Hospital grading management standards is the objective basis for China's hospitals to achieve standardized management. The implementation of hospital hierarchical management, can strengthen the macro management of medical and health services and hospital micro management of the dual mechanism, improve the function of hospitals at all levels, sound, consolidate the three-tier medical prevention system, better play the overall effect, to achieve the full and rational use of the limited health resources, to promote the development of science and technology, and to strengthen the construction of medical ethics and medical style, and constantly improve the quality of medical care, and better service for the people's health. At the same time can also mobilize the enthusiasm of all parties to support the development of health care. Hospital hierarchical management is a major reform of the hospital management system.
"General hospital management standards" is from the actual situation in China, guided by the theory of modern scientific management, summed up China's three-tier medical and health network construction and the creation of "civilized hospital" activities, by the Ministry of Health, the Ministry of Health Department of Medical Affairs organization of the eleven provinces, municipalities, and the Chinese Academy of Medical Sciences, Beijing Medical University, etc. After thorough research and validation of the draft. It was drafted by the Department of Medical Affairs of the Ministry of Health, organizing eleven provinces, cities, the Chinese Academy of Medical Sciences, Beijing Medical University and other units, after thorough investigation, research and argumentation. The relevant issues are explained as follows:
1. Basic standards for hospitals at all levels: This standard is the standard that hospitals at all levels must meet, but also the qualification criteria for hospitals. Basic standards are assessed and evaluated separately, separate from the assessment and scoring of graded standards. If you do not meet the requirements of the "basic standards", not pass, as unqualified hospitals, new applications for the opening of the hospital will not be approved.
2. Hospitals at all levels of grading standards: according to the different tasks and functions, the hospital is divided into three levels, namely, the first level of hospitals, second level hospitals and third level hospitals. Also according to the level of technical level, quality level and management level of hospitals at all levels, and with reference to the necessary facilities and conditions, respectively, are divided into A, B, C, and the third-level hospitals to add a special class.
3. Assessment of the determination criteria: the establishment of the mathematical model scoring method before the temporary adoption of the thousand-point system method of assessment. In the review, qualified hospitals according to the total number of points to assess the grade.
Class A: the standardized assessment of classification must reach 900 points or more (including 900 points).
Grade B: The standardized assessment of grading must reach 750 to 899 points.
Grade C: The standardized assessment of grading shall be less than 749 points (including 749 points). (Including 749 points)
Tertiary specialized hospitals must meet the conditions necessary for hospitals in addition to meeting the standards for tertiary specialized hospitals.
4 . Hospital accreditation application: is the hospital to the accreditation committee to apply for the necessary procedures, but also the accreditation committee to determine the hospital accreditation qualifications of the main basis. Requirements of the hospital must be serious, realistic and fill out the item by item, declaration.
5. Standards of other relevant annexes: is the standard specific indicators, requirements and assessment and inspection points such as the description.
The formation of the "general hospital grading and management standards" is still very imperfect, only as a draft in the country on a trial basis. I hope that in the trial implementation of the standard in all parts of the revised opinions, so that it will be gradually improved.
Health centers, primary hospitals (level 1 hospitals) standards
Level 1 hospitals are primary health care institutions that directly provide medical, preventive, health care and rehabilitation services to communities with a certain population (≤ 100,000), and are the primary health care institutions that implement primary health care and realize the global goal of "health protection for all" in China. It is the primary health care organization that implements primary health care in China and realizes the global goal of "health security for all".
Basic standards for first-class hospitals
These standards are essential for the qualification of first-class hospitals, and only those who have reached the qualifying line of these standards can participate in the grade review.
Basic standards include the following seven aspects:
I. Scale of the hospital
Scale of the hospital should be compatible with the function, mission and management requirements of the first-class hospital.
1. The number of hospital beds shall not be less than 20. If it is less than the above limit, a reasonable explanation must be given.
2. The necessary facilities per bed unit in the ward meet the prescribed requirements (see Annex VI).
3. The floor area per bed is not less than 45 square meters.
4. The ratio of hospital beds to the number of regular hospital employees: 1:1-1.4.
5. The ratio of health technicians to the total number of employees in the hospital is 80-85% (non-health technicians, not allowed to engage in medical care, medical technology and nursing technology.)
II. Hospital functions and tasks
The first-level hospital shall undertake all medical and health services and certain health administrative work in the community.
(I) preventive health care
1. To do a good job in the community health epidemic prevention and control work, including planned immunization, infectious diseases, parasites and endemic diseases, under the guidance of the higher level of health epidemiological departments, the implementation of health supervision and management work.
2. Actively carry out maternal and child health care work, carry out women's, infants and children's disease screening and treatment, to carry out marriage, childbearing, maternity system of health care, and to promote the scientific midwifery and other work.
3. To do a good job in family planning surgery and technical guidance.
4. To carry out health education in various forms, popularize health knowledge on factors that endanger the health of the community, and improve the self-care ability and overall health of the population.
(2) medical services
1. To complete the outpatient and inpatient (including family hospital beds) diagnosis and treatment of common and frequent diseases in the community, to provide emergency, serious and critical patients with life-sustaining signs of rescue, and to organize referrals.
2. Popularize first aid knowledge and techniques among the public, and in-hospital medical staff must master effective hands-only cardiopulmonary resuscitation (Hands-Only CPR).
3. According to the conditions to carry out community rehabilitation medicine, mental health services, chronic non-communicable diseases of the population control.
(C) health administration
1. Under the leadership of the local government and higher health administrative departments, based on the local socio-economic development plan, to assist in the development and implementation of community primary health planning.
2. With the relevant departments to mobilize and organize the masses to carry out patriotic health activities, and gradually improve the community health situation.
3. To carry out the implementation of various national health laws and regulations, and to supervise and manage the relevant industries in the community.
4. To be responsible for the management and technical guidance of village-level health organizations and individual practitioners, and to train village doctors, health workers and midwives.
Three, hospital management
The hospital should have a sound management system, with appropriate systems, measures, supervision, assessment and evaluation. Some people are responsible for the division of labor and administrative management. Business management and ideological and political work.
(a) the necessary system
According to the 1982 Ministry of Health issued the "National Hospital Work Regulations, Hospital Work System and Hospital Staff Duties," the relevant provisions of the hospital, combined with the actual hospital, must be carefully formulated and strictly enforced rules and regulations, including:
1. In addition to the general hospital work system, should include maternal and child health care, health epidemiology, family hospital beds work system, guiding rural doctors and other work system.
2. All levels and types of personnel job responsibility system.
3. Various technical operating procedures.
4. Continuing education system for employees.
(B) information management
1. According to the Ministry of Health, "health statistics system (for trial implementation)" with the provisions of the comprehensive information management special (part-time) staff.
2. Timely collection, storage, analysis, feedback and utilization of information, and effective.
3. There is a library management system, ordered an appropriate amount of medical books and journals.
(3) Financial management
1. There is a financial organization or full-time accounting staff.
2. Accounting vouchers, books and statements are in accordance with the accounting system.
3. Establishment of accounting records and management system.
4. Accounting supervision and audit system is sound, strict compliance with financial and price discipline, and no arbitrary charges.
(4) equipment management
1 . Set up a full-time or part-time staff to manage the equipment of the whole hospital.
2. There is a medical equipment storage, use, maintenance, regular repair system to ensure that the needs of medical work.
3. The file established for important equipment.
(E) general management
1. General supplies are managed on a quota basis, and there is a sound system of purchasing, acceptance, warehousing, distribution, and scrapping.
2. Proactive, timely service for the whole hospital, to ensure that water, electricity, quilts, meals supply, all kinds of facilities timely maintenance.
(F) building management
1. Hospital buildings in line with the requirements of hygiene, old buildings have a maintenance system, unreasonable buildings have a remodeling plan.
2. Dangerous buildings shall not be used, and in particular, medical activities shall not be carried out in them.
Four, quality management
(a) There are full-time (part-time) staff responsible for the quality management of the whole hospital, and the establishment of a sound level-by-level quality assurance system.
(2) There is a hospital-wide quality management program, and seriously implemented.
(3) Control of nosocomial infections:
1. The infection control organization should be in accordance with the provisions of the 1988 Ministry of Health Interim Measures for the Establishment of a Sound Hospital Infection Management Organization.
2. There is a hospital-wide infection control program.
3. Establishment of strict disinfection and isolation and infectious disease registration and reporting system and aseptic operation regulations.
4. There is a hospital infection control education system, health care workers must establish the concept of asepsis and correct aseptic technical operation.
5. There is a rational use of antibiotics management methods.
6. There are measures to protect special areas (such as operating rooms, treatment rooms, supply rooms, labor and delivery rooms, etc.).
7. Sterilization supply room should meet the requirements of the Ministry of Health's "Hospital Sterilization Supply Room Acceptance Standards (Trial)".
V. Ideological and political work and medical ethics construction
1. Implementation of the Party's line, guidelines, policies, party, government, industry and trade unions **** management, development of ideological work and medical ethics and medical ethics construction plan, and organization and implementation.
2. With ideological and political work management system and the corresponding work system.
3. To conscientiously implement the "medical ethics of medical personnel and the implementation of the norms", to carry out and adhere to the pre-post education system.
4. Establishment of mass supervision system.
5. According to the survey, the satisfaction of patients, communities or contracted units to the hospital meets the requirements.
6. There are sound measures for the clean practice of medicine.
6. Hospital safety
1. Establishment of a sound hospital safety and security management system, and a full-time or part-time staff responsible.
2. Develop usual and emergency security management program, and regular inspection.
3. There are special safety management measures for high-pressure systems, operating rooms, radiology rooms, distribution rooms and other high-risk equipment and areas.
4. Equipped with necessary fire-fighting equipment.
5. There is a management system for highly toxic, narcotic and psychotropic drugs, which is strictly enforced.
6. Lighting system in the event of an accident, there is a safe alternative source of light to ensure the need for emergency.
7. Hospital environment
1 . Attaching importance to hospital cleanliness and hygiene, there are cleaning system and measures, there is a person in charge.
2. Smoking is prohibited in outpatient clinics, wards and other medical areas.
3. Attention to greening in the hospital, there is a green area (including indoor and outdoor planting of flowers and trees, three-dimensional greening) with the hospital occupies the appropriate area.
4. Harmless treatment of dirt and sewage, and the treatment meets hygienic standards.
5. Outpatient noise is no higher than 50 decibels, and noise in wards and operating rooms is no higher than 38 decibels.
6. General lighting in the operating room is 100 meter candles, and the comprehensive lighting of the working area is 2000-3000 meter candles.
First-class hospital grading standards
This standard is a standard for the construction and development of first-class hospitals, as well as its level and quality of evaluation basis.
I. Departmental Settings
Departmental settings should be adapted to the functions, tasks and actual needs of the community of a first-class hospital.
1. Clinical sciences: internal medicine, surgery, obstetrics and gynecology, emergency room should be set up. If there are conditions to set up pediatrics, five palace department, Chinese medicine, family hospital bed section (group), etc..
2. Medical and technical departments: should be set up in the pharmacy (including mixing room), laboratory (test centers can not be required to have a unified arrangement), radiology, operating room, disposable room, supply room, medical records and statistics room, library and so on.
3. Administrative section: set up the hospital office (responsible for medical, nursing, personnel, secretarial, security, finance, logistics, etc.).
4. Preventive health care (section): set up health prevention room, maternal and child health room (including family planning technical guidance).
II. Staffing
To achieve the ratio of beds to personnel in the basic requirements. Among them, the ratio of each type of personnel is as follows:
Personnel of all kinds
Administrative workers%
Health technicians%
Among them, various types of health technicians
Chinese and Western medical doctors (doctors)
Nursing%
Inspection%
Radiology%
Pharmaceuticals%
Others%
Other%
15-20
80-85
38
38
4
4
8
8
Of these, the division of labor in preventive health care accounted for more than 25% of the health technicians.
Three, technical level
Technical construction should be practical, able to carry out the diagnosis and treatment of common and frequent diseases in various disciplines in the community, and the ambulance service for the general critically ill. Basic requirements:
(a) medical
1. Emergency medical treatment:
The emergency cases in the community can be 24-hour response (including outpatient).
2. Internal medicine and pediatrics:
Correctly handle common illnesses and be able to appropriately handle and refer difficult cases.
Able to make initial diagnosis and perform life-sustaining resuscitation treatment for circulatory, urinary and respiratory failure, acute poisoning and shock and other general emergency patients.
Masters the treatment of local infectious diseases and sterilization and isolation techniques.
3. Surgery, obstetrics and gynecology:
Can make clinical diagnosis and timely and correct treatment of surgical emergency abdomen.
Can perform general upper abdominal surgery.
Capable of completing surgical management of hemostasis, suturing, bandaging, and fracture fixation.
Capable of completing the management of physiologic obstetrics, some common pathologic obstetrics, and cesarean section.
4. Pentacenter:
Can diagnose and treat common diseases and some emergencies in this department.
Preventing blindness, caries and deafness.
5. Department of Traditional Chinese Medicine:
Can diagnose and treat common diseases in internal medicine, external medicine, gynecology, pediatrics and some difficult cases.
To carry out acupuncture, massage and so on.
6. Nursing
Skilled in the care of various diseases, strict implementation of the technical procedures.
Doing good ward management and hierarchical care, correctly writing five kinds of nursing forms (temperature list, medical orders, medical records, nurse shift, nursing records).
7. Medical technology department:
Able to carry out electrocardiogram and ultrasound.
Can carry out blood, urine, stool routine tests and some biochemical tests.
(Testing centralized areas, the relevant arrangements to have a contract)
Capable of carrying out fluoroscopy, photographic film, general gastrointestinal imaging and other tests.
(2) preventive health care
1. Can carry out immunization programs, epidemic treatment, "two management of the five changes" technical guidance.
2. Being able to carry out perinatal health care, children's systematic health care, and mastering the four techniques of family planning.
3. Be able to carry out community chronic non-communicable disease prevention and treatment, geriatric health care, mental health and community rehabilitation medicine.
(3) Teaching
1. To be able to train village doctors, health workers and midwives.
2. Able to accept students from health schools for some clinical studies.
4. Hospital Management
1. The director should be familiar with the management of a first-class hospital and have undergone short-term training in hospital management.
2. The hospital has a long-term development plan and specific implementation steps.
3. Hospital employees ≥ 80% satisfaction with the work of the hospital leadership.
4. Community, contracted units and patient satisfaction with the hospital ≥ 80%.
5. Information management:
Mastering the incidence of various infectious diseases in the population and establishing a sound system of registration and reporting of infectious diseases. Registration rate ≥ 95%, omission rate ≤ 0.5%.
Do a good job of hospital statistics, equipped with statisticians to grasp the community population, life, disease (multiple, chronic, endemic) dynamic information, timely analysis and countermeasures; timely and accurate completion of a variety of health statistics according to the provisions of the report.
Establishment of case management system, a full-time or part-time staff responsible for, and gradually according to the International Classification of Diseases (ICD) management, requiring outpatient medical records, inpatient writing a complete medical record; written according to the standard, grade A medical records ≥ 80%, to eliminate grade C medical records.
V. The basic equipment of the main departments is detailed in (Annex VII).
VI. Statistical indicators
1. Diagnosis of admission and discharge diagnosis compliance rate ≥ 85%
2. Diagnosis of pre- and post-surgery compliance rate of ≥ 95%
3. Outpatient referral rate of ≤ 20%
4. Cure and improvement rate of a single disease: compared with the same level of hospitals in the average level
5. The rate of death of single disease: compared with the average level of peer hospitals
6. The rate of successful rescue of critical patients with single disease: compared with the average level of peer hospitals
7. The rate of transfer of hospitalized patients ≤ 3%
8. The rate of qualified nursing operation ≥ 85%
9. The number of bedsores of comatose and paralyzed patients: 0
10. 3%
11. Sterile surgical incision infection rate of ≤ 1%
12. One person, one needle, one tube implementation rate of 100%
13. Routine instrument disinfection bacterial qualification rate of 100%
14. Bed utilization rate of ≥ 60%
15. Annual turnover of beds ≥ 32 times
16. Average hospital stay of 6 days
17. p>17. Outpatient prescription rate ≥ 98%
18. Outpatient medical record writing rate ≥ 90%
19. Inpatient medical record writing rate ≥ 98%
20. Grade A X-rays ≥ 40%
21. Nursing care of the five forms of writing a qualified rate of ≥ 85%
22. Level 2 or higher medical liability accidents Number of occurrences 0
23. equipment utilization rate of ≥ 80%
24. special diagnostic equipment ≥ 20% positive rate of examination (mainly refers to ultrasound)
25. 0 to 7 years old children's card rate in rural areas ≥ 98% in urban areas ≥ 100%
26. live measles vaccine vaccination rate of ≥ 90% in rural areas ≥ 95% in urban areas
27. Polio vaccine vaccination rate in rural areas ≥90% urban ≥95%
28. DPT vaccination rate in rural areas ≥90% urban ≥95%
29. BCG vaccination rate in rural areas ≥90% urban ≥95%
30. The full coverage of the four vaccines ≥85% in rural areas and ≥92.5% in urban areas
31. ≥60% urban ≥90%
32. perinatal mortality rate rural ≤20% urban ≤90%
33. prenatal checkup rate rural ≥80% urban ≥95%
34. new method of delivery rate of ≥95%
35. postnatal visit rate rural ≥70% urban ≥80%
36. health technicians three basic assessment rate of 100%
36. Qualified rate of health technicians 100%
37. 100% of first aid items in good condition
38. ≥80% qualified rate of basic nursing care
39. ≥80% qualified rate of first-level nursing care
First-level hospital grading criteria
Hospitals should conduct self-evaluations on a regular basis of their construction, management, technical level, quality of work, civilized service, cost-effectiveness, etc., and formulate improvement measures. Conduct self-evaluation and formulate improvement measures. The local (municipal) hospital accreditation committee conducts out-of-hospital evaluation of hospital quality according to this standard. According to the evaluation results of the first-class hospitals are divided into A, B, C three grades.
I, a first-class hospitals
Hospital construction achievements are remarkable, departmental settings, staffing, management level, technical level, quality of work and basic hospital facilities and other combined level, the assessment reached 900 points and above.
Second, the first class B hospital
Hospital construction achievements are still good, its departments set up, staffing, management level, technical level, quality of work and basic hospital facilities and other combined level of assessment and inspection reached 750-899 points.
Third, first-class C hospitals
Hospital construction has some achievements, the basic standards of the assessment is qualified, but there is still a large gap between the requirements of the sub-class standards. After a comprehensive assessment and inspection at 749 points or less (including 749 points). Grade C hospitals should have practical improvement measures and development planning.
Second-grade hospital standards
Second-grade hospitals are health institutions that provide medical, preventive, health care, and rehabilitation services to multiple communities (whose radius populations are generally over 100,000), and they are the intermediate level of the three-tiered health care system.
Basic Standard for Level II Hospitals
This standard is a necessary condition for validating the qualification of Level II hospitals, and only those who have reached the qualifying line of this standard can take part in the level assessment.
I. Scale of the hospital
There should be a scale of the hospital that is compatible with the mission, function, technical level and management requirements of the second-level hospital.
1. No less than 100 beds.
2. Each bed unit necessary facilities to meet the prescribed requirements (see Annex VI).
3. Each bed floor space of not less than 45 square meters.
4. The net usable area per bed unit is not less than 5 square meters.
5. Daily average of outpatient visits per outpatient building area of not less than 3 square meters.
6. The ratio of beds to the number of hospital employees is 1:1.3-1.5.
7. Must be equipped with nationally recognized qualifications of health professionals. Health technicians account for no less than 75% of the total number of employees in the hospital.
Two, hospital functions and tasks
(a) medical and health services
To the community can provide comprehensive and continuous medical care, preventive health care and rehabilitation services.
1. Undertake the region (prefecture, city, county) within the common diseases, common diseases and more difficult to diagnose and treat the task; rescue acute and critical illnesses; accept the first level of medical and health institutions referrals.
2. Carrying out daily pre-hospital first aid; undertaking on-site first aid for disaster accidents, and rapidly organizing matching first aid teams to receive batches of patients for in-hospital first aid.
3. Carrying out health education and mastering the disease dynamics in the community. Participate in preventive health care and rehabilitation services in the community.
(2) Teaching and research work in conjunction with medical treatment
1. Be able to undertake further training and training of various types of health technicians in the primary health care units and on-the-job education for the staff of the hospital.
2. It can undertake clinical teaching in secondary health schools and clinical internships for students in medical and health schools above the secondary level.
3. Be able to undertake provincial or municipal research projects.
(3) Guiding the grass-roots level
Collaborating with the relevant departments to guide the primary medical and health care units in the region to do a good job in community treatment, preventive health care, rehabilitation and mental health. It establishes regular business relationships with first-level hospitals, carries out two-way referrals, helps develop new technologies, solves difficult problems and trains health technology and management personnel.
Third, hospital management
Hospitals should have a sound management system, with the appropriate organizational structure, personnel, systems, measures, implementation of the program and its assessment and evaluation methods.
(a) organizational management
Necessary are:
1. administrative management organization
2. medical, preventive, teaching, research management organization
3. nursing management organization
4. financial management organization
5. general security organization
6. ideological and political work and professional ethics Education Management Organization
7. Necessary Committees
(2) System Management
According to the requirements and relevant provisions of the "National Regulations on Hospital Work, Hospital Work System and Duties of Hospital Workers" issued by the Ministry of Health in 1982 and taking into account the actual situation of the hospital, it is necessary to formulate a set of practicable rules and regulations and to have the corresponding education, implementation, supervision, inspection, evaluation, rewards and punishments. The system should include:
The system should include The necessary systems should include:
1. hospital work system
2. all levels and types of personnel job responsibility system
3. various technical procedures
4. staff continuing education system
(3) administration
1. there is a sound administrative organization, there is a hospital leader in charge of administrative work.
2. There is a long-term development plan, annual work plan, quarterly arrangements and the progress of the completion of the plan, indicators, measures, steps, as well as checking the summary.
3. Hospitals have a variety of administrative management system, and organization and implementation. The necessary systems are: the meeting system, the hospital general duty system, medical and administrative inspection system, paper file management system.
4. There are the masses to register letters to the room, visits, hospital records.
5. Hospital leaders should often go into the department, the community to understand the situation, to seek advice to improve the work.
(D) medical management
1. There is a sound medical management organization, staffing is reasonable, there is a corresponding work system, there is a deputy hospital in charge of medical work.
2. Developing practical medical construction plans and work plans for the whole hospital and organizing their implementation.
3. There is a sound medical work system, practical technical procedures and quality standards of medical care.
4. Establishment of a sound medical quality management organization, regular activities, medical, nursing, medical technology quality supervision, inspection, evaluation, and put forward ideas for improvement. The necessary quality management organizations are: medical care quality management committee, pharmacy management committee, hospital infection control committee, case management committee.
5. Strengthen the technical training and assessment of operational personnel, and establish the operational and technical files of health technicians.
6. Non-state-recognized qualifications of technical personnel shall not be directly engaged in medical medical technology and nursing technology.
(E) Nursing Management
Managed in accordance with the relevant requirements of the Nursing Management Standards and Accreditation Methods.
(F) Teaching and Research Management
Teaching:
1. There is a sound teaching management organization, and there is a leader of the hospital who is responsible for teaching management.
2. There are practical teaching planning and work plan, and organization and implementation.
3. There is a sound teaching work rules and regulations, to achieve supervision, inspection and evaluation.
4. There are appropriate teaching facilities and equipment.
5. "Teaching hospitals" recognized by the Ministry of Health, according to the Ministry of Health "National Higher Medical Schools Teaching Hospitals Interim Provisions" (to be issued) for management.
Scientific research:
1. There is a full-time (part-time) staff responsible for scientific research management and a corresponding work system.
2. Establishment of scientific and technological personnel, scientific research results files.
3. Encourage the development of medicine and management of scientific research.
(VII) information management
1. There is a sound information management organization and related work system.
2. There should be a library (room) and a sufficient number of medical books and periodicals.
3. There are full-time managers who deal with medical, management and library information.
4. The information provided by all departments in the hospital should be true, complete and accurate, and timely analysis, feedback and utilization.
(VIII) measurement management
According to the "Chinese People's *** and State Measurement Law", the hospital must strengthen the measurement of work management.
1. There are responsible for measuring the management of the department or personnel.
2. Establishment of the relevant measurement management system, including:
(1) measurement management approach.
(2) measurement of personnel responsibilities.
(3) measuring instruments cycle verification system.
3. The use of national legal units of measurement.
4. In the use of mandatory calibration of measuring instruments should be carried out cycle inspection.
(IX) financial management
1. There are financial institutions, reasonable staffing, clear scope of responsibility, and a sound job responsibility system and work system.
2. There is a full-time (part-time) fee management personnel, strict implementation of medical fee standards, the implementation of price tags, and accept public supervision.
3. Accounting vouchers, books, statements in line with the accounting system.
4. Establishment of accounting files and management system.
5. There is a sound financial and accounting supervision system, the violation of financial and price discipline should be dealt with promptly and seriously.
(J) audit management
1. There is an audit organization parallel to the financial institutions or rank corresponding to the audit staff, staffing is reasonable, and has a certain audit expertise.
2. Regular audit supervision of financial income and expenditure and related economic activities.
3. Supervision and inspection of the safety and integrity of funds and property, as well as the soundness and effectiveness of the internal control system.
4. Regularly check and evaluate the efficiency of the use of funds and property and make recommendations for improvement.
5. No major loss and waste, embezzlement and theft and serious violations of financial regulations.
(XI) equipment management
1. There is a sound management organization, the implementation of program management.
2. More than 10,000 yuan of large precision instruments to be purchased to have the appropriateness and feasibility of the demonstration, the purchase to acceptance, the use of a person to keep.
3. Medical equipment has a regular maintenance, repair and update system to ensure that medical work needs.
(XII) general management
1. There are sound general management organization, job responsibilities and work system.
2. General supplies are managed on a quota basis, and there is a sound system of purchasing, acceptance, warehousing, distribution, and scrapping.
3. Proactive and timely service for all departments in the country, especially clinical departments, to do the three under (under the receipt, under the delivery, under the repair), to ensure that the three through (water, electricity, gas), not two leaks (leakage of water, leakage of electricity), and to do the two satisfaction (staff, patient satisfaction).
4. There are unexpected power supply measures to ensure temporary lighting.
5. Ambulances are equipped with basic equipment and medicines and are on call to ensure medical treatment, rescue and transfer of patients.
(xiii) building management
1. The hospital's new construction, remodeling and expansion, after feasibility studies, to adapt to the overall development plan, the information is kept intact.
2. New hospital site selection, layout, design should be reasonable, in line with building codes and hygiene requirements.
3. The architectural layout of the hospital parts (outpatient department, inpatient department, medical and technical departments, operating room, disinfection and supply room, emergency department (room)) and the flow of people are reasonable. (Indoor lighting, color design in line with the requirements of hygiene).
4. Old hospital buildings have maintenance plans and budgets, and seriously implemented. Shall not engage in medical activities in dangerous buildings.
4. Quality management
(a) The hospital should have a practical quality management program.
(B) there are hospitals and departments at the two levels of quality management organization.
(3) quality management focuses on: medical, nursing, medical technology, teaching, research and case quality.
(4) There are quality education, supervision, inspection and evaluation systems and improvement programs.
(v) Nosocomial infection control
1. The infection control organization shall be in accordance with the Interim Measures for the Establishment of a Sound Hospital Infection Management Organization issued by the Ministry of Health in 1988.
2. There are hospital-wide infection control programs, countermeasures, measures, effects and evaluation.
3. Establishment of strict sterilization, isolation and infectious disease registration and reporting system. The setup of infectious disease room should be in accordance with hygienic requirements.
4. There is an on-the-job education system for nosocomial infection control, and health care workers must establish the concept of asepsis and perform correct aseptic technical operations.
5. There is a rational use of antibiotics management.
6. There are measures to monitor the cleanliness of special areas (such as operating rooms, sterilization supply rooms, delivery rooms, baby rooms, neonatal wards, treatment rooms, etc.).
7. On-site inspection to meet the specified requirements.
V. Ideological and political work and medical ethics construction
1. A strong ideological and political work management system and the corresponding work system.
2. To formulate plans on ideological and political work and medical ethics and medical style construction, and organize the implementation.
3. Implementation of the party's line, guidelines, policies, party, government, workers, and the management of the ****, and do a good job of regular ideological and political work of the whole hospital staff, and regularly organize learning, research, analysis and summary.
4. conscientiously implement the "medical personnel code of medical ethics and implementation measures", there are medical ethics education measures. Strictly implement the pre-service education system.