Hospital Perception Annual Work Plan 1 In order to improve the quality of hospital infection management, further improve hospital infection management and ensure medical safety, according to the relevant documents and regulations such as Hospital Infection Management Measures, Disinfection Technical Specification and Hospital Infection Monitoring Specification, with the support of hospital leaders, we have mainly done the following work:
I. Main tasks and measures
(a), hospital infection monitoring:
1, randomly check the discharged medical records every month, investigate the rate of missing reports of discharged patients by retrospective investigation, reduce the missing reports of hospital infection, and gradually realize the institutionalization of hospital infection case reports;
2, disinfection and sterilization effect monitoring and environmental hygiene monitoring, monthly cycle of the floor medical air, surface, staff hands, disinfectants, disinfectants, sterile items, such as disinfection effect monitoring.
3. Continue to monitor key departments, especially icu and neonatal wards, and strengthen the targeted monitoring of the "three pipes"; Select a surgical incision as the target monitoring of surgical incision infection.
(2) Strengthen quality control inspection, earnestly implement hospital infection monitoring measures, carry out quality inspection of hospital infection management, and provide guidance for hospital cleaning, disinfection, sterilization and isolation, aseptic technology and medical waste management. Found the problem and timely feedback to the clinical department, urge the rectification, continuous improvement, to ensure medical safety. All clinical departments should conduct self-examination once a month according to the quality inspection and continuous improvement records of hospital infection management. Further strengthen multi-departmental joint inspection and do a good job in hospital infection control.
(3) Strengthen the management of nosocomial infection in key departments, focusing on cleaning and disinfection records in supply room and disinfection management in operating room.
Second, strengthen hand hygiene management according to the "Medical Staff Hand Hygiene Standard", strengthen hand hygiene training and publicity for medical staff at all levels, improve hand hygiene facilities, and improve medical staff's hand hygiene awareness and compliance.
The third is to strengthen the further training of occupational protection management of medical staff, guide the occupational protection work of health and safety of medical staff, enhance the awareness of occupational exposure protection of medical staff, and conscientiously implement occupational exposure protection measures to ensure the occupational safety of employees.
Four, strengthen the hospital disinfection medical equipment and disposable medical supplies audit work.
Regularly check the use and certificates of disposable medical supplies and sterilized medical devices.
Five, strengthen the training of infection management knowledge, improve the hospital awareness of medical staff, and carry out hierarchical hospital infection knowledge training. The main plan is to train the following contents:
1, knowledge about hospital sensation and personal protection;
2. Nursing staff mainly include aseptic technology, disinfection and isolation knowledge, medical waste management, etc. 3. Hand hygiene, medical waste classification, occupational exposure protection training, etc.
4. Pre-job training for new employees (including interns). Occupational protection training for cleaning personnel
The annual work plan for nosocomial infection is 20xx years. Under the unified leadership of the hospital, strengthen the active cooperation with the clinical laboratory, conscientiously implement the Measures for the Management of Hospital Infection, the Law on the Prevention and Control of Infectious Diseases in People's Republic of China (PRC), the Technical Specification for Disinfection, the Regulations on the Management of Medical Waste and the Management Specification for Disinfection Supply Center, with the participation of all departments. In this regard, I, Kurt, have made a work plan for 20XX years, as follows:
First, the main objectives:
1, the training rate of college sense knowledge in another university is over 90%, and the qualified rate of training is 100%.
2, air, medical staff hands, object surface qualified rate of 98% or higher; The qualified rate of disinfectant in use is100%; The qualified rate of disinfection items reached 100%.
3. Missed diagnosis rate of nosocomial infection
4. Epidemic report of patients with infectious diseases100%; The timely rate is 98%;
5. The recovery rate of medical waste is 100%.
Second, the guarantee measures
(1) Strengthen education and training: the training of infection management knowledge will be included in the focus of this year's work, and all staff will be trained and papers will be distributed through various channels in the form of in-hospital lectures to improve the awareness of hospital infection prevention among medical staff. Train general practitioners on hospital infection knowledge every month.
1, every month, the department organizes hospital infection related knowledge training according to the undergraduate business development, and makes records.
2. Actively participate in the hospital awareness knowledge education and training organized by the hospital, and incorporate the learning situation into the department assessment.
3. Conduct pre-job training for new employees. The main training contents are disinfection and isolation knowledge, prevention and control of hospital infection, and classified collection and treatment of medical wastes, so that they can carry hospital awareness throughout their work.
4. Strengthen the training of nurses' disinfection and isolation knowledge, such as job requirements of nurses, basic knowledge of disinfection and sterilization, cleaning procedures and personal protective measures.
5, the implementation of personnel responsibilities at all levels, do a good job of isolation and protection, to avoid cross infection.
(2) Strengthen the monitoring and management of hospital infection.
1, give full play to the role of hospital quality control management team, and find problems and correct them in time through monthly quality control inspection.
2. According to the requirements of Technical Specification for Disinfection and Management Measures for Hospital Infection, the disinfection effect of air, object surface, staff hands, disinfectants, disinfectants and sterilized items in key departments should be monitored every quarter.
3. General practitioners are required to do a good job in occupational protection of medical staff, and those who have occupational exposure and injuries should be reported and registered to protect susceptible people and effectively control hospital infection.
4. Clean the air disinfection machine filter in use once a month.
(3) Strictly manage the classification, collection, transportation, storage and transportation of medical wastes to prevent leakage.
1. Medical wastes shall be classified and placed as required, sealed and transported, and the packaging bags shall be marked and registered when leaving the department. Designate a special person to collect and sign it, and send it to the temporary storage point of medical waste for centralized storage.
2, medical waste transfer form by full-time personnel to fill in, and save the stub for future reference.
Hospital infection annual work plan 3 Hospital infection management is an important part of hospital infection management and an indispensable part of medical quality. In order to ensure medical safety and improve medical quality, referring to the evaluation standard of hospital infection work of provincial health department and combining with the actual situation of our hospital, the hospital infection management work plan is formulated:
First, earnestly implement it.
The Law of People's Republic of China (PRC) on the Prevention and Control of Infectious Diseases strengthens the management of direct reporting of infectious diseases on the Internet, collects infectious disease report cards daily for direct reporting on the Internet, and does a good job in the management of tuberculosis referral;
1, sign the infectious disease report card at any time, and review the contents of the card to ensure the completeness;
2, daily check the clinical laboratory, radiology positive results register, found missing timely notify the relevant departments to repay.
3, conscientiously do a good job in the health administrative department at a higher level of hospital epidemic management and inspection report, cooperate with the disease prevention and control departments to do a good job in epidemic investigation.
Second, do a good job in hospital infection monitoring
1, control infection rate: emphasize the importance of hospital infection control and strengthen the basic training of hospital infection quality control personnel in various departments.
2, environmental health and other key departments to monitor five times a month, the rest of the departments do not regularly check the self-inspection.
3. According to the requirements of Technical Specification for Infection Prevention and Control in Disinfection Supply Center and Technical Specification for Disinfection, supervise and test the cleaning, disinfection and maintenance of instruments.
Three, hospital infection knowledge training into the focus of this year's work.
To train and assess all the staff in the form of inviting experts and lectures in the hospital, so as to improve the awareness of hospital infection prevention of medical staff. Implement pre-job training, including:
1, the diagnostic standard of nosocomial infection;
2, the rational use of antimicrobial agents knowledge;
3. The main training contents for nursing staff are disinfection and isolation knowledge, prevention and control of hospital infection, and classified collection of medical wastes;
4, medical staff hand hygiene disinfection, cleaning staff job requirements, basic knowledge of disinfection and sterilization, cleaning procedures and personal protective measures, etc.
Four, do a good job in the management and supervision of medical waste.
Regularly supervise the medical waste sorting, collection and transportation system to prevent leakage. Check the medical waste handover register, temporary storage place and disinfection register every month, and fill in the missing items in time.
Hospital Infection Annual Work Plan 4 According to the requirements of the document "Hospital Infection Management Measures", this plan is formulated in order to strengthen the management of hospital infection in our department, improve the quality of hospital infection management in our department and ensure medical safety, combined with the actual work of our department.
One is to strengthen organizational leadership.
Conscientiously perform the duties of the hospital sensory team, fully understand the importance of hospital sensory management in medical work, clarify the duties of each member of the hospital sensory management team, and do a good job in training relevant members, requiring team members to conscientiously perform their duties, participate in and know the work in hospital sensory management in departments.
Second, strengthen the monitoring and supervision of hospital consciousness in departments.
1, analyze the sense of hospital and its related risk factors, put forward measures to solve the problem and guide the implementation;
2. Timely report the hospital-acquired incidents of this department, and assist the hospital infection management committee to deal with them;
3, according to the requirements of "hospital infection management measures", do a good job of cleaning, disinfection, sterilization and isolation, aseptic technology;
4, according to the requirements of the regulations on the management of medical waste, do a good job of medical waste management.
5. Do a good job in hospital sense monitoring and sampling every month, register and analyze in time, summarize the shortcomings and put forward improvement measures.
Third, strengthen the rational use of antibacterial drugs.
Doctors are strictly required to use antibiotics rationally according to the classification management system of antibacterial drugs, strictly grasp the indications of joint use, pay attention to the incompatibility and interaction, and report and deal with adverse drug reactions in time.
Fourth, improve the awareness of hospital infection prevention and control of medical staff in departments, strengthen their own protection, and nip in the bud.
1, strengthen the prevention awareness of medical staff and the training of relevant laws and regulations;
2. Strictly require medical personnel to carry out aseptic technical operation, disinfection and isolation, hand hygiene and hand disinfection;
3, strict medical personnel to implement standard preventive measures, try to avoid infection due to occupational exposure.
Hospital infection annual work plan 5 20xx According to the hospital infection management work plan of our hospital, the hospital infection work plan of our department this year has been made, and the plan is as follows:
First, abide by the rules and regulations of hospital infection, strictly implement the corresponding management system formulated by the oral room, conscientiously implement the relevant rules and regulations of hospital infection, and adhere to the principle of "early detection, early reporting and early control" to prevent the occurrence of hospital infection.
Second, strengthen the undergraduate course room infection training, improve the knowledge of hospital infection prevention and control, according to the actual situation of the department, organize a department hospital infection related knowledge training and learning every semester, and make records.
Third, the hospital feeling group of our hospital conducts a hospital feeling assessment on our department every quarter, and the departments discuss the deduction points, analyze the problems existing in the management of our hospital feeling, and actively rectify them.
Four, strict management of medical waste, regular inspection and supervision of medical waste collection and classification, infectious, destructive and domestic waste must be strictly separated.
Five, strengthen hand hygiene management, improve the hand hygiene awareness and compliance of our staff. Before touching the patient; Before cleaning (aseptic) operation; After contact with body fluids; After contact with the patient; Hand hygiene must be carried out after contact with the patient's surrounding environment.
Six, the infirmary ventilation regularly, daily ultraviolet lamp air disinfection, daily department mesa, desktop, ground cleaning.
Seven, sterile items should be neatly arranged according to the sterilization date, expired or be affected with damp should be sterilized again. Hand washing facilities are complete, equipped with hand sanitizer and quick hand sanitizer. Strict implementation of aseptic technical operation procedures, alcohol, hydrogen peroxide and other disinfectants should be sealed and preserved; Sterile instruments packed in disposable medical packaging bags are stored in sterile containers for later use. Once opened, the use time shall not exceed 4 hours. The sterilization date and expiration date should be marked on the outside of the sterilization instrument package. One person, one needle and one tube should be injected. Disposable latex gloves should be used and replaced by one person. Oral instruments such as oral speculum, tray, saliva suction tube, etc. should be replaced by one person. Implement standard prevention, wear a hat and mask when operating, and wear a protective mask when blood or saliva splashes. Once occupational exposure occurs during the operation, it should be reported to the hospital sensory department immediately, handled according to the infection management regulations, and registered, regularly tested and followed up.
In the new year, the hospital infection management department will adhere to the policy of putting prevention first, strengthen the management of hospital infection, improve the quality of medical care, and do a good job in the management of hospital infection with the goal of patient safety. The following work plan is specially formulated.
First, further improve the system and measures of hospital infection control, continue to check the implementation of the system and measures according to the requirements of secondary hospital evaluation, and supervise the infection quality of key departments such as operating room, supply room, delivery room, endoscope, pediatrics, stomatology, hemodialysis room and laboratory, so as to prevent and control the outbreak and epidemic of hospital infection. And regularly check and assess the quality of hospital infection links in various departments of the hospital.
Second, strengthen the hospital infection knowledge training, through various forms of hospital infection knowledge training for employees, so that employees can understand and pay attention to the importance and necessity of hospital infection management, and organize employees to take two hospital infection knowledge exams.
Third, do a good job in the monitoring and management of hospital infection, including the hygienic monitoring and effect evaluation of environment, air and aseptic materials, monitor the clinical departments of the hospital every quarter, urge the departments to do a good job in disinfection, sterilization and isolation, monitor and evaluate the irradiation intensity of ultraviolet lamps in various departments of the hospital every six months, urge the unqualified lamps and disinfectants to be replaced in time, and monitor the intensity of newly purchased lamps before the qualified products can be put into use by the departments.
Four, monthly statistics and summary of hospital infection cases, and urge the clinical departments to report and summarize hospital infection cases, regularly understand the situation of the next department, check the cases for omission investigation, analyze and summarize the hospital infection situation. Conduct spot checks on outpatient prescriptions every month to check the use of antibiotics and calculate the utilization rate.
Five, continue to strengthen the management of medical waste, often check and supervise the standardization of medical waste collection, classification and transportation, and dispose of medical waste in accordance with the requirements of the Regulations on the Management of Medical Waste and other laws and regulations.
Six, the implementation of medical staff hand hygiene management system, strengthen hand hygiene publicity, education and training activities, enhance the awareness of preventing hospital infection, regularly or irregularly check the medical staff hand hygiene knowledge and hand hygiene implementation every month, to ensure the effect of hand washing and hand disinfection.
Seven, the establishment of infectious disease prevention and control work organization system, the implementation of hospital infection management measures and hospital infection emergency plan. Formulate departmental management system and personnel responsibilities. Resolutely implement the rules and regulations of the Measures for the Administration of Hospital Infection and the Law on the Prevention and Control of Infectious Diseases, and formulate the work flow and norms for the prevention and control of infectious diseases. Infectious disease reporting strives to achieve "early detection, early diagnosis, early treatment, early reporting and early control". Hospital infection control department
Hospital's sense of annual work plan 7. First, comprehensively promote the establishment of the "three-level", strengthen organizational construction, and strengthen the division of responsibilities management.
1. Give full play to the functions of the Hospital Infection Management Committee of Stomatological Hospital, hold regular working meetings and carry out regular inspections.
2, functional departments cooperate with each other, give full play to the functions of various functional departments, detailed tasks, carry out their duties.
3, hospital infection management into the overall hospital work planning and quality and safety management objectives. According to the requirements of higher authorities and hospital infection, formulate and implement the "Thirteenth Five-Year Plan" and work plan.
Second, improve the system and workflow, do a good job in training all kinds of personnel at all levels and improve the implementation rate.
1, according to the relevant laws and regulations, constantly revise and improve the hospital infection prevention and control system, revise the hospital infection management workflow of all medical activities in the hospital, guide and supervise specific measures, and make all the work implemented.
2, hospital infection management related personnel at all levels are familiar with the relevant system, workflow and the characteristics of the departments under the jurisdiction of the hospital, the floor staff are familiar with this department, this position and hospital infection management related systems and requirements, and correctly implemented.
3, for all kinds of personnel at all levels of hospital infection management training program, training programs and training content, preparation of training manuals and design related knowledge and skills test questions.
Third, strengthen the targeted monitoring of hospital sense and carry out targeted prevention and control of hospital sense.
1. Hospital infection monitoring is carried out in a planned way, including targeted monitoring and comprehensive monitoring in the whole hospital. The scope of monitoring catalogue/list conforms to the requirements of "Hospital Infection Monitoring Standard". Hospital infection monitoring covers all hospital infection monitoring items and different specimen types, and has a complete record.
2. Focus on the management and monitoring of key groups such as supply room, ward, operating room, outpatient operating room, surgery, planting surgery and other high-risk factors such as cleaning, disinfection and sterilization of medical devices, and formulate prevention and control measures and workflow.
3. Conduct risk assessment on the departments with high risk of infection and infection control, and formulate targeted control measures.
4, continue to do a good job in the prevention and control of surgical site infection, and constantly improve the system and measures.
5, key departments such as operating room (including outpatient operating room), supply room and other hospital infection prevention and control system and measures to implement the monitoring data.
Four, do a good job in hospital infection outbreak emergency handling ability training.
1, according to the hospital situation, conduct training and drills, and re-establish the hospital infection outbreak reporting process and disposal plan.
2, there are various forms and channels, so that medical personnel and hospital infection related management personnel can get hospital infection information in time, open network information, and report the hospital infection epidemic in time as required.
3. The awareness rate of relevant personnel on hospital infection outbreak reporting process and disposal scheme reached 100%.
Five, continue to do a good job in the management of medical staff hand hygiene behavior norms.
1. Conduct "Three Points: Grading, Stratification and Grading" once every quarter, train and assess the health knowledge and skills of opponents, and incorporate them into the comprehensive target assessment of departments.
2. The awareness rate of hand hygiene knowledge of medical staff should reach 100%, the correct rate of hand hygiene should reach 90%, and the standard rate of hand hygiene should reach 70%.
Six, strictly implement the joint meeting system of multi-drug resistant bacteria management, strengthen management.
1, aiming at the diagnosis, monitoring, prevention and control of hospital infection with multi-drug-resistant bacteria, and combining with the actual work, constantly improve and formulate rules and regulations and prevention and control measures, and implement the management of multi-drug-resistant bacteria infection.
2. Regularly supervise the implementation of control measures for multidrug-resistant bacteria in wards, including hand hygiene measures, isolation measures, aseptic operation, cleaning and environmental disinfection systems, etc.
3, according to the bacterial drug resistance monitoring, joint medical department, medical machinery department to strengthen the management of clinical application of antibacterial drugs, the implementation of the rational use of antibacterial drugs.
4. Workflow of implementing MRSA, CRE, VRE, CRPAE and CRABA control measures. Improve and revise the cooperation mechanism and specific implementation plan of clinical departments, laboratory departments and hospital infection management departments in the management of multi-drug-resistant bacteria.
5, clinical laboratory regularly provide clinical trends of drug-resistant bacteria and antimicrobial sensitivity report.
6. Establish training system, training plan and implementation measures for clinical medical personnel and laboratory personnel to prevent multi-drug resistant bacteria infection.
7, continue to do a good job of bacterial resistance monitoring and early warning mechanism, and regular feedback (at least once a quarter); Timely publish the names and drug resistance rates of the top five pathogenic microorganisms in hospital infection; Statistical analysis of monthly microbial inspection rate of clinical therapeutic use of antibacterial drugs; Annual statistical analysis of clinical application of antibacterial drugs and microbial detection.
8. Investigation and statistics were made on "the implementation of prophylactic use of antibiotics in perioperative period" and "the standard of prophylactic use of antibiotics in class I surgery (variety selection, drug use opportunity, postoperative application time, etc.). )"; Relevant personnel know and implement rate management.
Seven, strengthen the management of hospital medical environment cleaning and disinfection, continue to do a good job in hospital management and supervision, formulate inspection standards, strengthen the assessment.
1, the layout of wards and outpatient departments should reasonably meet the requirements of specifications, the environment should be clean and tidy, the ventilation facilities should be good, and the air disinfection should meet the standards.
2, ward, outpatient department and related departments have hospital infection prevention and control related rules and regulations and work norms, and seriously implement them. The workflow of ward and outpatient departments conforms to the principle of hospital infection control.
3. Strictly implement hand hygiene standards, technical specifications for disinfection of oral instruments and medical waste management standards, so that medical personnel can use occupational protective equipment correctly.
4, develop the operating room, supply room, ward, clinical laboratory, outpatient department hospital feeling inspection standards to implement regular inspection assessment score, the assessment results into the medical quality assessment.
Eight, strengthen the supervision and information management of disinfection supply room.
1, guiding the disinfection and isolation system of the supply room and the ten processes of cleaning, disinfection and sterilization; And standardize the procedures and criteria for monitoring the cleaning, disinfection and sterilization effect.
2. The awareness rate of disinfection and sterilization knowledge of disinfection personnel is 100%, and they receive regular disinfection and sterilization training.
3. Establish the information system of hospital infection monitoring index system, and carry out monitoring work and record it according to the Norms for Hospital Infection Monitoring (WS/T3 12-20xx). There are monitoring information collection and feedback channels to ensure information quality.
Nine, strengthen the hospital staff awareness knowledge training and assessment work.
Educate and train medical staff on relevant knowledge and disinfection and isolation technology as planned, establish complete training and assessment records, and improve the training record manual.