With the strong support of hospital leaders, the medical department has made great progress in medical quality, service quality and medical safety. The Medical Department will, as always, under the leadership of the Hospital Committee, take Scientific Outlook on Development as the overall situation of medical work development, as always, enhance the ability of independent innovation, continue to carry out the activities of "Hospital Management Year" and "Two Good and One Satisfied", and constantly promote the work of the Medical Department.
First, prevent medical accidents and ensure medical safety.
Earnestly do a good job in medical quality evaluation, strictly abide by the management norms, working systems and revised evaluation rules formulated by the hospital, carry out management work, strictly implement medical preventive measures and medical accident handling plans, implement the accountability system for medical defects, and carry out medical activities in strict accordance with the standards of medical operation procedures. Organize hospital staff to learn relevant medical laws and regulations. Strengthen the quality management of key links and departments, and expand the focus of medical quality management from the final quality evaluation of medical care to the quality inspection and supervision of every link in the whole medical process. The key points include: (1) emphasizing that the written specifications of admission notice, power of attorney and all kinds of informed consent forms for diagnosis and treatment are complete. (2) Truly and accurately record "discussion on death cases", "discussion on critical cases", "discussion on rescuing critical patients" and doctors' handover; (3) Organize departments to strengthen the study and evaluation of diagnosis and treatment norms and related laws and regulations. (4) further change the work style, strengthen the service consciousness, and achieve "more explanation, more comfort, more understanding, more warmth and more help" to improve the service quality of the hospital; (5) Strengthen the inspection of diagnosis and treatment plan and medication safety.
Second, medical quality management
1, strengthen the department's own construction
According to the shortcomings of the city's work inspection in 2008, we will continue to strengthen our own quality and system construction in 20xx, mainly including: perfecting and updating the activities and meeting records of various commissions and bureaus; Strengthen the management of departmental archives; Change work style, strengthen service consciousness, gradually change from experience management to scientific management, from people-oriented management to system management, enhance independent innovation ability and keep pace with the times.
2, to participate in the hospital quality control management committee rounds, every Thursday morning to a certain department rounds regularly, and all clinical departments in the hospital take turns to circulate. The contents of rounds include: handover of doctors, including the actual handover of departments and written records; Third-level department rounds, focusing on supervising and standardizing the implementation of department teaching rounds and director rounds; Writing quality of inpatient medical records; Implement the five-discussion system of departments, including the discussion of critical cases, difficult cases and deaths, and learn more about their records and implementation; Listen to the director's opinions on medical operation, quality management, scientific research and teaching, and put forward reasonable suggestions for improvement.
3, medical record quality management
(1) link quality Check the medical records of 4-6 links in clinical departments every Monday and Tuesday, and monitor the three-level rounds, five-level discussions, consultations (in-hospital consultations, in-hospital consultations, and out-of-hospital consultations) and doctor's orders in medical records in strict accordance with Shandong medical document writing standards; In addition, strictly regulate doctors' succession, spot check the monthly quality education analysis of departments, help departments find problems, put forward improvement plans, and supervise the study records of three basics and three strictness and political study records.
(2) Final medical records: randomly select 10 medical records of various departments in the medical record room every month, and assess the final cases every six months. The rewards and punishments shall be strictly implemented in accordance with the Measures for Quality Assessment of Medical Documents in Lingxian People's Hospital.
4. Supervision of key departments
(1) In order to monitor the quality of icu, icu was randomly selected every week. The key points are: strictly standardize the medical record writing of critically ill patients and the handover records of medical staff; The actual ward round of the department; The implementation of the reporting system for critically ill patients; Actually watch the proficiency and standardization of medical staff in various technical operations of critically ill patients;
(2) Monitor the anesthesiology department and check it regularly every month. The main contents include: the actual situation of preoperative anesthesia visit; Improve the signing of various anesthesia agreements; Strictly check the implementation of the narcotic drug management system.
Monitoring of key departments, the medical department will strictly check the records, check them correctly, summarize, compare and evaluate the poor contents every time, and discuss the corresponding improvement measures to eliminate potential safety hazards while improving the quality of departments.
Third, continuing medical education.
1. Strengthen the training of new recruits. In view of the shortcomings of the new recruits in the past year, such as irregular medical record writing, weak legal knowledge and incorrect working ideas, the Medical Department will further strengthen the training of new recruits in 2009. The training is mainly divided into three parts: medical record writing, practicing physician law and how to be a good clinician. It will be conducted in stages in the form of lectures. The medical department monitors and checks the trainer's learning records throughout the process, and conducts on-site questions and written examinations after the stage of learning.
2, strengthen the scientific research work of each department, after the completion of daily work, should be planned, targeted organization 1-2 scientific research projects, attending physician or above doctors to write and publish no less than two scientific research papers. While urging scientific research, medical departments should make every effort to create favorable conditions for their departments.
3. Strictly manage off-campus study and interns. While receiving interns from Dezhou Health School, Modern Medical College, Xinglin Medical College, Tai 'an Medical College and other institutions and interns from township hospitals, we will further strengthen organizational discipline management and pay attention to the training of their basic knowledge, basic theory and basic skills.
4. Strengthen the professional training of professional and technical personnel According to the situation of our hospital, under the principle of on-demand training and hospital economic conditions, send medical personnel to study in higher-level hospitals, absorb advanced technology, and improve technical level. Professional and technical personnel with intermediate titles should closely combine their own majors, encourage self-study and full-time study, consciously and strictly supplement, increase new theories, technologies and methods of their professional skills, and master the knowledge of interdisciplinary and related disciplines. Professional and technical personnel with junior titles should combine their posts, train their professional technical knowledge and skills, master professional technology skillfully, participate in scientific research, and solve complicated and difficult diseases, strive to improve the professional quality of professional teams on the principle of inviting in, sending out and learning by themselves, and invite superior experts to our hospital for professional technical guidance with the approval and support of the hospital Committee, so as to continuously improve their professional level in the form of rounds, operations and lectures. And support each topic to invite experts to guide the development of new topics.
5. Continue to strengthen business learning management. Strictly study the business of each department every Monday and week. The medical department randomly checks the actual learning situation of each department and asks questions on the spot in combination with the learning records. In addition, special lectures for young doctors are arranged every Thursday, which are taught by the directors of various departments in turn, and the medical department participates in the whole process and makes records, and conducts on-site assessment from time to time.
6. Emphasize the importance of academic lecture activities inside and outside the hospital, arrange relevant work for professors in higher hospitals, and ensure that relevant professionals can attend.
7. Organize the theoretical assessment of "three basics and three strictness" every six months, formally carry out the practical skill assessment in our hospital in September, and carry out the training of "three basics and three strictness" every quarter, specifically: in the first quarter, conduct the application training of cardiopulmonary resuscitation, ventilator and electric defibrillation for all middle and junior doctors; In the second quarter, the training of common clinical techniques such as catheterization, various punctures, intubation and the first theoretical examination was carried out; In the third quarter, carry out all-staff knowledge training on narcotic drugs and antibacterial drugs; In the fourth quarter, the second theoretical assessment and practical skills assessment were conducted, and special training was conducted for weaknesses.
The hospital needs to be reformed in 20xx. As long as there are unreasonable places, we must reform. This is something we should be optimistic about. In the future, I will gradually adapt to my current job and only move in a new direction. This is what we have always wanted to do. Do a good job, do a good job!