Hospital Self-Inspection Report (General 5)
Time slips away, the work has come to an end, review this period of hard work, there are defects, at this moment we need to write a self-inspection report. I believe that we are again worried about writing a self-examination report! The following is my collection of hospital self-examination report (General 5), I hope it can help you.
Hospital self-examination report 1
According to the spirit of the relevant documents and regulations of the higher level, our hospital immediately carry out medical quality inspection and make the following summary:
First, pay close attention to the quality of medical care, to ensure medical safety
1, strictly in accordance with the process and diagnosis and treatment of the guidelines for the conduct of clinical work, to ensure the quality of care and medical safety. The company's website is a great source of information about the company's products and services.
2, the strict implementation of the doctor's room system, and need to be in the condition of the record on the detailed record of room: condition analysis, medical treatment and the next step of the diagnosis and treatment plan record.
3, the strict implementation of the management system of practicing physicians.
4, the strict implementation of the doctor on duty system,
5, do a good job of the "evening checkup" work. The "evening checkup" includes the newly admitted patients, critically ill patients, the results of the daytime medical treatment follow-up, the results of the analysis and processing of test results, special test results, informed consent to communicate (especially patients who will undergo surgery or invasive tests), tomorrow will be discharged to arrange for patients, the treatment of patients with consultation. And with the physician on duty to carry out the work of the shift.
6, do a good job of shift handover. The morning shift and the afternoon shift before the end of the shift is particularly important, critical patients must be bedside shift. The physician on duty every day after the shift must be the patient's undergraduate test single detailed access to once, and abnormal results for processing and review.
7, the implementation of the implementation of the consultation system.
8, the department set up a special quality control inspection of medical records responsible for physicians, random sampling of medical records and do a good job of quality control, timely revision of errors and omissions.
9, for the checkup of the various feedback information, and put forward the views of the problems found in a timely manner to do a good job of rectification, to avoid making the same mistakes.
10, led by the director of the department every month, business learning, update the new knowledge and new progress in diagnosis and treatment.
11, the section of the irregular, no advance notice of the quality inspection, found that the problem, the deadline for rectification, to help implement
12, the establishment of difficult cases consultation and discussion system, the purpose is to solve the difficult cases of diagnosis and treatment at the same time, improve the overall academic level of the various disciplines and at the same time, the training of physicians and to improve their clinical competence and level of business.
Second, the implementation of the system, strengthen the doctor-patient communication to enhance the understanding of doctors and patients
1, communication is a very important link.
(1) to do a good job of communication at the time of admission: let the patient and his family to understand the patient's current condition, the critical patient to the physician to explain the condition in detail, if necessary, sign the sick (critical) serious notice. To let the patient and his family to understand the name of the physician and nurse, and know the time of the communication of the condition.
(2) hospitalized communication: changes in the condition, test results, treatment plans; especially when the diagnosis and treatment of major changes, more timely communication. For the daytime can not come to the hospital in time to understand the condition of the patient, must be the condition of the shift to the duty physician, so that the patient's family with the duty physician to understand the condition.
(3) communication before discharge: the diagnosis of the disease and the results of treatment, outpatient follow-up time and the possible side effects of drugs, the condition of the possible changes in the treatment method, the need to review the examination program.
(4) outpatient communication: diagnosis and treatment of the disease, the role of drugs and side effects, follow-up time.
(5) communication between doctors and nurses: the implementation of medical behavior in place in a timely manner, whether a variety of timely examination, whether changes in the patient's condition has been dealt with in a timely manner, whether there are medical hazards or disputes.
2, seriously implement the signing of informed consent. For the relevant treatment, must be treated by the personnel and family and the patient for face-to-face communication, the necessity of the diagnosis and examination, indications, possible risks and complications, medical costs, medical needs to be observed or treatment time to the patient's family to explain, and sign the informed consent.
3, for the existence of security risks of patients, such as critical condition, fluctuations in the condition of large changes, mental anomalies, do not cooperate with medical operations, casually out of the patient, must do a good job of explaining the work, and to obtain the cooperation and understanding of the patient's family members, the establishment of a full-time chaperone, and do a good job of handover work.
4, reasonable deployment of the department of extra beds, in order to improve the quality of medical care and ensure medical safety under the premise of the sustainable development of the department must have a clear goal and direction.
Hospital Self-Inspection Report 220xx year I hospital in the leadership of the higher health departments, the organization of all hospital medical staff to seriously carry out the creation of a safe hospital. Strengthen the basic management of hospitals, improve the quality of medical services and technical level, so that the doctor-patient disputes significantly reduced; through the gradual improvement of the mechanism for the mediation of doctor-patient disputes, so that the relationship between doctors and patients is more harmonious development, and to promote the sustainable and healthy development of health undertakings of my town. According to the requirements of the "Guangdong Province," the creation of a "safe hospital" assessment scoring rules, our hospital special organization staff to carry out self-examination, self-assessment, and now the results of the self-examination reported as follows:
Through the development of this work, the hospital's practice environment has improved significantly. Our hospital has carried out a number of creative activities this year, and timely replacement of the content of the publicity column of creative activities. The hospital has customized health care newspaper and distributed it to the village health stations at the relevant regular meetings in a timely manner.
First, our hospital monthly self-examination of the quality of medical services, hospital medical staff, good medical ethics, basic management in place, a very few medical personnel in the medical paperwork is not very standardized, this is to be improved. Medical services, our hospital adheres to the concept of patient-centered service. Timely for patients to solve problems. For medical safety and medical charges, the hospital strictly implements the regulations of the relevant departments at the higher level. The management of medicines and medical devices is also carried out in strict accordance with the relevant laws. Strictly implement the management of surgical classification and categorization, and do a good job of each record.
Second, the hospital has no internal doctor-patient disputes, criminal cases, public order cases. Measures related to safety management are in place. Our hospital also organizes personnel to carry out drills for public **** incidents and public **** health emergencies. And have the relevant plans.
Third, our hospital's internal security organization still needs to be strengthened, this work is not quite in place. To continue to improve, the hospital has strengthened the contact and cooperation with the local public security police station.
Fourth, the hospital set up a special group to regularly investigate the problems of doctors and patients, hospital affairs open to the public, the reasonable requirements of patients, we do our best. Respect for the rights of patients, in the relevant aspects of the patient's written informed consent to go to the implementation. Patient satisfaction with the work of our hospital more than 95.
Fifth, our hospital to establish a sound hospital as the main body, to build the system as the core of the creation of a long-term mechanism, with a medical accident prevention system and treatment plan and held two times a year related to the legal knowledge of the seminar, regular annual safety goal assessment, medical safety meetings, and have relevant records of the material.
Sixth, for the individual temporarily did not do the work, the hospital is actively improving.
According to the "Guangdong Province," the creation of "safe hospitals" assessment scoring rules, the results of this self-assessment of our hospital: basic good!
Hospital self-examination report 3
According to the higher issued by the "Beijing Municipal Health Planning Commission on the development of district medical centers and primary health care institutions hospital infection special supervision notice", my community health service center organization staff of all departments to carry out a serious self-examination. Now the summary report is as follows:
First, the results of self-examination
1. Our hospital has set up a hospital infection management team, fully responsible for the management of hospital infection surveillance and control, the development of a three-tier management system of hospital infections, clearly defined the position responsibilities of the members of the team, the development of a hospital infection management system, monitoring measures and hospital infection in-service It has developed hospital infection management system, monitoring measures and on-the-job hospital infection training, organized the implementation of hospital infection monitoring measures, and carried out hospital infection monitoring in the whole hospital on a regular or irregular basis. A monthly hospital infection quality control and registration.
2. Strengthen the quality control of infection in key departments, such as: treatment room, injection room, dressing room, laboratory, stomatology, gynecology and other departments.
3. Strictly in accordance with the disinfection, sterilization operation specification, disinfection, sterilization of various items. And seriously and regularly carry out disinfection, sterilization effect monitoring work, supervise the relevant departments to do a good job of disinfectant replacement, ultraviolet lamp wiping, ultraviolet disinfection, such as registration and record work.
4. In accordance with the norms of medical waste disposal, signed a medical waste transfer agreement with Beijing Erqing Group, according to the standardized process of collection, temporary storage, transfer of medical waste, and make a good record of the handover, to ensure that the hospital's medical waste disposal process norms in place.
5. Treatment room, dressing room, injection room daily cleanliness and hygiene and air, surface disinfection, and do a good job of registration. Strict implementation of rules and regulations and operating procedures in the work, and do a good job of air culture every month.
6. Stomatology strictly comply with the stomatology disinfection norms and stomatology diagnostic and therapeutic equipment disinfection and isolation system, so that one person, one machine, all diagnostic and therapeutic equipment into the oral cavity must meet the requirements of one person, one with a sterilized staff to do a good job of personal protection.
7. The hospital infection management team on the purchase of disposable medical supplies, management and use of post-processing to perform supervision and inspection duties. Where the purchase of disposable medical supplies used in our hospital "three certificates" complete, with sterilization mark, date of production, expiration date, product packaging meets the requirements. Pharmacy to establish a register, items stored in a cool, dry, well-ventilated shelves. Disposable medical supplies after the use of disfiguring disinfection measures.
The main problems in the management of hospital infections in our hospital
1. hand hygiene compliance is not high
2. hand drying equipment is not perfect
3. the lack of medical fabrics management system
4. the lack of minutes of the Hospital Infection Management Committee
The main problems in the management of hospital infections in our hospital are the following
All the other parts of the hospital infection management system are in place.
2. Equipped with disposable dry hand towels
3. The development of medical fabrics washing system and management system
4. Regularly convene the hospital infection committee meeting, and timely records.
Hospital Self-Inspection Report 4
Since my city medical and health units to carry out anti-smoking activities, our hospital has developed a series of work plans and systems, through health education topics will be, hospital staff meeting and other forms of publicity on smoking is harmful to health knowledge, so that the whole hospital staff to fully understand the harm of smoking and the significance of anti-smoking, the strict implementation of the hospital's anti-smoking system. To do the hospital public **** place no one smoking, no smoking awareness. Now the hospital specific anti-smoking self-examination work report is as follows:
First, the establishment of a leading group, the implementation of anti-smoking duties
In order to promote the implementation of the "xx city health care system comprehensively carry out anti-smoking work implementation program", the hospital leadership to convene an anti-smoking mobilization meeting, called on the entire hospital staff to quit smoking, anti-smoking. At the same time, the establishment of anti-smoking leading group, xx President as the leader, the vice president of the vice president of the vice president of the vice president, the functional section chiefs as members. The leading group set up an office, the director of the office by xx concurrently, members of the xxxx. leading group in accordance with the provisions of the higher level of anti-smoking, strictly grasp the line of our hospital anti-smoking work, effective control of the phenomenon of smoking in the hospital.
Second, combined with the actual, the development of anti-smoking system
In order to thoroughly implement the implementation of anti-smoking program for patients and hospital workers to create a smoke-free environment, to ensure that the hospital personnel's health, the development of the "xx City xx Hospital anti-smoking system," "xx City xx Hospital anti-smoking rewards and punishment standards," "xx City xx Hospital anti-smoking assessment records. Records". The anti-smoking system clearly points out that all employees of the hospital are prohibited from smoking in the hospital, all workplaces in the hospital are prohibited from placing ashtrays, all employees of the hospital are obliged to carry out peer education and mutual supervision, and all employees are obliged to publicize tobacco control to patients and their families. At the same time, certain rewards are given to departments and individuals who perform well in tobacco control, and certain penalties are given to departments and individuals who violate the system. The establishment of the anti-smoking system, so that the hospital smokers in the work area in accordance with the provisions of self-restraint, self-control, to create a smoke-free environment.
Three, vigorously publicize, enhance the health knowledge
Make full use of the health education theme of the meeting, study sessions, training sessions and other forms of active anti-smoking publicity and education, to improve the anti-smoking awareness of all cadres and workers, to cultivate cadres and workers do not smoke, and in time to dissuade others from smoking a good behavior, enhance the "smoking" of the good behavior, and to enhance the "smoking" of the hospital, and to improve the quality of life. To enhance the health awareness and self-protection ability of the "smoked" people and further improve tobacco control efforts. Tobacco control publicity materials are incorporated into outpatient and inpatient guidelines to publicize the medical knowledge that smoking is hazardous to health, to warn patients, family members and visitors that smoking is prohibited in hospitals, and to vigorously publicize the hazards of smoking to enhance the effect of tobacco control. Smokers with a history of smoking will be able to quit slowly in a smoke-free environment. Since the event, more than 5,000 copies of anti-smoking and smoking cessation publicity materials have been distributed to patients and their families.
Four, strict supervision and inspection, rewards and punishments
In order to ensure that the anti-smoking work can be put into practice, the whole hospital to achieve a smoke-free environment. The office of the anti-smoking work weekly from time to time to organize spot checks, surprise inspections, focusing on the establishment and implementation of the anti-smoking system to check the inspection found `problems in a timely manner issued to the various departments, and require timely rectification. For example, if the hospital staff is found smoking in the workplace, according to the established anti-smoking evaluation and reward and punishment system, the first time to give a verbal warning, the second time to give a serious warning, the third time to give the whole hospital notice of criticism and start withholding bonuses (starting amount of 50 yuan, and then every time you increase the amount of withholding the amount of the previous amount of two times the monthly cumulative amount of money, deducted from the month's individual bonuses); more than three times (including three times) per year violations of tobacco control regulations will be Those who violate the tobacco control regulations more than three times (including three times) per year will be recorded in the Tobacco Control Evaluation Reward and Punishment Record Sheet, and will be disqualified from the evaluation of excellence in the current year. In addition, the hospital also set up the "excellent smoke-free department award", for not violating the relevant provisions of the department, the annual award of 500 yuan.
Since my hospital launched the "create a smoke-free" activities, the effect of anti-smoking is very obvious. It not only promotes the construction of health education and spiritual civilization, but also raises the awareness of our staff and social smokers of the health hazards of tobacco, and improves the self-control of all hospital staff in refusing cigarettes. We have made certain achievements in creating a good smoke-free environment and promoting the physical and mental health of all staff in the hospital. In the future, we will continue to grasp the anti-smoking work, do our best to open up a clean, beautiful, pure health environment.
Hospital self-examination report 5(a), organizational management
1, according to the law practice hospitals strictly implement medical and health laws, rules and regulations, strictly in accordance with the "medical practice permit" in the subjects specified in the diagnostic and therapeutic activities, no over the scope of practice of medicine, no non-health technicians engaged in diagnostic and therapeutic activities, licensed physicians, The licensed physicians and nurses are all registered according to the regulations, and there is no over-scope of practice. The hospital does not rent out or contract out departments, and there are no false or illegal medical advertisements.
The hospital has established and improved rules and regulations and all levels and types of staff duties and medical core system, most of the staff are familiar with their work duties and related regulations, thirteen medical core system is well established, the hospital has compiled health care laws, rules and regulations into a booklet, issued to the departments and regular or occasional organization of the study, the full training at least once/year.
Medical personnel in the clinical diagnosis and treatment activities can follow the main laws, regulations, rules, diagnosis and treatment of nursing norms and routines related to their practice. The hospital carried out departmental study of laws, regulations and implementation of the inspection work, found that the problem of timely rectification.
2, the hospital administration and management mechanism of the hospital to implement the presidential system of responsibility and hospital management at two levels, the president and vice president of the division of labor responsibilities are clear, the responsibilities of the functional departments are clear, there is a perfect management system and procedures. Organizational charts can reflect the hospital leadership, functional departments and clinical departments of the management level, the establishment of a unified coordination mechanism of the functional departments, coordination records, management organization set up a reasonable, efficient operation, to meet the needs of the hospital's work.
The hospital has established and perfected the system of openness of hospital affairs, perfected the system of staff congresses, major matters are discussed and passed by the staff congress, and in accordance with the requirements of the Ministry of Health and the provincial health department on the establishment of open hospital affairs system to implement the open hospital affairs, open system of departmental affairs. Employees of the management organization and hospital leadership praise survey are ≥ 85%.
3, human resources hospital physicians, nurses and other health professionals to meet the requirements of the number of third-level physician visits and first- and second-line staff on duty to meet clinical needs. The number of ward beds and ward nurses ratio of 1:0.53 (orthopedic beds and nurses ratio of 1:0.6), ICU ward beds and beds ratio of 0.04:1, the proportion of specialized training nurses to meet the prescribed requirements.
The ratio of education, title and age structure of the health technician team is reasonable. The ratio of beds to health technicians is 1:1.06, and the professional and technical personnel of medicine, inspection and radiology have the corresponding academic qualifications and titles, and the ratio of serving professional and technical personnel to the number of employees, and the ratio of middle- and senior-level technical personnel to the number of health technicians basically meets the stipulated requirements.
All major professional departments have a deputy senior title or above subject leader; hospitals have added talent management, strengthened the training of young and middle-aged backbone, to ensure that the experts to come, stay, use live. In recent years, no experts and young backbone of the phenomenon of leaving.
Medical personnel continuing education system to implement the perfect, continuing education management to meet the higher requirements, the implementation of the new staff pre-service training to ensure the smooth implementation of medical personnel continuing education work completed.
4, the scientific planning of hospital development and construction and expansion have been demonstrated, in line with regional health planning and approved by the authority of the health administration. According to the hospital's level, function and mission, the hospital developed 3-5 years of development planning, annual plan, and effective organization and implementation, the annual work summary can accurately reflect the completion of the plan.
(2), information management
The hospital has established and improved the hospital management information system to achieve the hospital information management. The hospital information system can be timely, accurate, systematic collection, collation, analysis and feedback on medical quality, safety, service, cost, etc. can meet the hospital management, clinical work and health administration at all levels of the hospital statutory statistical information needs.
The hospital information system operation is basically stable and safe, can not fully ensure that workstations connected to the LAN to meet the requirements of "avoid direct connection to the Internet". The establishment of anti-virus measures, the installation of anti-virus and firewall software, hardware, regularly upgraded anti-virus software, there are off-site backup. The establishment of telemedicine and higher hospitals of technical consultation pathway.
(C), financial management
1), the hospital's financial adhere to the "unified leadership, centralized management" principle, all financial income and expenditure activities are included in the unified management of the financial sector. In accordance with the "Accounting Law", "Hospital Accounting System" and "Hospital Financial Development" and the relevant provisions of the State, the establishment of accounting entries, the establishment of books of accounts, accounting, preparation of accounting statements.
The internal departments and divisions of the hospital have not set up off-accounts, "small treasury". The audit department of the higher competent unit carries out regular and irregular inspections of the "small treasury", the financial personnel on duty have the qualifications, and there is a post responsibility system for accounting personnel. Bank card numbers are opened and used in accordance with financial regulations. The establishment of the hospital financial accounting management information system.
2), major projects are discussed collectively and then submitted for approval in accordance with the prescribed procedures. The implementation of the leadership responsibility system and accountability system for major economic matters, responsibility to a person. The establishment of a sound and effective financial accounting internal control system.
3), the implementation of internal cost accounting in hospitals, strengthen the management of drugs, materials, equipment and other supplies, and gradually standardize the internal cost accounting system in hospitals, and strive to reduce the cost of medical services and consumption of drugs and materials. There is a procurement management system for medicines, equipment, reagents and consumables. A cost accounting leading group led by hospital-level leaders has been established to set up a separate cost accountant, and the consumption of medicines, sanitary materials, low-value consumables and other materials can follow the principle of the accrual system, and basically can be calculated in accordance with the actual amount incurred in the current month. Can clearly delineate the main body of accounting, cost center and its economic activities corresponding to the business income and costs.
(D), protection management
(a) equipment management to implement the scientific management of equipment, large-scale equipment purchases after a rigorous feasibility study.
Belonging to the "configuration and use of large-scale medical equipment management measures" stipulated in the category A, B items of large-scale medical equipment, in accordance with the provisions of the application for the configuration of the license. The hospital has formulated the "medical equipment management measures", strictly in accordance with the provisions of the procurement of equipment (including consumables), in and out of the warehouse, maintenance, repair, renewal and scrapping. Rescue equipment (emergency department, ICU, operating room,) the completion rate of 100%, regularly and irregularly to the clinical departments to seek advice on equipment management, and timely improvement.
(ii) logistics management logistics support to meet the needs of clinical work, can take the initiative, in a timely manner for the whole hospital to provide water, electricity, gas, quilt supply and related facilities timely maintenance. The hospital has been able to implement the national environmental protection laws and regulations, set up a sewage purification system, and the water used for living is in line with the national standard, without secondary water use.
Can provide nutritional dietary guidance. The whole hospital working rooms without dangerous houses.
(C) drug management hospital pharmacy, patient drug waiting area layout is basically reasonable, standardized management, set up a consulting desk, providing medical consulting services, the hospital printed the "basic medication directory", the development of the "emergency pharmaceutical emergency management plan", drug management information system can be real-time dynamic reflection of the use of drugs, quality and safety situation.
It can provide patients with safe, timely and humanized services.
The hospital has formulated and implemented relevant systems for drug procurement management, selection principles and approval procedures for the introduction of new drugs, and approval and management of temporary drug purchases, etc. The hospital uses drugs purchased through the provincial bidding platform, and has set up a qualification file for drug supply units, and has earnestly carried out the acceptance and registration of warehousing processes, and has filed the relevant information for the blood products with required batch numbers and inspection reports, and has not found the use of blood products without batch numbers, expired, or spoiled. The company has not found the use of drugs without batch numbers, expired, deteriorated, and invalid drugs.
The storage of medicines is in line with the norms, and there is a management system for the storage and maintenance of medicines, and the medicines are stored in strict accordance with the prescribed conditions. The development and implementation of regular inspection of Chinese and Western medicine stores, outpatient and ward pharmacies, ward treatment rooms, small medicine cabinet, ward rescue vehicles, anesthesiology, operating rooms and other storage and use of drugs system.
(D) teaching and research management to establish a sound hospital teaching management organization and management system, assumed the Liaodong College students of clinical teaching internship tasks, the development of internship management system, interns unified management.
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