I. Guiding ideology
Insist? People-oriented health and harmonious health? The development concept focuses on the reform of medical and health system, deepening the reform of hospital management system and operation mechanism, strengthening the connotation construction of medical institutions, continuously improving the quality of medical services, creating a harmonious practice environment, ensuring medical safety and improving people's satisfaction.
Two. Objectives and scope of activities
The activity cycle of the continuous improvement plan of medical quality: take three years as a cycle, and this cycle is determined to be from August 20 17 to February 20 18; Activity goal: to improve the quality of medical services and the satisfaction of the masses; Scope of activities: all kinds of medical institutions at all levels in the city, with emphasis on medical institutions above the second level (including the second level).
Third, the organization and management
The Municipal Health Bureau has formulated a plan for continuous improvement of medical quality. Does the medical quality go to Wan Li Road? And then what? Hospital management year? The activity leading group (hereinafter referred to as the leading group, see annex) is responsible for formulating the implementation plan of the city's medical quality continuous improvement plan and organizing its implementation. There is an office under the leading group, located in the Medical Administration Department of the Municipal Health Bureau.
County (city, district) health bureau should set up the organization of the continuous improvement plan of medical quality at the corresponding level, and be responsible for formulating the work plan of the continuous improvement plan of medical quality in this area and organizing its implementation.
Medical institutions should set up a leading group and office for the continuous improvement plan of medical quality, specifically manage the continuous improvement of medical quality in our hospital, formulate activity plans, clarify work responsibilities and implement various measures.
Four. Activity content
Continuous quality improvement is a quality management theory based on total quality management, which pays more attention to process management and link quality control. It is a quality management model that starts from details and is closely related at different levels. The continuous improvement plan of medical quality mainly aims at improving and establishing four systems, namely, establishing and perfecting the quality management organization system, improving the quality evaluation and assessment system, establishing the quality information reporting and analysis system, and creating the quality management education and training system.
(A) to further establish and improve the quality management organization system
All kinds of medical institutions at all levels should make it clear that the president is the first person responsible for medical quality management, and set up a medical quality management Committee with the president as the director to be fully responsible for the organization and leadership of medical quality in our hospital; Strengthen the functions of medical business management departments, especially the construction of medical technology departments, and the number of beds should be set according to the actual situation? The ratio of 1: 100 should be fully staffed with powerful medical management personnel, and the medical department should give full play to the comprehensive and coordinated management function of medical quality; Relevant medical business management departments should perform their duties and cooperate with each other to promote the improvement of hospital quality management. The hospital should improve the medical quality control teams of all specialties, including five basic specialty quality control teams, including medical records, nosocomial infection, nursing, pharmacy and equipment, and also establish special specialty quality control teams, such as emergency, clinical examination, radiation, anesthesia, stomatology, pathology, hemodialysis, tumor, medical records of traditional Chinese medicine, Chinese herbal pieces and nursing of traditional Chinese medicine, in combination with the approved diagnosis and treatment subjects; The director of the department should be fully responsible for the medical quality management of the undergraduate course room, and each department needs to set up a part-time quality controller.
Further establish and improve the three-level medical quality control network of city and county hospitals, implement the management system of quality control institutions, and improve the operating mechanism of institutions. Clarify the main position of quality control experts in medical quality management, attach importance to and adopt the effective suggestions of quality control experts, and give full play to the role of quality control networks at all levels. At the same time, to strengthen the construction of all kinds of medical quality control institutions, health administrative departments should give necessary funds for activities, and subordinate units should actively support the work of quality control centers, provide necessary working environment, equipment and other safeguard measures, continuously improve the medical quality of the city, and form a medical quality control, management and improvement system with perfect functions and sound network.
(2) Further improve the quality evaluation system.
All localities and units should conscientiously implement the management norms, diagnosis and treatment guidelines and evaluation standards formulated and promulgated by health administrative departments at all levels. Actively implement the requirements of the series of "Technical Specifications for Management and Diagnosis and Treatment of Medical Institutions in Zhejiang Province"; Actively study the path of clinical diagnosis and treatment and the quality control standard of single disease; Actively study the evaluation standards of various hospitals at all levels, and comprehensively improve the evaluation level of medical quality.
We should constantly improve and innovate quality evaluation methods. Establish a medical quality observer system to form an atmosphere in which everyone participates in quality management; Encourage the introduction of relevant management tools, combine the characteristics of medical quality management, and innovate quality management methods; Explore various forms of inspection, evaluation and assessment methods; The implementation of quality management expert access system, establish and improve all kinds of quality assessment and evaluation expert database. The municipal quality control center shall report the management and evaluation methods of medical quality control to the Municipal Health Bureau at the beginning of each year.
(3) Accelerate the establishment of a quality information reporting and analysis system.
Establish a system for reporting, collecting, analyzing and judging quality information, and find problems in quality management in time; Implement the feedback and notification system of quality information, and eliminate all kinds of factors affecting medical quality in time.
The medical quality management committee of a medical institution shall comprehensively collect the medical quality information of the hospital, actively take effective measures against the existing problems, and regularly report the quality information to the health administrative department at the same level; Each quality control center is responsible for collecting quality information in the professional field, proposing improvement suggestions on the quality problems existing in medical institutions on the basis of correct judgment and analysis, and reporting quality control management information to the health administrative department at the same level and the quality control center at a higher level in time; The administrative department of health shall organize experts to judge and analyze the local medical quality information regularly, formulate quality improvement plans in time, determine the key points of quality control, and notify major quality incidents.
(d) Establish and improve the quality management education and training system.
Fully rely on all kinds of quality control centers, technical guidance centers and relevant medical associations and societies to establish a quality management training system and carry out quality management training; Make full use of information network technology to establish a digital education platform for quality training; Cultivate and select a group of quality management backbones, establish a team of management training teachers, and give full play to their main role in all-staff training. At the same time, in the practice of medical quality management, we should sum up the good experiences and practices of popularizing quality management in time, set an example and carry out demonstration education. Medical institutions should make full use of their own technological advantages, organize their own medical staff, especially primary medical staff, to carry out various forms of study and training, form a good habit of studying hard and thinking more, and constantly enrich the hospital culture construction.
The four systems are combined with each other and complement each other. On the basis of perfecting its own system construction, it also promotes the perfection of other systems, realizes the continuous improvement of quality management, and ensures the quality and safety of medical care.
Verb (abbreviation for verb) key task
According to the requirements of the provincial health department, in this cycle of activities, we should closely focus on the main contents of the "continuous improvement plan for medical quality" and focus on the following eight aspects.
(a) the implementation of the "measures for the administration of clinical application of medical technology"
Medical institutions should establish and improve the relevant rules and regulations of the clinical application management of medical technology in their own units, and establish medical technology management files; Technical review of the first type of medical technology, strict management, preparation and application for the third-party technical review of the second and third types of medical technology before clinical application; Medical institutions should establish a grading management system for operations, formulate specific implementation rules and management measures, and report to the health administrative department at the same level for the record. Only after the doctors' professional technical ability has passed the examination can they be granted the corresponding operation authority and implement dynamic management.
The administrative department of health will focus on the following three types of medical technology: first, it is immature or has many ethical problems; Second, it must be allowed by the health administrative department but not allowed; Third, the relevant medical subjects have not been obtained. Inspection found that medical institutions to carry out the clinical application of the above medical technology, will be punished in strict accordance with relevant laws and regulations.
(B) the implementation of single disease quality management and clinical pathway
Single disease quality control is an important measure to standardize clinical diagnosis and treatment, strengthen medical quality management and improve medical service level. All localities and units should actively implement the Ministry of Health's quality control indicators for six single diseases, such as acute myocardial infarction, heart failure, pneumonia (hospitalization), cerebral infarction, hip and knee replacement and coronary artery bypass grafting, as well as the clinical pathways of eight diseases, such as acute simple appendicitis, nodular goiter, breast cancer, femoral shaft fracture, acute st-segment elevation myocardial infarction, hysteromyoma, planned cesarean section and senile cataract. Hospitals above the second level in the city should seriously promote the application of single disease quality control indicators and clinical pathways. Third-level general hospitals should go first, and health administrative departments should increase their efforts. It is necessary to focus on the inspection and evaluation of the implementation of six single disease quality management improvement evaluation indicators and eight disease clinical pathways in tertiary general hospitals, constantly sum up experience and gradually popularize and apply them.
(3) Pay close attention to quality management in key areas.
Promote the annual meeting of China Hospital Association? Patient safety goals? To strengthen the quality control management in key areas, all localities and units should intensify their implementation and constantly improve quality management and technical specifications. Pay attention to the following aspects of quality management:
1. Comprehensively strengthen the prevention and control of hospital infection. Medical institutions should regularly or irregularly carry out inspections in key departments such as neonatal ward, hemodialysis room, intensive care unit, infection department, hematology department, operating room and disinfection supply center, sort out the difficulties and problems existing in hospital infection management in key departments, eliminate hidden dangers of quality and safety in time, and resolutely control the occurrence of major hospital infection incidents.
2. Establish the responsibility system of the attending physician for anesthesia operation, standardize the anesthesia workflow, make full preparations before anesthesia, strengthen the monitoring of patients during anesthesia and after anesthesia, implement the whole process and standardized anesthesia resuscitation monitoring, and find and solve all kinds of anesthesia accidents and complications in time.
3. Implement the Prescription Management Measures and the Guiding Principles for Clinical Application of Antibacterials. Medical institutions should conscientiously implement the prescription review system, implement prescription dynamic monitoring and extraordinary early warning, and timely intervene in irrational drug use. Establish and improve the classification management system of antibacterial drugs, strictly control the preventive use of antibiotics in type I incision surgery, and establish an early warning mechanism for clinical application of antibacterial drugs and bacterial resistance. It is necessary to establish and improve the system of pharmacy rounds and closely combine pharmacy with clinic.
4. Strengthen the supervision of clinical blood use, improve the blood cold chain management process, analyze the blood use in key departments, and promote the scientific and rational use of blood in medical institutions. Medical institutions should attach importance to the construction of blood transfusion department (blood bank) and strengthen the implementation of the system and hardware configuration. The Municipal Health Bureau should introduce a management system for clinical blood use, standardize clinical blood use, and regularly organize clinical blood use inspections in hospitals above the second level to ensure the safety of blood use.
5. Strengthen emergency management, improve emergency service process, enhance the ability to deal with emergency and critically ill patients, and improve the diagnosis and treatment technical level of emergency medical personnel. Carry out professional training for medical personnel engaged in first aid, formulate the first aid inspection standards for medical institutions below the second level and the on-the-job training system for medical personnel, popularize first aid knowledge to the society in various forms, and improve the self-first aid ability of the whole people.
6. Implement the operation safety checklist system. Strengthen the effective cooperation and communication among surgeons, anesthesiologists and surgical nurses, prevent the occurrence of surgical patients, sites and surgical errors, and ensure the implementation of surgical safety management system.
7. Strengthen medical record quality management in strict accordance with Zhejiang medical record writing standards, actively carry out in-hospital medical record writing quality appraisal activities, link medical record quality with performance appraisal, ensure medical record writing quality, and improve medical staff's professional quality and professional level.
(four) efforts to implement the "Interim Measures for the management of outpatient services in hospitals in Zhejiang Province"
Medical institutions shall, in accordance with the requirements of the Interim Measures for the Administration of Hospital Outpatient Service in Zhejiang Province, adhere to the patient-centered, optimize the outpatient service process, improve the service environment and experience, reasonably arrange the medical staff to ensure the normal operation of the outpatient service. Clarify the responsibilities of outpatient management department, and implement the core system of outpatient management, quality management monitoring and reward and punishment system. Implement outpatient real-name registration system, especially specialist outpatient and specialist special needs outpatient real-name registration system; We will implement various forms of registration, such as telephone appointment, online appointment and two-way referral appointment, to facilitate people to seek medical treatment. Third-level hospitals should improve various systems, fully implement them during the year and gradually extend them to second-level hospitals. The administrative department of health will supervise the implementation of the Measures, and invite the public and the media to participate in the supervision, so as to further improve the outpatient service process and improve the service quality and efficiency.
(five) the implementation of the "Regulations on Nurses", pay attention to nursing safety management.
Conscientiously implement the "Regulations on Nurses" and the "Implementation Plan of Zhejiang Province", earnestly safeguard the legitimate rights and interests of nurses and ensure the safety of patients. The administrative department of health should supervise the implementation of the Regulations on Nurses, and medical institutions should increase the number of nurses in strict accordance with the requirements to meet the standards for nurses.
Through? Patient-centered? Pay attention to the quality of basic nursing and provide patients with all-round and high-quality nursing services. Strengthen the observation of illness, correctly implement various treatment and nursing measures, strengthen nurse-patient communication, and provide patients with good life nursing services and rehabilitation health guidance. Improve the evaluation mechanism of internal nursing quality management in the hospital, timely feedback and rectification, and promote the continuous improvement of nursing quality. Strive to improve the realization of various nursing quality management indicators such as the qualified rate of basic nursing in hospitals, and effectively reduce the incidence of nursing complications and medical accidents caused by nursing.
Implementation of the "Zhejiang Specialist Nurse Training Plan (Trial)", through the training of specialist nurses, explore the establishment of a post-oriented nursing talent training model, form a relatively complete on-the-job nurse training system, improve the professional quality of nursing staff, adapt to the development of diagnosis and treatment technology, provide professional services for patients, and improve the nursing level of patients with intractable diseases and acute and critical diseases. Third-level hospitals and some second-level first-class hospitals should actively send nurses to carry out specialist nurse training, and strive to reach at least 1 specialist nurse in each department within three years.
(six) to strengthen the management of quality control centers at all levels.
To implement the requirements of "Administrative Measures for Medical Quality Control Centers (Trial)" issued by the Ministry of Health, each quality control center shall conduct professional quality assessment for all kinds of medical institutions at all levels within its scope of responsibility at least twice a year, and each municipal quality control center shall be responsible for the professional quality control supervision of hospitals above Grade II (including Grade II), and each county-level quality control sub-center shall be responsible for the professional quality control supervision of medical institutions below Grade II, and each quality control center shall issue quality control reports objectively and fairly and be responsible for them. The inspection and quality control report shall be informed to the medical institution in written form and copied to the health administrative department at the same level as the verification basis of the medical institution.
Counties (cities, districts) with imperfect quality control systems should speed up the improvement and establish corresponding quality control centers. For the specialties involved in the 16 municipal quality control center established in our city, where there are more than three medical institutions under the jurisdiction of the county (city, district) Health Bureau, the county (city, district) Health Bureau shall set up a quality control sub-center for this specialty. For majors that do not reach the third-level medical institutions, they can be unified into the' quality control category' of the Municipal Quality Control Center. Counties (cities, districts) must set up corresponding quality control sub-centers before 20 17 1654381October 30th. Health bureaus of counties (cities, districts) shall report the completion of the establishment of professional quality control sub-centers (or the establishment documents of professional quality control sub-centers) to the Medical Administration Department of the Municipal Health Bureau before 20 17 12 15.
Our bureau will take various forms to comprehensively evaluate the quality control management of the municipal quality control center, establish the exit mechanism of the quality control center, stop its quality control qualification, rectify or cancel its qualification within a time limit, and re-select those who fail to carry out quality control work or can not give full play to the guiding role of the center in the professional quality of medical institutions in the city. And according to the relevant requirements, consider re-selecting medical institutions to undertake municipal quality control work through open competition (refer to the management of municipal technical guidance center). County (city, district) health administrative departments should also strengthen the management of quality control centers, establish systems, standardize operations, and play a role.
(seven) innovative hospital medical quality observer system.
Medical quality observers refer to employees who have received relevant training, participated in the daily business and management of hospitals, put forward suggestions and opinions on the problems existing in medical activities, and promoted the improvement of medical quality and safety management. Medical institutions should establish a medical quality observer system, formulate the selection, evaluation and withdrawal mechanism of medical quality observers, train medical quality observers, and gradually play their role in medical quality supervision.
Third-level hospitals should start to establish a medical quality observer system within the year, report the selected medical quality observers to the Municipal Health Bureau, and gradually extend them to second-level hospitals. The health administrative department will rely on this team to carry out the inspection and evaluation of medical quality and safety, and recommend trained observers with strong professional ability and management evaluation ability as provincial and municipal medical quality assessors, inspectors and grade hospital assessors.
(eight) make full use of hospital evaluation carrier.
Health administrative departments at all levels should make full use of various work carriers such as practice acceptance, regular calibration, daily evaluation and grade evaluation to effectively strengthen hospital evaluation and improve the quality management level of hospitals. It is necessary to strengthen the practice acceptance of medical institutions in strict accordance with the Regulations on the Administration of Medical Institutions and its implementation rules; In order to implement the "Administrative Measures for Calibration of Medical Institutions (Trial)" of the Ministry of Health and the "Notice on Strengthening the Calibration Management of Medical Institutions" of the Provincial Health Department, give full play to the calibration function, further standardize the name of medical institutions, diagnosis and treatment subjects, and ensure the access of institutions and subjects.
Give full play to the role of hospital grade evaluation in promoting medical institutions to strengthen medical quality management and evaluating the comprehensive ability of medical institutions. During the activity, according to the requirements of the provincial health department, do a good job in the supervision and pre-evaluation of the evaluation of tertiary hospitals and complete the third round of grade evaluation of secondary hospitals; At the same time, prepare for the evaluation of specialized hospitals.
Activity steps of intransitive verbs
(1) Mobilization and deployment stage (2065438+August-September 2007)
Complete the preparation, mobilization and organization of the continuous improvement plan of medical quality.
(2) Organization implementation stage (201710-201812)
1. Health administrative departments at all levels and medical institutions at all levels should combine with the Ministry of Health? Does the medical quality go to Wan Li Road? And then what? Hospital management year? Activities, the full implementation of the "medical quality continuous improvement plan".
2. Annual priorities. According to the overall requirements of the plan, combined with the annual medical work priorities, determine the key contents of annual quality continuous improvement, and earnestly grasp, grasp, grasp deeply and thoroughly.
3. Inspection and guidance. Medical institutions should actively implement and meet the inspection. Three hospitals should accept the supervision and evaluation of the activities carried out by the Provincial Health Department every year, and the Municipal Health Bureau is responsible for the supervision, evaluation, inspection and guidance of the two hospitals within its jurisdiction to ensure the implementation effect.
(3) Summarize the communication
1. Annual summary. County (city, district) Health Bureau and municipal medical institutions shall report the progress of activities, inspection results and activities to the Office of the Leading Group for the Continuous Improvement Plan of Medical Quality of the Municipal Health Bureau in a timely manner every year. Every year, the office summarizes the activities of all kinds of medical institutions at all levels in the city and reports them to the provincial health department to ensure orderly progress and obvious results.
2. Summary of activities. After the expiration of the three-year cycle, organize an activity experience exchange meeting to promote the good experience, good practice and good model of the activity, and at the same time study and deploy the key work in the next cycle to further establish and improve the long-term mechanism for continuous improvement of medical quality.
Seven. job requirement
(A) to strengthen leadership, unified understanding
Is the implementation of the "continuous improvement plan for medical quality" beneficial to the Ministry of Health? Does the medical quality go to Wan Li Road? And then what? Hospital management year? The further deepening of the activity is of great significance for improving medical quality, strengthening the connotation construction of medical institutions, building a harmonious doctor-patient relationship and promoting the healthy development of medical and health undertakings. Health administrative departments and medical institutions at all levels should attach great importance to it, strengthen leadership, unify understanding and strengthen quality awareness.
(two) extensive publicity, and strive for practical results.
Health administrative departments and medical institutions at all levels should make careful arrangements, make overall plans scientifically, innovate methods and pay attention to actual results. All localities and units should take the continuous improvement plan of medical quality as the starting point, standardize medical behavior, promote construction with quality, and ensure medical safety; It is necessary to actively use lectures, videos, exhibitions, special reports, brochures and other forms to carry out publicity and education activities, actively coordinate local news media, increase publicity, and mobilize public participation to create a good atmosphere for improving medical quality, ensuring medical safety, improving medical environment, and promoting harmony between doctors and patients; It is necessary to closely combine activities with daily medical management, fully mobilize the enthusiasm of the majority of medical staff, and ensure that the activities are effective.
(3) Be good at summarizing and establishing mechanisms.
In the process of organizing and implementing activities, all localities should conscientiously sum up experience, make timely improvements in view of existing problems and weak links, and promote while rectifying. It is necessary to strengthen the construction of the core system in activities. Real? Looking for kung fu online, at? Really? Seeking practical results, in? New? It is necessary to change around the world and establish a long-term mechanism for continuous improvement of medical quality. It is necessary to set an example, promote the good experience and good practices of medical quality management through demonstration hospital construction and on-site meetings, and constantly improve the level of medical quality management to serve the broad masses of the people.