Part I
Medical quality is the root of the survival and development of a hospital, is a hospital level embodied in high and low, medical safety management is an important aspect of medical quality. Over the past year, our hospital in the Health Bureau under the direct and correct leadership, seriously study the Ministry of Health, the Bureau of the relevant spirit of the reform of the health care system, to join the reform of the health care system, open up the health care market, and actively participate in market competition. Adhere to the patient-centered, all for the patient service, and constantly improve the quality of medical services, improve service attitude. Strictly grasp a variety of medical quality control indicators to improve the overall level of medical effectively reduce medical disputes, to prevent the occurrence of medical errors.
The medical treatment and medical safety work of this year is summarized as follows:
First, effectively improve medical services
Strengthen medical ethics and medical laws and regulations, rules and regulations of education, so that the majority of staff to further establish the wholeheartedly for the patient service ideology, adhere to the "patient-oriented" service concept. Service concept, seriously carried out the content of "good service, good quality, good medical ethics, public satisfaction" of the "three good and one satisfied" activities, and constantly improve the level of medical services. Innovative service process, optimize the diagnosis and treatment environment. We have enriched outpatient physicians, rationalized working hours, and insisted on opening clinics on time to ensure that patients are seen in a timely manner. The establishment of an open and transparent system of medical expenses, the implementation of a one-day list system for hospitalized patients, patients can always query the price of drugs, hospitalization costs and other details, by the patient's praise.
Strengthen doctor-patient communication, improve the content of communication, improve communication, focus on the effect of communication, and effectively strengthen the basic management of the hospital, the establishment of a sound medical safety management organization, the implementation of the core medical work system and safety measures, to ensure that medical instruments and equipment are legal, reasonable, and safe to use, to avoid the occurrence of medical errors and accidents. Strict technical access system, standardize medical practice behavior. Seriously implement the "Drug Administration Law", "Medical Devices Supervision and Administration Regulations", and strengthen the supervision and management of the purchase, storage and use of drugs and medical devices.
Second, effectively improve the quality of medical services
Medical quality and safety is related to the public's health and safety, is the lifeline of medical services, is the core content of hospital management and eternal theme. The first step in medical safety is to improve the quality of medical care and enhance the level of service. Strengthen medical quality management, pay close attention to the implementation of rules and regulations, always adhere to the "patient-centered", quality as the core, quality and safety as the theme, and seriously implement the rules and regulations, job responsibilities, strict implementation of diagnostic and treatment technology routines, and the implementation of the various systems in all aspects.
The establishment of Yao Town Health Center medical quality management group, strengthen the quality management of medical documents, strict implementation of the "basic norms of medical record writing", the quality of the case of the implementation of the whole monitoring and management. The development of Yao town health hospital professional and technical personnel assessment program to implement the reward and punishment mechanism to ensure that rewards and penalties in place, the quality of medical services assessment of excellent results in the department or individual to give praise and material incentives; the quality of medical services assessment of the results of substandard departments or individuals in addition to economic penalties and hospital-wide notification of the criticism to strengthen the "three basics and three strict" training, held from time to time at all levels and types of personnel, the quality of medical documents to strengthen the management of the quality of medical documents. The company's training, held from time to time at all levels and types of personnel three basic assessment of the level of clinical theoretical knowledge of medical personnel and practical skills for a comprehensive assessment, and the results of the assessment and personal assessment linked to ensure that the medical and technical personnel of their own technical qualities continue to improve and update, and comprehensively improve the quality of the medical staff business.
Third, the establishment of a perfect quality management system, standardize medical behavior is the core
This year, our hospital from the strengthening of the system construction, combined with the nature of the work of the job, the work of the content, the development of the relevant management system and assessment rules, and the development of functional departments, business departments, the comprehensive objectives of the responsibility to achieve the first level of management level, the first level of responsibility to the first level of the pattern. Clearly responsible for ensuring that the function, so that the responsibility, the right to clear, moderate interest, so that the management of the chapter to follow, the chapter must follow, and gradually improve the management of the legal system, institutionalization, standardization, standardization.
Fourth, in accordance with the law to properly dispose of disputes between doctors and patients
According to the relevant laws and regulations, the disposal of disputes between doctors and patients into the legal system, standardized track, to safeguard the legitimate rights and interests of doctors and patients. According to the "Medical Accident Handling Regulations" set up Yao Township Health Center Medical Dispute Coordination and Handling Group, in accordance with the law to properly deal with doctor-patient disputes. Adhere to the principle of prevention in the first, found in the early, disposed of in the small, establish and improve the prevention and disposal of disputes between doctors and patients mechanism, the careful implementation of the relevant preventive and control measures, and strive to resolve all kinds of disputes between doctors and patients, to prevent the disputes between doctors and patients caused by mass incidents and vicious incidents.
V. Strengthen security measures to ensure the safety of the hospital
Regularly organize key positions for staff to learn and train, the implementation of various internal security measures. Regular and irregular fire safety to carry out a comprehensive inspection, easy to cause fire, the storage of dangerous goods and the concentration of people in the place of key inspections (such as the drugstore, outpatient, wards, etc.), the fire facilities for regular maintenance and replacement, to ensure that the fire fighting equipment in good condition. Our hospital implements the general duty system of hospital leaders, clearly defines each person's time period division of labor, and conducts hospital-wide patrols during the duty period, so as to effectively implement the security precautionary measures such as fire prevention, anti-theft, and anti-sabotage into practice. Strictly implement the security responsibility system, to improve the destabilizing factors investigation, found that the problem is immediately rectified. The development of human defense, material defense, technical defense emergency measures to ensure that the hospital does not appear major security incidents.
Part II
According to the deployment of the municipal and county health planning bureau, the hospital against the "medical service quality management project" program requirements, combined with the "quality nursing service demonstration project", "antimicrobial drug clinical trial project", "the hospital", "the hospital", "the hospital", "the hospital", "the hospital", "the hospital", "the hospital", "the hospital", "the hospital", "the hospital".
According to the deployment of the city and county health plan bureau, our hospital, in accordance with the requirements of the "medical service quality management project" activity program, combined with the "quality nursing service demonstration project", "special rectification of the clinical application of antimicrobial drugs" and the creation of the "three good and one satisfied" hospital, in-depth development of the theme of "medical service quality awareness to strengthen medical care, to ensure that medical service safety The theme of the "medical service quality management project" activities, and constantly strengthen the hospital medical safety management, medical safety hidden trouble, to protect the quality of medical care and medical safety, and strive to achieve for the people to provide safe, effective, convenient, inexpensive medical and health services.
First, the strict implementation of the core system of medical quality and medical safety, and seriously implement the quality of medical services management project
Medical quality is the lifeblood of the survival and development of hospitals, is the core of hospital management. This year, our hospital to take the opportunity of the second hospital review, improve the diagnosis and treatment system, standardize the service process at the same time, adhere to the scientific concept of development as the guide to improve the quality of medical care and medical safety as the core, and effectively strengthen the management of hospitals, increase medical safety supervision, pay close attention to the implementation of the measures to strictly regulate the medical behavior, and strive to create a "three good and one satisfactory "The company's main goal is to improve the quality and safety of medical care.
(a) the strict implementation of the core medical system, strengthen the management of medical services
strict implementation of the first doctor is responsible for the system, the three-stage physician check-up system, the handover system and the pre-operative discussion system, the consultation system for difficult cases, the death of the case discussion system, and other core systems; strengthened the "perioperative" safety management, establish and implement surgical qualification access. The hospital has strengthened the safety management of "perioperative period", established and implemented the qualification access and grading management system for surgeries, the reporting and approval system for major surgeries, the verification and risk assessment system for safety of surgeries, and the system of responsibility of the attending physician for anesthesia operations, so as to ensure safety of surgeries and anesthesia. It has improved the internal medical quality and safety evaluation and control system of the hospital, strengthened the management of medical service quality, and improved the mechanism for continuous improvement of medical quality. Meanwhile, in accordance with the relevant laws and regulations such as the Law on Practicing Physicians, Regulations on Nurses, Regulations on the Administration of Medical Institutions, and Measures for the Administration of Clinical Application of Medical Technology, the hospital strictly adheres to the admission of practice and qualification, and strengthens supervision, and the hospital as a whole has no unlawful practice behaviors. It has earnestly implemented the Administrative Measures for Periodic Examination of Physicians, and strengthened the periodic examination and evaluation of physicians' practice.
(B) optimize the medical service process, improve the quality of medical services
I adhere to the "patient-centered" service concept, improve the medical service measures to achieve a reasonable arrangement, enthusiastic service, smooth flow, strengthen the communication between doctors and patients, to promote the harmony of the relationship between doctors and patients, and improve the patient's satisfaction. Standardize the behavior of medical services, improve the quality of professional ethics of medical staff and the level of medical services; actively improve the medical environment, keep the hospital clean and orderly. Solidly carry out the "quality nursing service demonstration project" activities, effectively strengthen nursing management, standardize practice behavior, solid basic nursing services, fully mobilize the enthusiasm of the majority of nursing workers, and strive to establish a long-term mechanism conducive to the continuous improvement of the quality of nursing services, nursing careers continue to develop, and strive to provide patients with safe, high-quality, Satisfactory nursing services. The department and medical staff of antibacterial drug use, use rate and use of intensity of the situation of ranking and publicity, ranking ahead of the department in charge of the physician to carry out admonition.
(C) carried out a quality assessment of medical record writing activities
In accordance with the Shanxi Province, Wei "basic norms for medical record writing" and "medical institutions, medical records management regulations", to further standardize the management of medical records. Establishment of the assessment mechanism, monthly outpatient prescriptions, hospitalization medical records for a sampling review activities to strengthen the medical record writing assessment. Improve the rate of grade A medical records, eliminate grade C medical records.
(D) strengthened hospital infection management
First of all, in accordance with the "Hospital Infection Management Measures" and the relevant technical specifications, industry standards, developed the "Jingle County People's Hospital Emergency Response Plan for Sudden Hospital Infection Events", "Jingle County People's Hospital Infection Surveillance Plan", to strengthen the infection management of the Infection Department, Stomatology Department, Operating Room, Emergency Department, Maternity Ward, disinfection and supply room and laboratory and other key departments management and monitoring of infection. Management and monitoring of key departments. Secondly, in accordance with the Regulations on the Management of Medical Waste and other rules and regulations, we have strengthened the classification, transportation and temporary storage and treatment of medical waste, enhanced the standardized management of medical waste, effectively prevented and controlled hospital infections, and eliminated the occurrence of infection incidents. This year, the disinfection supply center successfully passed the acceptance of the standard. (E) strengthen the work of first aid, carried out a clinical first aid skills competition
Further strengthen the construction of first aid team, strengthen the basic skills of medical personnel first aid training, improve emergency treatment capacity and level. The establishment of the "three basic, three strict" training and assessment system, medical personnel can skillfully and correctly use a variety of rescue equipment, master a variety of first aid technology. First-aid skills competitions are conducted once every six months, using single competitions and comprehensive competitions, including single-handed cardiopulmonary resuscitation and three-person cardiopulmonary resuscitation techniques. The competition is held every six months, using single competition and comprehensive competition, which includes single unarmed CPR, three-person CPR and so on. Through the skills competition, to improve the emergency response and disposal capacity of health care personnel, comprehensive treatment capacity, enhance the coordination capacity of our hospital departments, in order to adapt to the needs of emergency rescue work in complex situations.
(F) strengthen the clinical pharmacological management, promote the rational use of clinical medicine
First, the establishment and improvement of the hospital pharmacological management and therapeutics committee organization, with clear responsibilities, a sound system, complete records, to improve the level of rational use of clinical medicine, reduce the cost of medical care for patients.
The second is to regularly monitor, evaluate and publicize the clinical use of drugs in the hospital. The system of prescription review is seriously implemented, dynamic monitoring of prescriptions and abnormal warnings, and timely intervention in irrational use of medication.
Third, the implementation of the Ministry of Health, the clinical application of antimicrobial drugs related regulations, follow the "guiding principles of clinical application of antibacterial drugs", adhere to the graded use of antibacterial drugs, to carry out rational use of medication training and education, regularly convene thematic analysis of the application of antimicrobial drugs, the implementation of the "double ten" system, the excessive use of antibacterial drugs, doctors take personal conversation, notification and criticism, and the use of antibacterial drugs, the use of antibacterial drugs. The doctor took personal conversation, notification and criticism, financial penalties and other severe measures.
Fourth, the establishment of an effective adverse drug reaction event handling procedures, serious, timely and accurate data collection and reporting.
Fifth, the standardized use and management of special kinds of drugs such as narcotic drugs, psychotropic drugs, toxic drugs and high-risk drugs have been strengthened, and a sound system for the acquisition, safe custody and use of the above drugs has been established. (VII) further standardize the management of clinical blood transfusion in hospitals
Improve the hospital blood transfusion management committee and working system, implement the registration system for clinical blood transfusion application and blood use approval procedures, establish the blood transfusion application and consultation system, pre-transfusion patient consent system, pre-transfusion testing and verification system, standardize the pre-transfusion infection screening and transfusion compatibility testing, improve the records, and discuss and analyze problems in clinical blood transfusion, promote the clinical blood transfusion, and promote the use of clinical blood transfusion. We have discussed and analyzed the problems of clinical blood transfusion, promoted scientific and rational use of blood in clinics, and ensured the safety of clinical blood use. Strict indications for blood transfusion have been strictly applied, and the proportion of component blood transfusion has been increased. In clinical blood transfusion, there is no illegal blood collection and supply behavior, and the qualified rate of cross-matching reaches 100%.
(H) strengthened the quality control of clinical testing
According to the "Pathogenic Microorganisms Laboratory Biosafety Regulations", "Department of Clinical Laboratory Management Measures" and other relevant provisions, comprehensively strengthened the laboratory biosafety, quality control and management work; development and strict implementation of the standard operating procedures for clinical testing programs and standard operating and maintenance procedures for testing instruments, and can effectively ensure the integrity and effectiveness of the detection system. Effectively ensure the integrity and effectiveness of the testing system; provide 24-hour emergency testing services to meet the clinical needs; clinical testing programs carried out indoor quality control and inter-room quality evaluation. (IX) to strengthen medical safety training, strengthen the quality of medical care, service and safety awareness
Carry out the whole medical safety education, improve the awareness of medical safety. It has earnestly implemented the Interim Provisions on Reporting of Medical Quality and Safety Incidents, and formulated the prevention plan and handling procedures for major medical safety incidents and medical accidents. We have further improved the organization and leadership of production safety, management institutions, rules and regulations, operating procedures and standards, clarified the staffing requirements, and put measures in place; we have taken special management and measures for key areas and departments to ensure that all kinds of equipments and facilities in the hospital can operate safely. The hospital fire channel is smooth, no obstacles, signs, all kinds of fire equipment, unified management of the Security Section, and in the various departments with special management. September 7, the hospital medical staff for fire knowledge and fire extinguisher use training, to further improve the fire safety of health care personnel preventive capabilities.
(X) comprehensive self-correction, eliminate security risks.
Strengthen the prevention of medical safety accidents, medical safety one by one, especially the key links and key departments, the problems found in the self-inspection of immediate rectification, and strengthen the mechanism, improve the management, to ensure medical safety.
Second, the solid development of "three good and one satisfied" hospital activities, and strive to achieve "good service, good quality, good medical ethics, the public satisfaction" goal
This year, the hospital to create a "three good and one satisfied" hospital activities as a health care system.
(a) Improve service attitude, optimize the service process, and constantly improve the level of service, and strive to achieve "good service".
1, optimize the hospital outpatient environment and processes.
Improve the people's experience of medical treatment as a point of innovation and breakthrough to strengthen medical services. The implementation of the window staff ten minutes in advance to hang on duty, medicine and other cases generally no more than 5 minutes. Strengthen the outpatient service window and clinic flexible scheduling; the implementation of the window, discharge, telephone, and other appointment methods to facilitate the examination of patients, and strive to do so as soon as possible; the full implementation of the test and inspection reports issued in a timely manner system to ensure the privacy of patients under the premise of reasonable arrangements for holiday outpatient emergency and inpatient health care services, improve the hospital signage and diagnostic procedures to guide the system; to promote the construction of hospital information technology, reduce unnecessary The hospital is also promoting the construction of hospital informatization to reduce unnecessary duplicate examinations.
2. Optimize emergency services.
Improve pre-hospital emergency care, strengthen the coordination of pre-hospital and in-hospital emergency medical services, and ensure the seamless integration of emergency medical services. Strengthen the hospital emergency department standardization, standardization construction, improve the emergency green channel. Patients with acute and critical illnesses should be rescued first and settled later to ensure timely treatment.
3. Improve hospitalization services.
The full implementation of the rational allocation of nurse manpower, the implementation of the responsible nurse system, standardize the provision of hierarchical care and overall nursing services as the core of the quality nursing services demonstration project activities. Strengthen the standardization of the construction of the ward, strict management of visits and escort, for hospitalized patients to create a clean, peaceful hospital environment. Seriously implement the telephone follow-up system for discharged patients, and the telephone follow-up rate of discharged patients within one week reaches 100%.
4, the implementation of the same level of medical institutions examination, test results mutual recognition.
On the basis of strengthening medical quality control, we vigorously promote the mutual recognition of medical examinations and test results at the same level, promote rational examination, and reduce the cost of patient visits.
5, the establishment of a sound medical dispute mediation mechanism and medical liability insurance system.
Seriously implement the medical complaint handling methods, strict implementation of the first complaint system, in-depth activities to create a "safe hospital" to build a harmonious doctor-patient relationship.
(2) strengthen quality management, standardize diagnostic and treatment behavior, continuous improvement of medical quality, and strive to achieve "good quality".
1, sound medical quality management and control system to enhance the quality of care.
In accordance with the law to strengthen the access to practice and supervision, the strict implementation of the first diagnosis is responsible for, the third level of physician room visits, difficult case discussion, critical patient rescue, consultation, preoperative discussion, death case discussion, shift handover and other core systems, the strict implementation of the "basic norms of case writing" and "surgical safety checking system" to standardize the writing of medical records and surgical safety checking work.
Strengthening the classification management of medical technology and surgical grading management, strict audit of the clinical application of medical technology, surgical ability and authority, and resolutely investigate and deal with illegal and irregular clinical application of medical technology and the phenomenon of transgressive surgery. Improve the medical quality control network, improve the medical quality management and control of organizational systems, systems and mechanisms, timely, complete, truthful and accurate reporting of quality control information.
Strengthen the construction and management of key departments and divisions, so as to achieve the staffing in place, supporting facilities and equipment, excellent technical level, scientific and standardized management. Continue to strengthen the capacity building of clinical specialties and training of medical personnel, strengthen the key links in the process of medical services, key areas, key personnel management, and continuous improvement of medical quality.
2, strictly regulate the behavior of diagnosis and treatment services, and promote rational examination, rational use of medication, rational treatment. The company is also committed to the implementation of the clinical path, the "Code of Clinical Practice", "Clinical Treatment Guidelines", "Pharmaceutical Management Provisions for Medical Institutions", "Prescription Management Measures", "Guiding Principles for the Clinical Application of Antimicrobial Drugs" and other regulations and norms. Vigorously implement the clinical path and single-patient payment, and promote medical quality management to scientific, standardized, professional and refined development.
3, strengthen the management of clinical application of medical technology and large-scale equipment to ensure the quality and safety of medical care and patients' rights and interests. Effectively strengthen the management of the clinical application of medical technology, in accordance with the requirements of the "management of the clinical application of medical technology", the establishment of a strict medical technology access and management system.
(C) to strengthen the medical ethics education, vigorously promote noble medical ethics, serious discipline, and strive to achieve "good medical ethics".
1, continue to increase medical ethics education.
To adhere to the positive education, continue to cultivate and set up a number of advanced models, increase the publicity of advanced models of high morality, excellent medical skills, dedication, combined with the characteristics of the health industry, in-depth awareness of the purpose of the professional ethics and discipline of the legal system education, to guide the majority of medical personnel to establish a good medical ethics.
2, the implementation of medical ethics and medical system norms.
Adhere to the principle of treating both the symptoms and the root causes, comprehensive treatment, punishment and prevention, focusing on prevention, and vigorously strengthen the construction of the system of punishment and prevention of corruption, and promote the smooth progress of the reform of the medical and health system. The establishment of doctor-patient communication responsibility system, hospitalized patients mainly by the responsible doctor, responsible nurse is responsible for communication, surgical patients pre-operative, post-operative by the surgeon in charge of communication, outpatient patients have the receiving physician is responsible for communication. Strengthen the medical ethics education, the implementation of medical ethics assessment, regular assessment of physicians and malpractice records and other systems, to increase the hospital inspection and punishment of violations of law and discipline, serious practice discipline.
3, resolutely put an end to the purchase and sale of medicine and medical services in the unhealthy wind, serious industry discipline. Firmly put an end to eat, take, card, want, indiscriminate charging, accept or ask for "red packets", accept kickbacks, commercial bribery and other undesirable phenomena. Strengthen the long-term mechanism for the control of commercial bribery in the field of medicine purchasing and marketing. Strengthen the economic management, improve internal control mechanism, strict unified authority and approval procedures.
(D) in-depth review of the wind, proactively accept social supervision, and strive to achieve "mass satisfaction".
1, seriously carry out patient satisfaction surveys and discharged patients return visit activities, to solicit comments and suggestions, targeted to improve services.
Part III
20** year I adhere to the patient-centered service concept, to improve medical quality, reasonable fees, reduce medical costs as the starting point, and strive to provide patients with quality medical services. Now the 20** medical quality management work is summarized as follows:
A...
1, adhere to the hospital medical departments to carry out regular medical quality and medical safety inspection, and summarize and analyze. Reduce medical defects, timely investigation and elimination of medical safety hazards, reduce medical malpractice disputes, and eliminate medical accidents as a top priority.
2, seriously do a good job in accordance with the law practice management. Do not have a licensed physician qualifications and licensed nurses are strictly prohibited to work.
3, strict 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, difficult and critical patients consultation and referral system, the quality of medical care is always in the first place, and resolutely put an end to the occurrence of medical accidents. Enhance the sense of responsibility, improve the precautionary measures to prevent the occurrence of accidents.
4, strengthen the quality of medical care, medical safety education, organize the entire hospital staff to study the "Medical Practitioners Law", "Regulations on the Treatment of Medical Accidents" and other relevant laws and regulations, to enhance legal awareness.
5, strengthen the quality education of the hospital's medical staff, establish a correct outlook on life, values, professional ethics. Education of the hospital's medical staff should be patient-centered, medical quality as the core, improve service attitude, improve service quality, reduce the occurrence of medical errors
Birth. Do a good job of continuing education, planned arrangements for personnel to higher hospitals for further training and to participate in short-term training courses organized by the City Medical Association, and actively participate in the training of general practitioners organized by the Municipal Health Bureau. Regular business learning, pay close attention to all kinds of medical instruments and prescriptions of standardized writing work not to relax.
Second, strengthen the management of hospital infection. The establishment of the hospital infection management leading group, specialists responsible for, responsible for the strict implementation of all manufacturing procedures to ensure medical safety. Regular hospital infection inspection, and summary, analysis, organization of the hospital medical staff to seriously study the "hospital infection management approach" and related technical specifications for training, strengthen the management of medical waste, to strengthen the hospital key departments (injection room) of the hospital infection control, effective prevention and control of hospital infections, to ensure that the patient's medical safety. Medical quality management work summarizes three, strengthen the hospital clinical drug management. Medical staff to the "prescription management approach", "the guiding principles of clinical application of antibacterial drugs," the strict implementation of special drug management system and adverse drug reaction monitoring and reporting system, timely reporting and disposal of adverse drug reactions. To do according to the disease treatment, rational examination, rational use of drugs, standardized charges, to eliminate the abuse of drugs, indiscriminate examination phenomenon.
Four, strengthen all kinds of information reporting, collection and analysis. Organize the whole hospital medical staff to study the "Prevention and Control of Infectious Diseases Law", and report the infectious diseases stipulated by the state in a timely manner.
20**, we will promptly rectify the existing medical defects, and constantly improve the quality of medical care, to provide patients with safe, effective, convenient and inexpensive medical services.
December 29, 20**