Summary of the work of the medical department in 2019

In 2019, under the correct leadership and strong support of the hospital committee, the staff of the medical department thoroughly implemented the scientific development concept, always "taking the patient as the center and taking the quality as the core", strictly following the "national people's assured demonstration hospital " and " hospital The “Year of Management” standard and the “Medical Quality Miles” campaign require strengthening scientific management, promoting the implementation of thirteen core systems and post responsibility systems, improving the quality of medical records, and strengthening the continuing medical education, improving medical quality and ensuring medical care. Safety has ensured the comprehensive development of all aspects of the medical services. The work of the medical department in 2019 is summarized as follows:

First, the quality of medical care

1. Completion of various work indicators:

420 open beds

Bed usage rate: 106.1%

The total number of outpatients in the year: 49,453 person-times

Total number of hospitalized: 24,405 people

Average hospital stay: 6.7 days

The actual number of bed days occupied by the hospital: 162506

Grade A of medical records: 98.5%

Prescription pass rate: 98%

Entrance and discharge diagnosis coincidence rate: 93.5%

Preoperative and postoperative diagnosis coincidence rate: 97%

Ct check positive rate: 70%

Emergency critical illness rescue success rate: 88%

Grade A healing rate of aseptic surgical incision: 100%

Aseptic surgical incision infection rate: 0

Pathological diagnosis accuracy: 98%

Carrying out component blood transfusion ratio: 99%

Preoperative average hospitalization days for elective surgery patients: 38 hours

The above completed indicators have reached the quality control requirements of the Ministry of Health for secondary hospitals .

2. Strictly grasp the quality of medical records and improve the writing standards of young doctors

Medical record writing is the focus of medical quality management. The medical department has always strictly adhered to the quality management of medical records. In particular, since the second half of the year, President Li, the head of the cattle, and the president of the hospital have led the medical department, the nursing department, and the infection department to conduct clinical departments. Since the three months of intensive supervision and management, the emphasis has been placed on the importance of medical record writing, and on-site reviews of medical records have been put forward, and more stringent requirements have been put forward for the supervision of medical services. Therefore, the reform of medical services focuses on the medical records of links. The details and completeness of the work began to strengthen the review of the main complaints, current medical history and physical examination in the hospitalization. The description of the main complaint should be accurate and in place, and the main features of the symptoms can be manifested. The contents of the current medical history must be comprehensive, complete and systematic. The main complaints are consistent; the physical examination must be written by the resident in an actual, meticulous, conscientious and comprehensive manner for the patient to check the body, and the positive signs appear to be recorded in detail, consistent with the chief complaint and the current medical history. The description of the main complaints appearing during the actual inspection process is not in place, the current medical history is not comprehensively written, the detailed examination is not carried out, and the clinical examination reveals the past history, personal history, family history, physical examination, and medical history of the disease, strictly in accordance with the medical treatment. Penalties for the quality assessment and punishment of papers were penalized. As of the end of November, there were more than 2,800 medical records in our department. The common problems were: no signatures were signed by the doctors before the treatment; the necessary items before the blood transfusion were incomplete; the current medical history was not Comprehensive, past history, personal history and other basic items are rough, and the consultation is not meticulous; the visit time of the preoperative anesthesia visit record conflicts with the operation time, the interview content is simple and the form is in circulation; the daily course record is not timely; the patient is discharged. At the time, no superior physician agreed to sign the discharge record. In response to these problems, we will continue to strengthen supervision in the future work, use business learning time to organize special training, strengthen the sense of responsibility of physicians, and strive to correct from the root causes.

In order to enhance the work responsibilities of young physicians and improve the business ethics and medical record writing of young physicians, the Medical Department requires all rotation physicians to select two representative diseases from their departments each week, according to their actual medical consultation, clinical examination and After the treatment observation, the inpatient medical record will be written. After the completion, the director of the department will make the revision. After the supplement, the doctor will review it and submit it to the medical department for review. The revised comments will be marked in the original medical record. As of the end of November, the medical department has reviewed more than 370 inpatient medical records. In the end of December, the exhibition was held in the hospital. After the evaluation, three to five in-house lectures were held for the major medical problems in the hospital.

For the terminal medical records, we still use the medical record room as the initial screening point, based on the "Standards for Writing Medical Care Documents in Shandong Province" and "Standards for Quality Evaluation of Inpatient Medical Records in Shandong Province", on the front page, admission records, three-level rounds, and discharge records. After all the projects were thoroughly examined and evaluated, as of the end of November, the medical department had a total of 370 points of final medical records, no B or C medical records, and a grade A rate of 100%. In addition, the medical record filing management was strengthened, and the 72-hour filing rate of the hospital reached 100%.

3. Continue to strengthen the implementation of the core system, update and improve the system construction of departments

In 1999, the Medical Department began to deepen the thirteen core systems from the actual situation of the department. Participate in the morning shift of the department and the third-level rounds: insist on weekly shifts in the morning room. The contents of the supervision include: whether the participants are complete; whether the medication and methods of treating the patients at night are correct and effective; whether the resident can do 24 Hours on duty. In addition, according to the time of reporting the large rounds of the departments, the department regularly participates in the three-level rounds of the departments, and the key inspectors: group rounds, the distribution of the rounds, the process of the rounds, the teaching situation, the actual operation ability of young doctors and the knowledge of related diseases. Master the situation, quality of care, etc. After the end, the medical department will promptly report the problems and improvement opinions to the department, and follow up the implementation of the supervision department. Continue to standardize departmental case discussions: focus on strengthening the stylization and institutionalization of difficult, preoperative, critical, and death case discussions, attending departmental discussions from time to time, and attending representative cases found in departmental shifts and rounds during normal times, medical services The department will also recommend the department to organize discussions and participate in and host the whole process. When it is necessary to invite other relevant professional and technical personnel to participate in the discussion, the medical department is responsible for coordinating the arrangements to ensure that the department staff can expand the knowledge related to the disease and improve the quality of case discussions. Strengthening the supervision of critically ill patients: In order to improve the success rate of critically ill patients, effectively ensure patient safety and reduce medical safety hazards, the medical department continued to strengthen the follow-up supervision of critically ill patients in 2009, and regularly conduct quality assessments to icu every week to check patient treatment. With the rationality of medication, patients who need consultation should organize the hospital in time or invite superior hospital experts to come to the hospital for consultation, and record the consultation information in detail to ensure the smoothness and quality of the treatment information.

At the same time, with the strong support of the Academic Committee, the Medical Department has standardized the departmental system in a more standardized and detailed manner, and has bound all the systems into a medical work system, 13 core system volumes, a medical technology management system, and medical research. Continuing medical education work system fascicles, medical documents, prescription management, special drug management system fascicles, medical safety system fascicles, six major items, issued to the clinical, medical technology departments archived, learning, completely changed the previous business department system management scattered Incomplete phenomenon. In addition, our department has further improved the records of various cases in the clinical department, the records of continuing medical education in the department, the records of the “three basics and three strictes”, the monthly quality analysis records, and the records of various activities in the medical department every quarter. All departments with imperfect records and irregularities shall be punished according to the appraisal rules.

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4, satisfactorily completed the quality inspection of various higher levels of medical work

As of the end of November, the Medical Services Division has successively greeted the " Hospital Management Year" activity inspection, the "National People's Reassuring Model Hospital " leadership group inspection and "the city's medical document inspection", and continuously improved various management systems, management standards and levels through inspection of the medical department. The construction of various types of processes, in response to the lack of feedback, timely find the root cause of the problem, formulate improvement measures, increase the intensity of improvement, and strive to check once and improve once. Especially in the inspection activities of the “National People's Reassuring Model Hospital ” at the end of June, the Medical Department also assumed the task of “National Licensed Practice Skills Test” in Texas, and faced many problems such as heavy tasks, urgent time, and insufficient staff allocation. The department is facing difficulties, working overtime, and on the basis of past work, combined with the “safety target self-checking table” to further strengthen the various early warning mechanisms, establish various patient management processes, standardize and organize the records of various activities, and pass the inspection and acceptance of the leading group. After the work of our department fully met the requirements, the implementation intensity exceeded 90%, the comprehensive index ranked in the forefront of the city, and was highly recognized by the city leadership team and the hospital leadership.

Second, medical safety

1. Conscientiously do a good job in medical quality assessment, and carry out management work in strict accordance with the thirteen core systems, medical work systems, and management norms established by hospitals . Such as strengthening the key monitoring of critically ill patients, strictly implementing medical preventive measures and medical disputes handling plans, implementing the medical defect accountability system, carrying out medical activities in strict accordance with the standards of medical operation procedures, and strengthening the rational development of consultations within the department and the whole hospital, Strive to implement each consultation and implement it effectively. In 2009, he organized a total of 16 consultations for difficult and critical illnesses, and eliminated doubts about patients and their families through consultations. It also effectively eliminated potential safety hazards.

2. Strengthen informed notification, pay attention to doctor-patient communication to ensure that patients and their families have an effective understanding of disease progression and treatment, and dispel their doubts and confrontation psychology, which is an effective way to ensure medical safety, so the medical department is strengthening communication with doctors and patients. At the same time of skill training, focus on the details, increase the supervision of the signing of the informed consent form and the actual notification situation, and require each doctor to inform the patient truthfully and also record the notification content in the consent form, The medical records that ignore the evolution and complications of the disease are ordered to be supplemented and corrected in a timely manner while criticizing and educating.

3. In order to improve the quality of medical records, comprehensively improve the comprehensive quality and responsibility of medical staff, and supervise the medical records of the links to urge medical personnel to pay attention to general physical examination, diligence and patient communication in the process of receiving patients. Discover the shortcomings in the process of diagnosis and treatment, so as to eliminate safety hazards from the fine links.

In 2019, the medical department handled a total of six medical disputes, and two were identified by the Municipal Medical Association. Four consultations were resolved. The communication between doctors and patients was not in place, and the condition was not detailed. After the implementation of technical operation, the patient inspected the ward and the patient was not in a position. It is the main cause of controversy. In response to these problems, the Medical Services Department will continue to strengthen the supervision of doctor-patient communication in the future work, improve the service attitude of medical personnel through training, and crack down on violations of medical order more severely. Medical safety.

Third, continuing medical education

The hospital can develop healthily for a long time, and talent cultivation is the key. In particular, the scale of hospitals has been expanding in recent years, and a large number of medical personnel have been introduced. Therefore, it is necessary to create a good learning environment and cultivate young doctors to become talents at an early date, which has become an important issue for hospital development. . With the support of the Academic Committee, the Medical Affairs Department in 2009 constantly adjusted management ideas, formulated various talent training programs and programs suitable for hospital development, and strived to reserve talents for hospital development.

1. Further strengthen pre-job training: In order to speed up the understanding of hospitals' relevant laws, regulations, and system standards, and to adapt to the role change as soon as possible, the medical department, the nursing department, and the infection department began on July 27, 2019. The Personnel Section jointly organized a one-month intensive training before the post. Vice President Su Changjun spoke at the beginning of the training and put forward strict requirements for the trainers. The training involves medical care, nursing work system, medical document writing norms, medical safety, medical ethics, hospital infection, drug management, etc. It is divided into fifteen class hours. After the training, comprehensive examinations are conducted. Those who fail are not allowed to go to work. The qualification rate of 89 rotation physicians was 100%, and 95% reached 85 points or more.

2, 2019, our hospital sent a total of 12 attending physicians to Qilu Hospital , Provincial Hospital , Beijing Children's Hospital , Beijing Fuwai Cardiovascular Hospital , Peking University People's Hospital , Beijing 301 Hospital for further education, Department of Cardiology, blood center, nicu, pathology , anesthesia and other majors. All kinds of short-term classes and seminars were sent to more than 130 people. The medical staff of the medical staff who returned to the hospital for training will organize a full-time lecture to ensure that the new knowledge and new technologies they have learned can be passed on to other medical personnel in time to ensure our hospital. The medical technology level has been improved as a whole.

3. In 2019, a total of 81 students were admitted to the hospital, including 11 fellows, 14 of 1127, and 12 of three supporters; Taishan Medical College, Xinglin Medical College, and Modern Vocational College. There are 43 interns, and our department has specially formulated a standardized training system for residents, and combined with its syllabus to ensure the quality of their study. In addition, our hospital also undertakes the practical teaching tasks of 18 fellows in Xiajin County Chinese Medicine Hospital . As of the beginning of November, the teaching tasks have been successfully completed, and the Xiajin County Chinese Medicine Hospital has also highly praised the teaching work of our hospital.

4. In 2009, the Medical Department organized business training and lectures including hand, foot and mouth disease and H1N1 flu in 25 years, and trained more than 4,000 person-times. Four times of knowledge assessment, a total of more than 800 person-times, the pass rate of 99%.

5. Complete the declaration work of the standardized training base for residents

Since April of 2009, under the guidance of the Academic Committee, the Medical Department has started the application of the “Shandong Provincial Standardized Training Base for Residents”, inside and outside, maternity and pediatrics. The Resident Standardization Training Committee and the Resident Standardized Training Guidance, Assessment, and Quality Supervision Working Group have been established, and the Medical Services Department has concurrently served as the Training Committee Office to handle the preparation of specific declarations. In order to ensure the smooth implementation of the base declaration and assessment network, the medical department sent a special person to the provincial Red Cross to participate in the training. As of the beginning of June, all the returns and specialist information sheets have been submitted to the Municipal Health Bureau to ensure the effective implementation of standardized training for residents in the hospital.
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6. In order to ensure the updating of medical personnel's knowledge and promote the development of departmental disciplines, in March, the Medical Department, with the strong support of the Academic Committee, ordered the "2009 version of the three basic three strict" medical fascicles, medical image books, A total of 345 test volumes were collected, and in June, clinical clinics and clinical medical technical treatment specifications were ordered for each clinical department, involving 42 disciplines including pathology, hematology, and cardiovascular surgery. The contents were detailed and novel. The clinical department is highly praised.

Fourth, actively cooperate with the hospital to carry out prevention, control and treatment of hand, foot and mouth disease and influenza A h1n1

1. Since the beginning of the hand, foot and mouth disease epidemic in April, the medical department quickly formulated and launched the emergency plan for hand, foot and mouth disease under the direction of the hospital committee, assisting the hospital leadership to improve the construction of the internal four isolation wards and hand, foot and mouth disease clinics. Increase the medical care force to ensure the smoothness of the "green channel" of hand, foot and mouth disease; in order to strengthen the in-depth understanding of each disease in the hospital, the medical department timely formulated the hand, foot and mouth disease diagnosis and treatment plan of the Lingxian People's Hospital according to the file issued by the Ministry of Health. Organize learning in various departments; all medical staff who go out to participate in the hand, foot and mouth disease academic conference will assist in the production of relevant courseware, organize academic lectures for all staff, and communicate the latest medical information to each medical staff. During the peak period of receiving such patients in our hospital, the director of the medical department will participate in the morning shifts and rounds in the four subjects, and guide the clinical medication and medical record writing. The patients with severe diseases will be organized to invite experts in the hospital or invite experts from higher hospitals to come to the clinic . Responsible for reporting the work of critically ill children. As of the end of November, 310 patients with hand, foot and mouth disease were treated in our hospital, including 7 critically ill patients. There were 2 cases of independent treatment in our hospital. There were no deaths, and the prevention and control work achieved a staged victory.

2 After the emergence of influenza A (H1N1) cases, our hospital responded promptly under the direction of the higher authorities. The medical department successfully responded to the experience of hand, foot and mouth disease. Under the leadership of the hospital committee, the leading group led by Dean Li Fengxin was quickly established. With the service dean as the captain's rescue echelon and expert group, the prevention and control plan was initiated, the various processes were completed, the equipment, medicines and protective equipment needed for the reserve were purchased, and the “green channel” and the dedicated isolation ward for patients with A stream were opened up. At the same time, the internship and deputy chief physicians of relevant disciplines were selected to attend the A-stream academic lectures, and more than ten special training sessions on influenza A were organized to ensure that the medical staff knew the latest medical treatment information. To be fully prepared for the treatment of patients with influenza A (H1N1).

The year of 2009 is a year in which the challenges and opportunities of the medical department coexist. In the past year, our department has made great progress in the work under the support of the leaders of the hospital. In the future work, we will continue to make up for and improve. Insufficient work, strive to achieve greater results, and contribute to building a harmonious hospital .

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