Department of quality control team work plan format (a)
First, the spine burns Department of quality control team composition
Leader: Shen Hongda (head of the department), Wang Ying (head nurse) quality control staff: Zhu Jinsong (doctor), Zheng Junke (nurse).
Second, the departmental quality control team responsibilities
1, the departmental quality control team by the head of the department, the head nurse, as well as quality control physicians, nurses, and other relevant personnel 3-6 people; the director of the department is the department of the quality of the first person responsible for;
2, combined with the characteristics of the specialty and the trend of development, the development and revision of the department's disease diagnostic and treatment routines, the use of medication specifications and the organization of the implementation of the development and revision of the quality control work of the department. Revision of the department's quality control system, personnel duties;
3, under the guidance of the Department of Medical and Nursing Department, is responsible for the department of medical, nursing quality control inspection, to grasp the quality of diagnosis and treatment in the department, the quality of nursing care, the quality of medical document writing;
4, do a good job of the department's quality of self-testing and self-assessment, analysis of the department's medical quality data, patient complaints, quality defects, self-assessment work, to find hidden medical problems, self-assessment work, to find hidden medical problems. Finding medical hazards, self-assessment of the work of the pros and cons.
Third, the departmental quality control team work plan
1, quality control team under the leadership of the director of the department of medical quality management supervision, guidance, inspection, to carry out daily quality control, monthly quality control;
2, quality control team activities should be at least once a month, each time should be seriously analyzed and assessed the quality dynamics of the Department of the quality of the summaries and summaries, the need to improve the contents of the proposed corrective measures, and seriously do a good job of quality control. Rectification measures, and seriously make a good record of quality control activities;
3, the department of diagnostic and treatment activities in all aspects of guidance and monitoring, through specific diagnostic and treatment demonstration operations, monthly organization of medical staff at all levels to learn the medical and nursing routines, norms and strengthen the awareness of quality and safety;
4, a variety of medical instruments written to check the situation (medical records, prescriptions, application forms, nursing care documents), the core system, and the quality and safety of the medical staff of the Department of Health. documents), the implementation of the core system to check the nursing work, put forward corrective measures and implementation.
Department of quality control team work plan model (two)
In order to strengthen the quality management of the Laboratory, the following work plan:
First, the head of the team is responsible for the supervision of the quality of the test, inspection, guidance, evaluation, rewards and punishments.
Second, the review of standardized operating procedures and improve, the organization of the entire staff to learn SOP documents.
Third, from time to time each month to check the quality of testing, including the quality of test report writing, indoor and outdoor quality control carried out, the implementation of operating procedures, the use of reagents and instruments.
Fourth, the organization of a monthly meeting to solve problems in the work, summary of the month's indoor quality control test results and evaluation.
Fifth, the completion of the provincial Pro-Test Center organized twice a year the results of the inter-room quality assessment returns, and summary evaluation and improvement.
Six, in the quality control of good people and good deeds, make outstanding achievements in the laboratory or individual rewards and praise, quality errors and accidents put forward serious criticism and financial penalties.
VII, often to the clinical department to listen to its requirements and recommendations on all aspects of the laboratory, timely improvement and strengthening of the test work in the problems, improve test quality, to meet the needs of clinical diagnosis and treatment.
Department of quality control team work plan model (three)
To implement the medical core system, to ensure that improve the quality and safety of medical care, to ensure that the quality of medical records written within the quality and completion of the medical indicators, to draw up the year's quality of medical care and safety work plan:
The director of the department, the head nurse continue to grasp the quality of management, the implementation of the rules and regulations. Monthly meetings of the Quality Management Committee, medical records quality control group meeting, hospital sensory group meeting, nursing management group meeting, medical safety group meeting, etc., standardize management, standardize medical behavior. So that each workstation in our department can work hard to improve medical technology and promote the sustainable development of the department.
Second, a clear section of medical, the main work indicators, and strive to complete
1, bed utilization rate?92%
2, the average hospitalization day?14 days
3, three days after admission to the hospital diagnosis rate?90%
4, the average hospitalization before surgery?3
5, admission and discharge diagnosis compliance rate?95%
6, hospitalized critically ill patients resuscitation rate? Successful rescue rate of hospitalized critically ill patients?85%
7, Diagnostic compliance rate before and after surgery?90%
8, Diagnostic compliance rate between clinical and pathological diagnosis?90%
9, Qualified rate of the three basic assessment = 100% (80/100 points)
10, Qualified rate of outpatient medical record writing?90% (90/100 points or more)
11, Class A medical record writing = 100% (90/100 points)
11, Grade A case rate?90%, no Grade C medical records
12, medical equipment, instrumentation intact rate?90%
13, first aid instrumentation, medication intact rate = 100%
14, antimicrobial use of 80% of the range of antibacterials, antimicrobials limit the rate of use of 30 days of the patient to do the big check focus on verifying that there is no evaluation records. Measures to shorten the average length of stay in each bottleneck waiting time to verify one by one, the implementation of the measures.
April: blood transfusion management system, including pre-transfusion application, blood preparation, laboratory items, application form written comprehensively; sign the patient's consent for blood transfusion before transfusion; rational use of blood, before and after the transfusion of the course of the analysis of records. Check the first quarter of the various kinds of discussion medical records (difficult, death, preoperative, discharge case discussion records).
May: random inspection of critical patients' superior checkup records, on-duty physician checkup records, critical illness notification, resuscitation records, etc..
June: the implementation of the preoperative condition assessment system and preoperative discussion system
1, in the preoperative completion of the medical history, physical examination, imaging and laboratory data, etc. assessment.
2, the scope of the focus of the assessment of the patient's preoperative condition
3, the assessment of surgical risk
4, preoperative preparation
5, clinical diagnosis, implementation of the surgical approach
6, to clarify the need to complete the operation in separate sessions, etc..
7, check the record of medical records
8, training and training records of relevant positions.
July:
①In terms of conversation system. Surgical patients preoperative, intraoperative, postoperative talk system, implantation cases talk, non-surgical patients 72 hours talk, the timeliness of the patient's signature, special checks, special treatment before the talk; critical condition informed; authorized in the case of the signature of the consistency.
② second quarter discussion of cases (difficult, death, pre-operative, discharge case discussion records).
August: rational use of medication, including antibiotic special governance and the situation analysis of the use of medication and the disposition of the disease.
September: the record of medical history. Including the three-stage check-in system, the medical record record requirements for examination, laboratory analysis and rational use of medication, disposal and so on. Strengthen the connotation of the first medical record. Focus on checking the content of differential diagnosis treatment plan. Difficult medical records, death record discussion and writing of the inspection. Consultation and referral record timeliness and completeness.
October: ① archived medical records scoring; ② discussion of medical records writing.
November: dynamic management of surgical grading, assessment, authorization, etc.
December: a year of medical quality and management summary, consolidate the achievements, correct the shortcomings, continuous improvement.
Third, regular meetings of the quality management team, timely feedback, summarize. After each inspection timely feedback to the section chief, medical records inspection timely feedback writing physician, monthly inspection of the existence of problems with a quarterly written summary of the dean, and in each quarter of the quality management committee meeting feedback, at the meeting, we ask you to put the section of the problems raised by everyone to discuss the proposed corrective action plan to continue to improve.