Work Plan of Medical Quality and Safety Management Team 1 Under the leadership and supervision of the Hospital Medical Quality Management Committee, according to the hospital's medical quality and medical safety management and continuous improvement plan and the detailed rules for the implementation of the 20xx tertiary specialized hospital evaluation standard of the Ministry of Health, the continuous improvement plan and management objectives of undergraduate medical quality and safety management are formulated.
First, the department management:
1, set up a departmental quality control team, with clear division of labor and responsibility to people. Carry out quality control activities at least once a month, check and monitor all aspects of the department's diagnosis and treatment activities, and fill in the quality control records of outpatient departments as required.
2, regular quality control group meeting, study the quality and safety of the department, to ensure medical safety.
3, according to the actual situation of the department work plan, finish the plan on time, and constantly improve the quality of medical care, strengthen the awareness of quality and safety.
4, according to the director of the manual, the head nurse manual project requirements to fill in on time.
Second, the medical quality management objectives
1, strictly implement the first-visit doctor responsibility system.
2, outpatient medical records written complete, standardized, accurate, 90% or higher grade a medical records.
3. Ask about the medical history in detail, have a physical examination carefully, and have a preliminary diagnosis.
4. Reasonable examination and rational drug use; The specific medication situation is recorded in the medical record.
5. Drug usage, dosage, course of treatment and compatibility are reasonable.
6, prescription writing specification qualified, the qualified rate of 95% or higher.
7, the secondary diagnosis is not clear, the attending physician should:
A, please consult a superior doctor;
B, admission or effective communication with patients.
8. If the diagnosis is still unclear at the third visit, the attending physician should:
First, hospitalization;
B, patients refused to be hospitalized need to perform the signing formalities.
9, according to the situation of specialist patients.
10, the patient didn't make a follow-up visit, and the doctor couldn't take time off from work. If you have to leave in an emergency, report to the outpatient department and arrange for relevant personnel to receive treatment.
1 1, and register the outpatient log.
12, and the reporting rate of infectious diseases was 100%.
13, the reference rate and qualified rate of "three basics" assessment of department personnel reached 100%.
Work plan of medical quality and safety management team. Gradually improve the organization and construction system of quality control centers, and establish and improve quality evaluation standards.
(a) to establish and improve the quality control center expert group.
(two) to assist all localities to establish medical quality control sub-centers.
In accordance with the requirements of the Ministry of Health's Administrative Measures for Medical Quality Control Centers (Trial) and the Notice of Sichuan Provincial Health Department on Building a Medical Quality Control Network, we will improve the construction of pediatric quality control sub-centers in various cities and States and comprehensively and effectively carry out pediatric quality control.
(3) Drafting the quality control standard of pediatrics in Sichuan Province.
Gradually complete the drafting of quality control standards for newborns, children's infectious diseases, children's digestive system, children's respiratory diseases, children's heart diseases, children's nephropathy, children's hematological diseases, children's neuropathy, children's endocrinology, children's hereditary diseases, children's immunity and other1/professional diseases, and formulate and improve the quality management and control standards for pediatric medical care; Strive to build a pediatric team in the province; Escort the health of children aged 0- 18.
Two, the province's pediatric management, quality control, operation research, using various forms of on-site supervision and inspection.
Comprehensively sort out the current situation of pediatric specialty, discipline development, talent team, diagnosis and treatment technology level and ability in the province; Carry out disease spectrum investigation, such as the incidence of nephrotic syndrome in children, to provide basis for health administrative departments and government decision-making; Measures or methods related to the collection, summary, analysis, evaluation, feedback, guidance and rectification of 20xx quality control information; Experts from the Provincial Pediatric Quality Control Center will go to cities and states together with experts from sub-centers to conduct spot checks on the inspection and guidance of pediatric quality control in relevant medical institutions in the province, find out the existing problems and propose improvement methods; Provide daily monitoring result data for hospital grade evaluation and evaluation.
Three, strengthen the construction of technical personnel, fully implement the technical training work.
1. Hold a training meeting for experts to strengthen standardized guidance and training for primary medical institutions. In 20xx, Sichuan Pediatric Quality Control Center plans to hold at least two provincial expert group meetings to strengthen standardized guidance and training for primary medical institutions.
2. Compile the training materials of Sichuan Pediatric Quality Control Center. According to the training objectives, the 1 training textbook for diagnosis and treatment of neonatal diseases was compiled, and relevant personnel were trained according to the contents of the textbook.
3. Training members of Sichuan Pediatric Quality Control Center. With the help of national and provincial continuing medical education projects and the provincial center as the platform, the standardized construction of pediatric departments, the promotion of appropriate technologies and the introduction of new technologies in the province were carried out; In order to standardize and improve the level of diagnosis and treatment of neonatal diseases by pediatric medical staff, the center's goal this year is to strengthen and standardize the construction, management and diagnosis and treatment of neonatal diseases.
Four, establish and improve the medical quality control center information system construction.
(a) to carry out relevant disease information report.
Gradually establish a pediatric diagnosis and treatment case information reporting system, designate a person to be responsible for information reporting and entry, and provide necessary equipment and technical conditions for information reporting; The center will collect, sort out, count, analyze, evaluate and feedback the quality control information of pediatric diseases reported by our province, and guide relevant measures or methods for rectification. At the same time, the quality control center should strengthen the technical guidance to medical institutions, and regard the timeliness, completeness and safety of information submission as an important index of medical quality control of pediatric diagnosis and treatment in medical institutions; Provide daily monitoring result data for hospital grade evaluation and evaluation.
(two) the establishment of medical quality control center adverse event information reporting system.
Gradually establish the adverse event information reporting system of medical quality control center, make full use of the platform of adverse event information reporting system of medical quality control center, exchange and share risk prevention experience, enhance risk prevention awareness and improve risk prevention ability, and finally achieve the purpose of protecting patients' health and medical safety.
(3) Improve the information construction of quality control center and build an information exchange platform.
Using the established website of Sichuan Pediatric Quality Control Center, we will expand the propaganda of pediatric quality control in the whole province, use the convenience and openness of the network to hang training courseware, related forms and other materials, strengthen communication with sub-centers, continuously improve the network construction of pediatric quality control centers, open remote consultation channels for difficult diseases, and organize experts to carry out various forms of appropriate technology promotion lectures, rounds, discussion of difficult patients, deaths and other activities to effectively improve medical quality and ensure medical safety.
Verb (short for verb) Other jobs
Assist and support the construction of pediatrics in cities and States, and promote the construction of provincial or municipal clinical key specialties. CC: Department of Medical Administration and Department of Medical Management of the National Health and Family Planning Commission, Provincial Administration of Traditional Chinese Medicine, Provincial Health Law Enforcement Supervision Corps, Provincial Clinical Quality Control Center, and Provincial Bayi Rehabilitation Center.
Work plan of medical quality and safety management team 3 In order to implement the core medical system, ensure the improvement of medical quality and safety in our department, and ensure the completion of the connotation quality and medical indicators of medical record writing, this year's medical quality and safety work plan is specially formulated.
First, strengthen ideological understanding and sustainable development:
The director and head nurse continue to do a good job in quality management and implement various rules and regulations. Hold quality management committee meeting, medical record quality control group meeting, hospital feeling group meeting, nursing management group meeting and medical safety group meeting every month to standardize management and medical behavior. So that every post in our department can strive to improve the level of medical technology and promote the sustainable development of the department.
Second, clear the main work indicators of the medical department, and strive to complete:
1, bed utilization rate ≥92%
2. The average stay time is no more than 8 days.
3. The diagnosis rate is more than 90% within three days after admission.
4. The average preoperative hospitalization time is ≤2 days.
5. The coincidence rate of admission and discharge diagnosis is ≥95%.
6, critically ill patients in hospital rescue success rate of 85% or higher.
7. The coincidence rate of diagnosis before and after operation is ≥90%.
8. The coincidence rate of clinical and pathological diagnosis is ≥90%.
9. The passing rate of "three basics" exam = 100% (80/ 100 points)
10, and the qualified rate of outpatient medical record writing is ≥ 90% (more than 90/100).
1 1, the first-class medical record rate is ≥95%, and there is no third-class medical record.
12, the intact rate of medical equipment and instruments is ≥90%.
13, the intact rate of first aid instruments and medicines = 100%
14, antibiotic use range ≤60%, DDD≤40%, drug sensitivity >; 80%, the utilization rate of antibiotics in the first kind of incision is ≤30%.
15500 operations
Third, improve the evaluation of medical quality in departments, implement standardized quality management, formulate evaluation standards, check by quality control staff every month, and make summary and feedback.
1, carefully grade the monthly work of the department according to the evaluation standard of the second-class first-class hospital and the evaluation standard of "three good and one satisfaction", and the results are linked to the bonus.
2. Improve and implement all kinds of medical systems, requiring all kinds of systems to implement record specifications and complete projects. The medical group strictly implements the three-level rounds system, with the attending physician making rounds within 48 hours of admission, the chief physician making rounds within one week, the superior physician making rounds before and after the operation, the superior physician making rounds at any time for serious patients, and the superior physician making rounds after the serious patients are discharged automatically. Strengthen the management of informed consent system. Non-surgical patients can talk for 72 hours at any time during hospitalization, before surgery, during surgery, after surgery, after implantation, in critical condition, during special diagnosis and treatment surgery, treatment and medication, after blood transfusion and before anesthesia. Strict implementation of case discussion system, consultation system, operation approval and operation authority system, handover system, etc. Each department holds monthly meetings to analyze, rectify and continuously improve the existing problems.
Four, do a good job in the management of medical documents.
1. Strengthen the self-examination of medical record writers and the monitoring of medical record quality team (related quality control personnel). Department medical record quality controllers check the links in the ward and the final medical record quality every month, cultivate the medical record quality consciousness of each quality controller, deepen the perceptual cognition of the examiners, and transmit the inspection results to their own departments in time to avoid repeating the same mistakes, so that the examinees can get attention, get feedback at the first time, and change the time in real time, which plays a virtuous circle role.
2. Pay special attention to the quality evaluation of medical records and implement the system of combining rewards and punishments. The quality controller of the medical records of the department shall check the quality of the final medical records in the ward every month, check the existing problems and report the B and C medical records to the quality control room. The quality control personnel of relevant departments shall report the inspection results in time. If it is not reported continuously, the total assessment score of the department in the current month will be deducted and linked to the bonus of the department. Encourage everyone to pay attention to each other and urge each other to avoid and reduce the occurrence of defects in medical records and achieve the purpose of improving the quality of medical records.
3, the implementation of medical record examination system, highlighting the key monthly inspection key arrangements are as follows:
1 month: rational drug use, including special treatment of antibiotics, drug use analysis and disease treatment.
February: register the "critical value" report, the nursing staff will report to the doctor in time, and the doctor will handle and record it in time.
March: For patients who have been hospitalized for more than 30 days, focus on rounds to see if there are evaluation records. Check the measures to shorten the waiting time of each bottleneck in the average hospitalization day one by one and implement them all.
April: Blood transfusion management system, including pre-transfusion application, blood preparation, laboratory test items, and comprehensive application form; Sign the patient's consent for blood transfusion before blood transfusion; Use blood rationally, analyze and record the course of disease before and after transfusion. Check all kinds of medical records discussed in the first quarter (discussion records of difficult, death, preoperative and discharged cases).
May: Check the ward rounds of superior critically ill patients, doctors on duty, critically ill notices and rescue records.
June: The preoperative condition evaluation system and preoperative discussion system were implemented.
Work plan of medical quality and safety management team. Strengthen the construction of medical quality office team and improve various medical quality systems and assessment standards.
Establishing a perfect quality management system and standardizing medical behavior are the core. Establish a quality management system in line with the actual situation of the hospital. The hospital has set up a quality management committee and a leading group for quality control assessment, with the executive vice president, medical department and clinical department as members, to be responsible for the quality management of the hospital. The whole hospital formed the main leaders to personally grasp; In charge of leadership; Functional departments grasp every day; Clinical departments have been paying attention to medical quality and medical safety management mode. Strengthen clinical pathway management, improve medical quality and ensure medical safety through medical business management during probation period.
Two, strengthen medical quality management, ensure and improve the quality of medical services.
Medical quality management is the core of hospital management, and improving medical quality is the fundamental purpose of hospital management. Medical quality is the lifeline of the hospital. On the basis of improving the medical management system, it is the most important thing to reduce medical quality defects, timely investigate and eliminate medical safety hazards, reduce medical disputes and prevent medical accidents. Strictly control the quality of medical care, requiring all departments to strictly implement various rules and regulations, standardize diagnosis and treatment behavior, and adhere to the responsibility system of first diagnosis, three-level rounds, consultation system for difficult patients, consultation system for critically ill patients and discussion system before and after operation. Strengthen the sense of responsibility, pay attention to the dynamic analysis in medical activities, and take various preventive measures to nip in the bud. In view of patients' increasing demand for medical information, various information systems should be improved. To strengthen the quality control management, hospital medical records should be written in accordance with the Medical Record Writing Standard, the Basic Standard for Electronic Medical Records (Trial) and the Basic Standard and Scoring Standard for Medical Record Writing in China promulgated by the Ministry of Health, and prescription writing should be implemented in accordance with the Prescription Management Measures.
Third, according to the problems found in the actual operation during the probation period, optimize the medical service process and improve the medical quality.
The identification of departments and services is standardized, clear, eye-catching and easy to understand. Adhere to the patient-centered, work hard to optimize medical procedures and facilitate patients to seek medical treatment, seek practical results, enhance service awareness, optimize the development environment, and strive to provide warm, convenient and high-quality medical services for patients.
Four, the implementation of medical quality, medical safety education, is the basis of strengthening medical quality.
Strengthen the quality education of medical staff in the hospital, so that all staff in the hospital have a correct outlook on life, values and professional ethics; Need a strong sense of responsibility, dedication and compassion; Establish a solid awareness of medical quality and medical safety; Carry out high-quality service and "safety is saving, accidents are wasting" activities in hospitals in an all-round way, stimulate employees' professionalism in learning and work, and form a good atmosphere for learning and catching up. Cooperate with the medical department and the science and education department to carry out "three basics and three strictness" education and training for medical staff in the hospital.
Work plan of medical quality and safety management team 5 In order to implement the medical core system, ensure the improvement of medical quality and safety in our department, and ensure the completion of the connotation quality and medical indicators of medical record writing, this year's medical quality and safety work plan is formulated:
First, strengthen ideological understanding and sustainable development:
The director and head nurse continue to do a good job in quality management and implement various rules and regulations. Hold quality management committee meeting, medical record quality control group meeting, hospital feeling group meeting, nursing management group meeting and medical safety group meeting every month to standardize management and medical behavior. So that every post in our department can strive to improve the level of medical technology and promote the sustainable development of the department.
Two, clear the main work indicators of the medical department, and strive to complete.
1, bed utilization rate ≥92%.
2. Average hospitalization time ≤ 14 days.
3. The diagnosis rate is more than 90% within three days after admission.
4. The average preoperative hospitalization time is ≤3 days.
5. The coincidence rate of admission and discharge diagnosis is ≥95%.
6, critically ill patients in hospital rescue success rate of 85% or higher.
7. The coincidence rate of diagnosis before and after operation is ≥90%.
8. The coincidence rate of clinical and pathological diagnosis is ≥90%.
9. The passing rate of the "three basics" exam = 100% (80/ 100 points).
10, and the qualified rate of outpatient medical record writing is ≥ 90% (more than 90/100).
1 1, the first-class medical record rate is ≥90%, and there is no third-class medical record.
12, and the intact rate of medical equipment and instruments is ≥90%.
13, the intact rate of first aid instruments and medicines = 100%.
14, the range of antibiotic use is 60%, DDD is 40%, drug sensitivity is 80%, and the restricted use rate of antibiotics is 50%.
15,720 operation.
Third, improve the evaluation of medical quality in departments, implement standardized quality management, formulate evaluation standards, check by quality control staff every month, and make summary and feedback.
1, according to the evaluation standard of secondary hospitals and the evaluation standard of "three good and one satisfaction", carefully grade the monthly work of the department, and the results are linked to the bonus.
2. Improve and implement all kinds of medical systems, requiring all kinds of systems to implement record specifications and complete projects. The medical group strictly implements the three-level ward round system. The attending physician rounds within 48 hours of admission, the chief physician rounds within one week, the superior physician rounds before and after operation, the superior physician rounds at any time for severe patients, and the superior physician rounds after the severe patients are discharged automatically. Strengthen the management of informed consent system. Non-surgical patients can talk for 72 hours at any time during hospitalization, before surgery, during surgery, after surgery, after implantation, in critical condition, during special diagnosis and treatment surgery, treatment and medication, after blood transfusion and before anesthesia. Strict implementation of case discussion system, consultation system, operation approval and operation authority system, handover system, etc. Each department holds monthly meetings to analyze, rectify and continuously improve the existing problems.