1. Medical department work situation report
20xx, under the direct leadership of the leadership of the hospital, with the quality first, patient first concept, pay close attention to the standardization of the medical system, in-depth study and implementation of the "Chinese People's Republic of China *** and the State of the Law of the Practicing Physicians," "Regulations on the Management of Medical Institutions", "Regulations on the Treatment of Medical Accidents", "Regulations on the Treatment of Medical Accidents", "Regulations on the Treatment of Medical Accidents" and "Regulations on the Treatment of Medical Accidents". Regulations on the Treatment of Medical Accidents", "Basic Standard for Medical Record Writing", etc., combined with the actual situation of our hospital, to take practical and effective measures to increase the quality of medical management, focusing on the quality of medical personnel training and professional ethics education, to further emancipate the mind, update the concept of improving the efficiency of the service, and vigorously promote the medical care, teaching and scientific research, and contribute to the reform and development of the hospital.
Medical quality is the fundamental issue of hospital survival and development, pay close attention to medical quality management, comprehensively improve the quality of medical services is the primary task of the Medical Department. Medical quality improvement and medical safety work, has achieved significant results.
(a) basic medical quality: we in accordance with the "medical quality management provisions of the implementation of the rules", the medical record writing system, reporting system, checking the system, the three-stage physician checking system, consultation system, case discussion system, surgical classification system, the first diagnosis of the first section of the system responsible for the implementation of the medical core rules and regulations of the supervision and inspection, according to the principle of combining education and guidance and criticism, to take the usual supervision and random inspection and centralized supervision and centralized inspection. The method of combining the usual supervision and centralized inspection is to strictly check the quality of basic medical care and the quality of medical care in the link, and to take multiple measures to improve the quality of medical care in our hospital.
(B) the quality of medical documents: in strict accordance with the "basic norms for medical record writing" requirements, the inpatient medical records, records of the course of the disease and the writing of related information to put forward further standardization requirements, seriously organize the study of the quality of the monthly supervision and inspection of one to two, the implementation of the implementation of the rewards and penalties, rewarding good and punishing the poor, so that the majority of clinicians' awareness of the medical record writing and the quality of the writing greatly improved. Each department can submit medical records in a relatively timely manner, the current medical records can be strictly in accordance with the "basic standards for medical record writing", standardized and timely writing of the current medical records and medical records; outpatient infusion observation medical records can basically be completed in accordance with the requirements. The quality of prescriptions has also improved to different degrees, with an average pass rate of 86.2% for five days of randomly sampled prescriptions per month. The basic registration of the outpatient and inpatient departments can also be carried out according to the requirements, basically in line with the quality standard requirements.
(C) medical quality of medical technology: to strengthen the technical training of medical staff and improve the quality of service, focusing on the test results of the rate of compliance and accuracy of the monitoring, and constantly add new items to meet clinical needs. Focusing on communication and exchanges with clinical departments, the department actively participated in the inter-room quality assessment and indoor quality assessment activities, achieved excellent results, and successfully passed the examination and acceptance of the Provincial Clinical Inspection Center. The Radiology Department has standardized the morning reading system and error correction system, effectively preventing the occurrence of medical disputes.
(D) outpatient medical quality outpatient department after the hospital to its decomposition of economic indicators, the outpatient doctor's sense of responsibility, risk awareness and sense of competition have significantly improved, can strictly abide by the first first medical first responsibility system, seriously outpatient registration and outpatient prescription writing, five consecutive months of the prescription quality inspection results show that the outpatient prescription writing pass rate of 86.2%, outpatient visits and economic income has also increased significantly. The company's business is also a major player in the market.
(E) medical safety work: the development of the "medical incident prevention and handling plan", to strengthen the professional ethics of medical staff, business and technical skills training, especially the "medical incident handling regulations" of the study, in November, but also organized the "medical incident prevention and handling" of the special lectures to educate the majority of medical staff to teach you how to effectively prevent medical disputes, to protect the patients and medical institutions and their legitimate rights and interests. The company's website has been updated with the latest information about the company's website, including its website and its website.
In short, the medical department in 20xx years of work in spite of certain achievements, but still need to make further efforts to strengthen, in the new year, and strive for our hospital's medical reform and construction to make greater contributions.
2. Report on the work of the Medical Department
xx the first half of the year the Medical Department in the hospital committee under the correct leadership of the patient-centered, to comprehensively improve the quality of medical care as the theme to establish and the doctor-patient relationship as the goal of the medical standardization and the implementation of the core system, from the source of preventing and controlling the medical hazards, innovative thinking, Changing concepts, so that the department's work efficiently and orderly.
Continuously improve the quality of medical care is to promote the development of the hospital's driving force, strict medical quality management, and comprehensively improve the quality of medical services is an important task of the Medical Department, the Medical Department has always been "xx province comprehensive hospital evaluation standards and implementation rules" and "two good and one satisfaction" as the standard, according to the established plan at the beginning of the year to focus on the implementation of the core system, case quality management and the Department of the quality of the case. The implementation of the case quality management and the department's own construction of the three aspects of the deep.
1, the first half of the work of the completion of the indicators (as of May 30, xx)
(1) the number of open beds 420
(2) the bed utilization rate: 111.3%
(3) the annual outpatient clinic visits: 19,911
(4) hospitalized in the number of 10,541
(5) the average hospitalization day: 7 days
( (5) Average hospitalization: 7 days
(6) Actual number of occupied bed days in the hospital: 69,875
(7) Grade A rate of medical records: 99%
(8) Qualified rate of prescriptions
(9) Diagnostic conformity rate on admission to the hospital
(10) Diagnostic conformity rate before and after surgery
(11) Positive rate of ct examination
(12) Successful rate of emergency rescue
(13) Grade A healing rate of sterile surgical incision
(14) Infection rate of sterile surgical incision
(15) Accuracy rate of pathological diagnosis
(16) Proportion of component blood transfusion carried out
(17) Average preoperative hospitalization days of elective surgical patients
2.Strictly control management On the basis of a more humane management, in the face of critical care patients in the department's focus on supervision, first of all, the department is required to report relevant information in a timely manner, the medical department for the record in a timely manner to the department to understand the patient's condition, access to medical records, specific arrangements for the whole hospital or departmental consultation, the organization of the consultation staff and time and to participate in the consultation throughout to ensure the quality of the consultation, so as to save time and energy for the department to focus on the treatment of patients and the collection of information for the consultation. This saves time and energy for the department to focus on patient treatment and consultation data collection, effectively improving the department's success rate in treating critically ill patients and reducing the disability and death rates.
3. The work of the medical department report
In the hospital under the direct leadership of the leadership of the hospital, with the "quality first, the patient first" concept, pay close attention to the standardization of the medical system, in-depth study and implementation of the "Chinese People's Republic of China *** and the State Practice Law", "medical institutions", "medical institutions", "medical institutions", "medical institutions", and "medical institutions". Medical Practitioners Law", "Regulations on the Administration of Medical Institutions", "Regulations on the Handling of Medical Accidents", "Basic Norms for the Writing of Medical Records", etc., combined with the actual situation of the hospital, to take practical and effective measures to increase the quality of medical care management, focusing on the quality of medical personnel training and professional ethics education, to further emancipate the mind, to update the concept of improving the efficiency of service, and to vigorously promote the medical care, teaching and scientific research work, and to contribute to the reform and development of the hospital.
First, the quality of medical care and the development of the hospital.
First, the quality of medical care and medical safety
Medical quality is the fundamental issue of survival and development of hospitals, pay close attention to the management of medical quality, comprehensively improve the quality of medical services is the primary task of the Department of Medical Services. Medical quality improvement and medical safety work, has achieved significant results.
(a) basic medical quality: we according to the requirements of the hospital quality management, improve the three-tier medical quality control system, developed the "medical quality control program", revised "medical quality inspection and assessment standards", to help and supervise the establishment of medical quality control of each department of the eight this, to the medical record writing system, request for reporting system, checking the system, the three-stage physician checking the system, the consultation system, Case discussion system, surgical grading system, the first diagnosis of the first section responsible for the system and other medical core rules and regulations of the implementation of supervision and inspection, according to the principle of education, guidance and criticism of the principle of combining the usual supervision and spot checks and centralized inspection of the combination of methods, the basic quality of medical care and links in the quality of medical care to carry out a strict gatekeeper, multi-measures, the quality of medical care in the hospital has improved significantly.
(B) the quality of medical documents: in strict accordance with the "basic specification for the writing of medical records," the requirements of the inpatient medical records, medical records and the writing of related information to put forward a further standardization requirements, seriously organize the study of the quality of the monthly supervision and inspection of one to two, the implementation of the rewards and penalties, reward and punishment, so that the majority of clinicians writing awareness of the medical record and the quality of the writing has improved. 20xx In 20xx, the number of hospitalized patients was 2,670, a year-on-year decrease of 0.03% compared with 2004; 2,670 filed medical records, 2,553 Class A medical records, Class A medical record rate of 95.6%; 2,670 qualified medical records, 100% qualification rate. Each department is able to submit medical records in a relatively timely manner, and the current medical records can be written in a standardized and timely manner in accordance with the "Basic Guidelines for Medical Record Writing", and the medical records of outpatient infusion observation can be completed in accordance with the requirements. The quality of prescriptions has also improved to different degrees. The average pass rate of January to November was 86.2% for five days of random checking of prescriptions every month. Outpatient and inpatient departments of the basic registration can also be required to carry out, basically in line with quality standards.
(C) medical quality of medical technology: to strengthen the technical training of medical and technical personnel and improve the quality of service, focusing on the test results of the rate of compliance and accuracy of the monitoring, and continue to add new projects to meet clinical needs. Among them, the Laboratory Department has newly developed hepatitis A antibody, hepatitis C antibody and syphilis spirochete testing program this year, which meets the needs of clinical blood transfusion safety. Focusing on the communication and exchange with the clinical departments, the department actively participated in the inter-room quality assessment and indoor quality assessment activities, achieved excellent results, and successfully passed the examination and acceptance of the Provincial Clinical Inspection Center. The Radiology Department standardized the morning reading system and error blocking and correction system, effectively preventing the occurrence of medical disputes.
(D) outpatient medical quality: outpatient department after the hospital to its decomposition of economic indicators, the outpatient doctors' sense of responsibility, risk awareness and sense of competition have been significantly improved, can strictly abide by the first consultation and the first department is responsible for the system, and conscientiously carry outpatient registration and outpatient prescription writing, five consecutive months of prescription quality inspection results show that the outpatient prescription writing rate of 86.2%, outpatient visits and economic income has also increased significantly. The economic income has also increased significantly.
(E) medical safety work: from May to July this year, our hospital had a few medical disputes, the medical department timely coordination and resolution, so that the hospital's losses were reduced to a minimum. Subsequently, the Medical Department, in response to the hospital's successive occurrence of several medical disputes, seriously analyzed the situation, developed a "medical incident prevention and handling plan", strengthened the professional ethics of medical staff, business and technical skills training, especially the "Regulations on the Handling of Medical Accidents," the study of the July and August, organized a series of emergency knowledge training, strengthened the medical staff's business skills training in October, but also organized a "Medical Accident Prevention and Handling" seminar. In October, we also held a special lecture on "Prevention and Handling of Medical Accidents", analyzing typical cases around us or in our hospital to educate the medical staff on how to effectively prevent medical disputes and protect the legitimate rights and interests of patients, medical institutions and their medical staff. At the end of November, we also organized the whole hospital's medical staff to study the Law of Practicing Physicians, Regulations on the Administration of Medical Institutions, Measures for the Administration of Nurses, Regulations on the Handling of Medical Accidents, and other health professional laws and regulations, which set off a hot lake of learning and understanding of the law and abiding by the law in the whole hospital. Through our efforts, we have effectively curbed the momentum of the frequent occurrence of medical disputes.
Second, the work of science and education
(a) Continuing medical education
1, continuing education into the hospital's work program, focusing on internal and external personnel training and missionary. This year, our hospital **** sent 5 people to go out to the province and abroad to specialize in three hospitals for further study, sent all kinds of short-term study class nearly 20 times, has been the end of further study back to the hospital of several doctors can learn new knowledge and new technologies quickly applied to the clinical and actively work to improve the level of our medical technology, play a greater role.
2, this year our hospital has nearly 10 people to participate in various types of adult college entrance examination and academic transformation education.
3, actively writing papers, the whole year **** published six papers, more than ten papers exchanged at the municipal medical association.
4, organized two academic training courses, a complete success. Held a basic theory of Chinese medicine training course, there are more than 60 doctors from the county townships of Chinese medicine to participate in the training; late November, our hospital and hosted the municipal continuing medical education program Shiyan City, Rehabilitation Medicine Association 20xx annual meeting and academic exchanges, **** there are more than 90 people to participate in the meeting.
(B) three basic training and teaching
This year, the Medical Department and the Nursing Department jointly carried out more than ten academic lectures, first aid series of knowledge training and first aid skills assessment, and then first aid knowledge closed-book exams, a complete success, so that most of the young medical staff of the first aid theoretical knowledge and skills have been significantly improved. Nursing Department and timely nursing operation practice, so that the majority of nursing workers have mastered the skillful operation skills. In addition, our hospital to strengthen the management of further training interns, further internship students discipline education and requirements, so that further training internship doctors and nurses feel that internship in our hospital can really learn. This year *** receive township health centers and hospitals outside the county of 25 students, accept Shiyan medicine and health school internship students 58 people.
(C) scientific research
This year, our hospital declared three scientific research projects, including acupuncture and liquid tension therapy for the treatment of vertebral artery cervical spondylosis project has passed the provincial appraisal, carotid artery injections of qi drugs to treat cerebral infarction and break the stasis of the capsule for the treatment of thrombosis of the two scientific research projects have been formally set up, the work of this work has created a precedent for the scientific research of our hospital.
Third, publicity and health education work
1, the use of "Utopia TV" and "Utopia newsletter" and other news media to expand the hospital's brand publicity, respectively, in the "Utopia TV" of the "health line of sight", "Utopia News" to do the topic and the news of the 16, and in the "Shiyan TV" of the "Checheng News" column to send a piece of writing in the "Utopia newsletter" to send more than 30 pieces of writing.
2, to carry out a variety of forms of health education work: each ward and outpatient *** out of the publicity column 2 period. Printed more than twenty kinds of common diseases of health education prescription, and in the various wards and outpatient clinics to the patient free distribution, combined with the television media for health education guidance, by the general public welcome.
Fourth, clinic activities and physical examination
1, the organization of experienced medical staff to the poor remote villages for the local people to clinic *** 9 times, with the County Health Bureau, the Red Cross and other respectively to the Utopia Road and Utopia Plaza, etc. to carry out clinic activities, *** for the patient diagnosis and treatment of more than 150 people, and distribution of health education prescription, well received by the masses.
2, this year, the organization of enterprises and institutions and life insurance companies physical examination of about 1,144 people, to facilitate the needs of the general public health checkups, by the people's praise, and achieved a double harvest of social and economic benefits.
The medical department in 20xx years of work, although certain achievements, but still need to make further efforts to strengthen, in the new year, and strive to make greater contributions to the medical reform and construction of our hospital.
4. Report on the work of the Medical Department
Under the leadership of the President, we have studied and implemented the "Practicing Physicians Law", "Regulations on the Administration of Medical Institutions", "Regulations on the Handling of Medical Accidents", "Code of Practice for Medical Records", "Measures for the Management of Prescriptions" and other laws and regulations, combined with the actual situation of the hospital, to take Practical and effective measures to increase the quality of medical management, focusing on the quality of medical personnel training and professional ethics education, further emancipation of the mind, update the concept of improving the efficiency of the service, and vigorously promote medical care, teaching, scientific research, for the reform and development of the hospital has made a certain contribution.
Strengthen the medical quality management, according to the requirements of hospital quality management, improve the three-level medical quality control system, and develop a continuous improvement program of medical quality. It strengthens the quality management, evaluation and supervision of clinical departments, medical and technical departments and pharmacy departments, and puts forward suggestions for improvement. The establishment of sound medical quality, medical records, pharmacy, infection, blood transfusion and other management organizations and their work system, clear responsibilities, regular organization of activities and work to comprehensively improve the quality of medical services.
Seriously grasp the work of medical education. The implementation of continuing education credit system, the organization of business personnel to study the "Department of Health on strengthening the work of continuing medical education of a number of opinions", "Continuing Medical Education project declaration, recognition approach", "Continuing Medical Education credit granting and management approach" and "Continuing Medical Education credit validation management approach" and other regulations and knowledge, to carry out self-study, lectures, room, job training and other skills training, organized in the first half of the year In the first half of the year, we organized 12 business and regulatory learning, and arranged a written test, so that the hospital's continuing education rate of more than 95%, through the study of business personnel to consolidate the basic knowledge, basic theories, basic skills, to understand the domestic and international medical technology, new knowledge, new progress, broaden their horizons, and the level of business has been further improved.
In the construction of the system, the requirements of the department as a unit to seriously study and implement. In particular, the implementation of the core system, such as: the first diagnosis responsibility system, three physician room system, consultation system, death case discussion system, difficult case discussion system, the implementation of medical records writing standards and other systems, and supervision and inspection of the implementation of the situation.
In the echelon construction and talent training, the medical department actively cooperate with the hospital leadership to select strong, moral and talented health professionals 8 people to higher hospitals for further training or short-term learning and training.
Regularly in-depth community service stations, strengthen the management, supervision and inspection of health records and the completion of the six community tasks, improve the level of diagnosis and treatment and community health services management level, so that primary health care deep into the lives of residents.
Strengthen disease control, in accordance with the provisions of the strict issuance of birth medical certificates, the issuance of death certificates, the issuance of diagnostic certificates. Network direct reporting of infectious diseases and death reports, contributing to the standardization of hospital management.
Strengthened the hospital infection monitoring work, improve the implementation of the system, the whole hospital infection monitoring work, the use of antimicrobial drugs are also monitoring management, to fill the gaps in the monitoring of hospital infections.
The first half of the year better completed the beginning of the year plan and the hospital leadership of the work arranged, in the future work, we will continue to maintain a good working style, innovation, solid work, wholeheartedly for the patient service.
5. Medical Department work report
In the first half of 20xx, my staff in accordance with the instructions of the hospital leadership and the standards and requirements of the three hospitals, to quality safety, safety and quality, to carry out the quality of medical care, safety management of the various work, as follows:
First, medical quality management
(a) process management
In-depth clinical, through the scene found that the problem of the form of a coordination meeting, sorting out the inter-departmental, intra-departmental processes, to achieve the purpose of continuous improvement. In the first half of the year to sort out the perioperative preoperative medication specifications, obstetrics maternity ward emergency operating room management, out-of-hospital consultation management, neonatal supervision management, clinical blood transfusion rescue plan and process, outpatient gynecology, women's health, medical desk, fee collection, blood transfusion management, obstetrics and gynecology second-line physicians, obstetrics, induced abortion and death of infants dealing with the management of the various processes, held a variety of coordination meetings 14, involving more than a dozen departments, and in a timely manner to solve many practical problems. The company has also held 14 coordination meetings, involving more than ten departments, and has solved many practical problems in a timely manner.
(B) to strengthen the core system management
1, referral, consultation system management: in the first half of 20xx, organized by the Medical Department of the out-of-hospital consultation 26 times, out of the consultation 5 times, the hospital to expand the consultation 10 times, the city to expand the consultation once. Management of referral patients 22 cases.
2, pay close attention to the "three basic three strict" Peishun assessment work. In the hospital leadership attention and support, in July 20xx organization of all medical, technical and pharmaceutical personnel "three basic" theory assessment, and actively organize medical staff to participate in the National Maternal and Child Health Skills Competition, is currently in the preparation stage.
3, clinical path, appointment service, critical care management has been normalized, clinical path, appointment service, critical care management has been normalized, in the first half of the hospital's total number of discharges of 11603, the path of the case ***3997 cases, the total rate of 34.4%, (the standard is 20%). The total number of appointments was 63,423, with a total appointment rate of 35% (the standard is 40%). My section monthly under the clinical and medical departments to check the implementation of the system, found that the problem timely communication with individuals and departments to deal with, and included in the performance appraisal.
4, adhere to the monthly on-site assessment and quarterly medical quality meeting system, analysis and summary of medical quality issues, especially the emergence of hidden safety hazards, medical complaints, medical disputes in the case, timely organization of the department, the system to discuss, find out the reasons for the example of the results will be included in the performance appraisal and evaluation of excellence and so on.
5, strengthen the business knowledge training, improve the level of diagnosis and treatment. Take the whole staff, sub-systems, departments, etc., professional and technical personnel for continuing education and training, learning and testing, focusing on the learning effect, the first half of this year, the organization of business learning 7 times.
6, difficult case discussion: 20xx the first half of the year I organized difficult case discussion 5 times, mainly for complaints and disputes in the case, the medical department also often participate in the department's difficult case discussion, especially the tendency to dispute cases, timely understanding of the situation in order to better deal with the problem.
Second, strengthen the awareness of medical safety, pay attention to laws and regulations, properly handle medical disputes
1, combined with the actual hospital, the use of various forms of safety training, the first half of the hospital organized two hospital-wide medical safety and quality of medical lectures, one of which invited the City Health Bureau of the Medical Affairs Section, deputy director of the Department of Medical Affairs, should be Wei on the "Jiangxi Provincial Regulations on the Treatment and Prevention of Medical Disputes," a profound interpretation, strengthened the medical staff of our hospital. Interpretation, strengthen the legal awareness of our medical staff, improve the ability of our medical staff to deal with medical disputes.
2, to further strengthen the adverse event reporting management. Mobilization of all staff to take the initiative to find and report medical, security and other aspects of the security risks. 20xx the first half of the medical section *** received 9 adverse events reported. In accordance with the "adverse event management approach" to the reported adverse events related to the department was rewarded, and according to the content of the report in a timely manner with the relevant departments to coordinate the rectification of all kinds of insecurity factors killed in the cradle.
3, the handling of medical complaints and disputes:
1) Complaints: in the first half of 20xx, the Department of Medical Services **** received 10 cases of complaints, of which 7 cases directly to the Department of Medical Services complaints, complaints by the Section of the upward referral of 3 cases. Every time we receive a complaint our department is actively responding to the first time to patients and departments to understand the situation, and convene the relevant departments to discuss and analyze, find deficiencies, propose rectification, and give the complainant a verbal or written response.
2) disputes: 20xx first half of the medical disputes 6 cases, 3 cases have been resolved (① Xie Hongmei inevitable miscarriage of twin deaths ② Zhao Yi tubal pregnancy rupture event ③ Li QiuLian hair humerus fracture event), to be resolved in 3 cases of medical disputes (① Peng Xiaorong placenta previa event, has been a medical appraisal ② gynecological Zhong Aiping rupture of bladder event, is going through the legal process ③ to the Mei intrauterine stillbirth event). The company is currently waiting for the results of the autopsy.
Complaints, disputes occurred in the case, the Medical Department is always to the first scene to understand the situation, and organize the relevant departments and personnel to discuss the case, some a case for multiple discussions; according to the situation to convene different forms of communication to solve the problem of thematic meetings, negotiation and resolution of the meeting, etc., and sometimes a complaint or a dispute up to dozens of times to communicate. With the introduction of dispute resolution regulations in Jiangxi Province, the resolution of the clear way, with the Medical Board, Medical Appraisal Office, lawyers, the court, the judiciary and other departments and personnel to contact more frequently. Dispute resolution, for the existence of problems in the organization of the Academic Committee to discuss, characterization, responsibility division, and the next cycle of the system, process optimization, rectification and rectification is also the current heavy responsibility of the Medical Department.
Third, the implementation of health support for agriculture, counterpart support work
20xx our hospital counterpart support work for the Lotus Square House Health Center and Chishan Center Health Center, our hospital to take a variety of forms to carry out counterpart support work. Lotus Square House of Health Hospital sent obstetrics and gynecology system of two intermediate or higher physicians in the recipient hospitals, monthly professional lectures once a day to participate in outpatient clinics or organization of room visits, regularly hosted difficult case discussions and other forms of; every Saturday to send an obstetrician and gynecologist and a pediatrician to Chishang Center Hospital for room visits, business guidance, etc., have been the recipient of hospitals of the praise. I support the hospital is Shangli County Chishang Hospital.
Fourth, the management of infectious diseases, five, the second half of the intention
I will continue to in-depth clinical, increase the strength of the site assessment, combined with the "dean of the administrative business checkup management approach" standards and regulations, found that the department's deficiencies and weaknesses of the whole, the quality of the security, safety and quality.