Notice of the General Office of the Ministry of Health on the Issuance of Quantitative Indicators for the Decomposition of Work Tasks in 2011 for the "Three Good and One Satisfactory" Activity Ministry of Health of the People's Republic of China 2011-07-29 17:25:05 Health Office of the Ministry of Health [2011] No. 103
Provinces, autonomous regions and municipalities directly under the Central Government. Health Department and Bureau, Xinjiang Production and Construction Corps Health Bureau:
In order to promote the "good service, good quality, good medical ethics, the public satisfaction" activities (hereinafter referred to as the "three good and one satisfaction" activities) in the national medical and health system, further refine the To further refine the work requirements of the "Three Good and One Satisfactory" activity and ensure the effectiveness of the "Three Good and One Satisfactory" activity, according to the "2011 Work Program of the "Three Good and One Satisfactory" Activity of the National Healthcare System", the Ministry organized and formulated the "Three Good and One Satisfactory" Activity Work Program", which was published by the Ministry of Health. According to the "National Healthcare System "Three Good and One Satisfactory" Activity 2011 Work Program", the Ministry of Health organized and formulated the "Quantitative Indicators for Decomposition of Tasks of the "Three Good and One Satisfactory" Activity of the National Healthcare System in 2011" (which can be downloaded from the website of the Ministry of Health). It is hereby issued to you, please follow it.
July 27, 2011
National Medical and Healthcare System's "Three Good and One Satisfactory" Activity
Quantitative Indicators of Work Task Breakdown for 2011
According to the 2011 Work Program of the "Three Good and One Satisfactory" Activity of the National Medical and Healthcare System, the National Medical and Healthcare System has been working on a number of tasks.
One, improve service attitude, optimize the service process, and constantly improve the level of service, and strive to achieve "good service"
(a) the universal booking of diagnosis and treatment services. All of the country's third-class general hospitals to implement a variety of ways to book appointments, urban community health service organizations referral booking priority treatment. By the end of 2011, urban community referral appointments accounted for 20% of local outpatient clinic visits, the rate of follow-up appointments for local patients reached 50%, of which the rate of follow-up appointments for stomatology, prenatal checkups, and post-operative patient review reached 60%.
(2) Optimizing the environment and process of hospital outpatient and emergency care.
1. Reasonable arrangement of outpatient and emergency services, simplify the process of outpatient and emergency services and admission and discharge services. Waiting time for registration, pricing, charging, medicine and other service windows ≤ 10 minutes.
2. Implementing the "first diagnosis and treatment, then settlement" mode. Strive to achieve the use of "first diagnosis and treatment, after the settlement" mode of patients accounted for 10% of the number of patients.
3. Ultrasound from the beginning of the examination to the time to issue results ≤ 30 minutes. Large-scale equipment inspection program from the application form to issue inspection reports to the time of issuing inspection results ≤ 48 hours. Blood, urine, stool routine tests, electrocardiogram, routine imaging tests from the beginning of the examination to the time of issuing results ≤ 30 minutes, biochemistry, coagulation, immunology and other tests from the beginning of the examination to the time of issuing results ≤ 6 hours, bacteriology and other tests from the beginning of the examination to the time of issuing results ≤ 4 days. Intraoperative frozen pathology from the time of delivery to the time to issue results ≤ 30 minutes.
4. Provide convenient and fast check results inquiry service. In addition to providing patients with paper inspection and test result report forms, at least 1 query method can be provided on-site, by phone, by SMS, and by internet query.
(C) the extensive development of convenient outpatient services. Hospitals in need and with the conditions should carry out outpatient services on weekends and holidays, enrich outpatient strength and extend outpatient hours.
(4) Promoting quality nursing services.
1. Coverage of quality nursing services. All tertiary hospitals nationwide will carry out quality nursing services, with 50% of tertiary-level hospitals covering more than 50% of their wards with quality nursing services, and 40% of prefectural and municipal-level secondary hospitals and 20% of county-level secondary hospitals carrying out quality nursing services. The aim is that by the end of 2011, 200 tertiary hospitals nationwide will have quality nursing services covering more than 80% of their wards. By June 2011, the original 72 ministerial key-contact hospitals had launched quality nursing services in more than 80% of their wards; the newly included 38 ministerial key-contact hospitals had launched quality nursing services in more than 50% of their wards. By the end of 2011, 110 key contact hospitals will strive to fully implement quality nursing services throughout their hospitals.
2. The number of hospital nurses has been rationalized. The number of nurses in all hospitals can meet the needs of clinical nursing work, and the proportion of clinical front-line nurses in all hospitals is no less than 95%. Each ward based on the nursing workload and patient condition configuration of nurses, the actual ward bed ratio ≥ 0.4:1.
3. Nurses income distribution and performance appraisal. Nurses in the hospital are treated fairly and equitably, reflecting the value of labor, and the distribution of salary is combined with the quantity, quality, technical risk, and patient satisfaction of work, reflecting the more work, more pay, and excellent performance.
4. Quality nursing service tasks to implement. The implementation of responsibility system overall care. Responsible nurses provide quality nursing services according to specialty characteristics and patient needs, and each responsible nurse in the ward is responsible for an average of no more than eight patients. Simplify the writing of nursing documents and reduce the writing burden of clinical nurses. The writing time for nurses is no more than 30 minutes per shift.
(E) Promoting mutual recognition of examination and test results in medical institutions at the same level.
On the basis of strengthening medical quality control, vigorously promote the mutual recognition of examination and test results of medical institutions at the same level, promote rational examination, and reduce the cost of patient visits. The mutual recognition program includes 2 major categories of medical tests and medical imaging.
1. Clinical test items mainly include some of the stability of the better, more expensive test items, the issuance of clinical test reports must indicate the test methodology and reference values. Mutual recognition of the project should at least include:
(1) clinical biochemistry at least 12 items, including: total protein, albumin, globulin, glutamine transaminase, glutamic oxalate aminotransferase, lactate dehydrogenase, alkaline phosphatase, r-glutamyl transpeptidase, total cholesterol, triglycerides, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol.
(2) At least 5 clinical immunizations, including: thyroid function assay, tumor markers (AFP, CEA quantitative assay), prostate-specific antigen (PSA), and hepatitis C antibody (except for abnormal liver function and preoperative).
(3) Clinical microbiology: bacterial typing.
(4) Clinical blood, body fluids and various types of smear cytology. Mutual recognition of test results need to be standardized operation, smear quality meets the requirements, the diagnosis is clear, and there is no clinical objection.
2. The medical imaging examination program mainly includes some of the more stable and costly items, and the mutual recognition program should at least include:
(1) general radiography, including general plain film, CR, DR, and the quality of the film is up to Class A.
(2) Examination projects using Class A and B large-scale medical equipment, including PET-CT, PET, SPECT, CT, MRI, DSA, etc., in which the imaging data involved should be standardized in the examination process, the shooting part is correct and complete, the film image is clear, the quality is reliable, and it meets the diagnostic requirements (with timeliness).
(F) Further development of "volunteer service in the hospital" activities. Gradually improve the management system and working mechanism of volunteer service, and actively explore new forms, contents and modes of volunteer service suitable for China's national conditions, so as to promote the harmonious relationship between doctors and patients. Medical institutions strive to achieve the organization of volunteer services 2000 person-hours/year.
(VII) to establish and improve the third-party mediation mechanism for medical disputes and medical liability insurance system, and conscientiously implement the medical complaints handling methods, and strictly implement the system of responsibility for the first complaint. By the end of 2011, to achieve full coverage of medical disputes people's mediation system above the county level, 100% of hospitals above the second level to set up doctor-patient relationship office or designate a department to undertake the management of hospital complaints and the implementation of the first-charge system, the second level of hospitals above the feedback rate of patients' complaints on time >90%.
Second, strengthen quality management, standardize diagnosis and treatment behavior, and continuously improve the quality of medical care, and strive to achieve "good quality"
(a) the implementation of the core system of medical quality and medical safety.
Strictly implement the core system of first diagnosis and responsibility, three-level physician checkups, difficult case discussion, critical patient rescue, consultation, preoperative discussion, death case discussion, shift handover, etc. Strictly implement the "basic specification for medical record writing" and "surgical safety checking system" to standardize the writing of medical records and surgical safety checking to ensure the quality of medical care and medical safety. Tertiary hospitals must achieve:
1. 100% reporting rate of statutory infectious diseases.
2. Medical quality and safety incident reporting rate ≥ 90%.
3. Drugs and medical devices clinical trials, surgery, anesthesia, special examinations, special treatment to fulfill the patient notification rate of 100%.
4. 100% fulfillment rate of government directive tasks.
5. In-hospital emergency consultation time in place ≤ 10 minutes.
6. Emergency detention time ≤ 48 hours.
7. 100% of emergency items are in good condition.
8. Qualified medical record rate ≥ 90%.
9. Average hospitalization days ≤ 15 days.
10. Average preoperative hospitalization for elective surgery patients ≤3 days.
11. Bed utilization rate of 85-93%.
12. Bed turnover ≥19 times/year.
13. Basic care pass rate ≥ 90%.
14. Critical patient care pass rate ≥90%.
15. 100% pass rate of medical equipment disinfection and sterilization.
16. Surgical safety verification rate of 100%.
17. 100% of preoperative discussion, death case discussion, and difficult case discussion rate.
18. General outpatient clinic with associate physician or higher professional and technical qualifications of our physicians ≥ 60%.
(ii) improve medical quality management and control system. Provinces (autonomous regions and municipalities) to build provincial medical quality control centers covering internal medicine, surgery, obstetrics and gynecology, pediatrics and other no less than 20 common specialties, and carry out quality control work. The proportion of case information registration for common key diseases required by the Ministry of Health is no less than 95%.
(3) Strictly regulate the behavior of diagnosis and treatment services, and promote reasonable examination, reasonable use of medication, reasonable treatment.
1. earnestly implement the clinical pathway, vigorously implement the clinical pathway and single-patient payment, promote the development of medical quality management to scientific, standardized, professional and refined, standardize the diagnosis and treatment behaviors, and control the unreasonable growth of medical costs.
(1) Clinical path management coverage. Not less than 50% of the jurisdiction's third-class general hospitals, each hospital at least 10 types of disease clinical path management. Not less than 20% of the jurisdiction's second-class A-class general hospitals, each hospital to carry out at least
5 types of clinical path management.
(2) Clinical path management enrollment ratio. Each hospital to implement the clinical pathway management of the hospital's disease, patients who meet the criteria for entry into the clinical pathway enrollment rate of not less than 50%, the completion rate of not less than 70% after enrollment.
(3) Quality management and control. Efficiency indicators: the average hospitalization day for clinical pathway management diseases is shorter or the same as before. Indicators of medical quality and safety: mortality rate of clinical pathway management diseases, incidence of hospital infection, rate of surgical site infection, in-hospitalization rate, incidence of unplanned return to the operating room, and incidence of common complications declined or remained flat compared with the previous period; cure and improvement rate of clinical pathway management diseases increased or remained flat compared with the previous period.
(4) Health economics indicators. Strengthen the monitoring of the total cost of single disease. The increase in total single-disease costs of clinical pathway management diseases has decreased or remained flat compared with the previous period.
(5) The growth rate of outpatient and inpatient visits is relatively stable and reasonable. The growth of outpatient and hospitalization average medical cost is not higher than the growth of China's GDP, and the overall control is within 9%.
2. Implementing the Clinical Technical Practice, Clinical Diagnosis and Treatment Guidelines, Provisions on Pharmaceutical Management in Medical Institutions, Measures for the Administration of Prescription, Guiding Principles for the Clinical Application of Antimicrobial Drugs and other regulations and norms, carrying out special remedial actions for the clinical application of antimicrobial drugs, implementing the prescription review system, strictly regulating the behavior of physicians' prescriptions, and promoting rational examination, rational use of medication, and rational treatment. Tertiary hospitals strive to achieve:
(1) Diagnostic compliance rate of admission and discharge ≥ 95%.
(2) Diagnostic compliance rate before and after surgery ≥95%.
(3) Clinical main diagnosis, pathologic diagnosis compliance rate ≥ 60%.
(4) Positive rate of CT examination ≥70%.
(5) Positive rate of MRI examination ≥70%.
(6) Positive rate of large X-ray examination ≥70%.
(7) Success rate of emergency and critical care resuscitation ≥80%.
(8) Cure improvement rate ≥90%.
(9) Clean surgical incision grade A healing rate ≥97%.
(10) Clean surgical incision infection rate ≤1.5%.
(11) Anesthesia mortality rate ≤0.02%.
(12) Prescription pass rate ≥95%.
(13) Hospital infection rate ≤10%.
(14) The actual rate of investigation of current hospital infection ≥ 96%.
(15) Clinical chemistry inter-room quality assessment of the year average pass (VIS ≤ 120).
(16) Hematology inter-unit quality assessment year-round average pass (improvement deviation index DI ≤ 2).
(17) The average score of the immunization inter-room quality assessment for the whole year is above the national average.
(18) Bacterial inter-room quality assessment of the year identified correctly ≥ 80%.
(19) The proportion of drug revenue to total medical revenue is ≤45%.
(20) In principle, there are no more than 50 varieties of antimicrobial drugs in tertiary hospitals, and no more than 35 varieties of antimicrobial drugs in secondary hospitals.
(21) The same generic name of the drug injection form and oral dosage form of no more than two, the prescription composition of similar compound preparations 1-2. Insulin used in diabetic patients and children's drugs are increased as appropriate.
(22) medical institutions in the supply of antibacterial drugs catalog of three and four generations of cephalosporins (including compound preparations) class of antibacterial drugs in oral dosage form of no more than 5 specifications, no more than 8 injectable dosage form, carbapenem antibacterial drugs in injectable dosage form of no more than 3 specifications, oral dosage form of fluoroquinolone antibacterial drugs and injectable dosage form of no more than 4 specifications, the depth of antifungal antimicrobials no more than 5 varieties ("one product, two specifications").
(23) Medical institutions antibacterial drug supply catalog adjustment cycle is not shorter than one year. Hospitals above the second level of antibacterial drugs catalog should be adjusted each time the hospital should be publicized (publicity at least include antibacterial drugs varieties, dosage forms and specifications), and to the provincial health administrative departments for the record.
(24) The utilization rate of antibacterial drugs in hospitalized patients does not exceed 60%.
(25) The proportion of antibacterial drugs prescribed for outpatients does not exceed 20%.
(26) The intensity of antimicrobial drug use strives to control below 40DDD.
(27) The proportion of antimicrobial drugs for prophylactic use in patients undergoing Class I incision surgery is no more than 30%.
(28) The prophylactic use of antimicrobial drugs for surgical procedures in hospitalized patients is controlled from 30 minutes to 2 hours before surgery.
(29) The time for prophylactic use of antimicrobial drugs in patients undergoing surgery for Class I incision is no more than 24 hours.
(30) The rate of microbiological test samples sent to hospitalized patients receiving antimicrobial drug treatment is not less than 30%.
(31) The proportion of component blood transfusion carried out is ≥85%.
(32) blood transfusion indications qualified rate ≥ 90%.
3. Strengthen the management of clinical application of medical technology and large-scale equipment to ensure medical quality and safety and patients' rights and interests. Establishment of strict medical technology access and management system, medical institutions to carry out more than two medical technology access rate of 100%.
Strictly regulate the clinical application of cardiovascular interventional diagnostic and treatment technology. Medical institutions should be in accordance with the "Code of Practice for Medical Institutions", "Clinical Diagnosis and Treatment Guidelines" and other relevant technical documents, and strictly grasp the cardiovascular interventional diagnostic and treatment technology indications. The proportion of clinically applied bare stents in medical institutions shall not be less than 20% of the total number of clinically applied coronary stents. Coronary heart disease interventional therapy patients need to be placed in the number of stents more than three, need to be agreed by the institution of cardiac surgery consultation physician consultation before implementation; medical institutions do not set up cardiac surgery, need to be agreed by the cardiovascular internal medicine specialty of three or more deputy director of the doctor's consultation before implementation.
4. The completion rate of counterpart support tasks is 100%.
Three, to strengthen medical ethics education, vigorously promote noble medical ethics, serious discipline, and strive to achieve "good medical ethics"
(a) continue to increase medical ethics education.
1. Continue to cultivate and establish a number of advanced models, and increase the publicity and recognition of advanced models of high medical ethics, excellent medical skills, dedication and commitment. Combined with the characteristics of the health industry, in-depth education on the sense of purpose, professional ethics and discipline and the legal system.
2. Strengthen professional ethics, discipline and legal system and medical ethics education in medical education, and lay a solid ideological and ethical bottom line for medical students.
3. Continuing to organize in-depth study of Amendment (VI) to the Criminal Law and the Opinions of the Supreme People's Court and the Supreme People's Procuratorate on Several Issues Concerning the Application of Law in Handling Criminal Cases of Commercial Bribery, with the coverage of education reaching 100%.
(2) the development and improvement of medical ethics and medical ethics system and norms.
1. Develop the "Code of Conduct for Employees of Medical Institutions" and organize the implementation of the localities, the rate of knowledge of medical personnel reached 100%.
2. To formulate the Guiding Opinions on Strengthening the Construction of Public Hospitals to Combat Corruption and Promote Integrity.
3. Researching and formulating implementation measures for the implementation of the Practicing Physicians Law and other medical and healthcare laws and regulations on penalties, and effectively increasing the disciplinary penalties for violations of laws and disciplines in the field of medical and healthcare.
4. Continuing to seriously grasp the implementation of the medical ethics appraisal system, further refinement of the work indicators and assessment standards, and the establishment of effective incentives and constraints on medical personnel. 100% of hospitals above the second level have implemented the content of the medical ethics appraisal system.
(3) resolutely investigate and deal with cases of unethical practices in the purchase and sale of medicines and medical services, and serious industry discipline. Seriously investigate and deal with arbitrary charges, accepting or demanding "red packets", accepting kickbacks, commercial bribery and other typical cases, and give full play to the warning effect of the case. Attention has been paid to giving full play to the curative function of investigating and handling cases, promoting the improvement of systems and plugging of loopholes, and purifying the social environment for the reform of the medical and health system. Research and development of "medical institutions practitioners to investigate and deal with disciplinary violations.
Four, in-depth review of the wind, proactively accept social supervision, and strive to achieve "public satisfaction"
We should seriously carry out patient satisfaction surveys and discharged patients return visit activities, and continue to carry out the democratic review of the wind as an important carrier to promote the work of health corrective action, safeguard the interests of the masses, actively organize and actively participate in the democratic review of the wind. The company has been actively organizing, actively participating in the democratic evaluation of the activities of the wind. We will continue to play the role of supervisors, pay close attention to and actively participate in the political style hotline, listen carefully to the voices of the masses, solve the outstanding problems reflected by the masses in a timely manner, and strive to satisfy the society. We are actively exploring the establishment of a scientific evaluation mechanism for health care practices, and reflecting the status of health care practices in an objective and fair manner. The system of hospital affairs disclosure has been fully implemented, with 100% of hospitals above the second level practicing hospital affairs disclosure. Enhance the awareness of hospital affairs disclosure in medical institutions, and promote the further optimization of service processes and internal democratic management decision-making in medical institutions.
(a) Employee satisfaction with the hospital management organization and leadership ≥ 80%.
(B) patients, physicians and nursing staff of the laboratory services satisfaction ≥ 90%.
(3) Patients, physicians and caregivers are ≥90% satisfied with the services of the medical imaging department.
(d) Patients, physicians, and caregivers were ≥90% satisfied with the services of the pharmacy department.
(v) Patients and physicians' and nursing staff's satisfaction with hospital logistics services ≥90%.
(F) Satisfaction of discharged patients with medical services ≥90%.