Three-level hospital grading standards
These standards are the standards for the construction and development of three-level hospitals, and is the basis for the evaluation of the level and quality of their standards. I. Setting up of departments
The setting up of hospital departments should be compatible with their functions, tasks and scale. Functional departments should be set up in line with the principle of streamlining, efficiency and adapt to the needs of management. Operational departments should be based on the guidance of regional health planning and comprehensive development, strengthen the construction of specialties, implement secondary sub-specialties, and highlight the advantages of specialties.
(I) Clinical Departments 1. First-level specialized departments
With Emergency Medicine, Internal Medicine, Surgery, Obstetrics and Gynecology, Pediatrics, Traditional Chinese Medicine, Ophthalmology, Otorhinolaryngology, Stomatology, Dermatology, Anesthesiology, Physical Therapy, Rehabilitation, or Geriatrics, Oncology, Family Medicine, and Interventional Radiology.
2. Secondary Specialty Subdepartment
(1) Internal Medicine ：Department of Digestive, Circulatory, Respiratory, Neurological, Hematological, Urological, Endocrinological, and other specialty departments.
(2) Surgery: specialized departments such as Abdominal Surgery, Cardiothoracic Surgery, Neurosurgery, Urology, Orthopedics, Burns, Plastic Surgery and so on.
(3) Obstetrics and Gynecology: divided into gynecology, obstetrics, family planning and other specialized departments. (4) Pediatrics: divided into neonatal, pediatrics, pediatrics and other specialized departments. (5) Others: ICU wards (rooms) and CCU wards (rooms) are required. (B) medical and technical departments and other business departments
There shall be a pharmacy, diagnostic imaging, laboratory, nuclear medicine, nutrition, pathology, physical diagnosis, endoscopy, operating room, disinfection and supply room, medical records, statistics, library, preventive health care.
(3) key specialties
1. The hospital should have more than two key specialties. 2. Key specialties:
(1) the leader of the discipline has the title of chief physician; (2) the level of professionalism in the domestic advanced ranks; (3) the formation of professional talent echelon;
(4) with more than 20 beds, with the development of the specialty of the medical treatment, teaching, scientific research, supporting equipment (including the equipment center of the relevant equipment). Second, the staff structure
Hospitals should be equipped with technical force appropriate to its functions, health professionals and other professional and technical personnel structure must meet the following requirements:
1. Physicians and nurses ratio of 1:2
2. Chief Physician: Deputy Chief Physician: Attending Physician: Physician ratio of 1:3:5:7, Nurse Practitioner or more than the total number of nursing staff ≥ 30%.
3. Clinical dietitian title above ≥ 2 people.
4. Engineering personnel (technicians, assistant engineers and above) accounted for ≥ 1% of the total number of health professionals. 5. The director of each first-level department and key second-level departments must be a chief physician, and the director of general second-level departments should be a deputy chief physician.
Hospitals affiliated with medical schools and universities, as well as hospitals undertaking national teaching and scientific research tasks, in accordance with the Ministry of Health in 1979 "on the establishment of general hospitals," an appropriate increase in the proportion of personnel. Third, the level of management
Tertiary hospitals must implement departmental management. Managers at all levels should have management expertise and skills corresponding to their management responsibilities. Hospital faculty leadership team should be: the structure should be reasonable, responsibilities should be clear, the authority should be commensurate, the work should be coordinated, and more efficient. The dean and vice president should also meet the following requirements:
1. Comprehensive understanding of the business of tertiary hospitals, with intermediate or higher health technology titles, more than three years of tertiary hospitals and more than one year of departmental management experience.
2. Professional training in management before starting work, and mastery of more systematic principles, principles and important methods of hospital management. 3. Be able to design and organize the development of comprehensive hospital development planning, project planning, annual work plan, and be able to organize and implement.
4. Be able to understand the dynamics of hospital management at home and abroad, and make full use of relevant information resources as a reference and basis for management conception and decision-making.
5. Ability to teach hospital management, conduct scientific research and supervise management trainees.
6. Pay attention to the public **** relationship, can strive for the local government, people from all walks of life, the community's understanding of the hospital, care and support. Fourth, the level of technology
Tertiary hospitals should have its function to adapt to the basic level of medical, teaching, research and comprehensive development. Can accept referrals from hospitals above the second level, can correctly deal with complex and difficult diseases, there are more than two key specialties level into the domestic or international advanced ranks.
(1) Clinical departments (see annex for details) (2) Medical and technical departments (see annex for details) (3) Key specialties
1. 2. Be able to skillfully carry out the diagnostic and therapeutic techniques required by (Annex I). 3. Able to carry out laboratory research.
4. There are ministries (commissions), the provincial level and above, scientific research results (see scientific research items). 5. There are international academic exchanges.
6. ≥ 2 papers published in national academic journals each year. (D) preventive health care and social medicine services
Hospital preventive health care and social medicine services, is one of the basic functions of modern hospitals, is a hospital-wide work, and to achieve a better level.
1. Guiding the grassroots and obtaining experiments.
2. To be able to carry out various forms of health education and have the effect evaluation. 3. be able to carry out outpatient services such as mental health and genetic counseling. 4. Carry out family hospital bed services.
5. The Department of Preventive Health Care can guide the community preventive health care and participate in the hospital environment management and hospital infection control. V. Teaching and Research
(1) Teaching
In accordance with the Interim Provisions on Teaching and Learning in Higher Medical Colleges and Universities, it has set up a perfect teaching management organization and has met the following requirements:
1. It is capable of undertaking clinical teaching and internships in medical colleges and universities.
2. There is postgraduate (master's and doctoral) education, and a system and plan for continuing education. 3. The use of teaching funds is reasonable.
4. The structure of the teaching team is reasonable, and the ratio of professors, associate professors, lecturers and teaching assistants is 1:2:4:8.
5. There is a system of class preparation, evaluation of teaching and learning, and inspection of lectures. Teaching materials (e-learning materials, self-compiled textbooks, etc.), teaching equipment (instruments, charts, specimens, models, laboratory animals, etc.), as well as the classroom, classroom, disease, the number of patients provided to meet the needs of clinical teaching
(ii) research
1.
2. In the statistical year, international papers ≥ 1; national papers ≥ 10; participation or international academic exchanges ≥ 1; hosting national academic lectures ≥ 1.
3. According to the statistics of the three years before the evaluation, there are ≥ 1 national scientific and technological progress (achievement) awards at the second level or above; ≥ 2 scientific and technological progress (achievement) awards at the ministry (commission) and provincial level.
4. Participate in the design of scientific research projects and participate in the actual research of young and middle-aged personnel awards ≥ 30%. Sixth, medical equipment
1. Medical equipment should be compatible with other functions, tertiary hospitals should have the basic equipment necessary for the medical care, teaching and research carried out by them, routine equipment must be well-matched, there are sound resources **** enjoy and improve the efficiency of the centralized use of the form.
2. Rescue room, ICU, CCU ward (room), operating room, disinfection and supply room, X-ray room, laboratory, pathology, functional examination room, speculum room and key specialties, should have to ensure that the completion of the medical, teaching and research tasks of the basic equipment, and meet the relevant standards.
3. Large-scale equipment should be cost-benefit analysis, and take corresponding improvement measures. Seven, information management
Hospital information work must be compatible with the medical, preventive, teaching, research and management work to do. 1. timely, accurate and comprehensive to complete the provisions of the various health statistics report.
2. To guide the grassroots to carry out the community population dynamics and analysis of the dynamics of the occurrence of disease in patients. 3. Participate in and guide the grassroots to carry out the monitoring of chronic non-communicable disease registration and reporting as needed. 4. To be able to carry out quality of care and cost-effectiveness analysis.
5. Be able to carry out Chinese and foreign cultural intelligence work related to hospital management, drugs, instruments and equipment, and clinical medicine (including nursing, medical technology, etc.).
6. Be able to carry out scientific classification, coding and indexing of information materials.
7. To give full play to the utility of various types of information and statistics, to achieve the utilization of records, evaluation and improvement measures.
8. can apply electronic computers for information processing.
9. Medical libraries (rooms) should be set up, with enough Chinese and foreign language medical books and periodicals. Eight, the statistical indicators
1. admission diagnosis and discharge diagnosis rate of ≥ 95% 2. pre- and post-surgery diagnosis rate of ≥ 90% 3. clinical diagnosis rate of ≥ 90%
4. secondary referrals of patients with key specialties to confirm the diagnosis rate of ≥ 95% 5. CT examination positive rate of ≥ 60%
(with case analysis report) 6. large-scale X-ray examination rate of ≥ 50% 7. 50% 7. Positive rate of nuclear magnetic **** vibration examination ≥ 70%
8. Clinical chemistry inter-room quality assessment laboratory annual average per VIS <120 (tertiary hospitals VIS <80) 9. Clinical chemistry indoor quality control of the CV value of the permissible error 10. Bacterial quality control reference 11. autopsy rate of ≥ 15 (except for neonatal necropsy)
12. Single disease cure rate (in the same level hospitals) Improvement rate (among peer hospitals) is at a high level 13.Critical patient emergency rescue success rate ≥ 80% 14.Critical patient ward rescue success rate ≥ 84% 15.Aseptic surgical incision Grade A healing rate of ≥ 97%
16.Re-hospitalization rate of the same case within one week (determined at the time of examination of the disease, compared with peer hospitals) is at a low level
17.Single-type disease death rate Lower than the average value of hospitals of the same level 18. hospitalized maternal mortality rate ≤ 0.02% 19. live birth neonatal mortality rate ≤ 0.5%
20. single disease postoperative mortality rate of ten days is lower than the average of specified diseases 21. anesthesia mortality rate of ≤ 0.02% 22. outpatient prescription rate of ≥ 95% 23. outpatient medical records written by the rate of qualified ≥ 90% 24. grade A case rate of ≥ 90%
(no grade C cases) 25. X-ray film ingestion rate of A ≥ 40%
26. five nursing form writing qualification rate of ≥ 95% 27. nursing technical operation qualification rate of ≥ 98% 28. basic nursing care qualification rate of ≥ 90% 29. Extraordinary, first-class nursing care qualification rate of ≥ 90% 30. Routine instrument disinfection qualification rate of 100% 31. to carry out the system of responsibility for nursing care ≥ 20%
32. Accompanying rate ≤5%
33. Treatment of dietary meals 100% 34. Inpatient meals ≥ 90% 35. Nosocomial infection rate ≤ 10%
36. Sterile surgical incision infection rate ≤ 0 .5% 37. Number of medical accidents 0
38. Medical malpractice, serious errors in the characterization of the treatment of the correct 100% 39. Coma and paralyzed patients with bedsores The number of accidents occurred 0 40.annual number of accidents 0
(including fire, explosion, building collapse, personal injury to patients, etc.) 41.bed utilization rate ≥ 85% - ≤ 93% 42.average hospitalization days ≤ 20 days 43.bed turnover ≥ 17 times / year
44.deputy director of the physician or above out of the general outpatient clinic ≥ 2 times / week 45.completion of the directive birth task 100%
(including rescue, foreign aid, border support, etc.) 46. more than 10,000 yuan of medical equipment, instruments intact rate ≥ 95% 47. more than 10,000 yuan of medical equipment, instrument utilization rate ≥ 30 hours / week 48. medical staff three basic assessment pass rate of 100% 49. first aid items intact rate of 100% 50. a needle and a tube rate of implementation of 100%
Tertiary hospitals classification Judgment standards
Hospitals should be its construction, management, technical level, quality of work, civilized service, cost-effectiveness and other regular self-evaluation, and develop improvement measures. Provincial (municipal) hospital accreditation committees conduct out-of-hospital evaluations of hospital quality standards in accordance with the standards. According to the evaluation results of the three hospitals are divided into special, A, B, C four levels. First, the three hospitals
Hospital on the construction of outstanding achievements. Its overall level ranks among the domestic leading ranks. Some of the specialties can reflect the international or contemporary medical development level, fully meet the requirements of the standards of the third-class hospitals, and should also meet the following requirements:
1. The comprehensive level of clinical disciplines in the country in a leading position, and can accept referrals from other tertiary hospitals. 2. At least one or more key specialties have entered the international advanced ranks and have certain influence. 3. Academic centers that cooperate with the World Health Organization or foreign academic institutions.
4. Undertake 2-3 research projects at the ministerial level or above in the same assessment cycle, and win at least one national research achievement award at the second level or above.
5. It is capable of training advanced trainees above the level of attending physician and has the ability to train doctors and postdoctoral fellows. Second, Grade 3A hospital
Hospital construction achievements are remarkable, departmental settings, staffing, management level, technical level, quality of work and technical facilities, etc., according to grading standards for comprehensive assessment and inspection of 900 points and above. Third-class B hospitals
Hospital construction achievements are still good, its departmental settings, staffing, technical level, quality of work, technical facilities, etc., according to the points of the standard comprehensive assessment and inspection of 750-899 points. Fourth, the third class C hospital
Hospital construction has some achievements, the basic standard assessment qualified, but with the requirements of this standard is still a big gap. According to the classification standard comprehensive assessment and inspection in 749 points and below. Level III C hospitals should have practical improvement measures.