examples of self-examination reports of medical institutions that I have carefully organized, I hope to help you.
Self-inspection report of medical institutions 1
In order to improve the quality of medical services and technical service level, my service station against the "Rules for the Implementation of the Regulations for the Administration of Medical Institutions" carried out a rigorous self-inspection and self-correction work. Now the relevant self-examination report is as follows:
First, the leadership attaches importance to the strict organization
I held a meeting of the service station, the self-examination of the work of strict deployment. At the meeting, the establishment of a self-check by the head of the leading group, strictly against the "Rules for the Implementation of the Regulations for the Administration of Medical Institutions" carried out a serious and detailed self-correction work, and achieved significant results.
Second, the basic situation of self-check
(a) institutional self-check: the full name of the unit? Keyuan Street Feng Yuan Community Health Service Station? , the nature of the private non-enterprise, located in; legal representative:; the main person in charge: District Health Bureau issued the "Medical Practice License", Practice License No. 20xx December 23rd. My service station on the "medical institutions practice license" has implemented strict management, has never been altered, trading, transfer, rent. Existing 6 beds, diagnosis and treatment subjects are preventive health care, general medicine; business room area of 320 square meters.
(ii) personnel self-examination: I service station existing attending physician 1, a licensed physician, physician assistant 2 Ming, 3 nurses. My service station has never been more than the scope of registration to carry out practice activities; never used without a licensed physician qualification, nurse practitioner qualification of personnel or a certificate of multi-location registration of physicians engaged in medical activities, belonging to the medical and nursing staff are listed on duty, and set up a monitoring column in the hall 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 management of medical quality, the implementation of medical quality assurance program; regular inspection, assessment of the regulations and systems 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.
(D) hospital cross-infection management: the establishment of a service station within the cross-infection management leading group, composed of and so on. 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 disposal: 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-stabbing, temporary storage of dirt to do? Five prevention? The medical waste transportation and transfer for a person in charge and have a signed record.
(F) single-use medical supplies processing: all single-use medical supplies after use to do soak disinfection, destroyed by the medical waste disposal station collection.
(VII) epidemic management and reporting: my service station has established a strict epidemic management and reporting system, which provides for a person responsible for the management of the epidemic, the epidemic register is complete, the epidemic report card fill in standardized, epidemic report to carry out a monthly self-check processing, there is no omission or late reporting occurs.
(H) drug management self-examination: it was found that my service station has never used fake, expired, expired and prohibited drugs. Strictly implement the provisions of the antimicrobial drug system.
Third, there are shortcomings
First, due to insufficient funding, some medical equipment can not be maintained or updated in a timely manner, to a certain extent, affecting the in-depth development of related business, the development of the lack of energy; second, by the establishment of the limitations of the staff, staff tensions, heavy workloads, to the provincial level of medical institutions to further training opportunities are not many, the knowledge of the cycle of updating is long, to a certain extent, affecting the level of service to a higher level of improvement. The first is that the company's staff is not enough.
Fourth, the direction of future efforts
I service station must take this self-examination as an opportunity, under the leadership of the higher business administration, conscientiously implement the spirit of the higher-level meetings, strict compliance with the "Regulations on the Management of Medical Institutions", strengthen management measures to optimize the quality of personnel, pragmatic and pioneering, and constantly improve the quality of health care services and technical service level.
Self-inspection report of medical institutions 2To further strengthen the management of our region's new rural cooperative designated medical institutions, standardize the behavior of diagnostic and treatment services, control the unreasonable growth of medical costs, to protect the safety of the new rural cooperative fund, to promote the new rural cooperative fine management, to promote the work of the health system line evaluation, according to the "Office of the Provincial Department of Health on the implementation of designated medical institutions to carry out the new rural cooperative service behavior inspection activities of the notification" document spirit, the district health bureau issued a "report on the implementation of the new rural cooperative service behavior inspection activities" document spirit. Health Bureau issued a "notice on the implementation of designated medical institutions to carry out inspection activities of the new rural cooperative service behavior" (point health hair 20xx55) document, the designated medical institutions in our region of the new rural cooperative service behavior checking activities for the arrangements and deployment of the medical institutions to carry out self-checks, the District Health Bureau to organize a special team, from September 5 to 9 on the jurisdiction of the medical institutions at all levels of the special inspection. Now the inspection situation activities are summarized as follows:
First, the achievements
District People's Hospital, the township health centers attach great importance to the work of the NPC, strengthen internal management, strict implementation of the NPC policy, and full service to the participating public to ensure the smooth progress of the work of the NPC to ensure that the level of participation in the benefit of the public to improve, and to ensure that the safety of the NPC fund. The main performance is as follows:
(a) the basic establishment of internal control mechanisms
The township health centers have established a new rural cooperative hierarchical management system, a clear division of responsibilities; strengthen the basic management, improve the rules and regulations, and strict assessment of rewards and punishments, to ensure that the provisions of the system to the letter.
(ii) hospitalization costs steadily declining
After the implementation of the hospitalization pay per bed day reform, the township health centers to strengthen cost control, strengthen medical services, to achieve a decline in costs, the service does not discount the good results. 20xx January-August, Lianpeng Township Health Center hospitalization average cost of 1200 yuan, a year-on-year drop of 272 yuan, a decline of 18.48%.
(C) outpatient total prepaid remarkable results
After the implementation of outpatient total prepaid payment method reform, the township health centers have strengthened outpatient integrated management, the development of the management program, and strengthen the day-to-day management, strict supervision and assessment, to ensure that the benefits of the masses participating in the clinic, outpatient fund security. Qiaobian Township Health Center to strengthen the system of supervision, quarterly assessment, household audit, January-August **** reduction of village health room irregularities in subsidies of 4140.80 yuan, effectively curbing the phenomenon of fictitious diagnosis and treatment of arbitrage fund to ensure that the total amount of outpatient prepaid fund use safe and effective.
Second, there are problems
(a) District People's Hospital
First, the internal management system of the new rural cooperative needs to be further improved. As the District People's Hospital into the integrated management of the Yichang City Central Hospital, the District People's Hospital does not have an independent and perfect new rural cooperative level management organization, the medical insurance office of the new rural cooperative management function needs to be further strengthened, the internal control and assessment mechanism needs to be further improved.
Secondly, the implementation of admission standards is not strict. District People's Hospital in the implementation of? The first community first aid? The first is to make sure that you have a good understanding of what you are doing and how you are doing it. The first is to make sure that you have a good understanding of what you are doing and how you are doing it. The system exists on the first admission, after the phenomenon of referral; admission standards are not strict, there are outpatient to hospitalization, the phenomenon of minor illnesses.
Third, the rational use of drugs to be strengthened. District People's Hospital is using the third-level hospital drug catalog, the overall drug prices are high, the use of antimicrobial drugs do not strictly implement the provisions of the management of graded use.
Fourth, the rational examination to be standardized. District People's Hospital has strengthened the management of ultrasound, CT and other large-scale inspection, inspection of the target, rationality has been improved, but there are still non-conventional requirements of the main disease has nothing to do with the inspection, the diagnosis and treatment of the significance of the unnecessary inspection and other excessive inspection behavior.
(B) township health centers
The township health centers of the new rural cooperative outpatient management basic norms, the implementation of the basic drug policy, compensation in place in a timely manner, no fictitious medical services to seize the fund phenomenon, the participation of the masses with a high degree of satisfaction, the community has a good response.
The township health centers in the new rural cooperative hospitalization management, there are mainly the following problems:
First, the proportion of individual health centers of the acute and critical patients is too high. 1-8 months, Tucheng health center according to the acute and critical management of the proportion of patients amounted to 28.78%, higher than the average level of the whole region of nearly 10 percentage points.
Secondly, the overall service capacity of township health centers is insufficient. Due to the influence of talent, equipment, technology, management and other factors, the township health center's medical service capacity is declining, some of the rural common diseases, frequent diseases can not be treated at the primary health care institutions, the proportion of patient outflow is rising, affecting the level of benefit to the participating farmers and the safety of the New Agricultural Cooperative Fund.
Third, the average cost of some township health centers is high. Compared with the same period last year, Aijia Township Health Center, Lianpeng Township Health Center, the average cost of a case decreased significantly, the NPC pay per bed day reform is more effective. Tucheng Township Health Center average cost of 1583 yuan, relatively high.
Fourth, the reasonable examination still need to be standardized. Some tests are not related to the main disease, and some tests (such as blood glucose) are repeated too often.
(C) village health center
First, the implementation of the basic drug policy is not in place. Non-basic drugs still exist in village health centers, which affects the benefit of participating farmers as they cannot be included in the compensation.
The second is that some village health centers are not included in the reimbursement of traditional Chinese medicine.
Third, some townships have a low utilization rate of the total prepaid fund for outpatient services. 72.93% of the fund in Aijia Township and 70.25% in Lianpeng Township in the January-August period have a low utilization rate of the fund, which has resulted in excessive sedimentation and a low rate of benefit for participating farmers.
Fourth, the phenomenon of fictitious medical services still exists to varying degrees. Part of the village health center did not implement the small ticket signing system, arbitrary arbitrary charges; less fill more than reported, fictitious number of people, such as the phenomenon of arbitrage fund is difficult to fundamentally eliminate.
Third, the rectification requirements
(a) strengthen the leadership, the implementation of responsibility. District People's Hospital to correctly handle the relationship between hospital development and the interests of the masses, and effectively strengthen the management responsibilities of the new rural cooperative, rationalize the relationship, establish and improve the internal control mechanism, the responsibility for controlling the cost of the implementation of the department, the implementation of the doctor. The township health centers should further implement the president's overall responsibility, the subordinate president of the implementation of the leadership system, the management responsibility to the department, extended to the village health room, and strict accountability system.
(ii) establish rules and regulations, standardize behavior. District People's Hospital, the township health centers to start from the construction of the system, the implementation of fine management, standardize the behavior of the new rural cooperative services, improve the level of benefit to participating farmers. District People's Hospital shall establish a relevant management system that conforms to the actual situation of Jiangnan Hospital District and highlights the responsibilities of the District People's Hospital, and strengthen the system management in terms of admission (discharge) standards, standardized diagnosis and treatment, and reasonable fee control, etc., so as to include the average cost of the case, the average cost per bed day, the ratio of the composition of the medicines, the rate of large-scale examination, the actual compensation ratio, the rate of use of the medicines out of the catalog, and the average hospitalization day in the assessment content. The township health centers should establish systems that are compatible with the payment method reform to ensure that the reform achieves the expected results.
(C) strengthen supervision, serious discipline. New Agricultural Cooperative Fund is the life-saving money of the participating public, strictly prohibit medical institutions and medical personnel at all levels of illegal fraud, extraction, misappropriation, squeezing. The district co-management office should perform the supervision duties, carefully review the relevant compensation information, strengthen online supervision, on-site supervision, telephone follow-up, household verification, the violations found to be reduced costs, notification and criticism, etc., on the problem is prominent, the situation is serious, the social repercussions of the violations of the case should be reported to the District Health Bureau to deal with. The township health center to strengthen the dynamic supervision of the village health room under the jurisdiction of the implementation of daily supervision, quarterly assessment, to further standardize the behavior of diagnosis and treatment reimbursement, to ensure that the medical services are not discounted, the level of farmers to benefit from the level is not reduced.
Self-inspection report on medical institutions3Self-inspection report on health insurance designated medical institutions under the correct leadership of the higher authorities, according to the Heilongjiang Provincial Office of Human Resources and Social Security, "on the issuance of the implementation of the hierarchical management of the basic medical insurance designated medical institutions in Heilongjiang Province," I hospitals strictly abide by the national, provincial and municipal laws and regulations related to health insurance, and conscientiously implement the policy of health insurance. Serious self-examination is reported as follows:
First, attach great importance to strengthening leadership, improve the health insurance management responsibility system
After receiving the notice requirements, our hospital immediately set up to the main leader as the leader, to the leaders in charge of the deputy leader of the self-examination of the leading group, against the relevant standards, to find deficiencies, and actively rectify. We know that basic medical care is an important part of the social security system, deepen the basic medical insurance system policy, is the inevitable requirement of the development of socialist market economy, is to protect the basic medical care of employees, improve the health of employees is an important measure. Our hospital has always attached great importance to the work of medical insurance, with hospital leaders specializing in management, sound management system, held many special meetings for research and deployment, and regular medical insurance training for physicians. Medical insurance work at the beginning of the year there is a plan to regularly summarize the work of medical insurance, analysis of the medical care of insured patients and the cost of the situation.
Second, standardize the management, to achieve the standardization of health insurance services, institutionalization, standardization
Over the past few years, in the District Labor Bureau and the District Health Insurance Office of the correct leadership and guidance, the establishment of sound rules and regulations, such as the basic health insurance referral management system, hospitalization process, health insurance work system, fee billing management system, outpatient management system. Setting up? Basic medical insurance policy bulletin board and Complaint box ; publicize the consultation and complaint telephone number 3298794; enthusiastically provide consulting services for the insured and properly handle the complaints of the insured patients. In the hospital, the medical insurance process is announced in a prominent position, which is convenient for insured patients to purchase medicines, and special windows are set up for the registration and settlement of medical insurance patients. Simplify the process and provide convenient and high-quality medical services. Strict identification is carried out when insured employees are hospitalized, so as to eliminate the phenomenon of impersonation and hospitalization, and to stop hospitalization in the name of the patient and decomposition of hospitalization. We strictly control the admission and treatment of patients, hospitalization and admission standards of guardianship wards, implement the principle of treating patients according to their illnesses, and achieve reasonable examination, reasonable treatment and reasonable medication; we do not falsify or change medical records. We actively cooperate with the Medical Insurance Office to supervise and audit the treatment process and medical expenses, and provide timely access to medical files and related information. The company strictly enforces the fee standards set by the relevant departments, and does not charge for its own programs or raise the fee standards.
Strengthening the publicity of medical insurance policy, the department as a unit regularly organized the study of the "Yichun City urban workers health insurance cost settlement management and the implementation of basic health insurance rules for employees", "Heilongjiang Province, the basic medical insurance, industrial injury insurance and maternity insurance drug directory," and other documents, so that each health care personnel are more familiar with the directory, and to become a propagandist, explainer, implementer of the health insurance policy. The site issued a satisfaction rate questionnaire, 98% satisfaction rate with the quality of service, by the majority of the insured people's praise.
Third, strengthen the management, for the insured to provide quality assurance
First, the strict implementation of diagnosis and treatment and care routine and technical operation procedures. The first physician is responsible for the implementation of the system, the third-level physician room system, the handover system, difficult, critical, death case discussion system, preoperative discussion system, medical record writing system, consultation system, surgical classification management system, technical access system and other core medical systems. Secondly, on the basis of strengthening the implementation of the core system, we focus on the improvement of medical quality and continuous improvement. It has generally improved and perfected the medical quality management and control system, assessment and evaluation system and incentive and constraint mechanism, implemented the three-level medical quality management responsibility system of hospitals, departments and groups, decomposed the medical quality management objectives layer by layer, and assigned responsibilities to the people, and shifted the checking and supervising gates to the front line of the clinic for timely discovery and solving the problems and hidden dangers in the medical work. We standardize the processes of early shift handover, director's room check and case discussion. Thirdly, the staff familiarize themselves with the core medical system and strictly implement it in the actual clinical work. They actively learn advanced medical knowledge, improve their professional and technical level, enhance medical quality, and serve patients well, as well as strengthen the learning and cultivation of humanistic knowledge and etiquette knowledge to enhance their communication skills. Fourth, strengthening safety awareness, the doctor-patient relationship is becoming more and more harmonious. Our hospital continuously strengthens medical safety education, improves the awareness of quality responsibility, standardizes medical operation procedures, establishes and improves the system of doctor-patient communication, adopts a variety of ways to strengthen communication with patients, and patiently and carefully confides in or explains to patients their conditions. We are prudent in preoperative, precise in intraoperative and strict in postoperative. Further optimize the service process to facilitate patients' access to medical treatment. By adjusting the layout of departments and increasing the integration of computer network in the whole hospital, we have simplified the process of medical treatment and shortened the waiting time of patients. The lobby set up a consulting desk, complaint desk and have a person to manage, equipped with green
channel emergency vehicles, stretchers, wheelchairs and other service facilities. Through a series of heartfelt service, patient satisfaction survey, the average satisfaction rate of more than 96%.
Fourth, strengthen the hospital management, standardize the hospitalization procedures and charges settlement
In order to strengthen the standardized management of medical insurance work, so that the provisions of the health insurance policy has been fully implemented, in accordance with the requirements of the district health insurance department, strict audit of the insured patients health insurance card, card. The doctors who are treating the patients are doing the treatment for the diseases, reasonable examination, and reasonable use of drugs. Strengthen the quality management of medical records, strictly implement the first physician responsibility system, standardize the clinical use of medication, the treating physician should consciously use safe, effective and reasonably priced drugs in the Drug List according to the clinical needs and the provisions of the health insurance policy. Because of the condition of the disease really need to use the "drug catalog" outside the self-financed drugs, [special] prescribed drugs,? Class B? Drugs, and drugs for which you are responsible for a portion of the cost. For medical materials and self-financed items, the treating physician shall explain the reasons to the insured person and fill out an informed consent form. Informed Consent Form
Fifth, the strict implementation of the provincial and municipal price departments of the charges
Medical costs are another focus of attention of the insured patients. The hospital insists on the cost list system, the daily cost is sent to the patient, and the patient confirms it before transferring it to the hospitalization office, so that the insured can consume in a clear way.
Sixth, the maintenance and management of the system
The hospital attaches importance to the maintenance and management of the insurance information management system, timely elimination of obstacles to the hospital's information management system to ensure that the system operates normally, in accordance with the requirements of the Yichun City, Friendship Forestry Bureau of health insurance agencies by the computer technology specialized managers responsible for the requirements of the special computer dedicated to the health insurance strictly in accordance with the provisions of the special machine, in case of problems in time to contact, not due to program problems. Contact, can not be due to program problems and lead to medical expenses can not be settled problems occur, to ensure that participants timely and rapid settlement.
We always adhere to the patient-centered, quality-centered, wholeheartedly for the patient service as a starting point, and strive to do the standardization of the establishment of rules and regulations, the humanization of the concept of service, standardization of quality of medical care, correcting the trend of self-consciousness, and actively provide participants with high-quality, efficient, inexpensive medical care and a warm medical environment, by the majority of the participants of the commendation, received a good social and economic benefits. The company has been praised by the majority of participants, and has received good social and economic benefits.
After strict self-examination against the "Yichun City basic medical insurance designated medical institutions graded management implementation measures" document requirements, our hospital meets the medical insurance designated medical institutions set up in line with the requirements of level a.
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