Annual inspection and self-examination report of medical institutions (selected 5 articles)
Time flies, and a period of work is over. Looking back at the work during this period, there are surprises and also exist For this reason, you must make a summary and write a self-examination report. So how to write a detailed self-examination report? The following is the annual self-inspection report of medical institutions (selected 5 articles) that I compiled for everyone. You are welcome to learn from and refer to it. I hope it will be helpful to everyone.
Annual inspection and self-inspection report of medical institutions 1
According to the ××× City Health Bureau’s “Implementation Plan for the Centralized Rectification of Primary Medical Institutions in ××× City in 20xx” (Health Medical Issues [20xx] 〕No. 15), in accordance with the rectification opinions of the ××× County Health Bureau on the problems found in the special inspection of Check and correct work.
1. The leaders attached great importance to it and established a self-examination leading group
On April 19, a work meeting on the rectification of medical institutions was held to study and implement the "XXXX City 20xx Primary Medical Institutions "Centralized Rectification Work Implementation Plan", all medical staff in the hospital carry out studies on medical and health laws and regulations, and incorporate the "Practicing Physician Law", "Medical Institution Management Regulations", "Nursing Regulations", "Prescription Management Measures", "Medical Record Writing Standards", etc. Norms and learning are included in the performance appraisal of staff. Establish a leading group with the president as the team leader, the vice president as the deputy team leader, and the heads of each department as members, to carry out self-examination and self-correction on the health center's standardized practice in accordance with the law and the improvement of the hospital's management level.
2. Adhere to practice in accordance with the law and standardize the scope of practice
1. All departments of the health center engage in professional activities in strict accordance with the "Scope of Practice License of Medical Institutions", and there is no practice of medicine beyond the scope of diagnosis and treatment.
2. The health center currently has 48 staff, including 13 practicing physicians and practicing assistant physicians, 14 practicing nurses, 6 pharmacists, 2 medical imaging technicians, and 1 laboratory technician. Strictly unlicensed and non-health technicians are allowed to engage in medical activities alone.
3. Health center consultations are strictly carried out in accordance with the "Interim Regulations on the Management of Medical Outbound Consultations".
4. There is no illegal or illegal medical advertisement.
5. Ban dental clinics opened without permission.
6. Standardize the writing and management of medical documents, and make medical documents timely, accurate, complete and standardized. Medical records, prescriptions, and nursing records must be written in accordance with the "Basic Rules for Writing Medical Records" formulated by the Ministry of Health and completed within the specified time. The format must not be changed at will or the items and content may be simplified, and the completion time must not be delayed. Standards", "Basic Standards for Traditional Chinese Medicine Medical Record Writing", "Prescription Management Measures", etc.
3. Conscientiously implement the essential drug system
All drugs in the ××× Health Center are national essential drugs. The supply of drugs to service stations and village clinics in the jurisdiction are purchased and distributed by the hospital uniformly online. , implement zero margin sales, and no fake, expired, or invalid drugs.
4. Implement the disinfection and isolation system to prevent infection accidents
Strictly implement injection operating procedures to achieve "one person, one injection, one tube, one use, one disinfection" and prevent the reuse of medical supplies . Carry out disinfection and sterilization effect testing regularly and establish records. Strictly implement the reporting system for hospital infections and infectious diseases. All disposable medical supplies are soaked and disinfected after use, destroyed, and then harmlessly disinfected and incinerated. Detailed medical waste handover records are kept, and there is no resale or gift.
In short, the health center attaches great importance to standardizing practice and pays close attention to the implementation of further standardizing practice behavior to lay a solid foundation for improving medical quality. Annual self-inspection report of medical institutions 2
The outpatient department is a private for-profit medical institution. In order to do a good job as a qualified pharmacy, we follow the "Regulations for the Implementation of the Drug Administration Law", "Pharmaceutical Business Quality Management Standards" and other relevant The document requirements have been carefully self-examined, and the relevant status is now reported as follows:
1. Basic situation of the enterprise
Since its establishment, the outpatient clinic has adhered to the patient-centered service concept. Adhere to the principle of honesty, operate in accordance with the law, and ensure that there are no quality accidents in the drugs we operate. The pharmacy has three on-the-job practitioners, one pharmacist and two other professional and technical personnel, who are engaged in drug quality management, acceptance and daily maintenance. The pharmacy has a usable area of ??ten square meters and a warehouse of fifteen square meters. It has a reasonable layout and complete equipment, meeting the requirements for classified storage of drugs. And there is a dedicated person responsible for management.
2. Main implementation process and self-examination
Strengthen education and training to improve the overall quality management quality of pharmaceutical practitioners.
(1) In order to improve the comprehensive quality of all employees, our hospital not only actively participates in various trainings organized by superior pharmaceutical administrative departments, but also adheres to internal on-the-job training. This includes legal and regulatory training, this outpatient system, work procedures, responsibility training, job skills training, drug classification knowledge training and employee ethics education, etc. All trainings are assessed and the training results are more obvious. The outpatient clinic arranges regular physical examinations for employees who are in direct contact with drugs.
(2) Facilities and equipment
Our clinic strives to further increase its efforts on the existing basis and improve and transform the pharmacy in accordance with relevant requirements. Equip and replace thermometers. Medicine shelves, refrigerated boxes. Replace or repair the Chinese medicine cabinet and purchase the necessary Chinese medicine crusher. Improve pharmacy ventilation and temperature control facilities. The environment should be bright, clean and reasonably laid out, equipped with necessary modern office equipment, and computerized management of purchase, sale and inventory should be implemented. The warehouse must be reasonably laid out, with flat floors, tight doors and windows, no sources of pollution, dust-proof, moisture-proof, mildew-proof, pollution-proof, insect-proof, rodent-proof, bird-proof equipment and facilities, and fire safety facilities that meet the requirements.
(3) Purchase management
Strictly control the purchase of medicines. Earnestly implement the first-run enterprise and first-run variety review system and its procedures, the drug purchase system and its procedures, pay attention to the investigation of the supplier's quality assurance system, and ensure that the supplier and the purchased drugs are 100% legal. The quality policy of "Quality First, Standardized Operation" is implemented, the drug purchase vouchers are complete and authentic, and the quality of drug procurement is strictly controlled. In accordance with legal standards, the acceptance personnel conduct drug quality inspections on batches of purchased drugs in accordance with the prescribed proportions. They conduct acceptance inspections on the appearance and properties of first-market varieties, injections, and first-time purchased drugs of various dosage forms to ensure that the acceptance rate of drugs entering the warehouse is 100%. , resolutely reject substandard drugs and counterfeit drugs.
(4) Storage and maintenance
Store in strict accordance with the storage requirements of drugs. First, store the drugs in normal temperature warehouses, cool warehouses and refrigerated warehouses according to the required storage conditions. Secondly, the near-expiration date drug report is filled in according to the prescribed time every month to ensure that the quality of the drugs in the warehouse is intact.
3. Self-examination summary and solutions to existing problems
All along, under the care and guidance of the municipal bureau and through the joint efforts of all staff, the quality has been improved management system and strengthened its own construction. After self-examination, it was deemed that it basically complies with the conditions stipulated by the drug administration department.
1. Outpatient pharmacies conduct sales activities in strict accordance with relevant laws and regulations and the hospital’s quality management system, and carefully check necessary information such as physician prescriptions, drug specifications, expiration dates, taking methods, precautions, and patient names. , ensuring accurate payment of medicines.
2. Adhere to business operations in accordance with the law and do not have business relationships with units or individuals without pharmaceutical business qualifications.
3. Ensure that drug payments comply with relevant regulations. Keep physician prescriptions and establish complete sales records.
4. Have a legal and valid "Business License".
5. There is no illegal operation of counterfeit and substandard drugs.
6. The person in charge of quality and the person in charge of quality management must hold certificates to work.
7. In order to facilitate the establishment of a long-term supervision mechanism for drug use, our clinic has established a computer management information system to achieve full-process quality control of drug purchase, storage, and sales. Establish a database for purchasing and selling units, business varieties and sales personnel, automatically control their legal qualifications and operating authority, and effectively manage the dynamics of inventory drugs.
8. Improve drug storage conditions and temperature adjustment facilities to meet drug storage temperature requirements. At the same time, we will take effective measures to seriously rectify some problems and deficiencies discovered. Main manifestations: First, the training of employees needs to be further strengthened; second, the consciousness and ability of each position to self-examine quality management work need to be strengthened; third, after-sales service needs to be strengthened, and drug quality must be further improved. Query work.
Our clinic will definitely implement the problems discovered during the self-examination and internal audit one by one, and continuously check and rectify them to make the drug operation quality management of this clinic more standardized and standardized. Our clinic will comply with relevant regulations. Self-examination and internal review found that it basically complied with the requirements of the drug regulatory department. Annual Inspection and Self-Inspection Report of Medical Institutions 3
In order to improve the quality of medical services and technical service levels, our service station conducted strict self-examination and self-correction in accordance with the "Implementation Rules of the Regulations on the Management of Medical Institutions". The relevant self-examination situation is now reported as follows:
1. Leaders pay attention to it and organize it closely
Our service station held a meeting to strictly deploy the self-examination work. At the meeting, a self-examination leading group headed by Ren was established and carried out careful self-inspection and self-correction in strict accordance with the "Implementation Rules of the Regulations on the Management of Medical Institutions" and achieved remarkable results.
2. Basic situation of self-examination
(1) Institutional self-examination situation: The full name of the unit is "Keyuan Street Fengyuan Community Health Service Station", which is a private non-enterprise and is located in ; Legal representative: ; Main person in charge: "Medical Institution Practice License" issued by the District Health Bureau, practice license number December 23, 20xx. Our service station has implemented strict management of the "Medical Institution Practice License" and has never altered, bought, sold, transferred or leased it. There are currently 6 beds, and the diagnosis and treatment subjects include preventive health care and general medical care; the business space is 320 square meters.
(2) Personnel self-examination: Our service station currently has 1 attending physician, 1 practicing physician, 2 assistant physicians, and 3 nurses.
Our service station has never been registered in multiple areas to carry out professional activities; it has never used personnel who have not obtained the qualifications of practicing physicians or nurses to engage in medical activities, or doctors who have registered in multiple places with one certificate to engage in medical activities. All medical staff are posted on duty and set up in the hall. The supervision column is made public.
(3) Improve service quality: Strengthen medical quality management in accordance with relevant regulations and standards of the health administrative department, and implement medical quality assurance plans; regularly inspect and assess various rules and regulations and the job responsibilities of various personnel at all levels implementation of the system, ensure medical safety and service quality, and continuously improve service levels.
(4) In-hospital cross-infection management: A leading group for cross-infection management in the service station has been established, consisting of others. Relevant personnel are regularly educated and trained, and relevant rules and regulations such as medical waste treatment management, nosocomial infection and disinfection management, and waste leakage treatment plans have been established and improved. There are dedicated personnel to keep complete records of the source, type, and quantity of medical waste, and regularly conduct Key departments and locations carry out disinfection effect monitoring, and the labels of prepared disinfectants are clear, complete and standardized.
(5) Disposal of solid medical waste: All medical waste has been classified and collected, and there are warning signs for the temporary storage time of waste according to regulations. The waste containers are sealed and puncture-proof, and the waste is temporarily stored. The depository has implemented the "five preventions", and the transportation and transfer of medical waste is the responsibility of a dedicated person and has a signature record.
(6) Disposal of disposable medical supplies: All disposable medical supplies are soaked, disinfected, destroyed and collected by medical waste treatment stations after use.
(7) Self-examination of drug management: It has been found that our service station has never used counterfeit, expired, invalid or illegal drugs. Strictly implement antimicrobial drug system regulations.
3. Shortcomings
First, due to insufficient funds, some medical equipment cannot be maintained or updated in time, which has affected the in-depth development of related businesses to a certain extent and lacks potential for development. Second, due to limited staffing, tight staff, heavy workload, few opportunities for further study in provincial medical institutions, and a long cycle of knowledge update, this has affected the improvement of service levels to a higher level to a certain extent.
4. Direction of future efforts
Our service station must take this self-examination as an opportunity, under the leadership of the superior business department, conscientiously implement the spirit of the superior meeting, and strictly abide by the " "Medical Institution Management Regulations", strengthen management measures, optimize personnel quality, seek truth and pragmatism, pioneer and innovate, and continuously improve the quality of medical services and technical service levels. Annual Inspection and Self-Inspection Report of Medical Institutions 4
In order to protect the life safety of the people and improve the quality of life of the people, in line with the principle of: "people-oriented, patients first", we have based on the spirit of superior documents, in the High-tech Zone Under the guidance of the Health Bureau, relevant personnel were organized to conduct a comprehensive inspection of the medical devices and equipment throughout the hospital. The specific situation is now reported as follows:
1. Strengthen leadership, strengthen responsibility, and enhance quality responsibility awareness.
The hospital first established a safety management organization with the president as the team leader and the directors of each department as members, making the management of medical equipment safety a top priority in the hospital's work. Strengthen leadership, strengthen responsibility, and enhance awareness of quality responsibility. The hospital has established and improved a series of medical device-related systems to ensure the safe and smooth development of the hospital's clinical work.
2. In order to ensure the quality and safety of purchased medical devices and equipment and prevent the entry of substandard medical equipment, our hospital has specially formulated a medical equipment purchase management system. Strict regulations have been made on the conditions for purchased medical equipment and the qualifications of suppliers.
3. In order to ensure the legality and quality of the medical devices and equipment stored in the warehouse, we must conscientiously implement the medical device storage system and ensure the safe use of medical devices.
4. In order to use medical equipment accurately and safely, our hospital regularly organizes business studies and invites professional and technical personnel to conduct equipment use training, and has achieved good results.
5. Do a good job in daily storage. Some medical equipment in our hospital are relatively expensive. While our hospital's technical staff perform regular self-inspections and maintenance, we also ask the manufacturer's technicians to check and correct them regularly.
6. Strengthen the management of unqualified medical devices and prevent unqualified medical devices from entering clinical practice. Our hospital has specially formulated an adverse event reporting system. If an adverse event occurs with a medical device, the location, time, adverse reaction or basic situation of the adverse event should be ascertained, records should be kept, and the report should be promptly reported to the district Drug and Medical Device Supervision and Administration Bureau.
7. The focus of our hospital’s medical device work in the future
Effectively strengthen the hospital’s medical device safety work, prevent the occurrence of medical device safety incidents, and ensure the safety of medical device use by the majority of patients. In the future At work, we plan to:
1. Further increase the publicity of medical device safety knowledge, implement relevant systems, and improve the hospital's awareness of medical device safety responsibilities.
2. Increase the frequency of daily inspections and supervision of medical device safety work in hospitals, promptly identify potential safety hazards of medical devices, firmly establish the "safety first awareness", serve patients, and continuously build a hospital that satisfies the people.
3. Continue to actively cooperate with superior departments to consolidate the results of the hospital’s medical device safety work, jointly create a good atmosphere for medical devices, and make greater contributions to building a harmonious society.
Annual Inspection and Self-Inspection Report of Medical Institutions 5
Municipal Health Bureau:
In order to further strengthen the management of the new rural cooperative medical institutions in our district, standardize the diagnosis and treatment service behavior, and control the unreasonable increase in medical expenses, To ensure the security of the New Rural Cooperative Medical System fund, promote the refined management of the New Rural Cooperative Medical System, and promote the evaluation of the health system, according to the spirit of the document "Notice of the Office of the Provincial Health Department on Carrying out Inspection Activities of the New Rural Cooperative Medical System Service Behavior of Designated Medical Institutions", the District Health Bureau issued The "Notice on Carrying out Inspection Activities of New Rural Cooperative Medical Care Services in Designated Medical Institutions" (Dianweifa No. 20xx55) was issued, and arrangements were made for the inspection activities of new rural cooperative medical care services in designated medical institutions in our district. Each medical institution conducted In order to conduct self-examination, the District Health Bureau organized a special team to conduct special inspections of medical institutions at all levels in the jurisdiction from September 5th to 9th. The progress of the inspection activities is summarized as follows:
1. Achievements
The District People’s Hospital and the township health centers attach great importance to the new rural cooperative medical work, strengthen internal management, and strictly implement The New Rural Cooperative Medical System policy fully serves the participating people, ensures the smooth progress of various tasks of the New Rural Cooperative Medical System, improves the benefit level of the participating people, and ensures the safety of the New Rural Cooperative Medical System fund. The main manifestations are as follows:
(1) The internal control mechanism has been basically established
Each township health center has established a new rural cooperative medical care hierarchical management system with a clear division of responsibilities; strengthened basic management and improved rules and regulations , strictly assess rewards and punishments, and ensure that all system regulations are implemented.
(2) Hospitalization costs are stabilizing but declining
After the implementation of the bed-based daily payment reform, various township health centers strengthened cost control and strengthened medical services, achieving a reduction in costs. Good results without discounting the service. From January to August 20xx, the average cost of hospitalization in Lianpeng Township Health Center was 1,200 yuan, a decrease of 272 yuan compared with the same period last year, a decrease of 18.48%.
(3) Outpatient total prepayment has achieved significant results
After the implementation of the reform of outpatient total prepayment payment methods, all township health centers have strengthened outpatient overall management, formulated management plans, and strengthened daily Management, strict supervision and assessment, ensuring the benefits of participating people and the safety of outpatient funds. Qiaobian Town Health Center strengthened system supervision, quarterly assessments, and door-to-door inspections. From January to August, it reduced illegal subsidy funds for village clinics by 4,140.80 yuan, effectively curbing the phenomenon of fictitious diagnosis and treatment to obtain funds, and ensuring the total prepaid outpatient fund. Safe and effective to use.
2. Existing problems
(1) District People’s Hospital
First, the internal new rural cooperative medical care system needs to be further improved. Since the District People's Hospital is integrated into the integrated management of Yichang Central Hospital, the District People's Hospital does not have an independent and complete new rural cooperative medical care management organization. The new rural cooperative medical care management function of the medical insurance office needs to be further strengthened, and the internal control and assessment mechanism needs to be further improved.
Second, admission standards are not strictly enforced. The District People's Hospital implements the "community first diagnosis" and "level-by-level referral" systems, where patients are admitted first and then transferred; the admission standards are not strictly controlled, and there are phenomena of outpatient transfer to hospitalization and minor illnesses to major treatments.
Third, the rational use of drugs needs to be strengthened. The District People's Hospital uses the drug catalog of tertiary hospitals. The overall drug prices are on the high side, and the use of antibacterial drugs does not strictly implement the hierarchical use management regulations.
Fourth, reasonable inspections need to be standardized. The District People's Hospital has strengthened the management of large-scale examinations such as color ultrasound and CT, and the pertinence and rationality of examinations have improved. However, there are still unconventional examinations that are not related to major diseases and unnecessary examinations that are of little significance for diagnosis and treatment. Such as excessive censorship behavior.
(2) Township health centers
The outpatient management of the new rural cooperative medical system in each township health center is basically standardized, the essential drug policy is implemented, compensation is in place in a timely manner, and there is no phenomenon of fictitious medical services to obtain funds. , the participating people have high satisfaction and good social response.
The township health centers mainly have the following problems in the management of New Rural Cooperative Medical Care hospitalizations:
First, the proportion of acute and critical patients in some health centers is too high. From January to August, the proportion of patients managed as emergency and critical in xx Health Center reached 28.78%, which is nearly 10 percentage points higher than the regional average.
Second, the overall service capacity of township health centers is insufficient. Due to the influence of factors such as talents, equipment, technology, and management, the medical service capabilities of township health centers are declining. Some common and frequently-occurring diseases in rural areas cannot be treated in primary medical institutions. The outflow rate of patients is increasing, which affects participating farmers. Benefit level and safety of New Rural Cooperative Medical System Fund.
Third, the average cost per case at some township health centers is relatively high. Compared with the same period last year, the average cost per patient at Aijia Town Health Center and Lianpeng Township Health Center has dropped significantly, and the reform of the New Rural Medical Care System’s bed-based daily payment has achieved relatively significant results. The average cost per case at xx Township Health Center is 1,583 yuan, which is relatively high.
Fourth, reasonable inspections need to be standardized. Some tests are not relevant to the primary disease, and some tests (such as blood sugar) are repeated too often.
(3) Village clinics
First, the essential drug policy is not implemented in place. Non-essential medicines still exist in village clinics, and because they cannot be included in compensation, it affects the benefits of participating farmers.
Secondly, traditional Chinese medicines provided by some village clinics are not included in the reimbursement.
Third, the utilization rate of total prepaid funds for outpatient clinics in some towns and villages is low. From January to August, the fund utilization rate in Aijia Town was 72.93%, and the fund utilization rate in Lianpeng Township was 70.25%. There was too much fund accumulation, and the benefit rate of participating farmers was low.
Fourth, the phenomenon of fictitious medical services still exists to varying degrees. Some village clinics do not implement the small receipt signature system and charge fees at will. It is difficult to fundamentally eliminate the phenomenon of fund evasion such as underpayment, overreporting, and fictitious patient times.
3. Rectification requirements
(1) Strengthen leadership and implement responsibilities. The District People's Hospital must correctly handle the relationship between hospital development and the interests of the masses, effectively strengthen the management responsibilities of the New Rural Cooperative Medical System, straighten out the relationship, establish and improve the internal control mechanism, and assign the responsibility for cost control to departments and doctors. All township health centers should further implement a leadership system in which the dean takes overall responsibility and the deans in charge are responsible for implementation, implement management responsibilities to departments and extend to village clinics, and implement a strict accountability system.
(2) Establish rules and regulations to standardize behavior. The district people's hospital and township health centers should start with system construction, implement refined management, standardize the new rural cooperative medical service behavior, and improve the benefit level of participating farmers. The District People's Hospital should establish a relevant management system that is in line with the actual situation of Jiangnan District and highlights the responsibilities of the District People's Hospital. It should strengthen system management in terms of admission (discharge) standards, standardized diagnosis and treatment, reasonable cost control, etc., and calculate the average cost per case and average bed-day cost. , drug composition ratio, large-scale examination positivity rate, actual compensation ratio, usage rate of drugs outside the catalog, and average hospitalization days are included in the assessment content. All township health centers must establish various systems that are compatible with the reform of payment methods to ensure that the reform achieves the expected results.
(3) Strengthen supervision and enforce strict discipline. The New Rural Cooperative Medical Care Fund is a life-saving money for the participating people, and medical institutions and medical personnel at all levels are strictly prohibited from illegally defrauding, extorting, misappropriating, and expropriating it. The district joint management office must perform its handling and supervision responsibilities, carefully review relevant compensation information, strengthen online supervision, on-site inspections, telephone follow-ups, and door-to-door inspections, and handle any violations found such as fee reductions, notifications and criticisms, and deal with outstanding problems. , serious cases of violations of laws and disciplines with strong social repercussions must be reported to the District Health Bureau for processing. All township health centers should strengthen the dynamic supervision of village clinics under their jurisdiction, implement daily supervision and quarterly assessments, and further standardize diagnosis and treatment reimbursement behavior to ensure that medical services are not discounted and farmers' benefit levels are not reduced.
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