Self-inspection report of medical institutions practicing according to law (Selected 3)
Busy and full of work in the time urged to come to an end, reviewing this period of time there is a problem with the work, let's work together to seriously write a self-inspection report. Do you know the format of the self-examination report? The following is my collection of medical institutions in accordance with the law self-examination report (selected 3), I hope to be able to help you.
Self-inspection report of medical institutions practicing according to law1
In order to further strengthen the awareness of medical institutions practicing according to law, to combat illegal practice, to strengthen the supervision of health and family planning administrative departments of medical institutions, to improve the quality of medical services, and to ensure medical safety, according to the Guang'an City Health and Family Planning Commission "on the implementation of comprehensive law enforcement inspections of medical institutions of the notice" (Guang'an City Health Office issued [ 20XX] No. 78), the Municipal Health and Family Planning Commission organized the relevant personnel of the Comprehensive Supervision Section, Medical Affairs and Medical Management Section and Health Law Enforcement Detachment to supervise and inspect the comprehensive law enforcement inspection of medical institutions in the city from May 23rd to 28th. The relevant information is reported as follows:
First, the basic situation
The inspection *** sampling including municipal medical institutions, including 30 medical institutions, of which, two public medical institutions above the third level, five public medical institutions above the second level, other public medical institutions, four private medical institutions, private health care institutions 9, township health centers 10. For the daily supervision of the medical institutions found more problems, the public reflected strongly, focusing on the medical institutions to see whether there is a contracted department rental or contracted departments in disguise, whether beyond the approved registration of diagnostic and therapeutic subjects to carry out diagnostic and therapeutic activities, whether the use of non-health technicians engaged in medical and health care technology, whether the naming of health care institutions is standardized to carry out the prohibited clinical application of medical technology in accordance with requirements For the record, whether there is any behavior of carrying out prohibited clinical application of medical technology. The inspection team will inspect the situation on-site feedback to the inspected units, at the same time, the problems found in the form of "health administrative law enforcement proposals" sent to the districts, cities and counties of the Health Bureau, in order to urge the rectification of the implementation of in place, and the discovery of violations of the law according to the investigation.
Second, there are problems
(a) the management of medical institutions: the vast majority of medical institutions can apply for calibration on schedule, in accordance with the health administrative department approved the registration of diagnostic and therapeutic subjects to carry out diagnostic and therapeutic activities, and has not been found to rent out contracted departments or rent out contracted departments in disguise. However, from a general point of view, the awareness of the medical institutions to practice according to law, medical quality still needs to be improved, and the phenomenon of illegal practice still exists. First, there is still the phenomenon of using non-health technicians. Inspection found that most of the private medical institutions have a relative lack of qualified health technicians, and ultrasound room, radiology and laboratory and other functional auxiliary departments is most obvious, there are qualified personnel are not in the post for a long time, do not have the qualifications to issue the relevant inspection report card phenomenon. At the same time, private medical institutions and township health centers and other primary health care institutions have a lack of qualified pharmacy staff, there is a general phenomenon that does not have the qualification of pharmacy personnel audit, issue of drugs; individual health care institutions registered address is not timely change to carry out diagnostic and therapeutic activities or registered in the hospital of the practitioner is not on duty. Second, the department set up, naming is not standardized, there are still individual medical institutions set up departments or additional departments. Third, the management of occupational radiation is not standardized. The inspection found that individual medical institutions did not obtain the "radiation treatment license" or did not carry out radiation treatment activities on time, copies of unregistered ray device details, radiation staff did not wear personal dose detector, did not carry out pre-job physical examination. Fourth, the management of medical records and prescriptions is not standardized. There are medical records are not timely, imperfect, print medical records are not printed in a timely manner and signed by the physician, unqualified personnel writing medical records supervising physician did not review the signature in a timely manner, prescription writing, medication is not standardized and other issues.
(ii) the clinical application of medical technology management: the city's existing record of 15 medical institutions to carry out the second category of medical technology, there is no record of medical institutions to carry out the third category of medical technology. Recorded to carry out the two types of medical technology is mainly concentrated in the second level of medical institutions, and to carry out more than three endoscopy, hip and knee joint replacement technology. From the inspection, among the 30 medical institutions sampled, 23 did not carry out restricted clinical application of medical technology, 6 have been filed in the administrative department of health and family planning as required, and 1 carried out hip replacement technology without filing. Record of medical institutions, individual medical institutions can not provide the record announcement, to carry out the 'medical technology management is not standardized, did not establish the relevant rules and regulations.
(C) medical advertising management: some medical institutions in the hospital medical publicity is not standardized, such as listing "cooperation with xx hospital", posting the introduction of cooperation "experts", exaggerated therapeutic role of medical technology publicity. The business sector has not received a request to revoke the diagnostic and treatment subjects or revoke the license of the medical institution.
(d) medical institutions named management: the overall situation, the public medical institutions named more standardized, some private medical institutions named to be further standardized. Such as involves the use of geographical name is not standardized name of medical institutions, such as: neighboring Chuandong Hospital, neighboring Southwest Stomatological Hospital, Guang'an City, Minsheng Hospital; the use of harmonics to produce ambiguity or mislead the patient's name of the medical institutions, such as neighboring Concordia Hospital, neighboring Huaxi Hospital, Guang'an Huaxi Hospital, Wusheng Boai Hospital, Wusheng Huaxi Hospital.
Three, the next step in the work requirements
(a) sort out the problem, according to the law investigation. The local units to the problems found in this inspection as a clue, carefully combing the problems, the organization supervision and law enforcement departments to further investigate and obtain evidence, the medical institutions of violations, once verified, resolutely in accordance with the "Regulations on the Management of Medical Institutions" and other relevant provisions, in accordance with the law to investigate and deal with, and will never be tolerant and relentless.
(2) Strengthen the daily supervision and management. Local units should attach great importance to this work, the jurisdiction of the medical institutions to strengthen the day-to-day management, urging medical institutions to regulate the practice of behavior. First, standardize the setup and management of medical institutions. It is strictly prohibited to rent out contracted departments, use of non-health technicians, and over-scope of practice. Second, strengthen the supervision of clinical application of medical technology. Strengthen the supervision of the clinical application of medical technology in this jurisdiction, and include the clinical application of medical technology in the focus of daily supervision. Third, strengthening the management of medical advertisements and carrying out review and licensing work in accordance with the law. Fourth, further standardize the naming management of medical institutions.
(C) to strengthen the review of medical institutions calibration. Proposed school inspection of medical institutions, a strict review of relevant documents, cases and materials, whether in line with the "basic standards for medical institutions", does not meet the "Regulations on the Administration of Medical Institutions", "Medical Institutions Inspection Management Measures" relevant requirements, ordered to rectify the deadline, to give a one- to six-month deferred inspection period, deferred inspection period expired can not be passed by the inspection, by the registration authority to cancel its "medical institutions practice permit
All the problems listed in the inspection supervision, the responsible unit by the end of July to rectify in place, overdue rectification or rectification is not in place, depending on its situation into the end of the year performance target management part. Rectification report by the end of July to report to the Municipal Health Commission integrated supervision section.
Medical institutions in accordance with the practice of self-examination report 2To further regulate the county medical institutions in accordance with the practice of law, and actively implement the "Medical Practitioners Law", "Maternal and Child Health Law", "Regulations on the Administration of Medical Institutions", "health care institutions, medical and health-care institutions and medical waste management measures" and other laws and regulations, to ensure medical safety, strengthen the supervision of medical waste, and effectively protect the people's health rights and interests and medical safety, the county. In 20XX our county to focus on the construction of long-term regulatory mechanism for the purpose of work, through the development of medical institutions, "law practice health" action, special supervision and inspection of public medical institutions, medical institutions, such as bad practice behavior score management and other effective measures, to further improve the level of our county medical and health care institutions in accordance with the law, and has achieved certain results. Effectiveness. Now the county work report as follows:
First, the current situation in the county
I county currently *** have all kinds of health care institutions 34, of which the county's health care institutions 5 (including three county medical institutions and two public **** health institutions), townships and townships 7 health centers, 17 village health clinics, individual clinics, school, enterprise medical clinic 5 There are 5 medical clinics in schools and enterprises. Health care services engaged in the work of health care personnel *** 448, of which 132 licensed physicians, 33 physician assistants, 21 rural doctors, 139 licensed nurses, 39 pharmacy personnel, 29 medical technicians and inspectors, other health care personnel 55 people. The area has a medical waste centralized Z unit, mainly responsible for the island's medical institutions medical waste centralized Z, the rest of the township medical institutions waste incineration Z. 7 township health centers in the management of medical waste to achieve norms level indicators **** 6, norms rate of 85.
Second, the main work carried out
(a) Awareness-raising, the implementation of regulatory responsibilities
Our county has always attached importance to the maintenance and supervision of the medical market order, the county government, the Health Bureau of the two levels of leadership in close conjunction with the main points of the reform of the medical and health system, will be the medical institutions in accordance with the law as a standardization of the medical market order, to protect the safety of medical care, to maintain social harmony and stability, and to promote the county's socio-economic Good and fast development of the height to recognize, according to the province, the city issued by the work requirements, by the Bureau of Medical Affairs, CDC Supervision and Health Supervision closely cooperate with each other to grasp **** tube, and effectively implement the regulatory responsibilities.
(2) strengthen the supervision, standardize the practice
In the daily supervision, our county to township health centers (community health service centers, stations), individual clinics, village health office as the key object of supervision to the management of the medical institutions license, the personnel according to law, the release of medical advertisements as the key inspection content, through the Strictly check the license verification, strengthen the legal awareness of medical personnel and other ways and means to further regulate the practice of medical institutions. First, the medical institutions practice permit verification. In the annual review of medical institutions license verification, the medical institutions to open diagnostic and treatment subjects with the approved subjects in line, whether the name and approved name is consistent, whether the medical staff licensed to practice as the key elements of the audit, found that there are violations of the law are not verified. Second, to strengthen the knowledge of laws and regulations of medical personnel training, improve the awareness of practicing according to law. On the one hand, the person in charge of the medical institution to carry out training, strengthen the sense of responsibility, on the other hand, the medical institution internal training of health care personnel, to enhance the overall awareness of the legal system of medical institutions. Third, to increase the daily supervision, illegal, illegal practice of medicine in a timely manner to investigate and deal with. Especially on the employment of non-health personnel, cross-professional practice, the opening of unapproved diagnostic and therapeutic subjects and other cases to be dealt with seriously. Fourth, to further consolidate and improve the county's small and medium-sized medical institutions practice grading supervision work, and establish a long-term management mechanism. At present, in addition to the four medical institutions under the county, there are 31 small and medium-sized medical institutions that should carry out graded supervision of practice in accordance with the law ****. Has carried out 31, quantitative grading implementation rate of 100%, of which 2 for the standardized level, 29 for the qualified level.
(C) focus on practical effects, promote the standardization of medical waste disposal Z
I actively from the actual start of the county, focusing on practical effects, to take the supervision of law enforcement and strengthen the principle of rectification, and gradually standardize the county medical institutions of medical waste disposal Z behavior. First, the focus on strengthening the township health center medical waste disposal Z standardized construction, in strict accordance with the "Medical Waste Management Regulations", "health care institutions, medical waste management approach" requirements, supervise the township health center to implement the management of medical waste responsibilities, standardize the classification of collection and delivery procedures, standardize the construction of medical waste temporary storage facilities, equipment. The phenomenon of random loss, leakage and proliferation of medical waste is eliminated. Second, the county medical institutions medical waste collection, transportation, storage, disposal of Z and other key links to carry out supervision and inspection. Third, the centralized disposal of medical waste Z units to strengthen guidance and supervision. The centralized disposal of medical waste Z unit of Z capacity assessment, a comprehensive grasp of the establishment and operation of the Z facilities.
(D) to strengthen self-examination and self-correction, the implementation of the rectification requirements
The leadership of the Bureau attaches great importance to the standardization of medical institutions in accordance with the law, in the first half of the City Health Bureau after the supervision, convened in a timely manner the Health Bureau, the Health Supervision Institute and the relevant responsible person of each health care institution, based on the problems found by the supervision, *** with the discussion of the rectification program to implement Various rectification responsibilities, clear to the Health Bureau supervision and rectification, health supervision to guide the rectification, medical institutions to implement the rectification of the task requirements. First, the strict implementation of the work system, process, improve the account information. Further establish and improve the relevant work systems, processes and regulations, and systems, processes in the corresponding clinics on the wall, so that medical staff work to follow the rules, the operation of the basis for strengthening the work of medical staff and health and safety awareness of responsibility, and the effective implementation of the "fixed, fixed, fixed duties" principle of the three fixed. Improve the medical waste handover registration, hospital infection prevention and control monitoring registration, medical equipment disinfection registration, medical staff hospital infection prevention and control of knowledge training records and other account information, the format is not correct, registration is not detailed registration form for modification, so that each work has a record. The second is the site guidance rectification, timely tracking of the rectification process.
According to the Municipal Health Bureau of medical institutions in accordance with the law to practice supervision of the briefing as well as the inspection team on-site inspection and rectification of the views of the Bureau in a timely manner on the existence of problems one by one to supervise the rectification. County Health Supervision assumed the responsibility of guiding the rectification, based on the "Medical Practitioner Law", "Hospital Disinfection Supply Center Management Code", "Medical Waste Disposal in Medical Institutions Z norms", "fever clinic set up Z norms" and other laws and regulations, to the medical institutions to carry out on-site guidance. Under the existing conditions of medical institutions, make full use of the available human and material resources, and solve the existing problems with medical institutions practically. At the same time, we have increased the supervision of medical institutions and followed up the rectification process. To date, the relevant medical institutions have improved some of the facilities and equipment, such as the County Hospital has been registered address and practice address does not match the medical staff to re-register, medical waste Z to strengthen the management, standardize the hospital's medical waste operation process, the temporary storage of the warning signs for correction, the addition of temporary storage of the fly facilities, the establishment of the emergency plan for medical waste; the County People's Hospital to strengthen the endoscopy room, the stomatology department of the disinfection management The company's main goal is to develop relevant work systems and workflows, strengthen the training of medical staff in the prevention and control of hospital-acquired infections, and rectify the disinfection and supply room, set up a buffer zone between the Z contaminated area and the clean area, and install dustproof and fly-proof facilities.
(E) change the mode of supervision, the implementation of malpractice points management
According to the provincial and municipal documents, the county fully understand the spirit of the higher documents, combined with the county's actuality, and actively carry out the management of malpractice points management of medical institutions. First, strengthen the learning and awareness. Bureau of leadership team attaches great importance to the management of medical institutions of bad practice score management, seriously study the documents, understand the essence of the spirit, unified ideological understanding, the development of the county medical institutions of bad practice score management work to implement the program and content. Secondly, the implementation of responsibilities, clear division of labor. County Health Bureau to determine the County Health Supervision as the county medical institutions score management specific departments, medical institutions in a timely manner, malpractice and score reported to the County Health Bureau of Medical Affairs by the County Health Bureau regularly announced to the community. Do the work of up and down communication, collection and reporting of information. Relevant sections of the county health bureau, county health supervision in accordance with the division of responsibility for the implementation of medical quality management, supervision and law enforcement. Third, strengthen supervision and promote improvement. Relevant sections of the county health bureau, health supervision will take daily supervision, special supervision, unannounced visits, regular and unscheduled spot checks combined with a variety of other forms of random supervision and inspection of medical institutions, and score management will be used as an important basis for health administrative departments of health care institutions to carry out calibration, malpractice scores as a health care institution must be submitted to one of the materials of the annual calibration. Through supervision, improve the quality level of medical institutions, management level, service level, and improve public satisfaction.
Three problems and difficulties
After carrying out a series of remediation and effective supervision, so that the county's medical institutions in accordance with the law and medical waste standardization of the Z situation has been further regulated. But because of the staffing, working funds, transportation and other reasons, there are still the following problems: First, the township health hospitals are not enough licensed physicians, licensed nurses, individual township health hospitals or the existence of a "one person multi-purpose" cross-professional practice of the phenomenon. Secondly, the medical institutions of health care personnel knowledge of laws and regulations training efforts and frequency is not enough, health care personnel need to improve the awareness of the legal system. Third, although the county's medical waste centralized Z unit holds a business license, but the licensing program does not include medical waste disposal Z. Centralized Z unit incinerator tends to age, which has a certain impact on the capacity of Z. Fourth, the island outside the township hospitals due to the inconvenience of transportation, medical waste can not be centralized Z, the township hospitals to incinerate their own destruction of Z is not standardized, such as the amount of medical waste generated by a small number of the existence of the phenomenon of the date of temporary storage for more than two days.
Four, the next step of the work intends
(a) to strengthen the leadership, raise awareness, combined with the reform of the medical and health system, to further improve the medical staff to practice consciously, the implementation of hospital infection prevention and control and infectious disease prevention and control measures.
(2) further implement the "Medical Practitioners Law", "Maternal and Child Health Law", "Regulations on the Management of Medical Institutions", "Medical and Health Care Institutions Medical Waste Management Measures" and other laws and regulations to regulate the practice of medical institutions.
(C) adhere to both the symptoms and root causes, focusing on long-term regulatory mechanism. Combined with the "Interim Measures for the Management of Undesirable Practices in Medical Institutions in Zhejiang Province", explore the long-term regulatory model for medical institutions.
(D) to maintain the order of the medical market, increase the supervision of licensed medical units, small and medium-sized medical institutions have been assessed according to the quantitative grading level, the implementation of categorized supervision.
(E) to strengthen the knowledge of medical and health laws and regulations to publicize, improve the public's awareness of self-protection, through a variety of forms to expand the number of complaints and reports of the rate of knowledge, the formation of the whole society on the medical institutions regulatory atmosphere.
Self-inspection report of medical institutions in accordance with the law3
To further strengthen the Suining City medical institutions in accordance with the law, to protect the people's health rights and interests, according to the Municipal Health and Family Planning Commission, "on the development of medical institutions in accordance with the law of special supervision and inspection of the work of the notice" and the province of the work of law and medical requirements, the city's urban areas recently carried out a special supervision and inspection of the law of the practice of health care organizations, is now a special report on the situation as follows. The situation is reported as follows:
First, attach great importance to the careful organization
The city detachment and the districts and counties of this work attaches great importance to the development of a detailed inspection program, all types of hospitals under the jurisdiction of the net check, the city detachment in accordance with the jurisdiction of the division of the detachment will be divided into three inspections of supervisors by the deputy director of the municipal health commission, the integrated supervision section chief and detachment deputy director of the municipal health commission, the city health commission. The city of the detachment in accordance with the division of the detachment will be divided into three inspection teams, by the deputy director of the City Health Planning Commission, the supervision of the section chief and the detachment of the deputy head of the detachment with a group, and the medical inspection, medical imaging and other related experts to assist, respectively, on the whole city of all the general hospitals, specialized hospitals and outpatient clinics to carry out a net check; the districts and counties have set up a leading group, the leadership team in charge of the inspection.
Second, the specific inspection situation
1, the basic situation of the inspection
During the supervision and inspection period, the city *** deployed 461 supervisors, vehicles 128 times, the city's hospitals at all levels of all types of 143 special supervision and inspection of the law practice . Mainly checked the following: First, whether the qualification of medical institutions is legal, whether the qualification of the use of health technicians is legal; Second, whether the medical practice behavior is legal. Whether strictly in accordance with the scope of practice registration to carry out diagnostic and therapeutic activities; Third, the management of sperm and numbness drugs, clinical blood and other norms, whether the use of custody in accordance with the provisions of the writing of medical records, prescriptions, etc.; Fourth, whether the development of medical technology is legal, whether strictly in accordance with the approved scope of the corresponding medical technology, medical equipment and instruments, medical equipment and maintenance, cleaning and disinfection, hygiene and prevention, quality testing and so on in accordance with the national provisions of the requirements. Medical institutions to issue inspection, test reports are true and standardized. Fifth, medical safety work: medical elevator maintenance, medical oxygen cylinder use and storage, dietary safety and other work in accordance with the requirements of the implementation, rectification of unsafe hidden dangers. Daying County in this inspection, in addition to checking the above mandatory content, but also combined with the focus of this year's inspection work plan for all types of hospitals, comprehensive management, quality of medical documents, rational use of medication, and the hospital public **** place management, and the inspection of the situation in the county was informed.
2, there are problems
(1) the qualification of medical institutions
The city hospitals at all levels, the vast majority of medical institutions with a strong sense of legal practice, institutions and related personnel are basically with the legal qualifications, can be done in strict accordance with the scope of practice to carry out Diagnostic and treatment activities, Shehong County found a medical institution using non-health technicians to engage in medical technology, has been filed for investigation, Shehong County, part of the general township health centers did not obtain the "Maternal and Child Health Care Technology Practice License," on the 0 to 6 years old children's health management services and maternal health management services. Daying County found five township health center "medical institutions practice license" is not timely calibration, and not bright, hanging in the hospital in a conspicuous position.
(2) medical practice behavior
All types of medical institutions at all levels are strictly in accordance with the scope of practice registration to carry out diagnostic and therapeutic activities, the management of spermatic drugs is more standardized to achieve the management of specialists, the prescribing of spermatic drugs of the physician have passed the training, assessment, and prescription qualifications, the individual township hospitals, private hospitals have not established a specialized spermatic drugs in and out of storage register. Specialized in the entry and exit register of spermatic drugs; clinical use of blood, the clinical use of blood units have been set up by the relevant leaders as the head of the relevant departments as members of the Clinical Use of Blood Management Committee, clinical use of blood related work system is more complete, have developed a clinical use of blood management system manual. However, some medical institutions, especially those below the second level, such as some township health centers and private medical institutions, have the phenomenon that the clinical blood management committees are not in place to perform their duties, which is mainly manifested in the following: they do not convene clinical blood transfusion meetings on a regular basis; they do not summarize and report the situation of clinical blood use in their units; they do not carry out education and training on rational and scientific use of blood in the clinic; and there is no clinical blood use consultation or guidance on the use of blood. Records. There was no effective plan for clinical blood use, and no scientific and reasonable storage of blood in light of the actual blood use situation. The first step in the process is to make sure that you are able to get the best out of your computer, and that you are able to get the best out of your computer.
However, there are also some medical institutions that are not standardized in writing, such as incomplete filling of items, scribbling of prescriptions, doctor's signature is illegible or missing signatures, and so on. Part of the hospital surgical patients did not sign a power of attorney; risk of informing the content of the lack of rationality, can not play the role of informed conversation to prevent risk. Medical institutions radiology, laboratory, Shehong County found a medical institution suspected of not obtaining a "radiation diagnosis and treatment license" to carry out radiological diagnosis and treatment activities, law enforcement officials found individual medical institutions radiology protective equipment is not in normal use, a number of medical institutions, especially some of the township health centers of the Laboratory Department of the equipment is not required by the national requirements of the calibration and the annual mandatory approval of the Laboratory Department of the disposal of positive specimens is not standardized. Medical waste disposal is not standardized, not using special containers. In addition, some medical institutions outpatient waiting hall did not handle the "public **** place health license". In response to the existence of problems, the supervisor are issued a "health supervision opinion letter", ordered to rectify in place, and 8 suspected illegal medical institutions to investigate and obtain evidence, the city **** counts 8 suspected illegal institutions to file an investigation.
The next step, the city's health supervision agencies will continue to increase the medical institutions in accordance with the law to practice inspection, especially on the medical institutions of the laboratory, imaging, gynecology, medical cosmetology, infertility professional and other key departments of the law enforcement efforts, found violations will be investigated and dealt with, and to further enhance the various types of medical institutions at all levels of awareness of the law, and continue to promote the standardization of the health care services market, to ensure that people have access to health care services. To protect the people's medical safety escort.
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