Part I medical quality management year-end summary report
I. Strengthen the leadership, improve the understanding of the importance of medical quality management
Hospital management is closely related to the interests of the people, is one of the hot issues of great concern to society. Since the reform and opening up, the medical institutions adhere to the patient-centered, quality-centered service concept, and constantly deepen the reform, strengthen management, improve service attitude, optimize the service environment, simplify the service process, improve the quality of service to meet the basic medical needs of the masses, and effectively safeguard the people's health and safety of life. However, with the economic and social development, the people's demand for medical services is getting higher and higher. At the same time, the health reform is not in place, the development of health care is relatively lagging behind, the total amount of health care resources and the unreasonable structure of the double contradiction gradually emerged, the doctor and the patient conflict intensified, medical disputes occur from time to time, to the doctor and the patient caused great social and economic losses, serious interference with the normal working order of the medical institutions, damage to the overall image of the health system, to the community caused by the destabilizing factors.
In order to effectively solve these hotspots, difficult problems, and further improve the people's satisfaction with the work of medical services, our hospital from 20xx, the quality of medical management on the important agenda, through the whole process of health work, adhere to the annual organization of medical quality management activities. In order to strengthen the leadership of the activities, our hospital specifically set up a medical quality management activities leading group, specifically responsible for the supervision of medical quality management activities, regular inspection, assessment and scheduling of the activities carried out in a timely manner to detect and correct the existing problems. Requirements for the establishment of a sound hospital, section of the two levels of medical quality management organization, clear the main leader is responsible for the overall responsibility of the leaders in charge of a specific grasp; each functional section of a clear division of labor, carefully organized, and conscientiously perform their duties to strengthen the activities carried out by the supervision and inspection of the situation, to ensure that the activities of the smooth implementation of the activities.
Second, a clear theme to ensure that medical quality management activities are rich in content
Since 20xx, the city to the party and the country's guidelines, routes, policies as a pointer to rectify the medical order, to ensure medical safety, to strengthen the connotation of the construction of the purpose of the elimination of medical errors and accidents; in order to strengthen the ideological education, change the style of work, and strengthen the legal system as the focus of the awareness; in order to improve the rules and regulations, The implementation of job responsibilities, strict diagnosis and treatment routines and technical procedures as the main measures, a clear theme each year to carry out medical quality management activities, guide, lead the medical institutions to grasp the quality, management, development, medical quality management gradually pushed to the depths of efforts to shape a good social image of the health sector, to meet the people's ever-increasing demand for medical services and quality and safety.
Third, strengthen the training, and strive to improve the medical staff's business and technical skills and level
Medical staff only through continuous training and learning, professional and technical knowledge and level can be updated and improved, the service capacity of the medical institutions in order to continue to enhance. To this end, in the annual organization of medical quality management activities, we have always put the training of medical personnel in an important position, taking a variety of forms, comprehensive training of business and technical personnel, and strive to enhance the business and technical capabilities and level of medical personnel. Specific practices are:
First, the organization of health laws and regulations, rules and regulations, duties and regulations, routine norms of learning. We compile and print "Compilation of legal documents related to medical quality management", "hospital management system and personnel duties", requiring all personnel in each medical institution to have a manual, through the hiring of experts to give lectures, centralized learning units, self-study of medical personnel, lectures, typical case analysis and discussion, so that all personnel in each medical institution to understand and master the health laws and regulations, rules, regulations, duties, procedures, and routines to strengthen their legal awareness, enhance the legal awareness, and strengthen their legal awareness. Strengthen their legal awareness, enhance the conscientiousness of practicing according to law.
The second is to carry out various forms of training activities. Over the past few years, we have organized training for directors, business leaders, case writing training, three basic and three strict training, nursing training, drug training, hospital infection knowledge training, medical dispute prevention and other training activities, so that the medical staff's business skills have improved significantly.
Third, the implementation of science and technology strategy. Firmly establish the idea of relying on scientific and technological progress in the development of health undertakings, to take the invitation to come in, send out, the selection and training of subject leaders, in the continuing education of staff, and to strengthen the construction of medical infrastructure and other measures, focusing on the training of talents, scientific research and specialty (project) construction, improve the overall level of health technology team.
Fourth, standardize medical documents, strengthen the quality control of medical records. In accordance with the Ministry of Health, the State Administration of Traditional Chinese Medicine, "the basic norms of medical record writing", "Shandong Province, medical and nursing paper writing norms", "diagnosis and treatment routines and operating procedures", standardize the medical staff of the medical record writing, improve the quality of medical and nursing paper writing; from 20xx, each year, insisted on the implementation of the quality of the medical record level by level of control and review. On the basis of the quality review of medical records at the hospital and department level in each medical institution, I randomly selected a certain percentage of discharged medical records, experts were drawn to centralized review, the results of the city notification, in accordance with the provisions of the treatment, and with the medical staff's salary and benefits linked to the effective promotion of the quality of medical records.
Fifth, the organization of theoretical examinations and technical competitions. Over the past three years, we have been training to improve the application of first aid techniques, procedures, common methods and treatment plans for the township health center medical staff as the focus, in accordance with the principle of easy to difficult, from shallow to deep, each year, the selection of appropriate technology to the township health center medical staff to promote. The method is: the Bureau of organization experts, take the theoretical lectures and on-site operation of the combination of the way, the organization of township health hospitals health care personnel training, application; the end of the year, the application of the mastery of all health care personnel to participate in the training of theoretical exams, based on which, select 3-5 commonly used technologies to organize competitions than the game. Outstanding performance units and individuals, to give recognition and reward.
Sixth, actively participate in the training lectures organized by higher levels. Provincial and municipal organizations on a variety of medical quality management and business technology training lectures, and actively organize the units to participate in the study, so that medical staff to learn and accept new knowledge, new technologies, new ideas, new ideas.
Fourth, according to law supervision, comprehensively improve the quality of medical management and service level
In order to ensure that the quality of medical management rules and regulations have been implemented, we have been adhering to the law supervision as the main, administrative management for the attached, the management and punishment of the quality of medical management supervision mechanism. First, adhere to the law supervision. Change the passive aftermath of the didactic inspection for the active supervision beforehand according to law, the medical quality of the comprehensive supervision and inspection and special focus on the supervision and inspection of the work of the close combination of the daily work of the supervision of the law issued by the supervision of the instrument, strict supervision and management of medical institutions and medical personnel; second, pay attention to the implementation of various systems and measures. From the system, responsibility improvement to implementation, strengthen the management of the key links of medical quality, key departments and important positions, seriously implement the core system of medical quality and medical safety, timely detection and resolution of medical safety hidden trouble; third, sound organization, clear responsibility.
Requirements of the medical institutions to establish and improve the hospital department two-level medical quality management organization, to achieve a reasonable staff structure, clear division of labor, work coordination, the development of medical quality management and continuous improvement program and organization and implementation. The director of the medical quality management of the first responsible person, leading the organization of functional departments, regular guidance on the quality of medical inspection, supervision and assessment; fourth, the formation of the system to implement the monitoring system. Bureau and the medical quality management organization of medical institutions, develop medical quality assessment standards, take expert group quality assessment, section chief symposium, medical quality warning talk, medical quality dean's grand rounds, inspection visits to study and other forms of extensive medical quality inspection and supervision work.
Fifth, the effectiveness of the work and experience
Through the active development and effective implementation of the above measures, so that the city's medical institutions of the quality of medical management, has achieved significant results: the level of medical technology in various medical institutions has been a greater improvement in the majority of medical personnel in accordance with the law to enhance awareness of the quality of health care services have been greatly improved, the occurrence of medical disputes have been reduced, especially the accidental medical disputes have been very few, and the quality of medical services have been improved. The occurrence of medical disputes has been reduced year by year, especially the accidental medical disputes have been very few, the doctor-patient relationship has improved significantly, for three consecutive years, Tengzhou City, the democratic evaluation of the wind of the top three good results for the construction of a harmonious society has laid a solid foundation. In many years of medical quality management, we y appreciate:
(a) the quality of medical services is the lifeline for the survival and development of the hospital. Medical service quality is the core of hospital management, is the eternal theme of hospital management. In the increasingly fierce competition, only to establish the quality of medical services is the lifeline for the survival and development of the hospital this concept, adhere to the people to provide quality, safe, satisfactory medical services, social and economic benefits can be sustained growth.
(2) Technological innovation is the key to improve the core competitiveness of the hospital and inexhaustible power. Technological innovation, special diagnosis and treatment, science and education is the three major strategies of hospital management. Only by adhering to the advantages of hospitals, departments have characteristics, people have expertise in the development of ideas, hospitals can form and maintain the academic status of disciplines in the competition and technical level in the peer group, to occupy a larger market share, it is possible to be based in the market and development.
(C) people-oriented, patient-centered is to promote the fundamental concept of hospital development. In deepening the reform, change the concept, improve the service environment and service attitude, improve the work style, and establish a people-oriented service concept, which will help the level of medical services on a new stage, on the level.
(D) the combination of ethical construction and quality management is an effective way to solve the problem of medical ethics and medical style improvement. The combination of ethical construction management and medical service quality management, can be flexible management indicators into rigid management indicators, is an effective way to solve the technical quality management and functional quality management, is conducive to dealing with the quality of medical services management, fee management, ethical construction process of the contradictions that arise.
The city has done some work in the supervision of medical quality and achieved certain results. But from the higher requirements, compared with the brother city there is still a gap. In the future, under the correct leadership of the Zaozhuang Municipal Health Bureau, we will further update the concept, raise awareness, and take multiple measures to strengthen the quality of medical care management, to ensure medical safety, to promote the steady progress of the health industry, for economic development and social stability, to make a new and greater contribution!
Part II medical quality management year-end summary report
The ultimate goal of health care reform is to provide patients with better quality medical services at a cheaper cost. In recent years, our hospital and other municipal general hospitals, the same as the city's health care work as a basic component, but also the formation of a unique Chinese medicine health care system, in order to provide people with quality and inexpensive Chinese medicine health care services, inheritance of the development of traditional Chinese medicine academic and training of traditional Chinese medicine personnel have made unremitting efforts.
In the year of xx, our hospital adhered to the service concept of patient-centered, to improve the quality of medical care, reasonable charges, reduce medical costs as the starting point, and strive to provide quality medical services for the majority of patients. Hospital business income increased by 14.36% year-on-year, outpatient clinic volume increased by 12.18% year-on-year, inpatient hospitalization increased by 5.41% year-on-year, excluding the factor of increased workload, an increase of 4.85% year-on-year, while the cost of each outpatient clinic for 108.78 yuan, the lowest of the city's municipal 9 hospitals.
I. Strengthen medical quality management, to ensure and improve the quality of medical services
(a) Medical quality management is the core of hospital management, improve medical quality is the management of the fundamental purpose of the hospital. Medical quality is the lifeline of the hospital, the level of medical care, the quality of medical care is directly related to the survival and development of the hospital. xx year, our hospital in the "medical quality service year" on the basis of the activities of the medical quality to reduce the quality of medical defects, timely investigation and elimination of medical safety hazards, reduce the number of disputes on medical accidents, and eliminate medical errors as the most important work. The reduction of medical quality defects, the timely investigation and elimination of hidden medical safety problems, the reduction of medical malpractice disputes and the elimination of medical accidents are the top priorities. The hospital strictly control the quality of medical care, each department strictly implement the rules and regulations, standardize the diagnosis and treatment behavior, adhere to the system of responsibility for the first diagnosis, the three-stage examination system, difficult patients consultation, critical patients and pre-operative and post-operative discussion system.
Enhance the sense of responsibility, pay attention to the dynamic analysis of medical activities, and do a variety of precautions to prevent the problem before it occurs. In response to the current increase in patients' demand for the right to medical information, improve the notification system. Strengthen the quality control management, inpatient medical record writing implementation of the "** City of Chinese medicine medical record writing implementation rules" and scoring standards, through nearly a year of operation, our hospital inpatient medical record writing in the city's Chinese medicine system inpatient medical record quality control inspection, the total score of the city's second, the top ten winning medical records of the hospital accounted for three, the first two are our hospital medical staff.
(2) optimize the medical service process to improve the basis of medical quality. The service process is the structure and mode of operation of the medical institutions, on the basis of not increasing the number of wards, health and technical personnel, the optimized medical service process determines the efficiency and competitiveness of the medical institutions, which to a large extent enhances the long-term viability of the hospital, so that the available resources of the hospital through the balance of the process of the various components to reduce duplication and waste, so that the hospital's existing hardware and software to achieve a higher rate of utilization and a better Utilization level, as far as possible to give full play to the ability of professional and technical staff, as far as possible to meet the needs of patients, to achieve high economic and social benefits.
I adhere to the patient-centered, in the optimization of the medical process, to facilitate the patient to seek practical results, enhance service awareness, optimize the development of the environment, and strive to provide patients with warm and convenient, high-quality medical services. The introduction of various measures to facilitate the people, such as charging the registration window networking, to reduce the long queues for registration, some experts set up a special registration window, the introduction of telephone booking registration and other measures. Medical and technical departments out of the report form launched. Nursing department in the nurses selection activities emerged in a number of advanced nurses, 56 nurses rated throughout the year, nurses and patients to build a bridge, the introduction of convenient measures to find ways to solve practical problems for the patient, inpatient satisfaction with the nursing work up to 96%.
(C) the implementation of medical quality, medical safety education, is to strengthen the foundation of medical quality. How to improve the quality of the managers themselves and strengthen the quality of the whole hospital medical staff education is the basis of quality management. Improve the quality of medical care is not solely rely on the efforts of a few managers or part of the medical staff can be realized, but the need for all hospital workers have the correct outlook on life, values, professional ethics; need a strong sense of responsibility, dedication, compassion; need to establish a solid sense of medical quality, medical safety; in the hospital to carry out a full range of high-quality service and "safety is the savings, accidents is the waste" activities. Accident is the waste" activities to stimulate the staff than learning, dedication to the spirit of professionalism, the formation of a good atmosphere than, learn, catch up and surpass.
(D) the establishment of a perfect quality management system, standardize medical behavior is the core. In recent years, our hospital from the strengthening of system construction, combined with the nature of the work of each post, the work content, the development of job responsibilities, medical ethics, personnel management, meetings, learning, attendance, safety and security, logistics management, financial and property management, management of statistical reports, management of medical documents and archives, awards, punishments, etc. *** five parts of the 241 management system; the development of the administrative management, medical quality management, nursing quality management, drug management, hospital infections, and the development of a new system to ensure the quality of life of the people. Management, medical quality management, drug management, hospital infection control management, financial management, as well as ideological and political work and medical ethics management and other 26 quality control assessment rules; the development of functional sections, business sections of the comprehensive goal of responsibility to achieve the first level of management, the first level to the first level of responsibility pattern. Clear responsibility to ensure that the function, so that the responsibility, power, clear, moderate interest, so that the management of the chapter to follow, the chapter must follow, and gradually improve the management of the legalization, institutionalization, standardization, standardization.
The establishment of a quality management system in line with the actual hospital, the hospital set up a president, vice president, medical department and clinical departments as members of the quality management, quality control assessment leading group, responsible for the quality management of the hospital. The hospital has formed a main leader personally; the leaders in charge of specific grasp; functional departments daily grasp; clinical departments when the grasp of the medical quality, medical safety management pattern.
Strengthen the medical quality management adhere to the usual inspection and monthly, quarterly, annual quality control combined, strict link quality, to ensure that the end of the quality gate. "The three basics", "promote three strict", the implementation of the "three doctors" checkup system. The medical department often organizes the hospital staff to study health laws, regulations, systems, operating procedures and operating routines, and recorded in the personal business records. In recent years, through the development of medical business management, efforts to improve the quality of medical care, to ensure medical safety as the goal of the full range of quality management, so that the hospital's work to achieve the expected purpose of the integrated target responsibility system, medical quality gradually improved, the gradual reduction of safety hazards, no medical accidents, medical disputes are also relatively few, to improve the quality of medical care, to ensure medical safety, this year, through the successful re-assessment of the three-level B-class Chinese medicine hospitals in Zhejiang Province. B hospital reassessment work.
Second, improve the quality of medical care, reduce medical costs, is the most fundamental goal of the hospital
Improve the quality of medical care, reduce medical costs, so that the people with less money to enjoy the more excellent medical services is the most fundamental goal of the reform of the medical system. Reduce medical costs, improve economic efficiency is also every dean, patients, the community, health care workers and other *** with the concern of social issues, it is a direct reflection of the nature of society and the purpose of the service. As a hospital administrator to strengthen the quality of scientific management, reduce management costs to start from improving the quality of service and business quality, highlighting the "technology" to win rather than "fee" to win.
This year, our hospital strictly implement the drug, large medical equipment procurement bidding policy and drug "Shunga price" policy, the implementation of separate accounting for medicine, respectively, management, adjust the price of medical services, reduce the total cost of medical care, to reduce the proportion of drug revenue in the total income of the hospital. After the implementation of the drug price "Shunga for price" policy, our hospital to reduce the drug income of more than 500 million yuan, and actually reduce the economic burden of patients. To realize the goal of "reducing patients' costs", the first thing is to solve the problem of ideological understanding and improve medical ethics, to adhere to the purpose of "serving the people", correctly deal with the relationship between social benefits and economic gains, put social benefits in the first place, to prevent the one-sided pursuit of economic gains and prevent The first thing you need to do is to make sure that you have a good understanding of what you are doing and how you are doing it.
Part III medical quality management year-end summary report
In order to thoroughly implement the spirit of the National Quality Work Conference, strict implementation of the "State Council on the strengthening of the supervision and management of food and other product safety special provisions", received the municipal bureau of the "on the issuance of drugs and medical equipment quality and safety of the special rectification action program" and the district government office of "the". On the issuance of Luzhou Longmatan District product quality and food safety special rectification action plan notice", the leadership of the Bureau attaches great importance to seriously organize and implement, in accordance with the Bureau of the development and issuance of "Sichuan Luzhou Longmatan Food and Drug Administration on the issuance of drugs and medical equipment quality and safety of special rectification action plan notice" requirements for a period of four months of special rectification.
First, the establishment of institutions, the implementation of responsibility, clear ideas, develop programs. The establishment of the party secretary, the Secretary Zhou Xiaoquan for the leadership of the special rectification action leading group, a clear division of responsibilities for the smooth implementation of the special rectification action to lay the organizational foundation. I held a number of Bureau of the Party Group meeting, special study and deployment of special rectification action plan, clear rectification content, methods and steps, scientific organization, co-ordination arrangements. Developed and issued a "Sichuan Luzhou Longmatan Food and Drug Administration on the issuance of drugs and medical equipment quality and safety special rectification action program notice.
Second, extensive publicity, pay close attention to training. xx September-October, phased organization of the region's pharmaceutical business, medical device business enterprise responsible for the person in charge and quality management personnel nearly 1200 times to carry out special training, distribution of publicity materials more than 3,000 copies, so that they understand the "Special Provisions" of the profound connotation of the standardization of their business practices. Strengthen the quality awareness of enterprises, fully mobilize the initiative of enterprises. Since the special rectification action of the quality and safety of drugs and medical devices, I have repeatedly organized the jurisdiction of the pharmaceutical wholesale enterprises, retail enterprises and chain stores in my jurisdiction have a chain of enterprises held a meeting to arrange for the deployment of the relevant work, to fully mobilize the enterprise, so that enterprises really set up a quality first awareness, so that they take the initiative to do a good job in accordance with the relevant requirements of the self-checking and self-correction work.
Third, strengthen the supervision, pay close attention to the implementation. I Bureau since September, the jurisdiction of nearly more than 250 times the drug-related equipment unit to carry out inspections, **** 185 law enforcement officers, 50 vehicles, 11 cases, involving 8,400 yuan, confiscated illegal income of more than 6,000 yuan, a fine of more than 27,000 yuan, banned the illegal operation of the enterprise 2. Over nearly four months of remedial action, the production, operation and use of drugs to further standardize the behavior of the drug market order to further improve the quality of drugs to further ensure that the people's awareness of the rational use of drugs to further enhance. The main work carried out is:
(a) to check the implementation of the gmp situation as the focus, standardize the behavior of drug production
in the production of drugs, the Bureau of the implementation of the responsibility for the implementation of the quality of drug production enterprises and the purchase of raw and auxiliary materials, personnel qualifications, batch production records, the quality of the inspection as the focus of the inspection content, strengthened the jurisdiction of the Sichuan Baoguang Pharmaceutical Co. Ltd. and Luzhou Jianping Hospital Preparation Room; for the problems found during the inspection, the Bureau respectively put forward corrective comments. During the special rectification period, the Bureau *** on the Sichuan Baoguang Pharmaceutical Co., Ltd. to carry out inspection *** 3 times, Luzhou Jianping Hospital to carry out inspections 2 times, the inspectors 18 times.
(B) to check the implementation of gsp as the focus, standardize the behavior of drug business
in the circulation of drugs, the Bureau of the implementation of gsp drug business enterprises, the qualifications and training of enterprise personnel and whether there is the operation of the business and over the scope of the business behavior as the focus of the Bureau of the strengthening of the supervision and inspection of the drug business enterprises within the jurisdiction. Especially for the case of "7.26" fake human rabies vaccine and the case of Yongzheng's sales staff operating without license seized by the Bureau, the Bureau put forward two measures to strengthen the management of the enterprise's procurement and supply personnel: one is to fix the drug purchaser responsible for the procurement of drugs between enterprises within the jurisdiction; the second is that the enterprise will report the roster of sales personnel to the Bureau for For the record. This effectively prevents "extracorporeal circulation" of drugs and the phenomenon of "recognizing faces but not enterprises" in drug procurement. Since the start of the remedial action, I **** deployed 112 inspectors, **** inspection of more than 210 times the drug business enterprises, for supervision and inspection of illegal behavior found in accordance with relevant laws and regulations, the requirement to be corrected within a certain period of time, and four of the drug business enterprises to deal with the filing of the case.