Busy and substantial work has come to an end under the urging of time. Look back at the work problems that existed during this period, and let's write a self-inspection report together. Do you know the format of the self-inspection report? The following are the self-inspection reports (selected 3 articles) of medical institutions, which I collected and sorted out, hoping to help you.
Self-inspection report on legal practice of medical institutions 1 In order to further strengthen the awareness of legal practice of medical institutions, crack down on illegal practice, strengthen the supervision of medical institutions by health and family planning administrative departments, improve the quality of medical services and ensure medical safety, according to the requirements of the Notice of Guang 'an Health and Family Planning Commission on Carrying out Comprehensive Law Enforcement Inspection of Medical Institutions (Shi Guang Wei Ban Fa [20xx] No.78), the Municipal Health Planning Commission organized a comprehensive supervision department, a medical administration department and a health law enforcement detachment.
I. Basic information
This inspection randomly selected 30 medical institutions including municipal medical institutions, including 2 public medical institutions above Grade III, 5 public medical institutions above Grade II, 4 other public medical institutions, 9 private medical institutions and township hospitals 10. In view of the medical institutions with many problems found in daily supervision and strong reaction from the masses, it is important to check whether there is any behavior of renting contracted departments or renting contracted departments in disguised form in each medical institution, whether it goes beyond the approved and registered diagnosis and treatment subjects to carry out diagnosis and treatment activities, whether it uses non-health technicians to engage in medical and health technical work, whether the naming of medical institutions is standardized, whether the clinical application of medical technology is prohibited for filing according to regulations, and whether there is any behavior of prohibiting clinical application of medical technology. The inspection team will feedback the inspection situation to the inspected unit on the spot, and send the problems found to the health and family planning bureaus of all districts, cities and counties in the form of "Health Administrative Law Enforcement Proposal" to urge the rectification to be in place and investigate and deal with the illegal acts found according to law.
Second, the existing problems
(1) Management of medical institutions: Most medical institutions can apply for verification on schedule, and carry out diagnosis and treatment activities according to the diagnosis and treatment subjects approved and registered by the health administrative department, and there is no behavior of renting contracted departments or renting contracted departments in disguised form. However, on the whole, the awareness of legal practice and medical quality of medical institutions still need to be improved, and the phenomenon of illegal medical practice still exists. First, there is still the phenomenon of using non-health technicians. During the inspection, it was found that most private medical institutions are relatively short of qualified health technicians, especially the functional auxiliary departments such as B-ultrasound room, radiology department and laboratory department. There is a phenomenon that qualified personnel are absent for a long time and qualified personnel do not issue relevant inspection reports. At the same time, grassroots medical institutions such as private medical institutions and township hospitals lack qualified pharmaceutical personnel, and it is common for people who do not have pharmaceutical qualifications to review and distribute drugs; The registered address of medical practitioners in individual medical institutions has not been changed in time to carry out diagnosis and treatment activities or the medical practitioners registered in hospitals are not on the job. Second, the setting and naming of departments are not standardized, and some medical institutions still have dummy departments or additional departments. Third, occupational radiation management is not standardized. During the inspection, it was found that some medical institutions failed to obtain the Radiological Diagnosis and Treatment Permit, or failed to carry out the radiation diagnosis and treatment activities on time, and the details of the radiation device were not registered in the copy. The radiation workers did not wear personal dose detectors and did not undergo pre-job physical examination. Fourth, the management of medical records and prescriptions is not standardized. There are some problems such as untimely and imperfect writing of medical records, untimely printing of printed medical records and signature of doctors, untimely examination and signature of doctors by unqualified personnel, and irregular prescription writing and medication.
(II) Management of clinical application of medical technology: There are 15 medical institutions registered to carry out Class II medical technology in the city, and there is no medical institution registered to carry out Class III medical technology. The second-class medical technology for the record is mainly concentrated in medical institutions above the second level, mainly focusing on the development of endoscope and hip and knee replacement technology above the third level. According to the inspection, among the 30 medical institutions randomly selected, 23 have not restricted the clinical application of medical technology, 6 have filed with the health and family planning administrative department as required, and 1 family has not filed the hip replacement technology. Among the medical institutions for filing, individual medical institutions are unable to provide filing announcements, medical technology management is not standardized, and relevant rules and regulations have not been established.
(3) Medical advertisement management: some medical institutions lack standardized in-hospital medical publicity, such as listing "cooperation with xx Hospital", posting "experts" to introduce cooperation, and exaggerating medical technology publicity on treatment effect. No request has been received from the industrial and commercial department to revoke the diagnosis and treatment subjects or the practice license of medical institutions.
(4) Naming management of medical institutions: Generally speaking, the naming of public medical institutions is relatively standardized, and the naming of some private medical institutions needs to be further standardized. For example, the names of medical institutions with irregular place names, such as Linshui Chuandong Hospital, Linshui Southwest Stomatological Hospital, Guang 'an Minsheng Hospital, etc. Names of medical institutions that use homonyms to create ambiguity or mislead patients, such as Linshui Union Medical College Hospital, Linshui Huaxi Hospital, Guang 'an Huaxi Hospital, Vu Thang Pok Oi Hospital and Vu Thang Huaxi Hospital.
Third, the next work requirements
(1) Sort out the problems and investigate and deal with them according to law. All localities and units should take the problems found in this inspection as clues, carefully sort out the existing problems, organize and urge law enforcement departments to further investigate and collect evidence, and once the violations of laws and regulations of medical institutions are verified, resolutely investigate and deal with them in accordance with the Regulations on the Administration of Medical Institutions and other relevant regulations, and will never tolerate them.
(2) Strengthen daily supervision and management. All localities and units should attach great importance to this work, strengthen the daily management of medical institutions under their jurisdiction, and urge medical institutions to standardize their practice. The first is to standardize the establishment and management of departments in medical institutions. It is forbidden to rent contracted departments, use non-health technical personnel and practice beyond the scope. The second is to strengthen the supervision of clinical application of medical technology. Strengthen the post-event supervision of the clinical application of medical technology in this area, and incorporate the clinical application of medical technology into the daily supervision focus. The third is to strengthen the management of medical advertisements and conduct examination and certification according to law. The fourth is to further standardize the naming management of medical institutions.
(three) to strengthen the verification and review of medical institutions. For medical institutions that propose calibration, it is necessary to strictly review relevant documents, medical records and materials to see whether they meet the basic standards of medical institutions. Those who do not meet the relevant requirements of the Regulations on the Administration of Medical Institutions and the Measures for the Administration of Verification of Medical Institutions shall be ordered to make rectification within a time limit and given a suspension period of 1 to 6 months. If the suspension period has not passed the verification, the registration authority shall cancel the practice license of the medical institution.
For the problems found in the inspection and supervision of the list, all responsible units should rectify and put them in place before the end of July. Overdue rectification or rectification is not in place, according to its situation into the year-end performance target management part. The rectification report shall be submitted to the Comprehensive Supervision Section of the Municipal Health Planning Commission before the end of July.
Self-inspection report on the legal practice of medical institutions 2 In order to further standardize the legal practice of medical institutions in our county, actively implement the Law on Medical Practitioners, the Law on Maternal and Child Health Care, the Regulations on the Management of Medical Institutions, the Measures for the Management of Medical Waste in Medical and Health Institutions and other laws and regulations, ensure medical safety, strengthen the supervision of medical waste, and effectively protect people's health rights and interests and medical safety, in 20XX, our county made great efforts to build a long-term supervision mechanism. Through effective measures such as "practicing according to law to report health" in medical institutions, special supervision and inspection in public medical institutions, and scoring management of bad practice in medical institutions, the level of practicing according to law in medical and health institutions in our county has been further improved, and certain results have been achieved. The work of our county is now reported as follows:
First, the status quo of our county
At present, there are 34 medical and health institutions in our county, including 5 county-owned medical and health institutions (including 3 county-owned medical institutions and 2 public health institutions), 7 township hospitals, 7 village clinics 17, individual clinics 1 0 and 5 school-enterprise clinics. There are 448 health technicians engaged in medical and health services, including practicing doctors 132, practicing assistant doctors 33, rural doctors 2 1 39, practical nurse traditional Chinese medicine technicians 139, pharmaceutical technicians 39, medical technicians 29 and other health technicians 55. There are 1 medical waste concentration places in the jurisdiction, which are mainly responsible for medical waste concentration places Z of medical institutions on the island and waste incineration places Z of other township medical institutions. Among the 7 township hospitals, 6 hospitals met the standard of medical waste management, with a compliance rate of 85.
Second, the main work carried out
(1) Raise awareness and implement regulatory responsibilities.
Our county has always attached importance to the maintenance and supervision of the medical market order. The leaders of the county government and the Health Bureau closely combine the key points of the medical and health system reform, and regard the legal practice of medical institutions as the height of standardizing the medical market order, ensuring medical safety, maintaining social harmony and stability, and promoting the sound and rapid development of our county's social economy. According to the work requirements issued by provinces and cities, the Bureau of Medical Affairs, the Department of Disease Control and Supervision, and the Health Supervision Office work closely together to ensure effective implementation.
(2) Strengthen supervision and standardize practice.
In the daily supervision, our county focuses on township hospitals (community health service centers and stations), individual clinics and village clinics, focusing on the license management of medical institutions, the legal practice of personnel and the release of medical advertisements, and strengthening the legal awareness of medical personnel through strict license verification to further standardize the practice behavior of medical institutions. First, strictly check the practice license of medical institutions. In the annual audit of medical institution's practice license, whether the medical institution's diagnosis and treatment subjects are consistent with the approved subjects, whether the name is consistent with the approved name, and whether the medical personnel are licensed to practice are the key contents of the audit. Any violation of laws and regulations will not be verified. The second is to strengthen the training of medical staff's knowledge of laws and regulations and improve their awareness of practicing according to law. On the one hand, cultivate the heads of medical institutions and strengthen their sense of responsibility; On the other hand, medical staff should be trained in medical institutions to enhance their overall legal awareness. The third is to strengthen daily supervision and promptly investigate and deal with illegal medical behaviors. In particular, the hiring of non-health technical personnel, cross-disciplinary practice, and the opening of unapproved diagnosis and treatment subjects have been severely dealt with. The fourth is to further consolidate and improve the hierarchical supervision of small and medium-sized medical institutions in our county and establish a long-term management mechanism. At present, in addition to four county-level medical institutions, there are ***3 1 small and medium-sized medical institutions that should be supervised by classification according to law. 3 1 school has been launched, and the implementation rate of quantitative grading is 100%, of which 2 are up to standard and 29 are qualified.
(3) Pay attention to practical results and promote the Z-standardization construction of medical waste treatment departments.
Our bureau actively embarks from the reality of our county, pays attention to actual results, adopts the principle of combining supervision and law enforcement with strengthening rectification, and gradually standardizes the Z behavior of medical waste disposal in medical institutions in our county. First, the standardized construction of Z section of medical waste in township hospitals has been strengthened. In strict accordance with the requirements of the Regulations on the Management of Medical Wastes and the Measures for the Management of Medical Wastes in Medical and Health Institutions, township hospitals are urged to implement the responsibility of medical waste management, standardize the process of classified collection and transportation, and standardize the construction of temporary storage facilities and equipment for medical wastes. Put an end to the random loss, leakage and diffusion of medical waste. The second is to supervise and inspect the key links of medical waste collection, transportation, storage and disposal in county-owned medical institutions. Third, strengthen the guidance and supervision of the Z unit of the medical waste concentration department. Evaluate the Z treatment capacity of Z unit in medical waste concentration area, and fully grasp the establishment and operation of Z treatment facilities.
(four) to strengthen self-examination and self-reform, the implementation of rectification requirements.
The leading group of our bureau attaches great importance to the standardization of medical institutions' practice according to law. After the supervision of the Municipal Health Bureau in the first half of the year, the relevant responsible persons of the Health Bureau, the Health Supervision Institute and various medical institutions shall be convened in time. According to the problems found in the supervision, * * * discussed the rectification plan, implemented various rectification responsibilities, and defined the task requirements of supervision and rectification by the Health Bureau, guidance and rectification by the Health Supervision Office, and implementation of rectification by medical institutions. First, strictly implement various work systems and processes and improve ledger information. Further establish and improve relevant work systems, processes and rules and regulations, and clearly display the systems and processes on the walls of the corresponding consulting rooms, so that medical personnel can act according to the rules and operate according to the certificates, strengthen their sense of responsibility and health and safety, and earnestly implement the three principles of "appointing people, posts and responsibilities". Improve the medical waste transfer registration, hospital infection prevention and control monitoring registration, medical equipment disinfection registration, medical personnel hospital infection prevention and control knowledge training records and other accounting materials, and modify the registration form with incorrect format and incomplete registration, so that every work is recorded. The second is to guide the rectification on the spot and track the rectification process in time.
According to the notification of the Municipal Health Bureau on the legal supervision of medical institutions and the rectification opinions of the inspection team, our bureau promptly urged and rectified the existing problems item by item. The county health supervision office undertakes the responsibility of guiding rectification, and provides on-site guidance to various medical institutions according to the provisions of the Law on Medical Practitioners, Management Standard of Hospital Disinfection Supply Center, Z Standard of Medical Waste Disposal in Medical Institutions and Z Standard of Fever Clinic. Under the existing conditions of medical institutions, make full use of existing human and material resources to solve the problems existing in medical institutions. At the same time, strengthen the supervision of medical institutions and follow up the rectification process. Up to now, relevant medical institutions have improved some facilities and equipment. For example, the county hospital of traditional Chinese medicine re-registered the medical staff whose registered address did not match the practice address, strengthened the management of medical waste Z department, standardized the operation process of medical waste in the hospital, corrected the warning signs of temporary storage places, added fly prevention facilities in temporary storage places, and established an emergency plan for medical waste; County People's Hospital has strengthened the disinfection management of endoscopy room and stomatology department, formulated relevant working systems and workflows, strengthened the training of medical staff on hospital infection prevention and control, rectified the disinfection supply room, set up a buffer zone between Z polluted area and clean area, and installed dust-proof and fly-proof facilities.
(5) Change the supervision mode and implement the bad behavior score management.
According to the requirements of provincial and municipal documents, our county fully understands the spirit of the superior documents and actively carries out the management of bad practice scores in medical institutions in combination with the actual situation of our county. First, strengthen study and raise awareness. The leading group of this bureau attaches great importance to the scoring management of bad practice behavior in medical institutions, carefully studies documents, understands the essence of the spirit, unifies ideological understanding, and formulates the implementation plan and content of scoring management of bad practice behavior in medical institutions in our county. The second is to implement responsibilities and clarify the division of labor. The county health bureau determines the county health supervision office as the specific department of scoring management of county-owned medical institutions, and reports the bad practice behavior and scoring of medical institutions to the medical administration department of the county health bureau in a timely manner, which will be announced to the public regularly by the county health bureau. Do a good job in communication, collection and reporting of information. County Health Bureau, county health supervision office and other relevant departments implement medical quality management, supervision and law enforcement according to the division of responsibilities. The third is to strengthen supervision and promote improvement. The county health bureau, health supervision office and other relevant departments will conduct random supervision and inspection of medical institutions in various forms, such as daily supervision, special supervision, unannounced visits, and the combination of regular and irregular spot checks, and take score management as an important basis for the health administrative department to inspect medical institutions, and the score of bad practice behavior as one of the materials that must be submitted for the annual inspection of medical institutions. Through supervision, improve the quality level, management level and service level of medical institutions, and improve people's satisfaction.
Three. Existing problems and difficulties
After a series of rectification and effective supervision, medical institutions in our county practice according to law, and the Z situation of medical waste standardization department has been further standardized. However, due to staffing, working expenses, transportation and other reasons, there are still the following problems: First, the number of practicing doctors and practicing nurses in township hospitals is insufficient, and some township hospitals still have the phenomenon of "one person with multiple functions". Second, medical institutions have not trained medical personnel in laws and regulations, and their awareness of the legal system needs to be improved. Third, although the Z unit of the county medical waste concentration office holds a business license, the Z unit of the medical waste concentration office is not included in the licensing matters. The Z-unit incinerator in the concentrated area tends to be aging, which has a certain impact on Z production capacity. Fourth, due to inconvenient transportation, medical waste cannot be concentrated in Z, a township health center outside the island, and it is not standardized to destroy Z by self-immolation. For example, the amount of medical waste is small and the temporary storage date is more than two days.
IV. Next Work Plan
(a) to strengthen leadership, raise awareness, combined with the reform of the medical and health system, to further improve the consciousness of medical staff to practice according to law, and to implement the corresponding measures to prevent and control hospital infections and infectious diseases.
(2) Further implement the Law on Medical Practitioners, the Law on Maternal and Infant Health Care, the Regulations on the Administration of Medical Institutions, the Measures for the Administration of Medical Wastes in Medical and Health Institutions and other laws and regulations to standardize the practice of medical institutions.
(three) adhere to the symptoms and root causes, and strive to build a long-term supervision mechanism. Combined with the Interim Measures for the Management of Bad Practice Scores of Medical Institutions in Zhejiang Province, this paper explores the long-term supervision mode of medical institutions.
(four) to maintain the order of the medical market, strengthen the supervision of certified medical units, and implement classified supervision of small and medium-sized medical institutions according to the level of quantitative classification.
(five) to strengthen the publicity of medical and health laws and regulations, improve people's awareness of self-protection, expand the awareness rate of complaints and reports through various forms, and form an atmosphere in which the whole society supervises medical institutions.
Self-inspection report on legal practice of medical institutions 3 In order to further strengthen the legal practice of medical institutions in Suining City and protect people's health rights and interests, according to the Notice of the Municipal Health and Family Planning Commission on Carrying out Special Supervision and Inspection on Legal Practice of Medical Institutions and the requirements of treating medical institutions according to law in our province, special supervision and inspection on legal practice of medical institutions has been carried out in the city recently. The relevant situation is now reported as follows:
First, attach great importance to it and organize it carefully.
The municipal detachment and all districts and counties attached great importance to this work, and formulated a detailed inspection plan to carry out dragnet inspection of various hospitals in their respective jurisdictions. The municipal detachment divides the detachment supervisor into three inspection teams according to the division of jurisdiction, with the deputy director of the Municipal Health Planning Commission, the chief of the comprehensive supervision department and the deputy detachment leader each taking one group, and sending relevant experts such as medical inspection and medical imaging to assist in the dragnet inspection of all general hospitals, specialist hospitals and outpatient departments in the city. Leading groups have been set up in all districts and counties, and the leaders in charge led the team to participate in the inspection.
Second, the specific inspection situation
1, check the basic situation.
During the supervision and inspection, the city dispatched 46 supervisors and 28 vehicles1person-times, and conducted special supervision and inspection on 43 hospitals1person-times. Mainly review the following contents: First, whether the qualifications of medical institutions are legal and whether the qualifications of health technicians are legal; The second is whether the medical behavior is legal. Whether to carry out diagnosis and treatment activities in strict accordance with the scope of practice registration; The third is whether the management of refined drugs and blood for clinical use is standardized, and whether medical records and prescriptions are kept and written according to regulations; The fourth is whether it is legal to carry out medical technology, whether it is carried out in strict accordance with the approved scope, whether the use, maintenance, cleaning and disinfection, health protection and quality inspection of medical equipment and instruments meet the requirements stipulated by the state, and whether the inspection report issued by medical institutions is true and standardized. V. Medical safety work: whether the maintenance of medical elevators, the use and storage of medical oxygen cylinders, food safety and other work are carried out as required, and the unsafe hidden dangers are rectified. In this inspection, in addition to the above-mentioned compulsory inspection contents, Daying County also inspected the comprehensive management of hospitals, the quality of medical documents, the rational use of drugs, and the management of public places in hospitals in combination with this year's key inspection work plan, and notified the inspection situation throughout the county.
2. Existing problems
(1) Qualification of medical institutions
Most medical institutions in hospitals at all levels in the city have a strong sense of practicing according to law, and institutions and related personnel basically have legal qualifications and can carry out diagnosis and treatment activities in strict accordance with the scope of practice. Shehong County found that 1 Medical institutions used non-health technicians to engage in medical technical work, and an investigation has been initiated. Some comprehensive township hospitals in Shehong County have not obtained the practice license of maternal and child health care technology, and provide health management services for children aged 0-6 and maternal health management services. In Daying county, it was found that the practice licenses of medical institutions in five township hospitals were not verified in time and were not displayed and hung in a prominent position in the hospital.
(2) Medical practice.
All kinds of medical institutions at all levels carry out diagnosis and treatment activities in strict accordance with the scope of practice registration, refine the management norms of narcotic drugs, and manage them by special personnel. Doctors who prescribe refined narcotic drugs have passed the training and examination and obtained the prescription qualification. Individual township hospitals and private hospitals have not established a special register of refined narcotic drugs. In terms of clinical blood use, all clinical blood use units have set up clinical blood use management committees headed by relevant leaders, and the heads of relevant departments are members. The working system related to clinical blood use is relatively perfect, and the management system manual for clinical blood use has been formulated. However, some medical institutions, especially those below the second level, such as some township hospitals and private medical institutions, do not perform their duties properly, which are mainly manifested in the following aspects: no special meeting on clinical blood transfusion is held regularly, no summary and notification is made on the clinical blood use in their own units, no education and training on rational and scientific clinical blood use is carried out, and no consultation and guidance records for clinical blood use are kept. There is no effective scheme for clinical blood use, and it is unscientific and reasonable to combine blood storage with actual blood use. In terms of medical documents, it is absolutely necessary for some medical institutions to issue medical documents such as inspection and inspection reports.
However, some medical institutions also have irregular documents, such as incomplete items, scribbled prescriptions, illegible signatures of doctors or missing signatures. Some hospital surgical patients did not sign the power of attorney; The content of risk notification is disorganized, which can not play the role of informed conversation to prevent risks. In the radiology and laboratory departments of medical institutions, Shehong County found that 1 medical institutions were suspected of not obtaining the Radiological Diagnosis and Treatment License to carry out radiological diagnosis and treatment activities. Law enforcement officers found that some medical institutions' radiological protection articles were not used normally, some medical institutions, especially some township hospitals' laboratory equipment were not calibrated according to national requirements and were not subject to annual compulsory verification, and the disposal of laboratory positive samples was not standardized. Medical waste disposal is not standardized, and special containers are not used. In addition, some medical institutions did not apply for the Public Health Permit in the outpatient waiting hall. In view of the existing problems, the supervisors have issued the Opinions on Health Supervision, ordered them to rectify within a time limit, and investigated and obtained evidence from eight medical institutions suspected of violating the law. At present, the city has investigated eight institutions suspected of violating the law.
In the next step, the city's health supervision institutions will continue to strengthen the inspection of the legal practice of medical institutions, especially the law enforcement of key departments of medical institutions, such as laboratory, imaging, gynecology, medical beauty, infertility and so on. If illegal acts are found, hell to pay will further enhance the awareness of medical institutions at all levels to practice according to law, constantly promote the standardization of the medical service market, and protect the medical safety of the people.
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