1. Hospital quality control work self-inspection report
Quality control section in the dean, sub-director and medical quality management committee under the leadership of the leadership of the medical quality control work, and actively carry out medical quality control work. With medical work as the core, the development of medical quality management methods, the establishment of medical quality monitoring index system and evaluation methods, the organization of medical quality inspection, assessment, evaluation of the completion of medical indicators, and put forward improvement measures.
First, the development of medical quality assessment methods
In order to fully implement the medical core system, to protect the quality of medical care, I developed and issued the "medical quality assessment methods and implementation of the rules (Trial)", the results of the quality of medical inspection and the comprehensive target assessment linked.
Second, the monitoring of basic quality
Through the hospital lectures, pre-service training in the form of improving the quality of medical staff awareness, the last year, the quality control section of the *** pre-service training 8 hours, resident lectures 3 times, leading medical staff to learn the Ministry of Health's newly issued diagnostic standards, standardize the writing of medical records.
Third, the link quality monitoring
1, regularly carry out medical quality inspection work
Regularly carry out outpatient prescriptions, running medical records, application forms and report cards check every month. Throughout the year *** check outpatient prescriptions 6059, pass rate of 96%; throughout the year *** check medical records 562, no C-class medical records; check the defective outpatient medical records 155, pass rate of 97% or more; check the defective application form 689, pass rate of 96%.
2, to carry out clinical path management
Through the development of single-disease clinical path, standardize the diagnostic and treatment process, regular inspection of the clinical path registration, and the organization of personnel to carry out the review of clinical path medical records. In the previous year **** to carry out? The clinical path management of individual diseases, **** there are cases of xx cases. The average enrollment rate and completion rate of the whole hospital are in line with the requirements, but some of the disease types have fewer admitted cases.
3, to carry out "antimicrobial drug remediation work"
and other functional departments, combined with the clinical path management, the smooth promotion of antimicrobial drug special remediation work, and achieved good results.
4, check the implementation of the relevant rules and regulations
irregularly check the 'software registry' of each department, the inspection found that the software book is not in accordance with the requirements of the norms of registration or writing, according to the provisions of the departmental quality control points will be deducted.
Fourth, the end of the quality of the monitoring
with the Medical Department of the hospital's medical quality indicators and archived medical records of the quality of monitoring.
V. Regular notification of medical quality inspection
Through the weekly meeting of the hospital regularly announced the quality inspection of various links, the existence of the problem of notification, the departments put forward rationalization proposals, and constantly promote the improvement of medical quality.
Sixth, there are problems
1, the clinical work is still manual management, low efficiency, departmental diagnosis and treatment plan is often inconsistent with the form.
2, there is no regular meeting of quality controllers, timely listening to the department of medical quality control.
3, the implementation of electronic medical records time is relatively short, has not yet developed the relevant inspection methods.
2. Hospital quality control work self-examination report
20xx year is the key year of the hospital three a re-evaluation, the hospital will face some new opportunities and challenges. Our new outpatient complex will be opened, and the business of the Park East ward is expanding. In order to further improve the medical quality management and medical level of our hospital, further strengthen and standardize the medical behavior of medical and technical personnel, to ensure medical safety, so as to promote the continuous improvement of medical quality management and overall improvement.
First, play the role of the hospital's medical quality management committee
Quality control section will be the monthly quality control management to the president in charge and the director of the hospital's medical quality management committee report, the hospital's medical quality management committee insisted on holding a quarterly meeting to study the medical quality management issues, the deployment of the next step in the work of the existing problems, put forward rectification and resolution of the measures, and to urge the relevant The department and the responsible person to carry out rectification.
Second, the quality control management department (quality control section) focus on the following work
1, around the "to grasp the quality of medical records as the center", adhere to the monthly organization of experts on the clinical departments to run medical records on the shelf to check the archived medical records for random checks, the existence of problems in a timely manner in writing feedback back to the department, and proposed to rectify the measures. Rectification measures are taken. Each month or quarter around the use of antibacterial drugs, perioperative patients, critically ill patients, new patients, clinical path patients and other thematic inspections, while the newly opened departments or wards to focus on guidance.
2, monthly organization of clinical departments (including ** medical records) medical quality management of various accounts for inspection, found that the problem timely request departments to rectify.
3, the emergency department and medical technology departments, including laboratory, blood transfusion, radiology, ultrasound, pathology, electrocardiography into the quality control management, and regular inspection.
4, continue to ** branch medical records and ledgers for inspection, incorporating quality control points deduction, linked to performance pay, and the existence of problems in a timely manner to urge rectification.
5, the establishment of defective medical record review system. Adhere to at least one hospital-wide review of defective medical records every six months, requiring the director of the department or quality control to participate in the review meeting, to promote the improvement of medical record quality.
6, strengthen the management of outpatient prescription quality. Seriously implement the prescription review system, at the same time with the outpatient office, pharmacy, finance and other departments to strengthen the outpatient prescription inspection efforts, found that the problem of timely rectification.
7, strengthen the training work. The newly opened departments, key departments or new medical, medical and technical personnel to carry out quality control training or lectures, after the training to carry out random testing to ensure the effectiveness of training.
8, regular or occasional organization of department directors or quality control officer meeting, feedback on the quality of medical problems, coordination of various departments in the quality control process encountered problems and conflicts.
9, on the inspection process of the existence of medical quality problems, according to the departmental quality control standards and according to the relevant provisions of the deduction or punishment, reported to the Financial Services Division and departmental performance pay link.
10, to strengthen contact with the discipline inspection office, nursing, hospital sensory, medical insurance office, science education, audit, finance and other departments, the management of their work into the quality control scoring content.
Third, to strengthen the departmental quality control management
1, each department to develop an annual quality control plan, every six months and at the end of the year to do a good job summarizing, to ensure that the quality control work in practice.
2, each department should fill out the monthly medical quality control record book and the relevant ledger record book on time, the existence of problems to have a clear rectification measures.
3, the department director, quality control officer and other members of the quality control team to conscientiously fulfill their duties, and often check the medical records of the department, medical prescriptions, prescriptions, treatment orders, as well as the implementation of the rules and regulations, to ensure the quality of medical care and medical safety.
4, the medical department to establish a quality control account, in addition to monthly on time to report the quality control self-examination scoresheet, the Department of Medical Affairs (quality control section) feedback on the issue of rectification and record.
3. Hospital quality control work self-examination report
Quality control section was established in xx, is one of the hospital medical quality management department. Subdivided into hospital medical quality control, medical safety hazards monitoring.
First, work responsibilities:
1, quality control section in the president, the president in charge and the medical quality management committee under the leadership of the hospital medical quality monitoring; according to the hospital's ` overall development strategy, put forward the year, the annual stage of the nature of the control of the key objectives, and for the development of the assessment standards; the annual quality of medical management work to be summed up, put forward suggestions for rectification, and to promote the continuous improvement.
2, the development of hospital-wide medical quality management of rules and regulations, planning, standards and major measures, responsible for organizing and coordinating the implementation of hospital quality management, supervision, inspection, analysis and evaluation.
3, participate in multi-level quality control: first, hospital-level quality control, participate in administrative visits, the monthly release of the hospital's quality control report (including medical operation data, quality control focus on the goal, medical defects review, medical hazards warning); second, to fulfill the functions of the quality control section, based on the administrative visits, the section director of the monthly assessment results, various types of random inspection results, withholding bonuses, to the department or the hospital to send the questioning of notification form >, rectification notice > and the hospital to issue the notification form >. , rectification notice & gt;, and random review; third, joint clinical medical technology for rectification: based on the pharmacy department's prescription review, medical insurance office of the medical advice review, medical staff on the irrational use of medication to reflect, to determine the key monitoring of the drug catalog.
4, the construction of multiple lines of defense quality control: the first line of defense: for common diseases and common types of surgery, the adoption of clinical path management model, that is, the full control of medical quality; high-risk links, must implement a package of preventive intervention programs, that is, the link control of medical risk. The second line of defense: at the same time publicize the diagnostic quality of individual cases and treatment decision-making reviews, as well as the corresponding authority of the diagnostic path, diagnostic and treatment strategies, that is, the active process control.
5, continuous improvement of high-risk medical link monitoring: multi-level intervention in hospital infection (exogenous, endogenous, antimicrobial-associated hospital infection), prevention of serious complications, early warning of potentially critical illnesses, warning of miscalculation of the emergency link, screening of the three null dispositions (undocumented, unhelpful, ineffective), monitoring of surgical prophylactic antimicrobials, and so on.
6. Qualification training for QC personnel: QCs screen for medical defects (true, false, and uncertain) based on their own professional competence alone, which can lead to screening blind spots and diverse conclusions. Therefore, based on evidence-based evidence (reasonable evidence, evidence of benefit, evidence of safety, questionable evidence, negative evidence), warning information (interaction, medical contradictions, clinical falsehoods, clinical dangers, diagnosis and treatment of chaos, easy to ignore the problem, false test results) to determine the evaluation criteria, and gradually make the quality control tends to be systematic, standardized and effective. The end of the control.
Second, the organizational structure of the section
1 chief physician, return to 2 deputy chief physicians, 2 physicians, 2 nurse practitioners, 1 staff. Quality control section chief duties under the leadership of the President, specific organization and implementation of the hospital's clinical medical, medical technology, nursing and other quality management. Responsible for the development of the hospital's medical quality management implementation program, and often supervise and inspect, summarize and report on time. In-depth understanding of the medical quality of each department, urging each department against the medical quality standards of self-examination, the development of the standard program. In cooperation with the Medical Department and the Nursing Department, the department is responsible for checking the business training and technical assessment of all medical staff in the hospital, as well as the relevant medical, nursing and quality assessment and appraisal work. Supervise and inspect the quality and management of drugs and medical devices. It is responsible for organizing the quality inspection of prescription, medical record writing, clinical medication, prevention of nosocomial infection, outpatient and emergency treatment, analyzing the situation on a regular basis, and reporting to the president in time. Responsible for the training of quality controllers in the hospital. Completion of other related work assigned by the hospital leadership. Quality control section of the quality control officer duties in the section under the leadership of the director, specifically to help improve the hospital medical, nursing quality control work.
Carefully check the first three pages of the medical record and critical, general nursing record sheets, surgical nursing record sheets and laboratory tests to ensure that the quality of the medical record, found that the problem of timely correction. Monthly outpatient, emergency, clinical, medical technology, non-clinical quality control report. Doing and completing the various tasks assigned by the head of the department every day.