Classification standard of tertiary hospitals
This standard is the standard for the construction and development of tertiary hospitals, and it is also the basis for evaluating their level and quality. First, the department setting
The establishment of hospital departments should adapt to their functions, tasks and scale. The establishment of functional departments should conform to the principle of streamlining and high efficiency and meet the needs of management. Under the guidance of regional health planning and comprehensive development, business departments should strengthen professional construction, implement secondary zoning and highlight professional advantages.
(a) clinical departments 1. Professional department.
There are emergency departments, internal medicine, surgery, obstetrics and gynecology, pediatrics, traditional Chinese medicine, ophthalmology, otolaryngology, stomatology, dermatology, anesthesiology, physiotherapy, rehabilitation or geriatrics, oncology, family beds and interventional radiology.
2. Secondary specialized branches
(1) internal medicine: it is divided into digestive, circulatory, respiratory, neurological, blood, urinary and endocrine departments.
(2) Surgery: there are specialties such as abdominal surgery, cardiothoracic surgery, neurosurgery, urology, orthopedics, burns, plastic surgery, etc.
(3) Obstetrics and Gynecology: there are specialties such as gynecology, obstetrics and family planning. (4) Pediatrics: divided into neonatology, pediatrics and pediatrics. (5) Others: ICU wards (rooms) and CCU wards (rooms) must be set up. (2) Medical departments and other business departments.
There should be pharmacy department, imaging diagnosis department, laboratory department, nuclear medicine department, nutrition department, pathology department, physical diagnosis department, endoscope room, operating room, disinfection supply room, medical record room, statistics room, library and preventive health care department.
(3) Key majors
1. The whole hospital should have more than two key specialties. 2. Main professional conditions:
(1) The academic leader has the title of chief physician; (2) The professional level ranks among the domestic advanced ranks; (3) professionals form an echelon;
(4) Having more than 20 beds and supporting equipment (including equipment related to the equipment center) required for medical treatment, teaching and scientific research in this major. Second, the personnel structure
The hospital should be equipped with technical force suitable for its functions, and the structure of health technicians and other professional technicians must meet the following requirements:
1. The ratio of doctors to nurses is 1∶2.
2. Chief physician: deputy chief physician: attending physician: the ratio of doctors is 1: 3: 5: 7, and nurses and above account for more than 30% of the total number of nursing staff.
More than 3.2 clinical nutritionists.
4. Engineering and technical personnel (technicians, assistant engineers and above) account for ≥ 1% of the total number of health technical personnel. 5. The director of each primary department and key secondary department must be the chief physician, and the director of general secondary department should be the deputy chief physician.
Affiliated hospitals of medical colleges and hospitals undertaking national teaching and scientific research tasks should appropriately increase the proportion of personnel according to the Ministry of Health 1979 "Provisions on the Establishment of General Hospitals". Third, management level.
Third-level hospitals must implement departmental management. Managers at all levels should have professional management knowledge and skills corresponding to their management responsibilities. College-level leading bodies should have reasonable structure, clear responsibilities, commensurate powers, coordinated work and high efficiency. The president and vice president shall also meet the following requirements:
1. Fully understand the business of tertiary hospitals, have intermediate or above health technical titles, have worked in tertiary hospitals for more than three years, and have more than one year of department management experience.
2. After professional training in management, master the principles, principles and important methods of hospital management. 3. Be able to design and organize the formulation of hospital comprehensive development planning, project planning and annual work plan, and organize their implementation.
4. Be able to understand the trends of hospital management at home and abroad, and make full use of relevant information resources as a reference and basis for management concepts and decision-making.
5. Have the ability to accompany hospital management teaching, scientific research and guide management students' practice.
6. Paying attention to public relations can win the understanding, care and support of the local government, people from all walks of life and all walks of life. Fourth, the technical level.
Third-level hospitals should have the basic level of all-round development of medicine, teaching and research that is compatible with their functions. Can accept referrals from hospitals above Grade II, can correctly handle complex and difficult diseases, and has more than two key specialties entering the domestic or international advanced ranks.
(1) clinical departments (see annex for details) (2) medical technology departments (see annex for details) (3) key specialties.
1. Academic leaders have a certain reputation in China. 2. Can skillfully carry out (annex 1) required diagnosis and treatment technology. 3. Be able to conduct laboratory research.
There are 4 scientific research achievements at or above the provincial level (see scientific research). 5. There are also international academic exchanges.
Publish 6 or more papers in national academic journals every year. (4) Preventive health care and social medical services
Hospital preventive health care and social medical service are one of the basic functions of modern hospitals, which are hospital-wide work and have reached a good level.
1. Guide grass-roots units to obtain experiments.
2. Can carry out various forms of health education and effect evaluation. 3 to carry out mental health, genetic counseling and other outpatient services. 4. Carry out family sickbed service.
5. Preventive health care department can guide community preventive health care and participate in hospital environmental management and hospital infection control. V. Teaching and scientific research
teaching
In accordance with the Interim Provisions on Teaching in National Medical Colleges and Universities, establish a perfect teaching management organization and meet the following requirements:
1. Be able to undertake clinical teaching and internship tasks in medical colleges.
2 postgraduate (master's, doctoral) education, continuing education system and plan. 3. Rational use of teaching funds.
4. The teaching team structure is reasonable, and the ratio of professors, associate professors, lecturers and teaching assistants is 1: 2: 4: 8.
5. There is a system of preparing lessons, evaluating teaching and checking lectures. Teaching materials (audio-visual teaching materials, self-made teaching materials, etc.). ), teaching equipment (instruments, charts, specimens, models, experimental animals, etc. ) and classrooms, demonstration classrooms, provide diseases and patients to meet the needs of clinical teaching.
(2) Scientific research
1. There are scientific and technological archives, scientific research archives, scientific research plans, achievements and archives management.
2. Statistical annual number of international papers ≥1; National papers ≥10; Participation in or international academic exchanges ≥ 1 time; Presided over national academic lectures ≥ 1 time.
3. According to the statistics of the three years before the review, there are more than two national scientific and technological progress (achievement) awards ≥1; Ministry (Committee), provincial three-level scientific and technological progress (achievement) award ≥2.
4. The number of young and middle-aged people who participate in scientific research project design and practical research is ≥30%. Six, medical equipment
1. Medical equipment should be compatible with other functions, tertiary hospitals should have basic equipment necessary for medical treatment, teaching and scientific research, and conventional equipment must be in good condition and have a perfect form of centralized utilization of resources to enjoy and improve efficiency.
2. The rescue room, ICU, CCU ward (room), operating room, disinfection supply room, X-ray room, laboratory, pathology room, functional examination room, speculum room and key specialties should have basic equipment to ensure the completion of medical treatment, teaching and scientific research tasks, and meet relevant standards.
3. Cost-benefit analysis should be carried out for large equipment, and corresponding improvement measures should be taken. Seven. information management
Hospital information work must adapt to medical treatment, prevention, teaching, scientific research and management. 1. Complete various health statistics in a timely, accurate and comprehensive manner.
2. Guide the grassroots to carry out the dynamic analysis of community population and patients' diseases. 3 according to the need to participate in and guide the grassroots to carry out the monitoring of chronic non-communicable diseases registration report. 4. Be able to conduct medical quality and cost-benefit analysis.
5. Be able to carry out Chinese and foreign cultural information work in hospital management, medicines, instruments and equipment, and clinical medicine (including nursing and medical technology).
6. Scientific classification, coding and indexing of information materials.
7 can give full play to the utility of all kinds of intelligence and statistical data, so that the utilization situation can be recorded, evaluated and improved.
8. Be able to use electronic computers for information processing.
9 should set up a medical library (room), equipped with enough Chinese and foreign medical books and periodicals. VIII. Statistical indicators
1. The coincidence rate between admission diagnosis and discharge diagnosis is ≥ 95%. 2. The coincidence rate of diagnosis before and after operation is ≥90%. 3. The coincidence rate of clinical diagnosis is ≥ 90%.
4. The diagnosis rate of secondary referral patients in key specialties is ≥ 95%. 5. The positive rate of 5.CT is ≥60%.
(with case analysis report) 6. The positive rate of large X-ray machine is ≥50% 7. The positive rate of nuclear magnetic resonance vibration examination is ≥70%.
8. The average annual VIS of interstitial assessment laboratory in clinical chemistry room is <120 (VIS of tertiary specialized hospital VIS < 80). 9. The CV value of quality control in clinical chemistry room is within the allowable error range of 10. The reference value of bacterial quality control is 1 1. Autopsy rate ≥ 15 (except neonatal autopsy).
12. The cure and improvement rate of single disease (in the same hospital) is at a high level 13. The success rate of emergency rescue for critically ill patients is ≥80% 14. The success rate of emergency rescue for critically ill patients is ≥84% 15. The primary healing rate of aseptic operation incision is ≥97%.
16. The readmission rate of the same case within one week (the disease type was determined during the examination, compared with the hospital at the same level) was at a low level.
17. The mortality rate of single disease is lower than the average level of hospitals at the same level 18. The mortality rate of hospitalized women is ≤0.02% 19. The mortality rate of live births is ≤0.5%.
20. On 10 day after operation, the mortality rate of single disease was lower than the average level of specified diseases (265,438+0). Anesthesia mortality is less than or equal to 0.02%. 22 outpatient prescription qualified rate of 95% or higher. 23. Outpatient medical record writing qualified rate of 90% or higher. 24. The rate of Grade A medical records is ≥90%.
(No Class C medical record) 25. X-ray film A rate ≥40%
26. The qualified rate of writing five kinds of nursing forms is ≥ 95%. The qualified rate of nursing technique operation is ≥98% 28. The qualified rate of basic nursing is ≥90% 29. The qualified rate of special and first-class nursing is ≥90% 30. The qualified rate of disinfection of conventional instruments is 100% 3 1. Implementing responsible nursing ≥20% 32.
33. The eating rate of therapeutic diet was 100% 34. The dining rate of inpatients is ≥90% 35. Hospital infection rate ≤ 10%.
36. The infection rate of aseptic operation incision is ≤0 .5%. The number of medical accidents is 0.
38. The qualitative treatment of medical accidents and serious errors is correct 100% 39. The number of bedsores in coma and paralysis patients is 0. The number of accidents in 40 years is zero.
(including fire, explosion, building collapse, personal injury of patients, etc.). ) 4 1. Bed utilization rate ≥85%-≤93% 42. Average length of stay ≤20 days. Bed turnover ≥ 17 times/year.
44. The deputy chief physician walked out of the general clinic for more than 2 times/week. 45. Completed the task of guiding students 100%.
(including rescue, foreign aid, sideline, etc.). ) The intact rate of medical equipment and instruments with a price of over 460,000 yuan is ≥ 95%, and the utilization rate of medical equipment and instruments with a price of over 470,000 yuan is ≥30 hours/week. 48. The pass rate of the "three basics" examination for medical staff 100%. 49. The intact rate of first-aid articles is 65,438+000%, 50. One needle per person.
Classification standard of tertiary hospitals
Hospitals should regularly evaluate their own construction, management, technical level, work quality, civilized service and cost-effectiveness, and formulate improvement measures. The provincial (city) hospital review committee reviews the quality level of hospitals outside the hospital according to the standards. According to the evaluation results, the tertiary hospitals are divided into four grades: specialist, A, B and C. First-and third-level specialized hospitals
Outstanding achievements have been made in hospital construction. Its overall level ranks first in the country. Some majors can reflect the international or contemporary medical development level, fully meet the requirements of tertiary hospital standards, and meet the following requirements:
1. The comprehensive level of clinical disciplines is in the leading position in China and can be referred by other tertiary hospitals. 2. At least one key major has entered the international advanced ranks and has certain influence. 3. There are academic centers that cooperate with the World Health Organization or foreign academic institutions.
4. In the same review cycle, undertake 2-3 scientific research projects at or above the ministerial level and win at least 1 national scientific research achievement award at or above the second level.
5. Be able to train interns above the attending physician and have the ability to train doctors and postdocs. Second-and third-class first-class hospitals
Remarkable achievements have been made in hospital construction, and the comprehensive assessment of department setting, staffing, management level, technical level, work quality and technical facilities has reached more than 900 points according to the grading standards. Tertiary and tertiary hospitals
The achievements of hospital construction are still good, and its department setting, staffing, technical level, work quality and technical facilities have reached 750-899 points according to the grading standards. Fourth and third level hospitals
Some achievements have been made in hospital construction, and the basic standards have passed the examination, but there is still a big gap with the requirements of this standard. According to the grading standard, the comprehensive assessment is 749 points or less. Third-class and third-class hospitals should have practical improvement measures.