Article 22 The administrative department of health shall notify the accreditation organization within five working days after the hospital has issued a notice of acceptance of the accreditation; the accreditation organization shall, upon receipt of the notice, draw experts from the hospital accreditation expert database to form an accreditation team, and complete the accreditation work within the specified time.
Article 23 of the evaluation experts and the hospital being evaluated have a stake in the impartiality of the evaluation may affect, should take the initiative to apply for recusal. Hospitals can also be put forward to the health administrative department of the evaluation of experts to apply for recusal. The review expert's avoidance of the administrative department of health to decide.
Article 24 of the periodic review of hospitals, including written evaluation of hospitals, medical information, statistical evaluation, on-site evaluation and social evaluation of the comprehensive review.
Article 25 The contents and items of the written evaluation include:
(1) application materials for accreditation;
(2) results of unscheduled key evaluations and reports on rectification;
(3) acceptance of the results of the evaluation of specialties, technical assessments, etc. organized by the health administrative departments above the provincial level;
(4) acceptance of the medical quality evaluation control system set up by the health administrative departments above the prefectural and municipal levels; and (5) acceptance of the results of the medical quality evaluation control system established by the health administrative departments above the municipal level. (d) to accept the evaluation results of the medical quality evaluation and control organization established by the administrative department of health at or above the prefectural level;
(e) to accept other contents and items stipulated by the administrative department of health at or above the provincial level.
Article 26: The contents and items of statistical evaluation of medical information include:
(1) the first page of the cases of patients discharged from hospitals in each year and other diagnostic and therapeutic information;
(2) the monitoring indicators of the operation of the hospitals, patient safety, quality of medical care and rational use of medication;
(3) the evaluation of the performance of the hospitals by using the methods of diagnostic-related groups (DRGs);
(4) the provincial health administrative departments to specify the other contents and items.
(d) other contents and programs stipulated by the provincial health administrative departments.
Article 27 The main contents of on-site evaluation include:
(1) compliance with the basic standards of hospitals;
(2) compliance with the accreditation standards of hospitals;
(3) the situation of hospitals carrying out various tasks around patient-centeredness;
(4) the situation of carrying out the work related to the reform of public hospitals;
(5) other contents and items prescribed by the provincial health administrative departments. (E) other contents stipulated by the provincial health administrative department.
Article 28 The main contents and items of social evaluation include:
(1) the results of the evaluation of the conduct of medical institutions carried out by the local government;
(2) the results of the survey of patient satisfaction carried out by the health administrative department or entrusted to a third-party social survey organization;
(3) other contents and items stipulated by provincial-level health administrative departments.
Article 29 The accreditation team shall, within five working days after the end of the accreditation, complete the accreditation report and submit it to the accreditation organization after it is signed by the head of the accreditation team.
The accreditation report shall include:
(1) overview of the accreditation work;
(2) results of the written evaluation, statistical evaluation of medical information, on-site evaluation and social evaluation;
(3) total scores of the accredited hospitals and suggestions for accreditation conclusions;
(4) major problems, opinions on rectification and deadlines of the accredited hospitals;
Article 29 The accreditation team shall complete the report within 5 working days and submit it to the accreditation organization with the signature of the head of the accreditation team. p>
(v) other issues that should be explained;
(vi) other contents stipulated by the provincial health administration department.
Article 30 The report of the evaluation work shall be reported to the health administrative department after being reviewed and agreed by the evaluation organization.
The accreditation organization deems it necessary, may request the accreditation team to reconsider or review certain contents. Specific procedures are specified by the provincial health administrative department.
Article 31 of the original materials related to the evaluation work by the evaluation organization to archive and save at least four years.
Article 32 The administrative department of health shall, upon receipt of the report of the accreditation work, make a conclusion on the accreditation within 30 working days.
The conclusion of the evaluation shall be publicized in an appropriate manner to the community, and the period of publicity shall generally be 7 to 15 days. The results of the publicity does not affect the evaluation of the conclusions, written notification of the accredited hospitals, accreditation organizations and relevant departments, and at the same time reported to the higher health administrative departments for the record.
Article 33 of the review cycle, the health administrative department shall organize the management of hospitals, specialties and technical level of the focus of the evaluation from time to time, the score should not be less than 30% of the total score of the next cyclical review.
The specific content and methods of unscheduled key evaluation by the provincial health administrative departments.