Part I Health Rectification Self-Inspection Report
I, medical quality management
I pay close attention to the quality of service, prevent medical errors, practice according to the law, civilized practice. The hospital set up to Zhang Jiyue, vice president of the leading group of medical quality management, regular sampling of prescriptions, medical records, timely feedback to the relevant responsible person, the whole hospital to monitor the quality of medical care. A variety of single disease quality control to meet the city and district standards.
Second, the medical instruments
Strictly abide by the "basic specification for the writing of medical records" in the requirements for patients to do objectively, true, accurate, timely and complete writing of all medical instruments.
Third, the rules and regulations
Our hospital to improve and implement a series of rules and regulations, improve the management system, including the thirteen core systems, new technology access system, pharmaceutical management system, emergency public **** event management system. For patients who visit the hospital, they are required to present their medical card and ID card when registering, and hospitalized patients are required to submit a copy of both cards during hospitalization, which is carefully checked to prevent impersonation. The company's website is a great place to find out more about the company's services, and to learn more about the company's products and services.
I strictly abide by the health insurance system, the organization of the hospital medical staff to repeatedly and seriously study the relevant policies of the health insurance, and the assessment work, the assessment results and personal interests linked to the distribution.
Fourth, the basic drug system
For the examination and treatment of patients in the clinic or hospitalized patients, the hospital is strictly in accordance with the provisions of the "Basic Drug List". Each physician is required to strictly abide by the code of ethics of practice, and effectively achieve reasonable inspection, reasonable use of medication, reasonable treatment, reasonable fees, and can use low-priced drugs do not use high-priced drugs, and effectively reduce the burden of medical costs on farmers. The stock of medicines in the pharmacy reaches more than 90% of that stipulated in the catalog. The amount of medication prescribed is strictly controlled, with no more than 3 days' worth of medication for hospitalized patients and no more than 7 days' worth of medication for discharged patients; large prescriptions, favored prescriptions, and abuse of medication are strictly prohibited, and the number of days of discharged medication shall not exceed the actual number of days of hospitalization. Strictly in accordance with the provisions of the inspection, and resolutely put an end to the phenomenon of one person's health insurance, the whole family medication.
V. Medical cost control
Our hospital in strict accordance with the provincial, municipal and district price, health, finance and other departments jointly formulated the fee standard. Pay close attention to the connotation of construction, improve service quality, shorten the average length of stay of patients, and strictly control hospitalization costs.
Sixth, medical support
This year, the city and district health bureau has increased medical support, the city infectious disease hospitals, district hospitals have experts, professors in the countryside to carry out medical support work to improve the professional knowledge of the front-line medical staff, improve the knowledge structure, update the latest professional dynamics, are of great help.
Seven, the current shortcomings
1, due to insufficient funds, some medical equipment can not be timely maintenance or update, to a certain extent, affecting the relevant business in-depth, professional development of the lack of energy.
2, senior Chinese medicine practitioners have a poor grasp of computers, failed to realize all the electronic prescriptions, for the improvement of outpatient co-ordination there is a certain degree of resistance.
3, found that individual physicians have outpatient prescription failure phenomenon, including prescription format is not qualified, outpatient antimicrobial drug use ratio is greater than 20%.
Eight, the future direction of efforts
I must take this hospital level review and annual assessment as an opportunity, under the leadership of the higher business administration, strict compliance with the "Regulations on the Management of Medical Institutions", strengthen management measures, optimize the quality of personnel, pragmatic, pioneering and innovative, and constantly improve the quality of health care services and technical service level.
Part II Health Rectification Self-Inspection Report
In order to improve the quality of medical services and the level of technical services, Lincheng Street Community Health Service Center in accordance with the "Rules for the Implementation of the Regulations on the Management of Medical Institutions", "Xuecheng District, 20xx years of the implementation of the centralized rectification of the primary health care institutions," the organization of the relevant personnel to carry out a rigorous Self-examination and self-correction work. Now the relevant self-examination report as follows:
First, the leadership attaches importance to the serious organization
We held a meeting of medical institutions to rectify the work of the strict deployment of self-examination. At the meeting, the establishment of a self-checking leading group, each business section in accordance with their respective division of labor, in strict accordance with the "Regulations for the Implementation of Medical Institutions", "Xuecheng District, the implementation of the centralized rectification of primary health care institutions," carried out a conscientious and meticulous self-correction work.
Second, the basic situation of self-examination
(a) institutional self-examination: Lin Cheng Street Community Health Service Center is Xuecheng District Hospital extension of the urban community health service institutions, jurisdiction over four community health service stations, five administrative village health room, service Lin Cheng Street 100,000 urban and rural residents. All institutions are required to apply for the "medical institutions practice license", and according to the scope of the prescribed practice activities.
(ii) personnel self-examination: Lincheng Street Community Health Service Center existing staff of 76 people, 1 deputy chief physician, 7 attending physicians, 12 licensed physicians (including physician assistants), 6 nurse practitioners in charge, 24 nurse practitioners. Our hospital has never been more than the scope of registration to carry out practice activities or illegal issuance of "medical certificates"; never used without the qualification of licensed physicians, nurses licensed personnel or a certificate of multi-location registration of physicians to engage in medical activities, belonging to the medical and nursing staff are listed on duty, and set up in the hall of the supervision column open to the public.
(C) pay attention to medical safety, improve service quality: in accordance with the relevant provisions of the health administrative departments, standards to strengthen the management of medical quality, the implementation of medical quality assurance program; regular inspection, assessment of the rules and regulations and all levels and types of personnel job responsibility system implementation and implementation, to ensure that the medical safety and quality of service, and constantly improve the level of service. With reference to the provisions of medical record management, improve the outpatient registration system and standardize the outpatient registration. Strengthen the management and use of prescriptions, establish a prescription review system, carry out prescription review work, standardize the use of antibiotics, hormones and other drugs.
(D) the management of nosocomial cross-infection: the establishment of a nosocomial cross-infection management leading group, often educate and train the relevant personnel, the establishment and improvement of the management of medical waste disposal, nosocomial infection and disinfection management, waste leakage treatment program and other relevant rules and regulations, with special personnel to the source of medical waste, type, quantity, etc., complete records, and regularly carry out the focus of the departments and parts of the Disinfection effect monitoring, prepared disinfectant labeling clear, complete and standardized.
(E) solid medical waste disposal: all medical waste is classified and collected, according to the provisions of the temporary storage of dirt time with warning signs, dirt containers are sealed, anti-puncture, the temporary storage of dirt to do the "five prevention", medical waste transportation and transfer of a person responsible for and have a signature record.
(F) disposable medical supplies processing: all disposable medical supplies after use to do soak disinfection, destruction of type by the medical waste disposal station collection, harmless disinfection, incineration processing, and has a detailed medical waste handover records, no resale, gift and so on. All operators are trained and have specialized protective facilities and equipment.
(VII) epidemic management and reporting: Lin Cheng Street Community Health Center has established a strict epidemic management and reporting system, which provides for a person responsible for the management of the epidemic, the epidemic register is complete, the epidemic report card fill in the norms of the epidemic report to carry out self-inspection every month, there is no omission or late reporting.
(H) drug management self-examination: Lin Cheng Street Community Health Service Center all the use of the national basic drugs, under the jurisdiction of the service station and health center drug supply by the community center of unified online purchasing distribution, all zero-differential rate sales, never used fake, expired, expired and prohibited drugs.
Third, there are shortcomings
(a), due to the lack of government investment, some of the medical equipment can not be equipped with or not timely maintenance and updating, hindering the in-depth implementation of related business, the development of the lack of energy.
(2), by the establishment and personnel funding constraints, the staff is generally equipped with too little workload, not many opportunities to go out for further training, the knowledge of the long cycle of updating, affecting the level of service to a higher level of improvement.
(c), Lin Cheng Street Community Health Center and the jurisdiction of the health service stations, village health center business premises are leased, relatively small area, in addition to the center, Fuquan are not able to do diagnostic rooms and treatment rooms, infusion room separate, infusion room can not be done to achieve the management of the zones.
(d), in line with the public **** health work center set up a stomatology, the need to increase the corresponding diagnostic and treatment subjects.
(e), Lincheng street area in addition to the North City, Gujing village health room to meet the requirements of the standardized health room, the North two, Zhangqiao, West Ding have not met the requirements of the East Ding, Jiaoqiao, Nuozhuang is still a blank village, the new Linsan Apartments, Yongtai Gardens, Yanshan community also has no corresponding community health service station.
(F), some health care workers have a weak concept of asepsis, can not do a good job of disinfection and isolation and self-protection.
Lin Cheng Street Community Health Service Center must take this self-examination as an opportunity, under the leadership of the higher business administration, seriously implement the "Xuecheng District, 20xx years of primary health care institutions to focus on the implementation of the implementation of the program" conference spirit, strict compliance with the "Regulations on the Management of Medical Institutions", strengthen management measures, optimize the quality of personnel, pragmatic, pioneering and innovative, and constantly improve the quality of medical services and technical service level. The company's main goal is to improve the quality of medical services and the level of technical services.
Part III Health Rectification Self-Inspection Report
In order to increase the inspection and rectification efforts to promote the optimization of the political ecosystem, the provincial party committee decided to carry out a "one-accountability eight-clean-up" special action in the province from February to the end of June, focusing on solving the inspection of the found in the Weakness of party leadership, the main responsibility for the lack of discipline, laxity, not follow the rules, negligence and laziness, infringement of the interests of the masses and other constraints and impact on the overall situation of reform, development and stability of the province, and further promote the province's party culture and anti-corruption construction and the fight against corruption, and strive to create a clean and upright, entrepreneurial political ecology.
"an accountability", is the weakening of party leadership, the main responsibility for the absence of the party, the management of the party ineffective, the occurrence of serious violations of discipline and law, to seize the typical, serious accountability, public treatment, serious accountability and notification and exposure of a number of implementation of the "two responsibilities" ineffective Serious accountability and notification exposure of a number of typical cases of ineffective implementation of the "two responsibilities" to force the implementation of the "two responsibilities". Focus on solving the serious violation of party political discipline and political rules, the weakening of the role of the political core of the party organization, the lack of responsibility for the main body of the overall strict governance of the party, the lack of responsibility for the supervision of the construction of the party breeze and honesty in the four aspects of the problem.
"Eight cleanup", is the excess number of cadres, the problem of illegal entry, illegal public expenditure abroad (territory), public tourism, indiscriminate charging, indiscriminate distribution, leading cadres in business enterprises and their relatives to use the influence of their positions to seek undue benefits, detained intercepted and misappropriation of financial funds, especially agricultural funds, the provincial enterprises illegal allocation of funds, the provincial enterprises, the provincial enterprises, the provincial enterprises, the provincial government, the provincial government, the provincial government, the provincial government, the provincial government, the provincial government, the provincial government and the provincial government. The problems of illegal allocation and use of vehicles by provincial enterprises, irregularities in bidding and tendering, irregularities in land transfer, violation of planning and adjustment of plot ratio, and laziness and negligence, inaction, and absence from the state of affairs will be cleaned up - the problems of overstaffing of cadres and illegal recruitment will be cleaned up, and the efforts of cleaning and correcting will be increased, and the regulations will be improved, so that a comprehensive approach will be taken to promote and enhance the selection and appointment of cadres. Promote and enhance the standardization and discipline in the selection and appointment of cadres and the entry of people into institutions. Focusing on solving the problem of overstaffed cadres, irregularities in the two aspects of the problem.
To clean up the problem of illegal overseas travel at public expense and public funds, strictly implement the discipline of foreign affairs work, resolutely clean up and investigate and deal with illegal and disciplinary behaviors in the activities of temporary overseas travel on official business since 2015, and further improve the relevant rules and regulations to ensure that the work of temporary overseas travel on official business in our province is carried out in a healthy and orderly manner. Focusing on solving the false declaration of the task of going abroad (territory), the audit is not strict, the illegal use of funds to go abroad (territory), taking the opportunity to travel in public funds three aspects of the problem.
The problem of arbitrary fees and charges, and the establishment of a lawful, scientific, open and transparent regulatory mechanism, and resolutely prevent the problem from rebounding, effectively protect the interests of enterprises and the public, and optimize the environment for economic and social development. Focus on solving the administrative fees, administrative licensing intermediary services illegal charges, and the three aspects of the problem.
The leading cadres of business enterprises and their relatives to use their position influence to seek undue benefits to clean up the problem, map out the situation, find out the problem, serious correction, strict accountability, and explore the establishment of a long-term monitoring system to promote the integrity of the leading cadres. Focus on solving the leading cadres to participate in or disguised participation in business enterprises; leading cadres relatives in the place under their jurisdiction and business scope of business enterprises, social intermediary services and other activities that may conflict with the interests of the public ****; leading cadres to use their powers and positions to provide convenience and preferential conditions for their relatives to run businesses; leading cadres to use their powers to provide convenience conditions for each other's relatives to run businesses; leading cadres to use their powers to provide convenience conditions for each other's relatives to run businesses; heads of state-owned enterprises to do business with relatives. The company's main goal is to provide the best possible service to its customers, and the company's business is to provide the best possible service to its customers.
The problem of financial special funds, especially those related to agriculture, has been cleaned up, the mechanism has been improved, the system has been perfected, and the management of financial special funds has been improved and the efficiency of their use has been improved. Focus on solving the use of funds, project management, corruption, bribery, personal gain; grass-roots cadres fraudulent, private farmers subsidies and compensation funds; project declaration of fraud, arbitrage and fraudulent financial funds; retained, misappropriation of financial funds; detained, delayed project funds; unauthorized changes in the implementation of the project without approval of the content, location of the six aspects of the problem. Provincial enterprises in violation of the allocation and use of vehicles to clean up the problem, and effectively reverse the allocation and use of vehicles in the unhealthy wind, and promote the provincial enterprises to further strengthen the construction of party style and clean government. Focus on solving the problem of illegally equipped with official vehicles, the use of official vehicles, disposal of official vehicles and expenses, the issuance of official transportation subsidies in four areas.
The bidding and tendering irregularities, irregularities in the granting of land, violation of planning to adjust the plot ratio and other issues to clean up, improve the mechanism, strengthen the supervision, and create a good economic order and development environment. Focus on solving the bidding irregularities, irregularities in the granting of land, violation of planning to adjust the plot ratio of the three aspects of the problem.
Lazy government, inaction, not in the state of the problem of cleaning up, to promote the province's cadres at all levels of the spirit of the obvious change in outlook, take charge of the awareness of the obvious enhancement of service efficiency significantly improved. Focus on solving the problem of laziness, inaction, not in the state of the three aspects of the problem.
Part IV health rectification self-examination report
In order to implement the municipal health bureau of mediocrity and accountability self-examination and rectification phase of the document, and to further strengthen the style of the cadres and the industry style of construction, and to enhance the majority of cadres and staff only to create a first-class, job dedication consciousness, optimize the health care service environment, and to promote the reform of the medical and health system. Our hospital seriously organize party members and cadres and all employees, to carry out centralized investigation and self-examination activities, through the indicators of assessment, mass appraisal, questionnaires, thematic discussions, personal self-examination, etc., in recent years, the unit of cadres and workers and their own existence of the prominent part of the line of centralized investigation and self-examination. Self-examination and rectification opinions are reported as follows:
First, there are problems:
(a) found in a small number of cadres and workers there are still the following "lethargy, laziness, scattered" phenomenon: First, there is a weak sense of discipline, the phenomenon of doing private business during working hours. Second, there is not enough to fulfill their duties, can not penetrate into the front line of work, dealing with things not timely phenomenon. Third, there is negligence in learning and thinking, the phenomenon of self-conscious learning is not enough. Fourth, there is the phenomenon of not doing things and working seriously, not being able to take the initiative to respond to the work, and completing the tasks with quality and quantity. Fifth, there is the phenomenon of uncoordinated work, sense of the big picture, sense of collaboration is not strong.
(ii) the development of the hospital can not adapt to the rapid growth of health care needs, outpatient wards have been crowded, can not adapt to the needs of outpatient and inpatient, parking is getting tighter and tighter and so on.
(C) service attitude and doctor-patient relationship to be further improved. Medical staff in the reception of patients in the patient's explanation is not in place, the attitude is not good, speak raw, cold, hard and other phenomena, easy to cause complaints and disputes.
(D) the quality of medical services to be further improved, clinical health care work of the diagnosis and treatment norms and systems, to be further improved and implemented.
(E) the hospital's talent is not enough, scientific research and academic level is not enough, can not adapt to the increasingly fierce competition in the market, the cultivation of talent team needs to be further strengthened.
(F) management cadres have the phenomenon of shirking work, the implementation of which needs to be strengthened.
(VII) medical ethics construction needs to be further strengthened, I hope to establish and improve the good supervision mechanism, the implementation of good self-correction, mutual investigation and correction.
(H) the cadres of theoretical learning needs to be further strengthened, active learning is not enough, the theoretical level, working ability, innovation consciousness needs to be further improved.
Second, the staff of the hospital development work recommendations:
First, I hope to speed up the hospitalization building construction project, put into use as soon as possible, to alleviate the tension of the wards, the problem of poor equipment. Second, I hope to strengthen the comprehensive management of the hospital environment, but also a good medical environment for patients. Third, I hope to increase the staffing level and solve the personnel procedures for transferring and introducing personnel. Fourthly, we hope to solve the problem of tense operational rooms as soon as possible. Fifth, in terms of hospital management and medical services and aspects, to be more detailed, more humane.
Third, corrective measures:
(a) Accelerate the development of the hospital to meet the rapidly growing demand for health care.
To solve the problem of outpatient ward congestion, parking tension and so on. Over the years, our hospital outpatient and inpatient growth has been consistent, the business room has not been able to meet the needs of patients. 2010 we actively apply to the municipal government, the City Health Bureau to build an independent inpatient building, has now completed the inpatient building infrastructure land acquisition, most of the infrastructure procedures for the approval of the completion of the next step we speed up the infrastructure procedures to lose, and strive to the end of November to put into construction. The new building should reflect the modernization, scientific, intelligent, humane and energy-saving environmental protection, to alleviate the problem of difficult access to hospitalization.
(B) the establishment of a harmonious doctor-patient relationship, to create patient satisfaction with the municipal XX hospital.
Insist on strengthening the professional ethics education of medical staff to start, combined with the wind construction activities, publicize the "respect for patients, caring for patients, patient convenience, patient service" service concept, to improve the medical staff's awareness of patient service. Organize the whole hospital staff to study the code of professional ethics, each department to carry out "if I am a patient" discussion activities. With the deeds around us to educate everyone, so that the staff to take the initiative to enhance the sense of service. By thinking differently, rectify the problems found in the service attitude, service quality, enhance the conscientiousness of quality service, promote the communication between doctors and patients, enhance the understanding of doctors and patients.
(C) to further improve the quality of medical care, to adhere to the quality of medical services as the ultimate goal, to promote the construction of medical management system.
Strengthen the basic quality of health care. Adhere to the three basic theoretical examination, full training of medical and nursing technicians, to strengthen the inspection of the quality of medical records, to be established in due course of electronic disease and information technology, to ensure the quality of medical records. Strictly control the proportion of drugs and the proportion of antibiotics, and insist on monthly notification of medical quality. Actively advocate humanized care and seamless care. Develop a doctor-patient communication system, standardize the content of communication and reduce the occurrence of nursing disputes; establish a good professional image of nurses. Continuously deepen and improve nursing detail management and standardize nursing management process. Improve the outpatient medical environment, simplify the process, and improve measures to facilitate patients.
(D) in-depth development of "three good and one satisfaction" activities to further reduce the burden on patients.
To reduce the cost of patient visits as a breakthrough, increase the use of antimicrobial drugs governance, strict control of large prescriptions, adhere to the prescription inspection, review and publicity system. Strictly control the proportion of drugs, the proportion of antibiotics and average hospitalization days and other key indicators to standardize medical behavior. Strongly reduce the proportion of drugs, exceeding the hospital's drug ratio regulations, the strict implementation of the department and personal conversation system, and adhere to a strict performance deduction and punishment system, thereby reducing the burden on patients.
(E) further adhere to and improve the comprehensive quality assessment system, and promote the modernization of hospital management.
Improve the hospital and departmental management system, functional departments should resolutely manage the phenomenon of "lethargy, laziness, dispersal", conscientiously perform their duties and responsibilities, and resolutely rectify the problems of not doing what is ordered, not doing what is forbidden, not following the rules and regulations, etc. Increase the medical safety assessment system of each department. Increase the medical safety of each department, medical quality, drug ratio, average hospitalization days, medical fees, environmental health, labor discipline and other aspects of the comprehensive inspection and assessment. Operational departments should be assessed from the standardization of medical processes, improve medical services, and increase economic benefits in three aspects to improve the effectiveness of the work of employees.
(F) to further strengthen the talent team construction, improve the quality of personnel at all levels.
Strengthen the construction of cadres, functional departments have plans, purposes and steps to train professionals and management cadres. Improve the work system and job responsibilities of each department, further emphasize the first-question system of responsibility, resolutely put an end to the phenomenon of management cadres existed in the work of shirking each other, and improve the administrative execution. Through the rule of mediocrity and accountability activities to conscientiously perform their duties to promote the development of the hospital, through this activity can improve the cadres' ability to work and execution.
(VII) to strengthen the construction of medical ethics and cadres, seriously carry out the governance of commercial bribery special work.
With the focus on correcting unethical practices in the purchase and sale of medicines and medical services, and in accordance with the deployment requirements of the competent authorities, a solid grasp of the people, property, materials and other key positions, key sectors of the anti-corruption and integrity of the implementation of the tasks and long-term governance. Grasp the medical purchase and sale of commercial bribery in the field of special governance work, the establishment of a long-term mechanism to prevent and punish commercial bribery, to ensure the clean practice of medicine, clean government measures to implement.
(H) continue to strengthen the cadres of theoretical learning, in-depth development of the activities of the first to strive for excellence and the party style of clean government education.
Strictly implement the provisions of the leading cadres of clean politics. Continue to carry out in-depth activities to create excellence, implement the responsibility system for the construction of clean government, strengthen the responsibility assessment, adhere to the ideological and moral education as the basis for the further implementation and improvement of the theoretical learning system of the central group and cadres, continue to study and implement the rule of mediocrity and accountability of the relevant documents, and strive to build the hospital culture of honesty and integrity, and build a strong ideological line of defense against corruption and moral degeneration. Promote the leadership team and party members and cadres clean politics, set up a clean image, and strive to improve the ideological understanding and working ability of cadres.