To further improve medical quality and ensure medical safety, in accordance with the "Lishui District? Strengthening medical ethics and preventing doctor-patient disputes? Special Inspection Month Activity Program" (Lishui Wei Zi [2017] No. 81) requirements, in September 2017, I organized medical, nursing, hospital sensory experts to take the way of checking the accounts, sampling medical records, on-site inspection and other ways to carry out the inspection. The relevant information is now reported as follows:
First, the work that has been carried out
District People's Hospital monthly medical records for departmental mutual inspection, random sampling, carry out prescription review work, carry out the rational use of antimicrobials inspection, the development of a special issue to inform the results of the inspection, and through the large checkups and other forms of checking the implementation of medical measures, has achieved a certain effect. District hospitals in a timely manner to carry out doctor-patient disputes judging and analyzing the work of the prevention of doctor-patient disputes play a positive role.
Second, there are problems
(a) the quality and management of medical records
1. In the hospital running medical records management is not standardized. A number of in-hospital medical records appear sorting confusion, the phenomenon of mixed folder checklist, and even a week of patients admitted to the hospital test list has not been pasted in a timely manner. Admission card printed on scrap paper. District hospitals in the hospital medical records in the lack of temperature, doctor's orders, doctor-patient communication record sheet phenomenon.
2. The understanding and implementation of medical record writing standards are not in place. Most of the medical records of the hospitalization records on the significance of differential diagnosis of the negative symptoms of the lack of description or insufficient; the first record of the diagnostic basis of the record or description of the standardization, the lack of differential diagnosis content. The abnormal auxiliary examination results do not pay attention to, abnormal results did not analyze, processing records; medical records with English abbreviations such as: kcl.
3. The quality of the connotation of the medical record needs to be improved. The quality of the connotation of the three-stage system is not high, and the records of the higher-level physician's visits are in the form of a lack of targeted analysis of the patient's individual diagnosis and treatment programs, and a lack of significance of the guidance; preoperative discussion is in the form of a discussion of the patient's surgical indications, reasons for the choice of surgical procedures, and surgery and postoperative situations and countermeasures that may occur; the communication between the patient and the physician is in the form of a diagnosis of the condition, treatment, and the prognosis of the disease, and the transition of the patient's life. Accounting for the diagnosis, treatment and prognosis, regression is too simple, format, no personalized embodiment of the abnormal auxiliary results, new diagnosis after admission, important examination and treatment measures and other general lack of communication, the communication of the condition is not thorough, not clear and concise.
4. copy phenomenon prevails. For example: the content of the higher doctor's visit and the first record of the course of the disease is almost identical, there is a large copy of the phenomenon; transfer out of the record, transfer to the record of the . History records, physical examination and the first record of the course of the same, there is a copy of the phenomenon;
5. There is still a heavy defective medical records. Various types of consent forms not signed by the patient himself lacks a power of attorney or the identity of the delegated personnel.
(ii) the implementation of the core system
1. Handover records are not timely, incomplete, or even blank handover records.
2. Difficult and critical cases and death case discussion system is not in place. Most of the wards from January to September this year to discuss the record book blank or even missing.
3. The three-level checkup record is too simple, lack of analysis, and little guidance. The hospitalized patient history, condition, treatment is not deep enough, comprehensive, defective patient management, security awareness is weak.
4.? Critical value? Reporting system is not implemented. The patient record is not recorded in the analysis, there is no record of the superior physician's visit, there is no post-treatment review, treatment records, the diagnosis and treatment process does not reflect the? The clinical significance of the critical value is not reflected in the diagnosis and treatment process. The clinical significance of the critical value is not reflected in the diagnosis and treatment process. The clinical significance of the critical value is not reflected in the diagnosis and treatment process, and the critical value is not emphasized. The company's website is a great place to find out more about the company's services.
(C) hospital infection management
Medical personnel hand hygiene compliance implementation is not ideal, a small number of personnel have not mastered the standard wash hand. Cotton swabs and infusion stickers can be seen on the floor and at the entrance of the infusion room.
(D) medical quality supervision and management
Not effectively implement the hospital, the department of quality management. District hospital medical quality management committee did not organize regular inspection and evaluation according to the plan, functional departments did not regularly under the department of medical quality inspection. Most of the clinical departments in the two district hospitals have not carried out the corresponding quality control activities, and the quality of medical care in the department has not been effectively managed. The results of medical quality inspection and assessment are not linked to performance appraisal.
Third, the next step in the work of the recommendations
(a) raise awareness, improve the hospital, departmental quality management system. Improve the hospital, section two-level quality management organization, the dean is the first person responsible for medical safety work, clinical, medical technology and other sections of the department director and head nurse is the first person responsible for the quality management of the department, to effectively improve the understanding of the importance of the work of the quality of medical care, to strengthen the internal supervision and management, and to fully mobilize the enthusiasm and initiative of the person responsible for the management of the department, the responsibility of the division of labor to each person. The implementation of the hospital, the section of the two-level quality management system, to achieve hierarchical management, responsibility, power clear, strict assessment, so that the hospital gradually towards standardization, scientific management track.
(ii) strengthen quality control measures, increase supervision and assessment. Pay close attention to the core system of medical personnel,? The three basic and three strict? and doctor-patient communication and other knowledge training, so that everyone is familiar with health care laws and regulations, everyone masters the basic knowledge of the post, basic theory and basic skills, everyone focuses on doctor-patient communication. Strictly implement the medical core system such as the first diagnosis responsibility system, the three-level physician checking system, the difficult case discussion system, the critical patient rescue system, the surgical grading management system, the preoperative discussion system, etc., and improve the rules and regulations on the management of patient safety, the access to medical technology, the reporting of adverse events, and the grading of nursing care, etc., and implement them properly. The company has also made clear the objectives of various medical management work, formulated assessment rules, and formed a working mechanism of irregular inspection and regular assessment.
(C) pay attention to the application of medical quality inspection and assessment results, the formation of medical and nursing quality continuous improvement mechanism. The development of medical quality management assessment and rewards and punishments, medical quality inspection and assessment results with the department, individual efficiency assessment, title employment, annual assessment, etc., reward and penalize the poor.
The hospitals should focus on the weaknesses and deficiencies found in the inspection, learn from the past, carefully sort out the root causes, formulate practical rectification programs and measures, clarify the division of responsibilities, implement the objectives and tasks, and continuously improve the quality of medical care and service level, better serve the public health.
2017 Hospital Medical Quality and Safety Self-Inspection Report 2Supervise and guide to ? Continuous quality improvement, safeguard medical safety? as the theme of? Miles of medical quality? activities to carry out, February 21-18, 2017, the Municipal Health Bureau organized the relevant experts divided into three groups, taking the way of listening to reports, checking the information, on-site inspection, etc., the city's secondary comprehensive hospitals to carry out? Medical Quality Miles? Activities carried out supervision and inspection of the work situation. Now the supervision of the work is reported as follows.
First, the main results achieved
The counties (cities, districts) Health Bureau and medical institutions attach great importance to? Medical quality Miles? activities, are able to in accordance with the unified deployment of the Municipal Health Bureau, highlighting the key points, attacking the difficulties, solid activities, the work has achieved significant results.
(a) Leadership attention, careful deployment
The county (city, district) Health Bureau and the leadership of medical institutions can seriously organize the study of 2011? Medical quality Miles? Medical Quality Miles? Activity program, have set up an activity leading group, strengthen organizational leadership, clear division of responsibilities and implementation of work responsibilities. The establishment of a system of responsibility and accountability at all levels of medical institutions, to ensure that? Medical Quality Miles? Activities to achieve practical results. Xinkan, Jishui, Wanan, Suichuan and other counties combined with the local reality, developed a specific implementation plan, in the provincial department issued on the basis of the convenience of the people to benefit the people's measures, the convenience of the people to benefit the people's measures to carry out the refinement of the typical case review will be carried out.
(ii) co-ordination, comprehensive promotion
The counties (cities, districts) Health Bureau and the inspected hospitals can be busy at the end of the year, to overcome the many difficulties, for the welcoming work to make full preparations. The local units have done ? six combinations? The six combinations of the six areas of work are as follows Medical Quality Miles and? Special rectification of the clinical application of antimicrobial drugs The activity of "Medical Quality Campaign" and "Three Goods, One Satisfaction" are combined with the activities of The three good and one satisfaction? activities, promote major public **** livelihood projects, correct the pharmaceutical purchase and sale and medical services in the outstanding issues of special governance activities, safe hospital activities, development and enhancement of the year activities combined, integrated arrangements, comprehensive promotion.
(C) pay close attention to the implementation of quality assurance
1. Medical safety awareness has been strengthened. Most hospitals are able to carry out medical
quality, medical safety education and related training for medical staff, improve medical risk, medical safety responsibility awareness, strengthen medical ethics education, update the concept of quality and safety, and improve the level of quality management. Yongfeng County, County, Anfu County, Xiajiang County People's Hospital by carrying out a variety of forms of publicity activities, effectively improve the medical staff medical quality, safety awareness.
2. Basic medical quality is further enhanced. Most hospitals are able to strictly implement the core system of medical quality and medical safety, standardize clinical diagnosis and treatment behavior; able to adhere to the patient-centered, attention to the connotation of the construction, and continuous improvement of medical quality; able to carry out the basic clinical skills of medical personnel, clinical testing skills, hospital infection control skills and medical records connotation of the quality of the training and the big game activities, to improve the medical team's business quality and basic skills, emergence of a number of Outstanding Typical. Taihe County People's Hospital hospital surgery grading, doctor grading clear, supervision and implementation and penalties are clear, the quality of the connotation of the medical record is better, the basic clinical skills of the big competition activities to achieve good results.
3. The management system has been improved and implemented. Most hospitals are able to combine the actual hospital, the initial establishment of a scientific, reasonable, strong operation of the medical quality and safety management system and measures. Yongxin County, Suichuan County, Jishui County People's Hospital and the city's first people's hospital rules and regulations are sound, for the hospital's weak links, highlighting the focus and core system of improvement and implementation.
4. The burden of medical expenses on the public has been reduced. Most hospitals are able to vigorously carry out antimicrobial drug special rectification activities, clinical path management, quality nursing care project, mutual recognition of examination results of medical institutions at the same level and single disease cost control work, promote clinical reasonable examination, reasonable diagnosis and treatment, and reduce the burden of the masses of people to see a doctor. County People's Hospital clinical path management work solid; Taihe County, Xingan County People's Hospital antimicrobial drugs special rectification activities effective; County, Taihe County quality care project is actively carried out.
5. Mass satisfaction continues to improve. Most hospitals can better implement the Ministry of Health "on further improving the management of medical services in medical institutions notice" and the provincial Department of the introduction of medical services for the convenience of the people to benefit the people of the ten measures to improve the people's experience of medical care as a way to strengthen the medical services of the innovation and breakthroughs in the work of the plan, focus on the promotion of the measures to improve health care services, and better to do the diagnostic and treatment arrangements are reasonable, the service is warm, process The company's medical service level has been further improved by the smooth flow of medical services.
Second, the main problems
The inspection found that, although through? Medical Quality Miles? activities, the city's secondary comprehensive medical institutions have greatly improved the level of medical quality and safety management, but at the same time, the quality of basic medical care is still weak, medical safety is still a security risk.
1. Ideological understanding needs to be strengthened. The level of medical quality and safety management is still uneven, a small number of local health administrative departments do not pay enough attention to? The quality of medical care is not a problem, but it's a problem that can be solved with the help of a new technology. activities have not been implemented into the actual work, only simply forwarded the implementation of the program issued by the Municipal Health Bureau, the work is still at the text level. Individual places to the inspection, but still did not organize medical institutions to carry out self-inspection and supervision. Part of the hospital leadership team of medical quality and safety work is not enough to recognize, not enough attention, the team did not have a special study of medical quality and safety management, a small number of hospitals, medical quality, safety management is relatively weak.
2. The implementation of the medical core system needs to be strengthened. Some hospitals in the pursuit of development process, simply emphasize the increase in the number of patients, the expansion of beds, equipment investment, housing facilities improvement, ignoring the talent pool and standardized training, the implementation of the core system to be strengthened. Difficult and critical case discussion and death case discussion is not timely, the death case discussion puts forward fewer rectification suggestions, and the concluding comments are ambiguous; the preoperative discussion, assessment and pre-anesthesia assessment are poorly executed and not well targeted, and there is a large hidden danger of medical quality and safety. The core systems such as the three-level physician check-in system and the shift handover system have not been effectively implemented and have become a mere formality; there are misunderstandings in the management of surgical grading, and authorization and dynamic management have not been carried out in strict accordance with the provincial department's specification for the management of surgical grading and the surgical grading directory; the ? The three basic and three strict? Training is not standardized; critical patient rescue plan, rescue equipment and rescue drugs are incomplete.
3. Antibacterial drug special rectification efforts to be increased. Part of the hospital although the establishment of antimicrobial drugs special rectification management team, but the division of labor is not clear, the rectification of the work is not progress requirements, the responsibility of different departments according to the development of different control indicators; clean surgery to prevent the use of antimicrobial drugs is still high, antimicrobial drug use higher than the requirements of the Ministry of Health; antimicrobial drugs irrational selection of the more prominent, three-generation cephalosporins have a high rate of application; grading of directories and grading of management of the three lines of personnel settings Unreasonable; antimicrobial graded management implementation is not in place, physicians have overstepped the phenomenon of the use of antimicrobial drugs; bacterial drug resistance monitoring is not targeted; inpatient microbiology culture is not standardized; 24 hours after the surgery to stop the drug does not meet the standard, in particular orthopedics, cardiology and cerebral surgery 24 hours to stop the drug there are concerns about the doctor, in addition to strengthening the supervision, including incentives and penalties, to strengthen the business learning to find a basis for building confidence in the academic.
4. Quality nursing services need to be strengthened. Some hospital nurses do not fully understand the connotation and substance of quality care, not clear enough to grasp the way the division of responsibility, scheduling the existence of functional division of labor phenomenon, the existence of nursing scheduling method does not reflect the responsibility of the nurse to the patient's continuous service; nursing staff active service consciousness is not strong; nurses do not have a comprehensive grasp of the condition of the patient in charge, basic care is not in place; nursing staff is not sufficiently equipped; the needs of the individual patients in individual wards and responsibility for the nurse capacity does not match, content, concepts and the ability of the nurse. Nurses ability does not match, content, concept lagging behind, not timely update the responsibility system overall nursing requirements; nurses stratified division standards, job duties are not clear or part of the duties overlap; head nurse is busy with transactional work, responsible nurses rely on the team leader to guide the nursing care of patients, the formation of the formation of various levels of independent management of the phenomenon of the patient.
5. Diagnostic and treatment behavior and process to be improved. Part of the hospital emergency department layout and process is unreasonable, emergency medical staff mobility, staffing is small, emergency equipment is old, no observation beds, cardiopulmonary resuscitation and other basic technical operation mastery is not skilled, there are medical hazards; pathology department is located in the area does not meet the requirements of the layout is not reasonable, the lack of ventilation and exhaust facilities and equipment; disinfection and supply centers are not reasonable layout;? First diagnosis and treatment after settlement? There is a plan, no implementation; the proportion of registered appointments does not meet the standard, there is no unified inpatient escort system; critical patient identification is unclear, for surgery patients without wristband identification; clinical pathway into the pathway rate, variation rate, completion rate of the statistical concept of ambiguity, methodology is not uniform, low enrollment rate, the management of the hospital level is disconnected from the department, the assessment and analysis of variance factors and improvement of insufficient; a type of technical audit is not standardized, incomplete directory and The number is unclear.
6. Hospital infection management needs to be strengthened. Part of the hospital did not set up an independent hospital infection department, full-time hospital infection management personnel is not enough, and most of the nurses for the preparation, personnel affiliation is not clear, strictly in accordance with the norms of the work is difficult. Part of the hospital multi-drug-resistant bacteria infection patient isolation work is not well implemented, multi-drug-resistant bacteria target monitoring and antimicrobial drug susceptibility, drug resistance pattern monitoring, as well as for the hospital infection of high-risk links, high-risk factor monitoring and clinical intervention is not in place; part of the county hospitals did not carry out respiratory-related pneumonia infection, indwelling urinary catheter caused by urinary tract infections, central venous catheter caused by the primary blood-borne infection management. Infection management. The hemodialysis wards in a few hospitals are not strictly divided into clean, relatively contaminated, and polluted areas, and there is a phenomenon of mixing functional areas, and no dialysis treatment rooms have been set up. The layout of neonatal wards is unreasonable, the density of beds is too high, and the bed spacing is not in line with the regulations; some county hospitals have not opened ICUs and neonatal wards, and the phenomenon of combining mother and baby in the same room with the neonatal room is prominent. Not strictly infection isolation partition, neonatal ward without infection isolation ward, protection isolation measures are not in place.
7. Hospital management and discipline construction needs to be strengthened. Part of the hospital management system is not standardized, not sound enough, the lack of implementation of the process of record, can not be implemented and the effect of monitoring; technical operating procedures and personnel at all levels of job responsibilities are not clear, not clear enough; on the error accident summary analysis and rectification of the implementation of the poor; part of the system is limited to the text level, not the implementation of the real; the phenomenon of the serious phenomenon of extra beds, in accordance with the actual opening of beds, staffing Serious shortage of medical staff, long-term overload, safety hazards; substantial expansion of the scale, but departmental management and medical quality lagging behind the phenomenon. Some hospitals attach importance to departmental revenue generation, weakening the construction of disciplines. A few hospitals emergency department, anesthesiology, there are not enough beds set up, professional staffing is not enough, professional knowledge and technical mastery is not skilled, can not better complete the emergency and critical care rescue mission; most county hospitals did not open ICU wards and anesthesia recovery beds.
Third, the work requirements
1. Awareness-raising, strengthen leadership. Health administrative departments at all levels and all types of medical institutions at all levels to further enhance the development of? Medical Quality Miles? and? Antibacterial drugs clinical application of special rectification? activities such as enthusiasm, initiative and creativity, to overcome boredom, closely integrated with the actual, conscientious implementation of the work requirements, out of the practical, effective, and promote the activities continue to deepen.
2. Emphasis on publicity, guide public opinion. Health administrative departments at all levels and all types of medical institutions at all levels should continue to communicate with the news media, more consultation, vigorously publicize the hospital in strengthening the quality of medical management, to ensure medical safety, to provide quality medical services and other aspects of the new progress, new experience, publicity and reporting on the advanced people, advanced deeds, to set up advanced models, to create a good environment for the medical practitioners of the medical practice.
3. Compact foundation, focus on implementation. Health administrative departments at all levels and all types of medical institutions at all levels should be for the inspection of the general problems found in the implementation of tracking, supervision and rectification, to achieve? Six implementation? That is, the implementation of rectification matters, the implementation of rectification measures, the implementation of rectification time limit, the implementation of rectification effect, the implementation of the contractor, the implementation of the responsible personnel, and effectively safeguard the safety of the people's medical care, and gradually establish the management of the management, promote the quality of the safety of the long-term regulatory mechanism, to ensure that the long-term grasp of the unremitting, to grasp the results.
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