Summary of the work of the People's Hospital on "Medical Quality Miles"

Leaders, experts:

In 2019, according to the deployment of the Ministry of Health, the Provincial Health Department, the Municipal and County Health Bureaus, the hospital has implemented the work of the “Healthy Quality Miles” program in conjunction with the Hospital Management Year activities and the “Ping An Hospital ”. The “Medical Quality Miles” campaign, which aims to improve quality and ensure medical safety, continuously strengthens hospital medical safety management, guarantees medical quality and medical safety, and strives to provide safe, effective, convenient and inexpensive medical and health services for the people. . The specific work report is as follows:

First, raise awareness, strengthen leadership, and implement target responsibility

1. A group of people from the Party Committee of the hospital carefully studied the Notice of the General Office of the Ministry of Health on Printing and Distributing the "2019 "Medical Quality Miles" Program" and the instructions of the Provincial Department, the Municipal and County Health Bureaus on continuing the Hospital Management Year activities. Spirit, unify thoughts, raise awareness. At the same time, we carefully analyzed the achievements, problems and causes of our hospital's medical quality work; we focused on the methods and steps of the “Medical Quality Miles” activity in our hospital.

2. Establish a leading organization for the “Medical Quality Miles” activity. The Leading Group of the “Medical Quality Miles” activity was set up as the leader of the main leadership of the hospital, and the leader of each functional department was appointed as the member. The office was set up to take charge of the orderly development of the “Medical Quality Miles” activity. . The responsible persons of each department and related personnel form a group-level "Medical Quality Miles" activity group, and specifically carry out the "Medical Quality Miles" activity of the undergraduate.

3. Clear division of labor and implement accountability system. In order to promote the development of the “Medical Quality Miles” campaign, we have to manage everything and implement the parts. The hospital has a clear division of labor for the team members, implements the target responsibility system for the department, signs the target responsibility book, and establishes a step-by-step The accountability system has achieved the same action, clear objectives, clear responsibilities, and clear rewards and punishments. In late October 2019, 100 copies of the "Supervisory Inspection Standards for the "Medical Quality Miles" Campaign in Henan Province were issued, and one leader at the middle level and above was handed in. According to the eight major items in the supervision and inspection standards, the personnel responsibility was implemented item by item. The standard has been refined to further improve the level of “Medical Quality Miles” activities.

Second, extensive mobilization, everyone participates, creating a strong atmosphere

1. Convene the meeting and promote it. The school team meeting, the middle-level leadership meeting, the department staff meeting, and the Ministry of Health’s “Medical Quality Miles” activity plan were carefully held, and the provincial health department’s filework on the seven special activities of “Medical Quality Miles” was carefully carried out. Let all staff understand and master the activities and implement them conscientiously. The hospital conducts an inspection once a month, and the leading group at the hospital level conducts supervision and evaluation on the implementation of each subject, and issues evaluation results and rectification notices.

2. Organize various forms of publicity activities around the theme of “Medical Quality Miles”. Hanging slogans in eye-catching areas such as outpatient departments and inpatient wards, using the open bulletin board, electronic screens, and blackboards in various fields to promote new ideas, new measures, and new achievements in medical quality and medical safety management. The significance, requirements, good practices, and good experiences of the second activity create a public opinion atmosphere that is conducive to promoting medical safety, improving medical quality, and improving the relationship between doctors and patients.

Third, strengthen training to improve the medical quality and safety awareness of medical staff

In the "Medical Quality Miles" campaign, our hospital has always placed the training of medical personnel in an important position, taking various forms, comprehensively carrying out training of business technicians, and striving to improve the technical capabilities and level of medical personnel.

1. Organize the study of health laws, regulations, rules and regulations, and routine norms. We have successively carried out the "Practical Physician Law", "Nursing Regulations", "Infectious Diseases Prevention and Control Law" and other health laws and regulations, as well as the "People's Republic of China Public Security Punishment Regulations", through expert lectures, unit concentration learning, medical staff self-study, special lectures The typical case analysis and discussion forms enable medical personnel to understand the laws, regulations, rules and regulations, routine norms, strengthen their legal awareness and self-protection awareness, and enhance the consciousness of practicing according to law.

2. Conduct various forms of training activities. First, in the hospital organized business backbone training, case writing training, "three basics" and "three strict" training, nursing training, drug training, hospital infection knowledge training, medical dispute prevention and other activities, so that medical staff's business technology and medical safety Consciousness has improved significantly. Second, actively participate in training seminars organized by superiors. In the lectures on medical quality management and business technology training organized by the provincial and municipal levels, the staff were actively organized to participate in the study. In 2019, more than 50 medical personnel from various departments were selected to participate in provincial and municipal training for 16 times to learn new medical and health care. Knowledge, new technologies, new ideas, new ideas. The third is to strengthen the selection and training of academic leaders. From January to October 2019, a total of 10 people were selected to go to the provincial and above hospitals for further study. The head nurses of 14 clinical first-line departments went to the provincial department for training, and recommended 6 people to promote the vice high. job title. Through the above measures, the overall level of the health technology team in our hospital has been improved.

3. Organizational theory examinations and technical competitions. We focus on training and improving the first-aid technology, procedures, common methods and treatment plans for medical staff, and carry out training to promote new knowledge and new technologies in accordance with the principle of being easy to difficult and from shallow to deep. After entering October, our hospital conducted a theoretical and skill test on the training of all the medical staff who participated in the training. On this basis, the winners were selected to participate in the city's health technology competition competition, and won the excellent award, at the same level brother hospital. The middle ranks in the forefront.

Fourth, strict self-examination, serious rectification, and comprehensive improvement of medical quality

Medical quality is the lifeline of hospital survival and development. Medical quality is the core of hospital management and the eternal theme of hospital management. Only by establishing this concept can medical development be realized. Our hospital focused on medical quality work. In February and June of 2019, we held the "Medical Safety Work Conference" attended by all doctors, medicines, nursing technicians and technicians to investigate potential safety hazards and formulate medical safety measures. The activity plan, the spirit of the seven special actions of the “Medical Quality Miles” issued by the Provincial Department, combined with the actual situation of our hospital, the hospital leadership group on August 21, September 18, October 16 and November 13 The self-examination and rectification of the activities were carried out, and the quality of medical care was comprehensively improved.

1. Strengthened safety production work. Further improve the organization leadership, management institutions, rules and regulations, operating procedures and standards for safety production, clarify personnel allocation requirements, and implement measures in place; take special management and measures for key parts and key departments to ensure that all types of equipment and facilities in the hospital can Safe operation. The fire exits of the hospital are unimpeded, the obstacles are unobstructed, the signs are eye-catching, all kinds of fire-fighting equipments are fully equipped, and the security department is managed in a unified manner, and special personnel are managed in each department. On September 14th, in the hospital's preparation room, the Security Department organized more than 70 medical personnel from 26 departments of the hospital to conduct fire drills, which further improved the fire safety prevention ability of medical personnel.

2. Strictly implement the core system of medical care. In accordance with the requirements of the "Heart System for Medical Care in Henan Province Medical Institutions", the Medical and Medical Department of the hospital established a medical technology management file and implemented the core system of medical quality and medical safety. At the same time, in accordance with the "Practitioner's Law", "Nursing Regulations", "Regulations on the Administration of Medical Institutions", "Administrative Measures for the Clinical Application of Medical Technology" and other relevant laws and regulations, strict practice access, qualification access, and supervision, the court is not illegal Practice behavior. The "Measures for the Regular Assessment of Physicians" was carefully implemented to strengthen the regular assessment and evaluation of physicians' practice. Establish a surgical grade management system and formulate specific implementation rules and management methods. At the same time, according to the professional technical ability of the physician, the corresponding surgical permission is granted and dynamic management is implemented.

3. Strengthened clinical rational use of drugs. First, establish and improve the organization of the hospital pharmacy management committee, with clear responsibilities, sound system, complete records, improve the level of clinical rational drug use, and reduce the medical expenses of patients. The second is to regularly supervise, evaluate and publicize the clinical drug use in the hospital. Conscientiously implement the prescription review system, implement dynamic monitoring of prescriptions and supernormal warnings, and intervene in time for irrational use of drugs. The third is to implement the relevant provisions on the clinical application of antibacterial drugs by the Ministry of Health, follow the Guiding Principles for the Clinical Application of Antimicrobial Drugs, adhere to the grading of antibacterial drugs, conduct rational drug training and education, regularly hold special analysis meetings on antibacterial drug application, and implement “Double Ten” The system adopts strict measures such as personal conversation, notification criticism, and economic punishment for doctors who overuse antibiotics. The fourth is to establish an effective drug adverse reaction event processing program, and collect and report data in a serious, timely and accurate manner. Fifth, strengthen the standardized use and management of special types of drugs such as narcotic drugs, psychotropic drugs, toxic drugs and high-risk drugs, and establish and improve the system for the purchase, safe storage and use of these drugs.

4. Conducted the evaluation of the quality of medical records. In accordance with the Ministry of Health's "Basic Norms for Medical Record Writing" and "Regulations on Medical Record Management of Medical Institutions", the Henan Provincial Department of Health's "Regulations and Management of Medical Documents" supplemented the regulations, and the Medical Services Division further standardized the management of medical records. Establish an assessment mechanism, conduct a spot check and evaluation activity on outpatient prescriptions and inpatient medical records every month, and strengthen the examination of medical records. Improve the grade A medical record and eliminate the grade C medical record.

5. Strengthened hospital infection management. First, in accordance with the " Hospital Infection Management Measures" and related technical specifications and industry standards, the Hospital Infections Office formulated the "Emergency Plan for Sudden Hospital Infections in the People's Hospital of Yucheng County" and the "Infectious Surveillance Project of the People's Hospital of Yucheng County" to strengthen the Management and monitoring of infection management departments such as infection, stomatology, operating room, emergency department, delivery room, blood purification room, disinfection supply room and laboratory. Secondly, in accordance with the "Regulations on the Management of Medical Wastes" and other regulations, regulations, strengthen the classification, transportation, and temporary storage of medical waste, strengthen the standardized management of medical waste, effectively prevent and control hospital infections, and prevent infections. Since the beginning of this year, professional standards have been met in the infection management assessment organized by the higher-level health administrative departments.

6, strengthen the first aid work, carried out a clinical first aid skills contest. Further strengthen the construction of first-aid teams, strengthen the basic skills training for medical personnel, and improve the ability and level of emergency treatment. Establish a "three basic, three strict" training and assessment system, medical staff can be skilled and correct use of various rescue equipment, master a variety of first-aid technology. The first-aid skills were contested. Every six months, the competition was conducted in a single competition and a comprehensive competition. The contents included single-handed cardiopulmonary resuscitation and three-card cardiopulmonary resuscitation techniques. To assess the emergency operation techniques of 14 clinical staff in clinical departments. Through skill competitions, improve the emergency response and disposal capabilities of medical staff, comprehensive treatment capabilities, and enhance the coordination capacity between departments of the hospital to meet the needs of emergency rescue work in complex situations.

7. Further regulate the clinical blood transfusion management of hospitals . Improve the hospital blood transfusion management committee and work system, the hospital blood bank is set independently. The implementation of the clinical blood transfusion application registration system and the use of blood approval procedures, the establishment of a blood transfusion application and consultation system, pre-transfusion patient consent system, pre-transfusion testing and reconciliation system. Our hospital can provide 24 hours blood supply service for the clinic, strict blood transfusion indication, and carry out component blood transfusion. In clinical blood transfusions. There is no illegal blood collection and the qualified rate of cross matching is 100%.

2019 is the first year of the "Medical Quality Miles" campaign. Although our hospital has done a lot of work in the continuous improvement and management of medical quality, it has achieved certain results. However, there is still a certain gap from the requirements of the superior. In the future, under the correct leadership of the higher-level health administrative department, we will further update our concepts, raise awareness, take measures, strengthen medical quality management, ensure medical safety, promote the steady progress of health, and make new developments for economic development and social stability. Bigger contribution!

After the report is completed, if it is inappropriate, please ask the leaders and experts to correct me. Thank you!