Medical quality key links, key departments management standards and measures to implement the supervision form how to write

The township health center management year activity evaluation criteria

Public **** health service management part (160 points)

Strict implementation of the ** Provincial Township Health Center Public **** health service management regulations.

I. Public health office setup (10 points)

According to the requirements of the staffing of the public health office, operational rooms and related equipment and facilities, and the implementation of the treatment of public **** health staff.

Two, infectious disease outbreak reporting and management (20 points)

1 set up an infectious disease clinic, responsible for receiving and retaining infectious patients and suspected infectious patients. (5 points)

2The establishment of infectious disease register and laboratory test (including tuberculosis X-ray test) results register, fill in clear and complete. (3 points)

3 Timely collection, registration, verification and direct reporting of epidemic information on the Internet in accordance with the statutory time limit. (5 points)

4In accordance with the division of responsibilities, the implementation of cholera, tuberculosis, AIDS, schistosomiasis and other key infectious diseases prevention and control measures. (7 points)

Three, immunization planning (40 points)

1 Preventive vaccination clinics have waiting rooms and vaccination rooms, and each room is clearly marked. (5 points)

2Informationalized management of children's preventive vaccination. The rate of computerized entry and management of information related to preventive vaccination of target children within the jurisdiction is 100%. (10 points)

3 In accordance with the requirements of the Regulations on the Administration of Vaccine Circulation and Preventive Vaccination, the receipt, storage, transportation, distribution and use of vaccines are done properly. Refrigerators and freezers are managed by special personnel, vaccines are categorized and coded according to varieties, lot numbers and expiration dates, and temperature records are complete. (15 points)

4 preventive vaccination cards, certificates and books are complete, and the rate of full vaccination of children's immunization program vaccines is greater than 90% in the township as a unit. (10 points)

Four, emergency response to public **** health emergencies (10 points)

1 to establish and implement the reporting system for public **** health emergencies, duty and work records are complete. (5 points)

2 Assist the county-level health administrative departments and disease prevention and control agencies to carry out investigations and implement relevant preventive and control measures at the sampling office. (5 points)

V. Maternal and child health work (50 points)

1 held a regular meeting of village health care personnel once a month to grasp the basic situation of maternal and child health care in the townships, specializing in grass-roots time of no less than 15 days a month, the timely establishment of maternal health care manuals within the jurisdiction, correctly and completely fill out the work of the relevant tables, cards, books, and regularly report information on the work of maternal and child health statements. (11 points)

2 according to the regulations to complete the pregnancy situation, prenatal examination postpartum visit, the implementation of high-risk maternal card, tracking management and guidance to choose the delivery site tasks. Responsible for postpartum 42-56 days health check. The rate of pregnancy knowledge is greater than 95%, and the rate of management of high-risk pregnant women reaches 100%. (12 points)

3To do a good job of newborn visits, children under 7 years of age "4, 2, 1" regular physical examination or growth and development monitoring. The frail children found in the physical examination of children are managed on an ad hoc basis. The rate of case management is more than 60%. (10 points)

4 Township health centers that carry out technical services for hospital delivery, "** Provincial Township Health Center Obstetrics Construction Guidance Standards". (6 points)

5The implementation of graded management of maternity and the elimination of the interception of high-risk pregnant women. The rate of cesarean section in township health centers authorized to carry out cesarean section is controlled at 25% or less. (6 points)

6Promoting, mobilizing and assisting in the screening of newborns for diseases and prenatal screening and diagnosis. The issuance and management of Birth Medical Certificates is standardized. (5 points)

6 Rural health education (10 points)

1 Use of rural cable broadcasting, publicity windows, farmers' technical schools, health science and technology rushes and ethnic traditional programs to carry out health education. (3 points)

2 Carry out publicity on the prevention and control of infectious diseases, parasitic diseases, chronic non-communicable diseases, endemic diseases and occupational diseases. (4 points)

Seven, village health office management (10 points)

1 implementation of the integration of rural health service management focusing on public **** health services, strengthen the supervision of rural doctors in the area, regularly convene regular meetings of rural doctors, and coordinate the work tasks. (5 points)

2In accordance with the requirements of the **Provincial Rural Doctors Engaged in Public *** Health Services Labor Subsidy Measures, do a good job of performance appraisal and labor subsidy issuance for rural doctors engaged in public *** health services. (5 points)

Eight, public **** health management (10 points)

1. Mastery of the jurisdiction of the catering units and practitioners of the background, guidance to rural doctors to establish a rural meal information registration system and timely reporting, rural meal activities to carry out inspections and guidance. (5 points)

2. In accordance with the requirements of the "Medical Waste Management Regulations", the village health center under the jurisdiction of the medical waste disposal supervision. (5 points)

Clinical diagnosis and treatment service management part (300 points)

(1) establish and improve the post responsibility system for various types of personnel (15 points)

1. Combined with the actual situation of the hospital, the establishment of various types of personnel post responsibility, with information available. (15 points)

2. Various types of personnel are familiar with their respective job responsibilities, conscientiously fulfill their job responsibilities, sampling medical staff to answer the correct rate of 100%. (5 points)

3. Establishment of various types of personnel job performance appraisal system and implementation in place, with records available. (5 points)

(2) improve and implement the rules and regulations (35 points)

1. The establishment and focus on the implementation of the physician's room system, difficult case discussion system, consultation system, critical patient rescue system, bookmark discussion system, death case discussion system, checking the system, the handover system, talk to inform the system of the core system of quality and safety management of medical care, there are records to be found. (6 points)

2. Strictly implement the Hunan Province, "rural medical institutions, medical writing standards and management regulations". Medical records written in a timely, accurate, complete, standardized, sampling medical records pass rate of 100%, the rate of good medical records is greater than or equal to 90%, admission and discharge diagnosis compliance rate is greater than or equal to 90%. (10 points)

3 prescriptions in strict accordance with the prescription writing requirements, random sampling of outpatient prescriptions and medical records: prescription qualification rate of greater than or equal to 90%, the proportion of clinical diagnosis documented 100%. (8 points)

4. Strengthen the medical quality management of surgical cases. Diagnostic compliance rate before and after surgery is greater than or equal to 90%, the rate of healing of sterile surgical incision grade A is greater than or equal to 90%, and the infection rate of sterile surgical incision is less than or equal to 1%. (5 points)

5. Strictly comply with the diagnosis and treatment routine and operation procedures. Strengthen the management of outpatient (emergency) diagnosis and treatment, complete the common first-aid medicines and equipment, and keep them in a good state of reserve, to ensure that the outpatient (emergency) diagnosis and treatment in a timely and effective. Standardize the referral pointers and referral procedures for referred patients. Records are available. (6 points)

(C) the establishment of medical quality management system (25 points)

1. Clearly the director of the health center as the first person responsible for the management of medical quality, fully responsible for the quality of medical work. (5 points)

2. According to the size of the health center, in conjunction with the actual clear one full-time or part-time management personnel specifically responsible for medical quality supervision, exercise guidance, inspection, assessment, evaluation and supervision functions. (5 points)

3. Develop and implement systems for medical quality supervision and management, inspection and evaluation, analysis and evaluation, and information notification. Regular medical link quality inspection, evaluation and notification, corrective measures are implemented. Records are available. (10 points)

4. The development and implementation of medical quality management measures, medical quality continuous improvement program and medical quality inspection and evaluation standards. Records are available. (5 points)

(4) Strengthening the management of medical service safety (20 points)

1. In accordance with relevant laws and regulations, combined with the hospital's weaknesses in medical safety, the hospital regularly carries out education on medical service safety, and regularly carries out analysis of the quality of medical care and safety of medical services (once every quarter). (5 points)

2. Strengthen the management of medical safety, formulate and implement the system of acceptance, investigation, treatment and feedback of medical disputes and complaints, make clear that a part-time staff is specifically responsible for it, and do not hand over the contradictions and do not shirk their responsibilities. Records are available. (5 points)

3. Health centers and individuals signed a medical quality and medical safety certificate of responsibility, the responsibility is broken down to the person, the implementation of medical quality and medical safety responsibility and accountability system, accountability to the person. Records are available. (5 points)

Development and implementation of medical accident prevention plan and handling plan, with information available. Timely reporting of medical disputes, medical incidents and acts of gross medical negligence. The reporting rate of major medical negligent behavior and medical malpractice is 100%. (5 points)

(E) Strengthening the "three basic" training, mastery and use of appropriate technology in rural health (35 points)

In accordance with the requirements of the "Three Strictures", the ** Provincial Department of Health, "Township Health Center Medical Staff", "Three Basic" training, "Three Basic" training, "Three Basic" training, "Three Basic" training, "Three Basic" training, and the use of appropriate technology in rural health. The "Three Fundamentals" training guide of the ** Provincial Department of Health is the basis for strengthening the "Three Fundamentals" training of medical personnel in township health centers.

1. Establishment of the "three basic" training system and assessment of rewards and punishments, the development of the "three basic" training program, there are specific training arrangements and training records. (5 points)

2. Health centers to organize their own quarterly "three basic" theoretical examination, organized every six months "three basic" skills assessment, examination papers and records can be found. (6 points)

3. Supervision and inspection of a random sample of medical personnel "three basic" theory examination pass rate greater than or equal to 80%. (7 points)

4. In accordance with the requirements of the **Provincial Rural and Community Health Appropriate Technology Training Manual, each physician is able to master and use more than 10 rural appropriate technology. (10 points)

(F) Strengthen nursing management, improve the quality of care (80 points)

1. Improve the nursing management system. According to the size of the health center, set up the nursing management responsible person or nursing department, nursing management under the leadership of the director of the nurse or nursing department director responsibility system. Nursing manpower allocation in line with the relevant provisions, can meet clinical needs. (10 points)

2. In accordance with the requirements of the "Nursing Work Standards for Township Health Centers" prepared by the Hunan Provincial Department of Health, the nursing work system, nurses' job duties and work standards, nursing routines for common diseases and common nursing techniques and procedures are established and implemented. There are records and information available. (20 points)

3. Transform the nursing mode of work, strengthen the clinical basic care, the implementation of "patient-centered" service purpose and humane nursing service measures, provide rehabilitation and health guidance. Basic nursing pass rate is greater than or equal to 90%. (5 points)

4. Formulate standards for evaluating the quality of nursing care, regularly inspect and evaluate the quality of nursing care, enhance the quality consciousness of nursing staff in township health centers, and improve the quality of nursing care and the level of nursing services. (15 points)

5. Strengthen the management of operating rooms, labor and delivery rooms and supply rooms. Service construction, equipment configuration and functional needs, room layout and workflow is reasonable, in line with the requirements of the prevention and control of hospital infections. (10 points)

6. Strengthen nursing staff in-service training and continuing medical education. Develop training programs for nursing staff, including in-hospital training, academic education, advanced training in higher hospitals and study visits, etc., to improve the overall level of the nursing team. Records are available. (10 points)

(VII) Chinese medicine service management (35 points)

1. Strictly implement the Ministry of Health, the State Administration of Traditional Chinese Medicine "township health centers Chinese medicine service management of the basic norms" and the Provincial Department of Health "** Provincial township health centers Chinese medicine department construction standards", to strengthen Chinese medicine department of the Chinese medicine pharmacy construction and management, Chinese medicine department of the setup, equipment and Chinese medicine professional staff Configuration, etc. are in line with the requirements. (10 points)

2. Providing basic Chinese medicine medical services, applying Chinese medicine theories in outpatient clinics, wards and outpatient clinics to deal with more than 35 kinds of common diseases, multiple diseases and chronic diseases; Chinese medicine services shall account for more than 25% of the total medical services of the hospital. (8 points)

3. More than 5 types of Chinese medicine appropriate technology such as traditional Chinese medicine and acupuncture, tuina, fire pot, compress, gua sha, fumigation, acupoint injection, hot ironing, etc. shall be utilized in the medical clinic and rehabilitation and health care services. It can provide 100 kinds of proprietary Chinese medicines and more than 300 kinds of Chinese medicine tablets to meet the needs of clinical medication, and the sales of Chinese medicines account for more than 30% of the total sales of medicines. (7 points)

4. Strictly abiding by the national principles of diagnosis and treatment of Chinese medicine, technical standards and operation norms. (5 points)

5. Fully apply the knowledge of traditional Chinese medicine to prevent various infectious diseases, carry out more than two kinds of integrated services using traditional Chinese medicine technology to prevent and treat diseases, and participate in health guidance and behavioral intervention using traditional Chinese medicine theories and techniques; take various forms to publicize the popular knowledge of traditional Chinese medicine in disease prevention and health care. (5 points)

(VIII) Clinical drug management (30 points)

1. Strengthen the management of the use of antimicrobial drugs (***13 points).

Strictly implement the Ministry of Health's "Guiding Principles for the Clinical Application of Antimicrobial Drugs", and establish and improve the management system for the rational use of drugs. The development and implementation of the hospital's clinical application of antibacterial drugs hierarchical management system. There is information available. (2 points)

Outpatient prescriptions and inpatient instructions strictly control the irrational combination of antimicrobial drugs, advocate the use of single use, more than two kinds of caution, more than three kinds of prohibited. Patients using tertiary antimicrobial drugs must have records of consultation and discussion with experts from higher hospitals or with doctors from the hospital. Respectively sampling inpatient medical records and discharge medical records of five, a death medical records, inpatient medical records, the selection of antimicrobial drugs, change of use, discontinuation of use must be documented (5 points each, *** 10 points)

Surgical perioperative medication must be in accordance with the requirements of the guiding principles for the clinically rational use of antimicrobial drugs strictly, special circumstances must be signed by the director of the Department of Medical Records and recorded in the medical records (1 point)