Hospital medical quality management is the lifeline of hospital survival and development. To improve the level of medical management, hospitals can take the following ten major measures.

Establish and improve the medical quality management system

The hospital medical quality management committee regularly organizes quality management system audits and management reviews, checks the hospital's quality policy and goal achievement, and coordinates various departments of the hospital at any time , department quality management system to ensure the effective operation of the hospital quality management system.

2 Continuous Improvement

Continuously review and improve hospital quality evaluation standards and supporting implementation plans or measures, and timely revise the hospital quality control management plan.

3 Practice strictly in accordance with the law

Unqualified personnel are not allowed to work alone, are not allowed to issue reports, and are not allowed to write relevant medical documents. For newly graduated hospital employees who have not yet obtained professional qualifications, the department should designate senior doctors (nurses, technicians) to teach them and be responsible for their medical behavior. Strictly carry out graded management of surgeries, access management of tumor diagnosis and treatment, new technologies, and new projects.

Fourth, strengthen basic quality education and training to lay a solid foundation for final quality

The Ministry of Medical Education organizes "three basics" education for all employees, no less than 2 days per year Each clinical and medical technology department conducts basic professional knowledge education, training and assessment for all undergraduates every quarter. There must be detailed education and training plans for new employees.

5. Strengthen quality control education and strengthen legal awareness and quality awareness

The Quality Control Department and the Medical Education Department organize quality control education to learn various health laws, regulations, and diagnostic and treatment specifications. , operating specifications and work processes. Provide individual intensive education to those who violate medical and health laws, regulations, rules and technical operating procedures. In particular, special pre-job education is provided to new employees to establish good legal and quality awareness.

Sixth: Focus on prevention and implement full-process quality control

According to the laws and characteristics of medical quality formation and the factors and weak links that affect medical quality, preventive management is adopted to treat patients in a strict manner. The entire medical process from admission to discharge is subject to full quality control.

7. Clarify responsibilities, refine and decompose indicators, and implement them at all levels

Clearly distribute control indicators to relevant departments. The various quality indicators that the hospital focuses on monitoring will be refined and broken down into relevant departments. The departments can implement the statistics on the completion of the indicators on a monthly basis, and report in a timely manner if the standards are not met; conduct quarterly assessments of various indicators.

Eight quality control departments conduct regular and irregular inspections and supervision

(1) Operational medical records: Every month, the quality control team of each department inspects the undergraduate operating medical records, and there are a lot of them. For 30% of the total number of discharged medical records in the month, the inspection results will be carefully recorded, and improvement methods will be proposed for irregularities to ensure that unqualified medical records will not be discharged from the hospital. The Quality Control Department conducts spot checks on operational medical records every month and provides timely feedback on irregular writing found during the inspection. Terminal medical records are uniformly and centrally inspected, scored, and recorded by medical record management physicians to ensure that unqualified medical records are not put on the shelves, and the scoring results of each department are included in the performance appraisal of the department.

(2) Medical record quality: Before each medical record is put on the shelf, the medical record management physician will conduct a preliminary inspection. Every quarter, the medical record management committee organizes clinical experts to conduct spot checks on the final medical records of each department. According to the "Inpatient Medical Record Quality Evaluation Form" 》Score, include the "Grade A rate of medical records" into the department's "performance appraisal results", and provide individual rewards and penalties for excellent medical records and Class C medical records. The Quality Control Department writes a medical record quality report every quarter and reports it to the entire hospital. Departments or individuals that have failed multiple times or have major deficiencies in medical record inspections should be given timely feedback and corrected within a time limit. They should be treated as key monitoring objects and subject to key inspections. If necessary, they should be ordered to receive special training arranged by the Medical Education Department.

(3) Outpatient quality: The outpatient department evaluates outpatient quality every month, including the quality of outpatient medical records, the quality of inspection and imaging reports (including timeliness and accuracy), the quality of outpatient prescriptions, and patient satisfaction. Rate.

(4) Quality of application forms: Every month, the Quality Control Department organizes the medical technology department to inspect all types of application forms throughout the hospital, and statistics on the pass rate of application forms for each department and the main unqualified problems are reported to the quality The control department provides feedback to the department on a monthly basis.

(5) Prescription quality: Every month, the Quality Control Department organizes relevant departments to inspect the prescriptions of the entire hospital, comment on the standardized writing of prescriptions, rational use of medicines, etc., count the prescription pass rate by department, and report the quality Control the department and provide feedback on a monthly basis.

(6) Nursing quality: The nursing department conducts inspections on basic nursing, health education, nursing documents, basic operations, nursing quality management, etc. through a combination of monthly spot checks and quarterly centralized inspections. Assessment, linking assessment results with performance appraisal.

(7) Comprehensive inspection: Every quarter, the Medical Quality Management Committee organizes a comprehensive inspection of the basic quality, link quality, and final quality of clinical and medical technology departments, and links the assessment results with the department performance appraisal. .

Nine Quality Control Responsibility

Incorporate the completion of various quality indicators into the performance appraisal system as the core of department work, and link it to individual work reports, year-end assessments, and professional title promotions.

Monitor the completion of key quality tasks, and impose corresponding penalties on unqualified and non-standard behaviors, specific to departments and individuals. Various medical quality indicators that have been broken down into departments and departments are collected on a quarterly basis, and corresponding results are obtained based on the completion status, which are included in the performance appraisal results of departments and departments, and are linked to the economic income of departments and individuals.

For work quality defects and hidden dangers discovered during daily inspections, departments and departments with safety risks should analyze the reasons for their occurrence and propose rectification methods to eliminate safety hazards, control medical risks, and improve medical quality. .

Ten promotion of clinical path management

Using the "New Rural Cooperative Medical System" www.304wsjfm.com single disease control as the basic disease, gradually and in batches introduce common diseases and frequently-occurring diseases Single-disease clinical path management not only improves quality management levels, but also rationally utilizes limited medical resources, improves efficiency, and reduces patients' basic medical expenses.