Summary of the year-end work of the hospital in 2019

2019 is an extraordinary year, the reelection of the board of directors, the reorganization of the leadership of the hospital, the declaration of the third-level cardiovascular hospital , the departure of the core physicians of the cardiology department, the multiple events of cardiothoracic surgery, the changes of the new rural cooperative medical policy in various regions, international finance The crisis, etc., is a severe test for our hospital.

In 2019, under the leadership of the new board of directors, through the hard work and hard work of all the cadres and employees of the hospital, all the work of our hospital was carried out in an orderly manner, and the management work has made great progress. The number of outpatients in the hospital was 11,962, an increase of 26.8% over the same period of XX; the number of emergency cases was 823, an increase of 54.9% over the same period of XX; the number of hospitalizations was 3,275, which was 7.7% less than the same period of XX, the average length of hospital stay and XX years The same period of the year was basically the same; the number of discharged patients was 3,208, and the cure and improvement rate was 97.9%, including 14 deaths and 0.4% mortality; 193 cases were operated, including 17 cases of i-type surgery, 11 cases of class II surgery, and 25 cases of class III surgery. 140 cases of iv surgery; bed utilization rate of 60.5%, bed turnover rate of 19.9%; annual business income of 10,000 yuan, an increase of 9% over the same period of XX. The current work is summarized as follows:

Comprehensively strengthen hospital management and establish a scientific management mechanism

In 2019, we adhered to the hospital management year activity of “taking patients as the center and improving the quality of medical services” as an opportunity to improve the medical level and service quality, clarify job responsibilities, work procedures, and develop job specifications. The target responsibility has brought the hospital management work to a new level, mainly doing the following work:

First, it is to further improve management organizations and standardize management systems. The business department adheres to the weekly office meeting system and holds a quality and safety meeting every month to study and implement corrective measures for specific problems, effectively reducing medical errors and ensuring medical safety.

Second, put medical quality management in the first place, formulated the "Medical Quality Management and Continuous Improvement Program", established and improved the organization of medical quality management, adjusted the composition of the "Medical Quality Management Committee", defined the duties and regulations, and implemented them conscientiously. The first, second and third-level medical quality control organizations were improved, and the medical quality regular inspection and evaluation system was implemented. The three-level quality control organization checked the completion rate of medical quality by 100%, and timely rectified the problems identified.

Third, adhere to the strengthening of the first medical responsibility system, difficult cases, death case discussion system, three investigations and seven pairs of systems and other 12 medical core systems. All departments have re-established and improved the difficult, critical, major surgery patient consultation and preoperative discussion registration books, etc., strictly check the records during the monthly assessment, and carry out rewards and punishments; establish and improve the " hospital ward round system" and "medical error accident registration" , report processing system, "prescription system", "outpatient department, emergency department, radiology department", "care business ward rounding system", "care defects, accident registration report system", "care quality inspection, evaluation system", "care Consultation system, etc.

Fourth, strengthen the three-level ward round system. Adhere to the administrative and business rounds of the president, and check the medical quality management of each subject from time to time, with key points and plans. This year, the dean’s ward round was 5 times, the nursing ward round was 10 times, and the nursing supervision was 50 times.

Fifth, strengthen the quality management of medical records. Strictly follow the requirements of the "Code for writing medical records", reprint the patient satisfaction questionnaire, hospitalization education manual, etc. When the patient is admitted to the hospital, according to the changes and needs of the patient, they will separately talk and fill in as required, the doctor-patient communication system Got further implementation.

6. Further strengthen the management of quality objectives for nursing work. The first is to improve the hospital care management system. Formulated the “2019 Nursing Management Goals”, “Nursing Checking System”, “Responsibilities for Nursing Staff at All Levels” and other regulations, established “Nursing Quality Supervision and Coordination Mechanism”, and established a Nursing Management Quality Control. The group will conscientiously implement the circular monitoring system for supervision, analysis, evaluation, rectification and supervision. Each quality control team conducts a random inspection once a month, and conducts a comprehensive inspection once a quarter. The nursing department and the department review one time each month, and hold an analysis meeting every quarter to propose improvement measures for the problem and actively promote the improvement of the quality of care. The second is to strengthen the management and training of nursing human resources and strict technical access system. According to the " Hospital Nurse Training Program", from January to October this year, weaved nursing theory lectures 3 times, pre-job training 2 times, the whole hospital nursing staff have participated; nursing skills operation assessment 4 times, 98 people each department organized care The participation rate of personnel is 96%; each department continues to adhere to the “Daily One Question” activity, the monthly theoretical examination and the skill assessment each time. Through the above, the enthusiasm and initiative of each nurse has been effectively improved, the knowledge has been broadened, and the development of health education has been promoted. Third, the clinical nursing work is patient-centered, and provides basic nursing services and professional nursing technical services to patients. We have re-established the "Health Education Register", and used the infusion patrol card and health education registration to conduct on-the-spot operations, so as to "keep well done and keep a good record." At the same time, patients were visited from time to time, and the implementation status was checked. The ward inspection rate was 92%. In response to the safety of critically ill patients, the nursing precautions were formulated. The daily attendance of new, urgent and critically ill patients at the bedside was strengthened, and basic care for critically ill patients was strengthened to prevent complications.

7. Strictly implement various rules and regulations for controlling infections in hospitals. Emergency plans such as “ Hospital infection epidemic or outbreak infection emergency plan” and “Disinfection supply room outbreak infection plan” were formulated; “ Hospital Waste Management System”, “ Hospital Disinfection Management System”, “ Hospital Infection Surveillance System” and “ The hospital infection reporting system has six procedures, including the “medical waste treatment process”, “endoscopic catheter disinfection, cleaning process” and “patient terminal disinfection process”. Bacterial monitoring was carried out on key departments and key links every month. The infection rate in hospitals was far below the standard of 8%. The infection rate of aseptic surgical incisions was only 0.004%, and the one-person-one-one-tube implementation rate was 100%. In-hospital infection team was set up for inspection and supervision. A total of 12 inspections were conducted throughout the year. Special lectures and hospitality knowledge training were conducted for “ Hospital infection and standard hand washing”, “multiple misunderstandings of hospital infections and current countermeasures”, and medical staff of the hospital. Participation effectively prevented the occurrence of infections in hospitals .

Seriously organize the implementation of the "three-level cardiovascular disease hospital " declaration, review and "management year" activities, adhere to the "medical quality first" and continuously improve the level of medical technology.

In 2019, according to its own development and future development goals, our hospital submitted an application to the Anhui Provincial Health Department in March to set up our hospital as a tertiary cardiovascular disease hospital and delivered relevant application materials. The Anhui Provincial Health Department conducted relevant inspections and acceptances, agreed to the setting of our hospital, and proposed the next requirements for acceptance. Our hospital is actively working on this:

1. Established the “Triple Cardiovascular Diseases” Hospital Review Committee and formulated the “ Hospital “Level 3” Review Work Implementation Plan”; organized the hospital leadership team and the main responsible persons of each department to study the “Detailed Implementation Rules for Hospital Management Evaluation Guide” and “Three-level Cardiovascular Hospital Accreditation Rules”, and the responsibility was implemented to departments and individuals; many middle-level leaders were organized to visit famous cardiovascular hospitals in Beijing and Nanjing.

2. All the departments have issued various files such as “ Hospital Archives, Various Rules and Regulations, Various Pre-plans, Medical ethics, Comprehensive Target Assessment”, such as hospital management, medical management, general affairs, financial management, public security rules and regulations. The responsibilities of the staff at all levels have been improved, and the “ Hospital Management Regulations” have been prepared and the printing has begun. The hospital has established the "opening system for hospital affairs", " hospital civilized service system", "job employment system", and "medical equipment and consumables procurement management methods".

3. On the day of the month, the Health Department of Anhui Province organized relevant leaders and experts to inspect and accept the hospital's “three-level cardiovascular disease hospital ” level setting. The experts were divided into five groups: “ hospital integrated management, medical records, medical quality control, hospital care, nursing and medical skills” from five aspects: “ hospital comprehensive management, continuous improvement of medical quality, medical safety, hospital services and hospital performance”. I have checked all the work in our hospital. The leaders of the Health Department fully affirmed the work done by the hospital in recent years, but also raised the problems of “impatient medical records are not sound and the writing is not standardized, medical quality management must be further strengthened, and there is no full-time emergency doctor”. After the inspection and acceptance, the hospital organized relevant personnel to summarize the opinions and suggestions put forward by the experts, and formulated improvement measures to determine the responsible person and the completion time. The hospital conducted irregular inspections.

4. Strengthen medical safety management, and formulated “medical risk early warning system”, “medical safety education inspection system”, “care emergency error plan”, “ hospital waste management system”, “mental, anesthetic drug safety management system” Etc., increase the implementation of inspections, no major medical negligence and major safety accidents occurred during the year.

5. Fully implement the component blood transfusion work. Established and improved the corresponding rules and regulations such as blood transfusion records, registration of error accidents and registration analysis of adverse reactions of blood transfusion. In 2019, a total of 1003u of red suspension, 20u of concentrated platelets, 99750ml of plasma, and 1000ml of whole blood.

Pay close attention to the medical ethics and the construction of the style of work, and shape the good image of the hospital .

First, the hospital has further improved and perfected the "Evaluation Standards for the Construction of Spiritual Civilization and Medical Ethics", "Measures for the Assessment of Professional Ethics", "Standards for the Implementation of Medical Ethics and Implementation Measures", and "Measures and Punishment Measures for Medical Morality Construction" and " The practical and easy-to-operate systems and regulations, such as the management system for the purchase and sale of drugs, medical devices, and disposable materials, and the regulations and regulations that are practical and easy to operate, have formed a long-term mechanism to strengthen medical ethics assessment, complaints and reports, incentives, and punishments.

Second, the hospital nursing department, office organization, dean, medical department, general affairs department directors, etc. participated in inviting patients and their families to hold a symposium on the construction of hospital-level work style, solicit opinions and suggestions and solve them in time. The problems raised by the patients are solved one by one, which greatly improves the patient's satisfaction.

Third, the implementation of the purpose of education, enhance the sense of responsibility for serving patients wholeheartedly. We will focus on guiding you to understand the relationship between doctors and patients under current economic conditions, and make everyone realize that in the field of medical services, patients are in a passive position and medical personnel are in an active position; they must correct and overcome the wrong ideas under current economic conditions and establish benefits. The medical ethics that is unified with the purpose, keep in mind the purpose of serving the people wholeheartedly, so that the people can see the disease, see the disease, and see the disease well.

Fourth, striving for a health and civilized unit in Hefei City, implementing "window" education, and enhancing the sense of urgency for civilized medical practice and honest practice. Starting from the status and characteristics of the "window" of the socialist spiritual civilization construction, we will continue to organize medical personnel to conduct self-discipline inspections in accordance with the "medical staff medical ethics", and promptly handle the problems identified and inform all personnel. To continuously improve the consciousness of civilized practice and honest practice.

5. In the construction of medical ethics, education is the foundation, the monitoring mechanism is the guarantee, and the incentive model is also an indispensable driving force. Take the honor incentive as the leading factor. We insist on carrying out the advanced collective and advanced individual activities of medical ethics, conducting a comprehensive evaluation every year, and convening the commendation of advanced collectives and advanced individual conferences, and successively awarded more than 30 awards with outstanding achievements and high praise from patients. Honor has become a powerful traction for everyone to consciously establish a new medical wind. In the competition for excellence, the competition, learning, rushing, helping, and super-comprehensive.

Do a good job in the implementation of hospital planning and construction

After more than six years of development and construction, our institute has formed a certain scale. Due to the flow of hospital authoritative experts and the multiple incidents of cardiothoracic surgery in the second half of 2019, it has a certain impact on hospital planning. However, the hospital leadership team conducted analysis and research to identify deficiencies and prepared for the development of the hospital . First, the introduction of large shareholders to integrate the operation of the hospital , fill the funding needs of hospital development, and promote faster and better development of the hospital . Second, the hospital leadership team and all staff members proceeded from their own, carefully studied the current hospital form, identified the shortcomings of development and development deficiencies, re-established hospital development plans and hospital development goals, and established sound medical care.

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