Time flies and a piece of work is over. Looking back on this period, the results are hard-won. Let's write a work summary for this year's work. So how do you write it? The following is my annual summary of medical quality and medical safety management (generally 5 articles), which is for reference only and I hope it will help you.
1 20xx annual summary of medical quality and medical safety management, our hospital will deploy according to the arrangement of superior departments. In terms of medical quality and safety management, efforts were made to consolidate the implementation of medical norms and core systems, actively promote the reform of public hospitals, and successfully complete various tasks. In the whole year, 40,306 outpatient visits were completed, 3,958 hospitalizations (including 23 rural cooperative patients18, accounting for 58.5% of the total number of hospitalizations), 420 hospitalizations and 685 hospitalizations. Business volume increased to 65,438+05%.
In the past 20xx years, based on the previous work, our hospital has conscientiously summed up experience and continuously carried out activities such as "three good and one satisfaction", medical quality and special rectification of clinical application of antibacterial drugs. Adhering to the theme of "continuously improving quality and ensuring medical safety", the hospital constantly strengthens the concept of quality, enhances the sense of responsibility, builds a safe defense line, and strengthens the education and training of medical staff, especially medical nursing staff. The organization organized eight related trainings throughout the year, with more than 650 participants. Hospitals attach great importance to medical quality, improve quality management, strengthen quality control and ensure quality and safety. Establish and improve the medical quality control system, regularly check the medical quality of each department, and report the inspection results to the department and the whole hospital; Practice in strict accordance with the law, and use different forms to guide patients to seek medical treatment correctly and reasonably in their work. Further implement the medical core system, strengthen the quality management of medical records, strengthen the construction of key departments, and improve the management level of key departments. Strengthen the management of clinical medical technology application, establish a surgical grading management system and surgeon files, and carry out clinical application of medical technology in strict accordance with regulations. Standardize drug management, organize medical staff to carry out rational drug use training, carefully evaluate prescriptions, and intervene irrational drug use in time; The management of medical devices has been strengthened, and the monitoring and reporting of adverse events have been increased.
Improve the management system of antibacterial drugs, thoroughly clean up the varieties of antibacterial drugs used, and keep 32 dosage forms of antibacterial drugs. Unrestricted use of antibacterial drugs accounts for more than 2/3 of the total number of antibacterial drugs. Continue to promote and implement the "patient safety goal", improve the medical accident prevention plan and treatment process, strictly implement the check system and doctor's advice system, strengthen link management, and implement the medical safety related work system. There were no major medical errors and accidents this year. Strengthen hospital infection control, highlight management key points, and implement link norms. There was no missing report of infectious diseases and no nosocomial infection in the whole year. The clinical pathway work was further promoted. At present, seven diseases are included in clinical pathway management in our hospital, but there are some problems such as low participation rate and high variation rate. 20xx——20xx annual regular examination for physicians was successfully completed, and all 52 people in our hospital passed the examination. Medical liability insurance and people's mediation of medical disputes are being explored, but our hospital has not been officially opened.
Medical quality and safety are the core of hospital management. In the next 20xx years, our hospital will strive to achieve a new level of medical quality and safety by combining the reform of public hospitals and the grade evaluation of secondary general hospitals.
Annual Summary of Medical Quality and Medical Safety Management In 2 20xx, with the strong support and care of hospital leaders, the Department of Neurology adhered to the purpose of "building a national first-class hospital and a first-class professional discipline", and with the joint efforts of general medical staff, the quality and safety management of general medical care has made great progress. The work in 20xx is summarized as follows, and the rectification measures in 20xx are put forward.
1. The completion of the overall target management responsibility system has completely surpassed last year.
Under the leadership of department heads and head nurses, and with the joint efforts of general practitioners, the outpatient volume in 20xx was1-13107, an increase of 6.83% compared with the same period last year (12269). The number of inpatients 1739, an increase of 3.88% compared with the same period last year (1674); The number of discharged patients 1 709, an increase of 6.08% compared with the same period of last year (1, 6 1); The number of bed turnover was 22.9 1, an increase of 5.48% over the same period last year (2 1.72). The utilization rate of hospital beds was 87.97%, which was 65438 0.27% higher than that of the same period last year (86.87%). The average length of stay 13.33 days was 2.98% lower than the same period last year (13.74). The first-class medical record rate reached 100%.
2. Adhere to "three good and one satisfaction", and the level of clinical diagnosis and treatment has been significantly improved.
At the early stage of cerebral infarction, the scale of intravenous thrombolysis developed and the arterial thrombolysis made a breakthrough; Early rehabilitation treatment of stroke is leading in the province, with a win-win situation; Intravascular interventional therapy for cerebrovascular diseases is leading in the province and advanced in China; Carry out neuromuscular pathology independently to improve the quality of clinical diagnosis and treatment in our department; Set up ICU neurology department; The workload of epilepsy specialty has increased obviously, and the social recognition has improved.
3. Implement expert outpatient service without holidays.
Give play to the role of outpatient and emergency departments as external windows, and have expert consultations every day for 365 days. General outpatient clinics are all attended by experts, and the chief physician consults on Saturday and Sunday. In the case of a small number of staff in the department, doctors above the deputy high school are still sent to take turns in emergency treatment, and critically ill patients are treated in time, and the green channel for stroke runs efficiently.
4. Strengthen the management of departments and put an end to all medical disputes.
5. Pay attention to ideological and political study
Under the leadership and organization of Comrade Zhang Xiuqing, secretary of the Party branch, our department held many meetings for medical staff in party member and other departments to learn the relevant documents formulated by the Party and convey the hospital spirit in time. In-depth development in the whole hospital,
In-depth study and implementation of "striving for excellence and being qilu pioneer" activities, "three good and one satisfaction" activities, anti-corruption and "Several Guidelines for Leading Cadres of China * * * Production Party party member", be honest in politics, be strict with yourself, be honest in performing official duties, consciously accept supervision, and resolutely put an end to medical corruption and small coffers.
20xx rectification plan:
General practitioners should actively treat patients, increase the number of outpatients and inpatients, improve the cure rate and rescue success rate of critical cases, increase bed turnover times and bed utilization rate, reduce mortality and average hospitalization days, and control the proportion of drugs. Especially for the management of medical insurance patients, it is necessary to strictly implement the regulations of superiors and strengthen management from outpatient consultation, hospitalization, drug proportion, self-funded project proportion, large-scale inspection and so on. , so that the medical insurance policy can be fully implemented, which is really beneficial to the people's disease prevention and treatment.
1. Further improve the "three good and one satisfied" activities. In order to strengthen the harmony between doctors and patients, the department will set up a service supervision team with the director and head nurse as the mainstay, and work closely around the theme of how to satisfy patients. Think of patients everywhere, put yourself in their shoes, and actively provide value-added services for patients and their families, so that patients and their families are more comfortable, warm and assured in the process of diagnosis and treatment.
2. Single disease quality control and clinical pathway case reporting need to be further strengthened, and timely and accurate reporting should be achieved. For patients who enter the path, we should carry out diagnosis and treatment activities in strict accordance with the content of the path. For patients with mutation and patients who leave the path, the reasons should be carefully analyzed and recorded in detail.
3. Further strengthen the management of rational use of antibiotics and standardize the rational use of antibiotics.
4. Strengthen the disinfection of medical staff's hands to reduce the occurrence of hospital infection. Once hospital infection occurs, it should be reported to the hospital infection department in time to form perfect data to guide the prevention and treatment of hospital infection.
5. We didn't pay attention to this part for patients who have been hospitalized for more than 30 days. In the future, all patients who have been hospitalized for more than 30 days will fill in the form, analyze the reasons, take corrective measures, sign by the department director, and report to the medical department.
6. Continue to strengthen the standardized training of residents and the professional learning of departments, and promote the improvement of the professional level of all medical staff.
Summary of annual medical quality and medical safety management 3 Medical quality is the foundation of a hospital's survival and development and the embodiment of a hospital's level. Medical safety management is an important aspect of medical quality. Over the past year, under the direct and correct leadership of the Health Bureau, our hospital has earnestly studied the spirit of the Ministry of Health and our bureau on the reform of the medical and health system, devoted itself to the reform of the medical and health system, opened up the medical market, and actively participated in market competition. Adhere to the patient-centered, all services for patients, constantly improve the quality of medical services, improve service attitude. Strictly grasp all kinds of medical quality control indicators, improve the overall level of medical care, effectively reduce medical disputes and put an end to medical accidents.
The medical treatment and medical safety work this year is summarized as follows:
The first is to effectively improve medical services.
Strengthen the education of medical ethics and medical laws and regulations, so that the broad masses of workers can further establish the idea of serving patients wholeheartedly, adhere to the service concept of "patient-centered", earnestly carry out the "three good and one satisfied" activities with the content of "good service, good quality, good medical ethics and satisfaction of the masses", and continuously improve the level of medical services. Innovating service process and optimizing diagnosis and treatment environment. Enrich outpatient doctors, arrange working hours reasonably, insist on opening clinics on time, and ensure patients to see a doctor in time. The establishment of an open and transparent system of medical expenses and the implementation of a daily list system of inpatients are very popular among patients, which is convenient for patients to inquire about the details of drug prices and hospitalization expenses at any time.
Strengthen communication between doctors and patients, improve communication content, improve communication methods, pay attention to communication effect, strengthen basic hospital management, establish and improve medical safety management organizations, implement various core medical work systems and safety measures, ensure the legal, reasonable and safe use of medical instruments and equipment, and avoid medical errors and accidents. Strict technology access system, standardize medical behavior. Conscientiously implement the Drug Administration Law and the Regulations on the Supervision and Administration of Medical Devices, and strengthen the supervision and administration of the procurement, storage and use of drugs and medical devices.
Second, improve the quality of medical services.
Medical quality and safety is related to people's health and safety, is the lifeline of medical services, and is the core content and eternal theme of hospital management. To carry out medical safety, we must first improve medical quality and service level. Strengthen medical quality management, pay close attention to the implementation of rules and regulations, always adhere to the "patient-centered", take quality as the core, take quality and safety as the theme, conscientiously implement various rules and regulations, post responsibilities, strictly implement the routine of diagnosis and treatment, and implement various systems in all aspects.
Set up a medical quality management team in Shi Yao Town Health Center, strengthen the quality management of medical documents, strictly implement the basic norms of medical record writing, and monitor and manage the quality of medical records throughout the process. Formulate an assessment plan for professional and technical personnel in Shi Yao Town Health Center, implement the reward and punishment mechanism, ensure that rewards and punishments are in place, and give praise and material rewards to departments or individuals with excellent medical service quality assessment results; For departments or individuals whose medical service quality assessment results are not up to standard, in addition to economic punishment and hospital informed criticism, they should also strengthen the training of "three basics and three strictness", hold three basics assessments for all kinds of personnel at all levels from time to time, comprehensively evaluate the clinical theoretical knowledge level and practical operation skills of medical staff, and link the assessment results with personal assessment to ensure the continuous improvement and update of medical technicians' own technical quality and comprehensively improve their professional quality.
Three, establish and improve the quality management system, standardize medical behavior is the core.
This year, our hospital started with strengthening the system construction, combined with the nature and content of each post, formulated the relevant management system and assessment rules, and formulated the comprehensive target responsibility letter of functional departments and business departments, realizing the pattern of first-level management and first-level responsibility. Clear responsibilities, ensure clear functions, clear powers and responsibilities, and moderate benefits, so as to realize rule-based management and gradually improve the legalization, institutionalization, standardization and standardization of management.
Fourth, properly handle disputes between doctors and patients according to law.
According to relevant laws and regulations, the disposal of disputes between doctors and patients should be brought into the legal and standardized track to safeguard the legitimate rights and interests of both doctors and patients. According to the Regulations on Handling Medical Accidents, Shi Yao Town Health Center has set up a medical dispute coordination group to properly handle medical disputes according to law. Adhere to the principle of prevention first, early detection and small disposal, establish and improve the prevention and disposal mechanism of doctor-patient disputes, conscientiously implement relevant prevention and control measures, and strive to resolve all kinds of doctor-patient disputes to prevent mass incidents caused by doctor-patient disputes.
Five, strengthen security measures to ensure hospital safety.
Organize regular training for personnel in key positions and implement various internal safety measures. Conduct a comprehensive inspection of fire safety on a regular and irregular basis, focusing on places that are prone to fire, store dangerous goods and concentrate people (such as pharmacies, clinics and wards). ), and regular maintenance and replacement of fire fighting facilities, to ensure that fire fighting equipment is in good condition. Our hospital implements the general duty system of hospital leaders, defines the division of time for each person, carries out the inspection of the whole hospital during the duty, and earnestly implements the public security preventive measures such as fire prevention, theft prevention and sabotage prevention. Strictly implement the safety responsibility system, do a good job in the investigation of unstable factors, and immediately rectify the problems found. Formulate emergency measures for civil air defense, physical defense and technical defense to ensure that major safety accidents do not occur in hospitals.
Summary of annual medical quality and medical safety management in 20xx years, our hospital conscientiously studied and implemented the 18th National Congress of the Communist Party of China and the new medical reform policy, took the initiative to create a first-class Chinese medicine hospital as an opportunity, closely focused on the purpose of "patient-centered, quality-centered", gave full play to the characteristics and advantages of traditional Chinese medicine, and improved medical quality. At the same time, we will continue to strengthen medical safety management, investigate potential medical safety hazards, ensure medical quality and safety, and strive to provide safe, effective, convenient and inexpensive medical services for the people.
First, medical quality and safety management
(1) Strictly implement the core medical system and strengthen the management of medical services.
The hospital has set up a medical quality management committee, with the president as the first responsible person. The quality assurance system of medical quality management organizations at hospital and department levels was established. The director is responsible for undergraduate medical quality management. The Medical Department organizes the implementation of total medical quality management, conducts guidance, supervision, inspection, assessment and evaluation on medical quality management, regularly carries out medical quality and safety education, puts forward medical quality management and continuous improvement plans, and establishes quality management objectives, indicators, plans, measures, effect evaluation and information feedback.
Hospitals establish and improve the accountability system of medical quality management, strengthen the management of basic quality, link quality and terminal quality, and standardize the diagnosis and treatment behavior with "diagnostic routine" and "clinical pathway" Strictly implement the system of weekly business rounds, monthly administrative rounds, and inspection of presidents, functional departments and department directors on holidays to find and solve problems in time. Annual medical service volume: outpatient and emergency visits, hospitalization visits, bed utilization rate and various operations increased by xx% and xx% respectively. The cure rate of hospitalization was xx%, and all kinds of critically ill patients were rescued xx times, with a rescue success rate of xx%. Complete the physical examination of some county-level leading cadres and employees of some units and enterprises throughout the year, with xx person-times. There are xx people with chronic diseases and xx people with disabilities in the county.
(two) optimize the medical service process, improve the quality of medical services.
Our hospital adheres to the service concept of "patient-centered", takes "three good and one satisfaction" as the goal, improves various medical service measures, achieves reasonable arrangement, enthusiastic service and smooth process, strengthens communication between doctors and patients, promotes harmonious doctor-patient relationship and improves patient satisfaction; Actively improve the medical environment and keep the hospital clean and orderly. Solidly carry out the "quality nursing service demonstration project", strengthen nursing management, standardize practice behavior, consolidate basic nursing services, fully mobilize the enthusiasm of nursing staff, and strive to provide patients with safe, high-quality and satisfactory nursing services.
(3) Summarize the evaluation of medical record writing quality.
According to state administration of traditional chinese medicine's "Basic Standards for Writing Medical Records of Traditional Chinese Medicine" and "Regulations on Medical Records Management in Medical Institutions", medical records management has been further standardized. Establish an assessment mechanism, conduct spot checks on outpatient prescriptions and inpatient medical records every month, and strengthen the assessment of medical record writing. The first-class medical record rate of hospitalized medical records is xx%, and there is no third-class medical record.
(4) Strengthen the management of hospital infection.
According to the relevant requirements of "Management Measures for Hospital Infection" and "Evaluation Standard for Secondary Hospital of Traditional Chinese Medicine (20xx Edition)", various emergency plans have been formulated to strengthen the management and monitoring of key infection management departments such as stomatology, operating room, emergency department, endoscopy room and laboratory. The hospital infection management manual and the department hospital infection quality self-inspection book were formulated, the hospital infection quality control committee was established, the prevention and control management of hospital infection was strengthened, and the relevant systems were strictly implemented in biological monitoring, disinfection, medical waste recovery and destruction. The treatment rate of medical waste was xx%, the hospital infection rate was xx%, the annual prevalence rate was xx times, the actual investigation rate was xx%, and biological monitoring was carried out in xx copies, with the qualified rate of xx%.
(5) Strengthen first aid and first aid work.
First-aid teams, mainly Chinese medicine personnel, have been established, and the basic first-aid skills training of medical staff has been strengthened, so that medical staff can skillfully and correctly use all kinds of rescue equipment and master all kinds of first-aid techniques. Strengthen the coordination ability among departments in our hospital to meet the needs of emergency rescue work under complex circumstances.
(6) Strengthen the management of clinical blood transfusion.
Strengthen the management of blood transfusion, strictly implement the system of "Technical Specification for Clinical Blood Transfusion" and "Administrative Measures for Medical Blood Use", strictly implement the operating rules of blood transfusion technology, master the indications of blood transfusion, use blood scientifically and rationally, and formulate and implement the plan for controlling blood transfusion infection. Xx person-times, xx ml, component transfusion 100% were transfused throughout the year. There are no mistakes in illegal blood use and transfusion.
(seven) to strengthen the quality control of clinical inspection.
According to the Regulations on Biosafety Management of Clinical Experiments in Pathogenic Microorganism Laboratories and Departments
Room management measures "and other relevant regulations, comprehensively strengthen the laboratory biological safety, quality control and management; Provide 24-hour emergency inspection service to meet clinical needs; Indoor quality control and outdoor quality evaluation of clinical laboratory items.
(8) Infectious disease management
Report all kinds of infectious diseases in time according to relevant requirements and regulations. Xx cases of infectious diseases and xx cases of death were reported throughout the year, with no omission, delay or false report. The epidemic information network is operating normally.
(9) Strengthen the regular assessment of doctors.
According to the regulations of the Ministry of Health, doctors are regularly assessed every two years, and records of bad medical behaviors and stains are established for doctors, requiring doctors to have good professional ethics and medical ethics. Continuing education credits are up to standard. In 20Xx, I took an examination of xx medical practitioners and assistant doctors, all of whom were qualified.
(X) Clinical pathway management
In view of the actual situation of the hospital, the Medical Department has formulated the Regulations on the Management of Clinical Pathways of Chinese Medicine in Hospitals, and has taken the lead in formulating the implementation plan of clinical pathways for xx pilot specialties and xx pilot diseases. In the whole year, xx cases entered the route, the enrollment rate was xx%, xx cases were mutated, and xx cases exited the route, accounting for xx% of all discharged cases. The average length of stay was xx days.
(eleven) to guide the work of traditional Chinese medicine.
With the assistance of the county medical association, xx training courses on appropriate techniques of traditional Chinese medicine were held for township hospitals and rural doctors in the county. Training and teaching xx rural doctors for xx hours not only enabled rural doctors to master and apply the appropriate techniques of traditional Chinese medicine skillfully, but also enabled farmers to have a deep understanding and understanding of the appropriate techniques of traditional Chinese medicine, and fully enjoyed the benefits of "treating diseases with less money".
Second, nursing quality and safety management
Nursing work is patient-centered, aiming at improving nursing quality, deepening high-quality nursing service and ensuring nursing safety. Seriously implement the rules and regulations, strictly enforce them. Through quality control, some bad conditions can be blocked and changed, so that the nursing quality is always in a state that meets the requirements of quality standards. Adhere to the monthly head nurse meeting; Quarterly nursing quality management meeting; Seminar on analysis and discussion of nursing adverse events; Multi-sectoral coordination meeting of nursing, medical care and logistics. Complete key tasks in strict accordance with the work plan, summarize the advantages and disadvantages of last month's work, and put forward corresponding rectification measures. Conscientiously implement the core nursing system and insist on quarterly rounds and discussion of difficult cases.
Continue to carry out the activities of "quality nursing service demonstration ward" in inpatient department, and the satisfaction of inpatients is xx%. Business indicators completed throughout the year: rescuing critically ill patients xx times, the success rate of rescue xx times, inpatients xx times, outpatients xx times, intravenous infusion xx times, blood transfusion xx times, intravenous injection xx times, intramuscular injection and various skin tests xx times, catheterization xx times, oral care xx times, gastric lavage xx times, oxygen inhalation xx times, ultrasonic atomization xx times, operating table xx times, and traditional Chinese medicine nursing (cupping and oral care xx times)
Third, logistics and safety management.
Adhere to the principle of "strengthening quality, improving management, making the best use of everything and serving clinic" to ensure logistics supply. Strengthen the management of hospital medical equipment, instruments, water, electricity, vehicles, fire-fighting facilities and passages, and provide guarantee for the development of various work in the hospital.
Fourth, medical quality and safety incident management
Education on medical quality and safety for all employees has improved the awareness of medical safety. Conscientiously implement the Interim Provisions on the Report of Medical Quality and Safety Incidents and the Interim Measures for the Warning and Talk System of Medical Quality and Safety, and our hospital has formulated the prevention plan and handling process for major medical safety incidents and medical accidents. Further improve the organization and leadership, management organization, rules and regulations, operating procedures and standards of safety production, clarify staffing requirements, and put measures in place; Take special management and measures for key parts and departments. Hospitals regularly report medical quality and safety incidents, and report xx cases throughout the year. No medical accidents occurred throughout the year. There were no medical disputes throughout the year.
Annual summary of medical quality and medical safety management for 5 20xx years, according to the work plan of the hospital medical quality and medical safety management Committee, a number of goals were formulated and implemented one by one. But there are still many shortcomings, which need to be improved and perfected in the future work. 20xx's management of medical quality and medical safety is summarized as follows:
First, implement management according to law.
In order to further strengthen the implementation and implementation of legal practice and ensure medical safety, the Medical Department has strengthened the inspection, supervision, implementation, feedback, organizational learning and implementation of legal practice in the whole hospital. To strengthen the management of practice access, the directors of various disciplines are required to strictly check, and those without practice qualifications must practice under the guidance of practicing doctors.
The second is system construction, and continue to improve the system.
While implementing various medical rules and regulations and operating norms, the hospital revised the management norms of medicine, medicine and technology and the norms of clinical specialist diagnosis and treatment.
Third, regular medical quality inspection, continuous improvement of medical quality: the medical department conducts quality inspection on all clinical departments in the hospital. In strict accordance with the requirements of the Basic Specification for Medical Record Writing, organize medical record quality supervision and inspection at least once a month.
Fourth, the main defects
(1) The quality of medical documents in some departments is poor: the records of superior doctors' rounds are identical, the routine examination is imperfect, and there are many logical errors in the medical records (such as the patient's name, gender, age, and the inconsistency between admission and admission diagnosis). ), important abnormal examination results are not analyzed and recorded, the diagnosis basis is insufficient, some doctors or nursing staff should not sign, the daily course record is not written in time, and the operation safety inspection and operation risk are not timely.
(2) The use of antibiotics in some departments is not standardized.
(3) The work of medical quality control group in some departments has not been implemented.
Five, the next stage of medical quality and medical safety management focus:
1, strengthen the study of laws and regulations, strengthen supervision, strictly control the access to practice, and let medical personnel at all levels consciously practice medicine according to law.
2, strengthen the study of various quality management systems, improve the quality of medical care, so that the diagnosis is standard and the treatment is based.
3. Do a good job in the training of Basic Specification for Medical Record Writing (version 20xx) to improve the quality of medical record writing. Strengthen the "three basics and three strictness", continuously improve the professional quality and professional level of medical staff, and continuously improve the quality of medical services.
4, improve and unify the hospital medical quality evaluation standard.
5. Further improve the management organization at the hospital and department levels, and implement the medical quality management system and responsibility at the hospital and department levels.
6, now running medical records organized by the medical department for regular inspection; The medical department and the medical record room should organize the directors of relevant departments or quality control doctors to supervise and inspect the medical records regularly or irregularly, at least once a month.
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