Part I: Functions of Traditional Chinese Medicine Services
Chapter I: Measures to Utilize the Characteristic Advantages of Traditional Chinese Medicine
I. Based on the functions and tasks, the development strategy of the hospital is determined, and the medium- and long-term development plan is formulated, reflecting the direction of the development of the hospital that gives full play to the characteristic advantages of traditional Chinese medicine, with a clear development goal focusing on the enhancement of the clinical efficacy of traditional Chinese medicine.
Secondly, the annual work plan of the hospital is formulated around the medium- and long-term development plan of the hospital, with specific measures to give full play to the distinctive advantages of traditional Chinese medicine and to improve the clinical efficacy of traditional Chinese medicine, and is evaluated regularly in accordance with the year.
Three, the hospital management system to establish a system of assessment and incentives to guide the play of Chinese medicine and improve the clinical efficacy of Chinese medicine, the comprehensive assessment of the departmental objectives of the play of Chinese medicine and improve the clinical efficacy of Chinese medicine as an important indicator.
Fourth, actively carry out the work of Chinese medicine counterpart support, and formulate incentives.
Chapter II: Team Building
I. The relevant requirements of the State Administration of Traditional Chinese Medicine on the staffing of TCM hospitals are strictly implemented.
Second, the development of Chinese medicine personnel team building planning and planning, and seriously organize and implement.
Third, seriously carry out the regular examination of physicians, and actively carry out continuing education and training in Chinese medicine.
Chapter III Clinical Department Construction
I. In accordance with the relevant provisions of the State Administration of Traditional Chinese Medicine, the rational setup of clinical departments, department naming standards.
II. Strengthen the construction and management of clinical departments in accordance with the relevant requirements of the guidelines for the construction and management of clinical departments in Chinese medicine hospitals.
Third, on the basis of the diagnosis and treatment program issued by the State Administration of Traditional Chinese Medicine, develops and implements the Chinese medicine diagnosis and treatment program for common diseases and Chinese medicine advantageous diseases in this section. Regularly analyze, summarize and evaluate the implementation of the program, and optimize the diagnosis and treatment program. It also conducts annual analysis, summarization and evaluation of the efficacy and characteristics of Chinese medicine for diseases with Chinese medicine advantages, and formulates improvement measures.
Four, the implementation of the State Administration of Traditional Chinese Medicine formulated the common diseases and Chinese medicine advantageous types of Chinese medicine clinical pathway and Chinese medicine diagnosis and treatment program. Regular statistical analysis of the implementation of the clinical pathway, continuous improvement and improvement.
V. Strictly implement the "Basic Norms for Medical Record Writing in Chinese Medicine" and "Basic Norms for Electronic Medical Records in Chinese Medicine (for Trial Implementation)", and the format and writing of Chinese medicine prescription are in line with the relevant regulations.
Sixth, the strict implementation of "the guiding principles for the clinical application of proprietary Chinese medicines".
Seven, Chinese medicine category practitioners master the basic theories, basic knowledge and basic skills of Chinese medicine, common diseases, diseases, difficult diseases and acute and critical illnesses of the Department of Chinese and Western medicine diagnosis and differential diagnosis of the accuracy continues to improve.
Eight, in accordance with the relevant requirements, rational allocation and application of Chinese medicine diagnostic and treatment equipment.
Nine, the development of Chinese medicine diagnostic and treatment technology programs and Chinese medicine integrated treatment.
Ten, the development and use of a certain number of medical institutions, Chinese medicine preparations; outpatient Chinese medicine prescriptions, the number of Chinese medicine prescriptions in the total number of outpatient prescriptions and the ratio of the number of Chinese medicine prescriptions to the number of outpatient visits to meet the prescribed requirements.
Chapter IV: Construction of key specialties
I. The number of key Chinese medicine specialties (diseases) above the provincial level has reached a certain number, and the beds, equipment, personnel, technology and business of the specialties have reached the stipulated requirements.
Second, the development and implementation of specialty construction and development planning, work plan and give full play to the advantages of Chinese medicine and improve the clinical efficacy of Chinese medicine specific measures. Determine the advantageous types of diseases should have obvious advantages of Chinese medicine characteristics, the main research topics should be aimed at the advantageous types of Chinese medicine treatment difficulties.
Three, on the basis of the diagnosis and treatment plan issued by the State Administration of Traditional Chinese Medicine, develops and implements Chinese medicine diagnosis and treatment plan for the advantageous and common diseases of this specialty, regularly evaluates the clinical efficacy of Chinese medicine treatment methods, analyzes the difficulties of Chinese medicine treatment and puts forward the ideas and measures for solving the difficulties.
Fourth, promote the application of the clinical path of Chinese medicine issued by the State Administration of Traditional Chinese Medicine.
V. It carries out the organization and application of clinical experience in the specialty, strengthens the inheritance of academic experience of famous and old Chinese medicine practitioners, and cultivates academic successors in the specialty.
Sixth, to carry out specialized diagnostic and treatment techniques and characteristic therapies, the development and use of specialized Chinese medicinal preparations.
Seven, the establishment of key specialty research laboratories, to carry out specialty research work to improve the clinical efficacy of Chinese medicine.
Chapter V: Pharmaceutical Management of Traditional Chinese Medicine
I. The hospital's pharmaceutical management organization regularly supervises, evaluates and guides the clinical use of traditional Chinese medicine, and rationally selects traditional Chinese medicines to be used in medical institutions.
Two, the Chinese medicine room set up to meet the "basic standards of the hospital Chinese medicine room".
Three, the strict implementation of the "Hospital Chinese Medicine Drinks Management Code.
Four, according to the requirements of the active use of small packages of Chinese medicine tablets.
Fifth, the strict implementation of the "medical institutions, Chinese medicine decoction room management standards.
Sixth, the strict implementation of Chinese medicine prescription name and transfer to pay the relevant provisions.
Seven, to strengthen the management of medical institutions, Chinese medicine preparation.
VIII, clinical pharmacists involved in traditional Chinese medicine drug therapy, to promote the safe and rational use of drugs.
Chapter VI Chinese medicine nursing
I. Chinese medicine nursing work with reference to Chinese medicine hospitals, Chinese medicine nursing work guide.
Second, the implementation of "Chinese medicine nursing routine technical operation procedures", and actively carry out evidence-based care.
Third, the nurse masters the Chinese medicine nursing routine and Chinese medicine nursing technical operation of the common diseases in this section, and is able to provide rehabilitation and health guidance with Chinese medicine characteristics.
Chapter VII Cultural Construction
I. The hospital attaches importance to the cultural construction of Chinese medicine hospitals.
II. The value system of the hospital reflects the culture of Chinese medicine.
Three, the establishment and continuous improvement of the behavioral norms system, the formation of service culture and management culture rich in Chinese medicine culture.
Fourth, with reference to the example of Chinese medicine hospital environmental image construction, to carry out the construction of Chinese medicine hospital environmental image system.
Chapter VIII: "Curing the Future Disease" Services
I. Provide support for the development of "Curing the Future Disease" services.
Second, in accordance with the basic specifications for the construction of platforms for the provision of services for the "treatment of future illnesses", rationally set up and construct platforms for the "treatment of future illnesses" services.
Three, in accordance with the requirements of the standardized provision of "treatment of future diseases" services.
Fourth, the active application of the "treatment of future diseases" service technology, the application of technology in line with the relevant norms.
Part II Comprehensive Service Functions
Chapter I Basic Requirements and Hospital Services
I. Hospital Settings, Functions and Tasks
(1) Insisting on the public welfare of public hospitals, and putting the maintenance of people's health rights and interests in the first place.
(B) the hospital's functions, tasks and positioning is clear, to maintain a moderate scale, the hospital establishment and the number of beds are ≥ 400, departmental settings, floor space per bed, staffing and equipment, facilities in line with the basic standards of tertiary Chinese medicine hospital.
Second, hospital services
(a) hospitals have to improve the diagnosis and treatment environment, improve performance, optimize the medical service system and process, shorten the average hospitalization day, shorten the waiting time for patients, support the medical staff to engage in evening outpatient clinics and holiday outpatient clinics.
(2) Emergency green channel management is standardized, and patients with acute and critical illnesses are treated in a timely manner.
(3) The legitimate rights and interests of patients are safeguarded, and complaint management is strengthened.
(4) Providing nutritional guidance, meal preparation, decoction and other related services for hospitalized patients.
(v) Implementing the Standards for Smoke-free Medical Institutions (for Trial Implementation) and the Decision on a Comprehensive Smoking Ban in the National Healthcare System Starting from 2011.
Three, emergency management
(I) Undertake the tasks of detecting, treating, reporting and preventing infectious diseases in accordance with the Law of the People's Republic of China on the Prevention and Control of Infectious Diseases and the Regulations on the Emergency Response to Public *** Health Emergencies and other relevant laws and regulations, and the competent authorities conduct regular supervision and inspection and summarize and analyze the management of infectious diseases for the purpose of continuous improvement of the management of infectious diseases, and there are no underreporting of infectious diseases and no management reasons leading to the spread of infectious diseases.
(2) Compliance with national laws and regulations, strict implementation of emergency response plans formulated by governments at all levels, conscientious implementation of the requirements of the State Administration of Traditional Chinese Medicine on giving full play to the role of traditional Chinese medicine in health emergency response, and undertake the medical rescue of public **** incidents and prevention and control of public **** health emergencies.
(3) Strengthen the leadership, set up a hospital emergency work leading group, the establishment of emergency response team, the implementation of the responsibility to establish and continuously improve the mechanism of hospital emergency management.
(4) Define the main strategies of emergencies that the hospital needs to deal with, establish the hospital's emergency command system, formulate and improve all kinds of emergency plans, and improve the ability to respond quickly.
(E) to carry out emergency training and exercises to improve the quality of emergency response at all levels and types of personnel and the hospital's overall emergency response capability.
Four, clinical medical education
(a) teaching faculty, equipment and facilities in line with the requirements of Chinese medicine colleges and universities education and continuing education in Chinese medicine.
(2) Undergraduate and above medical students clinical teaching and internship tasks.
(3) Undertake the tasks of standardized training of residents and training of clinical backbone of grassroots Chinese medicine. It develops relevant systems, training implementation programs, and has specific measures to ensure.
(D) to carry out continuing education, continuing education planning, implementation program, provide training conditions and financial support.
V. Scientific research and promotion of its achievements
(1) There are systems and methods to encourage medical staff to participate in scientific research, and provide appropriate funding, conditions and facilities.
(2) Undertake various types of scientific research projects in Chinese medicine at all levels centered on solving the difficult problems of dominant diseases and improving the clinical efficacy of Chinese medicine, and obtain research funds both inside and outside the hospital.
(3) There are incentives for translating research results into practical applications and achieving results in improving the clinical efficacy of TCM.
(4) Obtain relevant qualifications in accordance with the law and conduct clinical trials in accordance with the requirements of the Code for Clinical Management of Drugs.
(e) The clinical research work of the hospital meets the relevant ethical review procedures and requirements.
Chapter II Patient Safety
I. Establishment of a checking system to identify patients.
II. Establishment of a surgical safety verification system to prevent errors in surgical patients, surgical sites and procedures.
Three, the establishment of clinical "critical value" reporting system, and properly deal with medical safety (adverse) events.
Fourth, to prevent and reduce the patient falls, falling out of bed and other accidents and pressure ulcers.
Chapter III quality of care
A medical quality management organization and system
(a) the establishment of hospitals, departments of medical quality management responsibility system, the dean of the medical quality management of the first person responsible for the director is responsible for the management of medical quality, the director is fully responsible for the management of medical quality of the department.
(2) rationally set up the hospital quality management organization, regular study of medical quality management and other related issues, record the process of quality management activities, to provide support for the dean's decision-making.
(3) medical, nursing and other functional departments are responsible for the implementation of comprehensive medical quality and safety management and continuous improvement program, undertake guidance, inspection, assessment and evaluation of medical quality management.
(4) the establishment of a specialized quality management department, responsible for monitoring the quality of medical care, nursing care and medical technology throughout the hospital, and the establishment of a multi-sectoral quality management coordination mechanism.
Two, medical technology management
(a) The hospital provides medical technology services appropriate to its functions and tasks, in line with laws, regulations, departmental rules and industry norms, in line with the principles of medical ethics, the application of technology is safe and effective.
(2) The management of medical technology is in line with the provisions of the "Measures for the Administration of Clinical Application of Medical Technology", the development of medical technology management system, the implementation of hierarchical classification management, supervision, evaluation and file management system, clinical application of new technologies in accordance with the provisions of the report for approval.
(3) the development of medical technology risk warning mechanism and medical technology damage disposal plan, and organization and implementation. The safety, quality, efficacy and economy of the new medical technology to carry out full tracking management and evaluation, timely detection and take appropriate measures to reduce the risk of medical technology.
(4) the implementation of surgery, intervention, anesthesia and other high-risk technical operations of health professionals and technicians to implement the "authorization" system, and regular evaluation of technical ability and quality performance.
Three, quality management of medical and technical departments
(a) clinical testing quality management
1. Clinical testing department set up, layout, equipment and facilities in line with the "Clinical Laboratory Management Measures for Healthcare Institutions", services to meet the needs of clinical diagnosis and treatment, can provide 24-hour emergency testing services.
2. Laboratory safety processes, systems and corresponding standard operating procedures, follow the implementation and record.
3. Qualified personnel with clinical laboratory testing quality control activities, interpretation of test results.
4. Test reports timely, accurate, standardized, strict audit system.
5. Laboratory and clinical to establish an effective means of communication and ways to ensure timely acceptance and processing of clinical consultation, to provide clinicians with the rational use of laboratory information services.
6. Establishment of quality and safety management team, the development of quality and safety management program and quality control indicators to carry out quality management. All immediate testing programs (POCT: Point-of-care testing) should carry out indoor quality control and hospital comparison experiments, and participate in inter-room quality assessment.
(2) Pathology quality management
1. Pathology Department set up, layout, equipment and facilities in line with the requirements of the Department of Pathology construction and management guidelines, services to meet the needs of clinical diagnosis and treatment.
2. The qualification of personnel engaged in diagnostic and technical work in pathology meets the requirements of the guidelines for the construction and management of the Department of Pathology, and the quality of diagnosis meets the relevant regulations.
3. There are hospital infection control and environmental safety management procedures and measures, follow the implementation and record. Environmental protection and personnel occupational safety protection in accordance with the provisions.
4. Timely provision of standardized pathology diagnostic reports, a strict audit system.
5. Implementation of total quality management and improvement system, quality control activities in accordance with the provisions, and records.
6. There is a system and process for pathologists to communicate with clinicians at any time, to interpret the results of pathologic examinations, and to provide support for clinical diagnosis and surgical programs.
(3) Medical imaging quality management
1. Medical imaging (general radiology, CT, MRI, ultrasound, nuclide imaging, etc.) department settings, layout, equipment and facilities in line with the "Radiological Diagnosis and Treatment Regulations", services to meet the needs of clinical diagnosis and treatment, and provide 24-hour emergency imaging services.
2. It establishes rules and regulations, implements job responsibilities, carries out technical operation standards, implements quality control, and regularly evaluates image quality.
3. Provide standardized medical imaging diagnostic reports, with an audit system, analysis and reading system for difficult cases and follow-up and feedback system for key cases.
4. To develop a regular testing system for medical imaging equipment, environmental protection, protection of examinees, and occupational health protection of staff and other related systems, and follow the implementation and record.
Four, quality management of other departments
(a) Surgical treatment management
1. The implementation of the admission system for the qualification of surgeons and surgical grading authorization management system, the establishment of a regular evaluation of the qualifications and competence of surgeons and the mechanism of re-authorization.
2. A system of patient condition assessment and preoperative discussion is implemented, and diagnostic and surgical plans are formulated and recorded in the medical record.
3. The informed consent of patients before surgery includes preoperative diagnosis, the purpose and risks of surgery, the use and selection of high-value consumables, and other optional diagnostic and therapeutic methods.
4. The hospital has established an approval system for major surgery reports and has emergency surgery management measures to ensure timely and safe emergency surgery.
5. Surgical prophylactic antimicrobial drug application selection and timing of use in accordance with the norms. There is a surgical antimicrobial drug application management system, preventive use of antimicrobial drugs standardized.
6. The whole process of surgery and postoperative precautions are timely and accurately recorded in the medical record; the isolated tissues of surgery should be pathologically examined to clarify the postoperative diagnosis.
7. A quality and safety management team has been set up to regularly evaluate perioperative quality and safety, and there is a system to monitor, analyze, feedback, improve, and control the causes of unplanned reoperation and surgical complications.
(2) Management of anesthesia treatment
1. Anesthesiologists' qualification graded authorization management system and norms, as well as regular evaluation of competence and re-authorization mechanism, and reasonable anesthesia staffing.
2. The system of assessing patients' conditions before anesthesia is implemented, treatment plans and programs are formulated, and the results of risk assessment are recorded in the medical records.
3. Fulfillment of the patient's informed consent before anesthesia (including treatment risks, advantages and other possible options).
4. Performs surgical safety verification, and the entire process of performing anesthesia operations is documented in the medical record and anesthesia orders.
5. Establishment of a post-anesthesia recovery room, management measures in place, implementation of standardized monitoring of the entire process, recording the recovery status of the patient after anesthesia, and preventive measures against anesthesia complications are in place.
6. Establishment of norms and procedures for the management of analgesic treatment for patients with postoperative, chronic pain and cancer pain, which can be effectively implemented.
7. Effective communication between the Department of Anesthesiology and the Department of Blood Transfusion should be established, autologous blood transfusion should be actively carried out, indications for intraoperative blood transfusion should be strictly controlled, and blood transfusion should be reasonable and safe.
8. Set up an anesthesia quality management team in the department, and carry out regular anesthesia quality inspection with records.
(3) Management of the Department of Intensive Care Medicine
1. The layout of the department, equipment and facilities, and professional staff are in accordance with the basic requirements of the guidelines for the construction and management of the Department of Intensive Care Medicine in Chinese medicine hospitals.
2. The department's work system, job responsibilities and technical specifications, operating procedures. Critical care patients are admitted and discharged in accordance with the indications, and the "criticality score" is implemented.
3. The qualification and technical ability of physicians and nursing staff to implement access and authorization management; the implementation of multidisciplinary joint check-up system for serious and difficult patients; patient diagnostic and treatment activities by the attending physician and above to preside over and be responsible for.
4. Hospital infection management regulations, ventilator-associated pneumonia, catheter-induced bloodstream infections, urinary tract infections caused by indwelling catheterization have preventive and monitoring programs, quality control indicators, and can be effectively implemented.
5. A quality and safety management team is established to regularly evaluate quality and promote continuous improvement.
(D) Infectious Disease Management
1. Implementation of the Infectious Disease Prevention and Control Act and related laws, regulations, rules and norms, improve the organizational structure of infectious disease prevention and control and management of hospital infections, and improve the management system and organization and implementation.
2. Infectious diseases section or infectious disease triage points set up in accordance with the provisions of the administrative department of health, the establishment of key infectious disease prevention and control expert group.
3. In accordance with the principle of standard prevention, standard protective measures are taken to provide medical personnel with disinfection and protective equipment in accordance with national standards, and waste is disposed of in accordance with the Regulations on the Management of Medical Waste.
4. Monitoring and reporting of infectious diseases is carried out. There is a specialized department or personnel responsible for the reporting of infectious disease outbreaks, and direct network reporting is carried out in accordance with the regulations.
5. Regularly train staff in knowledge and skills of infectious disease prevention and treatment.
(E) Blood Transfusion Management and Continuous Improvement
1. Implement the People's Republic of China*** and the State Blood Donation Law, the Measures for the Administration of Clinical Blood Use in Healthcare Institutions (for Trial Implementation) and the Clinical Blood Transfusion Technical Specifications and other relevant laws and norms, formulate a blood transfusion management system, and conduct training.
2. The Blood Transfusion Department has been set up, with the ability to provide 24-hour service to meet clinical needs, and there is no illegal self-pickup or self-supply of blood.
3. Strengthening the management of clinical blood use process, strictly mastering the indications for blood transfusion, and promoting the safe, reasonable and scientific use of blood in the clinic.
4. Carrying out the monitoring of blood quality management, formulating and implementing the program of controlling the serious hazards of blood transfusion (transfusion infectious diseases, adverse reactions to blood transfusion, and ineffective transfusion), and strictly enforcing the technical operation standard of blood transfusion.
5. Carrying out the whole process of blood management, implementing the system of clinical blood application and application review, fulfilling the procedures of blood application and approval, implementing the system of pre-transfusion verification, and managing the warehousing, storage and distribution of blood.
6. Implement the management system of blood transfusion compatibility testing, and do a good job of quality management of compatibility testing experiments to ensure the safety of blood transfusion.
(6) Management of hospital infection
1. Establishment of hospital infection management organization, hospital infection control activities in line with the "Measures for the Management of Hospital Infections" and other regulatory requirements, and match with the functions and tasks of the hospital and clinical work.
2. Training and education on hospital infection prevention and control.
3. In accordance with the "Hospital Infection Surveillance Code", monitor key links, key populations and high-risk factors, and adopt surveillance indicator management to control and reduce the risk of hospital infection.
4. Implementation of the Code of Hand Hygiene for Medical Personnel, implementation of compliance monitoring and improvement activities.
5. Formulate norms and procedures for the control and management of multi-drug-resistant bacteria (MDR) hospital infections, and implement supervision and improvement.
6. Apply infection management information and indicators to guide the rational use of antimicrobial drugs in clinical practice.
7. Disinfection work meets the requirements of Hospital Disinfection Technical Specification, Hospital Disinfection Supply Center Cleaning, Disinfection and Sterilization Technical Code of Practice, Hospital Disinfection Supply Center Cleaning, Disinfection and Sterilization Effectiveness Monitoring Standard; isolation work meets the requirements of Hospital Isolation Technical Specification; medical staff can obtain and correctly use the disinfection and protection supplies in accordance with the national standards; key departments, The management of key departments meets the requirements.
8. The hospital infection management organization monitors the risk factors of hospital infection, the rate of hospital infection and its trend; improves the diagnosis and treatment process according to the risk of hospital infection, the incidence and/or prevalence of hospital infection and its trend; and informs the results of the monitoring of hospital infection on a regular basis.
V. Quality Management of Medical Records
(1) In accordance with the "Regulations on the Management of Medical Records in Healthcare Institutions" and other relevant regulations and norms, set up a case section, with a full-time (part-time) staff responsible for the quality of the management and continuous improvement of medical records, equipped with the appropriate facilities, equipment and personnel echelon.
(2) Preservation of medical records in accordance with the regulations, to ensure accessibility.
(3) Establishing a mechanism for assessing the quality of medical record writing and providing regular quality assessment reports.
(4) Adopting the International Classification of Diseases and Codes (ICD-10), the Classification and Codes of Traditional Chinese Medicine (TCD) and the Classification of Surgical Operations (ICD-9-CM-3) to classify and code discharged medical cases, and setting up a scientific management system of medical records database, including case numbering and tracing system, and querying system of discharged medical case information.
Chapter 4: Pharmacy Management
I. Strengthening pharmacy management, effectively controlling the quality of drugs and ensuring the safety of medication.
Second, the implementation of the "prescription management approach", to carry out prescription review, to promote rational use of drugs.
Three, in accordance with the "Guidelines for the Clinical Application of Antimicrobial Drugs" and other requirements, the rational use of drugs, and a monitoring mechanism.
Fourth, there is a drug safety monitoring and management system, in accordance with the provisions of the report on adverse drug reactions.
Chapter V nursing quality management
I. Nursing management organization system is sound, the implementation of nursing personnel hierarchical management, clear job responsibilities and work norms, the implementation of accountability nursing measures.
Second, nursing human resources equipped with the functions and tasks of the hospital in line with the principles of nursing unit nursing staff configuration, there is a plan for the deployment of nursing human resources in emergency situations.
Third, the implementation of nursing measures according to the principles and requirements of graded care, there are standards for evaluation of the quality of care, and regular assessment.
Four, the implementation of responsibility system overall care, to provide patients with continuous, the whole process of basic nursing care and professional and technical services, quality nursing services in place.
Fifth, there are operating rooms, sterilization supply center (room) nursing quality management standards and monitoring measures.
Chapter VI Hospital Management
I. Practice in accordance with the law.
Second, strengthen the hospital information technology construction, to meet the needs of hospital management, clinical care and services.
Three, strengthen financial and price management, standardize the economic operation of the hospital.
Four, the establishment of medical equipment management department, establish and improve the medical equipment management system.
Fifth, the implementation of open hospital affairs, and actively carry out social evaluation of the hospital.