Guiding ideology
Thoroughly implement the spirit of the Seventeenth National Congress of the Communist Party of China and the Fourth Plenary Session of the Seventeenth Central Committee and the State Council's opinions on deepening the reform of the medical and health system, adhere to the guidance of Scientific Outlook on Development, adhere to the people-oriented principle, continue to take patients as the center, ensure the quality and safety of medical care, safeguard the legitimate rights and interests of patients, improve medical services, optimize service processes and build a harmonious doctor-patient relationship in accordance with the relevant requirements of deepening the reform of the medical and health system. Efforts should be made to provide the people with safe, effective, convenient and cheap medical services, and constantly improve the quality of medical care, medical services and hospital management to ensure medical safety.
Scope and theme of the activity
All kinds of medical institutions and blood collection and supply institutions at all levels throughout the country, focusing on public hospitals.
Activity theme: "Continuously improve quality and ensure medical safety".
Activity content and main requirements
The activity of "medical quality goes to Wan Li Road" focuses on system construction, publicity and education, and is combined with the activity of hospital management year and the creation of "safe hospital" to promote construction and ongoing construction. The goal of the activity is to improve the quality of medical care, promote medical safety, improve medical services, optimize the medical environment and harmonize the relationship between doctors and patients. The core is "continuous improvement of medical quality".
(a) continue to carry out multi-level and multi-form publicity and education, and strengthen the awareness of medical quality, medical service and medical safety.
1. Health administrative departments and medical institutions should continue to strengthen medical quality and safety education and related training for medical staff, and further improve their awareness of medical risks and medical safety responsibilities; Continue to strengthen the management and education of the principal responsible persons, quality and safety managers and all staff of medical institutions, update the concept of quality and safety, and improve the quality management level.
2. Increase publicity and education of public medical knowledge. Health administrative departments and medical institutions should make full use of relevant popular science books and publicity materials, focusing on the diagnosis and treatment of chronic non-communicable diseases, rational use of commonly used drugs, and the third and part of second-class medical technologies, and adopt various publicity forms such as on-site lectures, online videos, exhibitions and special reports to guide the masses to correctly understand medical science and medical risks, correctly choose doctors and seek medical treatment, improve medical risk awareness and the ability to identify fake doctors, fake drugs and false propaganda, and protect the legitimate rights and interests of patients.
3. Organize various publicity and reporting activities around the theme of "medical quality goes to Wan Li Road".
(1) Give full play to the role of newspapers, internet, radio, television and other media. The website of the Ministry of Health promotes the advanced practices and experiences of the "medical quality miles" activities in various places; Coordinate with major media for coverage. The provincial health administrative department shall organize and coordinate the local media, and do a good job in the publicity and reporting of the "medical quality travel thousands of miles" activities in this area.
(2) Strengthen the guidance of public opinion and highlight management, quality, service and safety. We will continue to vigorously publicize the new ideas, new measures and new achievements of medical quality, medical service and medical safety management, publicize the significance, requirements, good practices and good experiences of this activity, publicize advanced models with standardized management, reliable quality and satisfactory masses, and create a good public opinion atmosphere conducive to improving medical quality, promoting medical safety and improving the relationship between doctors and patients.
(3) Intensify the crackdown on illegal medical practice and false medical propaganda, and report and expose illegal medical practice and false medical propaganda.
(two) to further strengthen the management of medical institutions, strengthen service awareness, improve medical services, optimize service processes, and constantly improve the ability and level of medical services.
1. To implement the Opinions of the Central Civilization Committee on Deepening Volunteer Service Activities and the Task Division Plan of the Central Civilization Office, health administrative departments and medical institutions should actively explore the volunteer service model suitable for China's national conditions, gradually improve the volunteer service management system and working mechanism, and seriously organize and carry out volunteer hospital services and medical staff volunteer services to promote the harmony between doctors and patients.
2. To implement the Notice on Further Improving the Management of Medical Services in Medical Institutions (No.Weifa [20 10] 12), medical institutions should take improving people's feelings of seeing a doctor as an innovation and breakthrough to strengthen medical services, and provide convenience and speed by making an appointment for registration, rationally arranging outpatient and emergency services, simplifying outpatient and emergency services, and implementing the mode of "diagnosis first and settlement later". Actively explore, innovate, plan and focus on promoting various measures to improve medical services, so as to achieve reasonable arrangement, enthusiastic service and smooth process, and constantly promote the improvement of medical services.
(3) Implement the Administrative Measures for Medical Quality Control Centers (Trial) (No.512009) and strengthen the management and control of medical quality.
1. The administrative department of health shall formulate the planning for the construction of quality control centers in this administrative region, standardize the construction and management of medical quality control centers, actively promote the construction and development of quality control centers, gradually establish a quality control network, and carry out medical quality management and control in various professions.
2. Medical institutions have special departments and personnel responsible for the management and control of medical quality, accept quality control inspection by health administrative departments and quality control centers in accordance with relevant regulations, submit quality control information, organize rectification according to feedback information, and improve medical quality.
3 medical institutions in accordance with the relevant provisions, to carry out clinical pathway, single disease quality control, cardiovascular interventional diagnosis and treatment and blood purification case information registration.
(four) medical institutions should strictly implement the core system of medical quality and medical safety, standardize the construction of relevant departments of medical institutions, and implement the openness of hospital affairs. Key requirements:
1. Strictly implement the core systems such as first-visit responsibility system, third-level physician rounds, difficult case discussion, critically ill patient rescue, consultation, preoperative discussion, death case discussion and handover, so as to ensure medical quality and medical safety.
2. Implement the basic norms of medical record writing, standardize medical record writing behavior, strengthen the connotation construction of medical records, and improve the quality of medical records.
3. Implement the basic norms of electronic medical records, and standardize the construction and clinical application of electronic medical records.
4. Further strengthen the construction and management of key departments, such as emergency department, critical medicine department, pathology department and neonatal room, to ensure that personnel, equipment and facilities match their functions and tasks, and to carry out scientific, reasonable and standardized medical services, in accordance with the requirements of "Guidelines for Construction and Management of Emergency Department (Trial)" and "Guidelines for Construction and Management of Critical Care Department (Trial)".
5. According to the Basic Standards for Hemodialysis Rooms in Medical Institutions, the rules and regulations, equipment and personnel of hemodialysis rooms should meet the basic standards.
6. Fully implement the system of hospital affairs publicity, further implement the requirements of hospital affairs publicity and the Measures for Supervision and Assessment of Hospital Affairs Publicity of Medical Institutions (Trial), enhance the awareness of hospital affairs publicity of medical institutions, and promote medical institutions to further optimize service processes and internal democratic management decisions.
(5) Further strengthen nursing work, implement basic nursing, improve nursing service and improve nursing quality.
1. Further implement the regulations on nurses. Establish and improve nursing rules and regulations, disease nursing routine and nursing service norms and standards, establish nurse post responsibility system, and standardize nurses' practice behavior; Safeguard the legitimate rights and interests of nurses, contract nurses and nurses with equal pay for equal work.
2. Implement the Notice of the Ministry of Health on Strengthening Clinical Nursing in Hospitals (No.7 [2065438+00]) and related normative documents, improve nursing service and strengthen nursing management.
Hospitals should refine the service connotation and service items of graded nursing according to the requirements of Guiding Principles of Graded Nursing in General Hospitals (Trial) and Basic Nursing Services for Inpatients (Trial), and make them public to patients and the society. Hospitals should strengthen organizational leadership, improve and implement various rules and regulations for strengthening clinical nursing work, mobilize all forces, provide convenient conditions and strong guarantees for the effective development of this work, and gradually reverse the situation that patients' families or their families hire nurses to take care of patients' lives.
3. Carry out the activities of "Demonstration Project of Quality Nursing Service" in a down-to-earth manner, and do the key work of 16. In particular, it is necessary to establish a performance appraisal system for nurses, implement a responsibility system for clinical nurses to care for patients, make the proportion of clinical frontline nurses in hospitals not less than 95% of the total number of nurses, rationally allocate nurses' manpower according to the clinical nursing workload, encourage the use of tabular nursing documents, increase hospital funds, improve nurses' treatment, tilt to the clinical frontline, establish an incentive mechanism, and create a good practice atmosphere.
(six) the implementation of the "measures" management of clinical application of medical technology, continue to do a good job in the management of clinical application of medical technology.
Conscientiously implement the regulatory documents such as Management Measures for Clinical Application of Medical Technology, Management Specification for Cardiovascular Interventional Diagnosis and Treatment Technology, and Management Specification for Gynecological Endoscopic Diagnosis and Treatment Technology, establish a medical technology access and management system, and promote the development of medical science and the rational clinical application of medical technology. Key requirements:
1. The provincial health administrative department should do a good job in organizing the implementation of medical technology access and audit of medical institutions within its jurisdiction, formulate and publish the catalogue of second-class medical technologies within its jurisdiction, and guide medical institutions to apply for third-party technical audit before the clinical application of second-class and third-class medical technologies. Focus on strengthening the management of cell therapy technology, in conjunction with the provincial food and drug supervision and management departments to comprehensively sort out the relevant situation of cell therapy products or technologies in the region, find out the base, and immediately stop the clinical research and clinical application of unapproved cell therapy products or technologies.
2. The provincial health administrative department shall, in accordance with the regulations, implement access management for medical institutions that carry out cardiovascular interventional diagnosis and treatment technology and gynecological endoscopic diagnosis and treatment technology within their jurisdiction, and guide and supervise medical institutions to standardize the clinical application management of medical technology.
3. The main person in charge of a medical institution, as the first person in charge of the clinical application management of medical technology in this institution, is responsible for establishing and improving the relevant rules and regulations of the clinical application management of medical technology in this institution and establishing medical technology management files. Technical review and strict management of the first kind of medical technology; At the same time, do a good job in the third-party technical audit before the clinical application of the second and third types of medical technologies, and carry out the clinical application of related medical technologies in strict accordance with the regulations.
4. Medical institutions should establish a surgical grading management system, formulate specific implementation rules and management measures, and formulate a catalogue of surgical grading in their own institutions. Before granting corresponding surgical authority and implementing dynamic management, the professional and technical ability of doctors should be reviewed and passed in strict accordance with the regulations.
5 medical institutions to establish a medical technology risk early warning mechanism, formulate and improve the medical technology damage disposal plan and organize the implementation.
(VII) Implement the Drug Administration Law of People's Republic of China (PRC), Regulations on the Administration of Narcotic Drugs and Psychotropic Substances, Prescription Management Measures, Interim Provisions on the Administration of Pharmaceutical Affairs in Medical Institutions, Guiding Principles for Clinical Application of Antibacterials, Notice on Strengthening the Monitoring of Rational Drug Use in China, China Prescription Collection and Notice of the General Office of the Ministry of Health on Relevant Issues Concerning the Management of Clinical Application of Antibacterials (. Key requirements:
1. Establish the pharmaceutical affairs management organization of this institution, improve the relevant work and management system and implement it conscientiously.
2. Implement the national formulary of China, formulate the formulary of this institution, carefully organize training, implementation and evaluation, and promote clinical rational drug use.
3. Seriously implement the prescription review system, implement prescription dynamic monitoring and extraordinary early warning, and timely intervene in irrational drug use.
4. In accordance with the provisions of the Guiding Principles for Clinical Application of Antibacterials, establish and improve the classification management system of antibacterial drugs, clarify the prescription authority of doctors at all levels to use antibacterial drugs, and take practical measures to promote the rational use of antibacterial drugs.
5. Focus on strictly controlling the preventive use of antibiotics in type I incision surgery, and further strengthen the management of preventive use of antibiotics in perioperative period. Strengthen clinical microbial detection, clinical application of antibacterial drugs and bacterial resistance monitoring, and establish an early warning mechanism for clinical application of antibacterial drugs and bacterial resistance.
6. Do a good job in monitoring rational drug use, and collect and report data carefully, timely and accurately according to the requirements of the monitoring work plan.
7 establish and improve the safety management system of special drugs such as poison, hemp, essence and release, and earnestly implement it.
8. Establish a clinical pharmacist system with clear job responsibilities, corresponding clinical pharmacist work and management system, clear its responsibilities and tasks in the medical quality management system and earnestly implement it.
(eight) to further strengthen the safety management of key links in medical services to ensure medical safety.
1. Continue to promote and implement the "patient safety goal".
2. Implement the operation safety verification system and do a good job in operation safety verification.
3. Implement the normative documents such as Hospital Work System, Management Measures for Clinical Blood Use in Medical Institutions (Trial), Technical Specification for Clinical Blood Transfusion, Management Specification for Hospital Operating Department (Trial), implement the check system, and conscientiously do a good job in safety verification of key links of medical services such as blood transfusion, medication and inspection.
(nine) to implement the measures for the administration of hospital infection and related technical specifications, and strengthen the control of hospital infection in key departments, key departments and key links.
1. Establish and improve the hospital infection management organization. The hospital infection management department has clear responsibilities, reasonably deploys full-time and part-time staff, and formulates and implements relevant rules and regulations in line with the actual situation of our hospital.
2. Actively carry out hospital infection monitoring, establish a hospital infection information reporting system, find and deal with problems in time, and minimize the harm caused by hospital infection to patients.
3. Implement the "Hospital Operating Department Management Specification (Trial)" and other relevant normative documents, and strengthen the prevention and control of hospital infection in key departments such as operating room, hemodialysis room, intensive care unit, neonatal ward and disinfection supply room. The prevention and control of nosocomial infection in key links such as cleaning, disinfection and sterilization of medical devices meet the standards.
4. Carry out the "medical institutions hemodialysis room management norms", strengthen the management of hemodialysis room. The organization and management, quality control and hospital infection prevention and control measures of hemodialysis room meet the requirements of the specification.
5. Carry out knowledge training on hospital infection prevention and control for full-time and part-time staff in hospital infection management, key departments and key links of hospital infection, strengthen the awareness of hospital infection prevention and control, and improve the level of hospital infection prevention and control.
(10) Conduct a comprehensive inspection on the biosafety, quality control and management of laboratories in medical institutions, focusing on system construction, hardware facilities, personnel management, emergency response and implementation, in accordance with the Regulations on the Biosafety Management of Pathogenic Microbiological Laboratories, Measures for the Administration of Biosafety Examination and Approval of Highly Pathogenic Microbiological Laboratories and Experimental Activities of Human Infection, and Measures for the Administration of Clinical Laboratories in Medical Institutions.
(1 1) Implement the People's Republic of China (PRC) Blood Donation Law, the Measures for the Management of Clinical Blood Use in Medical Institutions (Trial), the Technical Specification for Clinical Blood Transfusion, the Notice of the General Office of the Ministry of Health on Further Strengthening Blood Management and the Questions and Answers of County-level Blood Station Personnel, focus on strengthening the management of clinical blood use, further standardize the management of clinical blood use, and promote clinical scientific and rational use of blood. Key requirements:
1. Medical institutions shall abide by the relevant provisions of the People's Republic of China (PRC) Blood Donation Law, and illegal blood collection is strictly prohibited.
2. Hospitals above the second level should establish clinical blood transfusion management committees, clarify their responsibilities, do a good job in standardized management and technical guidance of clinical blood use, and actively carry out education, training and inspection of clinical rational and scientific blood use.
3. Medical personnel in medical institutions shall use blood scientifically and rationally in accordance with the Administrative Measures for Clinical Blood Use in Medical Institutions (Trial), Technical Specifications for Clinical Blood Transfusion and guidelines.
4. The clinical departments of medical institutions shall, according to the Measures for the Administration of Clinical Blood Use in Medical Institutions (Trial), the Technical Specification for Clinical Blood Transfusion and the actual work situation, make weekly and monthly plans for clinical blood use, and assess the blood use of medical personnel.
5. Medical institutions shall equip the blood transfusion department (blood bank) with reasonable technical personnel, equipment and facilities, and the blood transfusion department (blood bank) shall establish a quality management system, formulate a blood reserve plan, and do a good job in the storage, testing and distribution of blood for clinical use.
6. Medical institutions should establish scientific and effective blood transfusion adverse reactions and emergency blood use plans, and seriously implement them.
(12) Establish a working mechanism for regularly investigating safety hazards such as safety production infrastructure, technical equipment, working environment and prevention and control measures, and focus on strengthening the rectification of weak links such as safety production system construction, safety management organization system, responsibility implementation, labor discipline, on-site management and accident investigation. Key requirements:
1. Establish and improve the organization and leadership, management organization, rules and regulations, operating procedures and standards for safety production. , clear staffing requirements, and seriously organize the implementation.
2. Strengthen the daily management and maintenance of important facilities, equipment, key equipment and devices for safe production, ensure safe operation and prevent electric leakage, air leakage and water leakage; Improve the equipment and use of labor protection articles.
3. Ensure that the fire escape is unobstructed, without obstacles, with complete fire fighting equipment, eye-catching signs, managed by special personnel and equipped with fire alarm system.
4. Strengthen emergency management, improve the formulation of various emergency plans, provide and maintain emergency relief materials, and conduct emergency drills regularly.
5. Strengthen the safety management of radiology department, medical oxygen cabin, isotope room, oxygen supply room, dangerous goods warehouse, power distribution room, pressure vessel and elevator.
(thirteen) continue to carry out special supervision and inspection activities on blood safety in blood collection and supply institutions nationwide, and the activity plan will be issued separately by the Department of Medical Administration of our Ministry.
(fourteen) continue to carry out the national three-level general hospital medical record quality appraisal activities, the activity plan shall be issued separately by the Department of medical administration of our Ministry.
(fifteen) to carry out the selection of advanced units of quality service in tertiary general hospitals in China, and the activity plan shall be issued separately by the Department of Medical Administration of our Ministry.
(sixteen) to carry out the supervision and inspection activities of radiation diagnosis and treatment of medical institutions nationwide, and the activity plan shall be issued separately by the Supervision Bureau of our Ministry.
Active step
(1) Mobilization deployment (May 20 10).
Complete the preparation, mobilization and organization of the 20 10 "medical quality travel thousands of miles" activity, and mainly carry out the following work:
1. According to this plan, the provincial health administrative department, combined with the development of the "Medical Quality Miles" activity in 2009, formulated the specific implementation plan for this region, defined the work focus, organizational division of labor and activity arrangement, implemented the contents of various activities, and deployed the "Medical Quality Miles" activity in 20 10.
2. Each medical institution has made its own 20 10 activity plan of "medical quality travels thousands of miles" according to the actual work.
(2) Organizing the implementation (June 2065438+00—March 2065438 +0 1).
1. Provincial health administrative departments and medical institutions at all levels should, in accordance with the unified deployment, comprehensively carry out the "medical quality miles" activity on 20 10. Continue to strengthen management, further improve the quality and safety management system, and organize the media to carry out publicity activities. The problems found in self-examination should be rectified immediately, and those that seriously violate relevant regulations or cause medical quality and safety incidents should be dealt with seriously.
2. Inspection and supervision. From mid-June, 20/kloc-0 to mid-March, 2065 438+06 5438+00, under the unified organization of the Ministry of Health, the provincial health administrative departments guided, inspected and supervised the medical institutions within their jurisdiction to carry out the "2065 438+00 medical quality journey" activity, summed up the problems and deficiencies in the work in time, and promoted the "medical quality journey" activity.
Inspection method: The provincial health administrative departments shall organize inspection of 30 medical institutions within their jurisdiction according to the unified requirements and inspection standards of the Ministry of Health. It should include five tertiary general hospitals, five tertiary specialized hospitals, 15 secondary hospitals and five private hospitals. The Ministry of Health sent supervisors to supervise the inspection of the "Medical Quality Miles" activity of 20 10 provincial health administrative departments.
(3) Summarize the exchange (April 20 1 1).
20 1 1 year before the end of April, the health administrative departments at the provincial level shall timely report the activities of "medical quality miles" within their respective jurisdictions to the Ministry of Health. The Ministry of Health summarizes the activities carried out in various places and forms a summary report of activities in 20 10. Organize activities and experience exchange meetings to publicize and promote good practices and advanced experiences. At the same time, study and deploy the 20 1 1 "medical quality travel thousands of miles" activity to further establish and improve the long-term mechanism of medical quality and medical safety management.
job requirement
(A) to strengthen leadership, put an end to lax mood.
Medical quality is the foundation of hospital, the core of hospital management, related to people's physical and mental health and life safety, related to the reputation and influence of medical institutions, related to the public image of health system. Carrying out the activity of "medical quality traveling thousands of miles" is an important measure for the health system to adhere to people-oriented, implement Scientific Outlook on Development, improve medical quality management and promote the healthy development of medical and health undertakings. It is also an important means to deepen the reform of the medical and health system, and we should always make unremitting efforts.
Provincial health administrative departments and medical institutions at all levels should further strengthen their awareness of quality and safety, constantly sum up their work experience, make clear that the person in charge of medical institutions is the first person responsible for medical safety management, and earnestly strengthen organizational leadership. We should continue to intensify publicity, guidance, training and inspection, and take effective measures to ensure the effectiveness of the activities.
(2) Strengthen quality management and eliminate potential safety hazards.
Provincial health administrative departments should deploy in accordance with relevant laws, regulations, rules and activities, not only to strengthen inspection, guidance and training, but also to strengthen supervision and management of medical institutions, and to explore the establishment of a long-term mechanism for hospital management. Medical institutions should attach importance to connotation construction, start with talents, technology and management, combine training, education and inspection, improve the implementation of various rules and regulations, and establish and improve the internal medical quality management and control system. At the same time, it is necessary to strengthen the management and inspection of key departments, key areas, key links and key personnel, further strengthen the rectification of medical technology, medical services, buildings, equipment, facilities, dangerous goods and potential safety hazards in key departments, and ensure medical safety with emphasis, measures and effectiveness.
(3) Clear objectives and mobilize social participation.
Provincial health administrative departments and medical institutions at all levels should take active actions around the core of the activity, actively coordinate and organize relevant departments, mobilize the whole society to participate extensively, and promote the activity at different levels, categories and projects. It is necessary to strengthen publicity and guidance of public opinion, mobilize the support and active participation of news media, publicize and popularize a number of advanced models with standardized management, reliable quality and satisfactory masses, and adopt various ways to promote exchanges, so as to create a good atmosphere for the reform and development of medical institutions.
(4) Establish a long-term mechanism and gradually turn to normal.
Strengthening hospital management and improving medical service level is a long-term task. All localities should gradually study and form a long-term working mechanism to continuously improve quality and ensure medical safety on the basis of their experience in the past two years.
The Ministry of Health has established a national medical quality management control center, and all provinces have established and improved provincial and municipal medical quality management control centers in accordance with the Measures for the Administration of Medical Quality Control Centers, and carried out medical quality control work on a regular basis in accordance with the unified deployment of our Ministry. The Ministry of Health guides and supervises the quality control work in various places, promotes the development of "medical quality travel thousands of miles" to specialization, refinement and systematization, and continuously improves the level and quality of medical services.