医院管理评价指南

医院管理评价指南 新航集团医院医疗质量、安全管理体系 为加强医院管理，科学、客观、准确地评价医院，指导医院坚持“以病人为中心”，坚持公益性质，端正办院方向，牢固树立为人民服务的宗旨，把社会效益放在首位，遵循社会主义市场经济和医疗卫生事业发展的内在规律，提高医院管理水平，把持续改进医疗质量和保障医疗安全作为医院管理的核心内容，为人民群众提供安全、有效、方便、价廉的医疗卫生服务，不断满足人民群众日益增长的医疗卫生需求，根据卫生管理法律、法规、规章等有关规定，制定本标准。医院据此加强内涵建设，卫生行政部门据此对医院管理进行指导、评价、检查和监督。 一、医院管理 认真贯彻执行国家有关法律、法规和规章制度，健全医院各项工作制度，加强科学管理，保障医院正常执业活动，不断提高医疗质量，保障医疗安全，改善医疗服务，提高运行绩效，促进医院健康、可持续发展。 (一)医院功能与任务 1、医院根据国家法律、法规提供全面、连续的高水平医疗服务，承担危急重症和疑难病诊治任务，承担灾害事故的紧急救援任务，并能接受成批伤病员进行院内急救。 、履行对下级医疗机构技术指导的职责和义务，开展双向转诊，指导社区医疗、护理、康复医疗服2 务，完成当地卫生行政部门的卫生对口支援或支农工作。 3、开展健康教育，承担预防保健，主要为慢性非传染性疾病的防治工作。 4、承担社区卫生人员的社区卫生培训工作。 (二)依法执业 1、严格执行医疗卫生管理法律、法规、规章、诊疗护理规范和常规。 2、严格按照卫生行政部门核准的诊疗科目执业，医院及科室命名规范。 3、不使用非卫生技术人员从事诊疗活动。 4、专业技术人员具备相应岗位的任职资格，不超范围执业。 5、按照规定申请医疗机构校验。 (三)组织机构和管理 1、医院管理组织机构设置合理，满足管理工作需要。 2、结合本院实际，建立健全各项规章制度和岗位职责，并能及时修订完善，职工熟悉本岗位职责及相关规章制度。 3、实行院长负责制，建立科学决策机制，重大事项经集体讨论并按规定程序报批。院级领导把主要精力用于医院管理工作，推进医院管理职业化进程。 4、建立院、科二级管理责任制，院、科领导了解和掌握国家有关医疗卫生管理法律、法规和规章及Municipal City Government for the work of a city attaches great importance to put forward clearly to 2017 years into the ranks of the "national civilized city" create the target. This year is also the county of a new round of urban civilization created the first year, we not only bear the city to create a "National Civilized City" in the work of the task, also do a good job of "provincial and civilized county Ying check evaluation, work responsibility for a large, heavy task. To the county at all levels and departments cooperate closely, grab get right on the job really, to tight style and promote the implementation of the work, ensure that a city made outstanding achievements. 1, the leadership to strengthen. The county at all levels and departments to the urban civilization was founded on the top of the agenda, and the development of economy and society, the focus of the work together to study the deployment of, together organization and implementation, together with the supervision and inspection, improve and perfect the county, the unified leadership of the county government, a county, a city office coordinated, create liability units of duties, the joint participation of society as a whole leadership system andWorking mechanism. This year, according to the city, a city leading group and special working group to adjust the arrangement, we adjusted the a city the work of the leading group members, the addition of the administrative environment and the effectiveness of the steering group, excellent culture communication group two special 有关卫生政策，至少每两年接受一次管理专业知识培训，不断提高科学管理水平。 5、制定年度工作计划和中、长期发展规划，内容包括学科建设和人才梯队建设，并组织实施。 (四)人力资源管理 1、医院有适宜的人力资源配置方案与使用制度，人员结构合理，满足医院功能任务的需要。 2、实施卫生专业技术人员准入、考核、评价和岗位职务聘任制。 3、建立卫生专业技术人员岗前培训、继续教育和梯队建设制度并组织实施。 4、医技人员的学历和专业知识结构合理。 5、加强重点学科建设和人才培养，建立学科带头人选拔制度。 6、落实奖惩制度。 (五)应急管理 1、制定突发事件(包括突发公共卫生事件、灾害事故等)应急预案并组织演练。 2、承担突发公共卫生事件和灾害事故的紧急医疗救援任务。 3、及时、妥善处理医院内部发生的突发事件。 (六)信息系统 1、医院信息系统(HIS)符合《医院信息系统基本功能规范》的规定，满足医院管理和临床工作需要。 2、信息系统运行稳定、安全，可系统、准确收集、整理、分析和反馈有关医院管理和医疗质量控制等信息，与其他医疗机构、卫生行政部门能够实现信息共享。 3、实行信息系统操作权限分级管理，保障网络安全，保护患者隐私。 (七)财务与价格管理 1、贯彻落实《会计法》、《预算法》、《审计法》、《医院会计制度》和《医院财务制度》等相关法律法规，设置一个财务部门，统一规范财务管理，严格执行预算，加强内部审计，严禁医院、部门、科室设立账外账和“小金库”。 2、建立规范的经济活动决策机制和程序，重大项目集体讨论，按规定程序报批。实行重大经济事项领导负责制和责任追究制，责任到人。 3、实行医院成本核算，降低运行成本。控制医院负债率，保障国有资产安全。 4、建立医院奖金分配综合目标考核制度，实行按岗取酬、按工作量取酬、按服务质量和工作绩效取酬的分配机制。严禁科室承包，严禁医务人员收入分配与医疗服务收入直接挂钩。 5、按照《价格法》等有关价格政策，严格执行医疗服务收费和药品价格。严禁在国家规定之外擅自设立收费项目，严禁分解项目、比照项目收费和重复收费。 6、执行国家有关药品、高值耗材集中招标采购政策规定，对中标药品、高值耗材按照采购，合理使用。 Municipal City Government for the work of a city attaches great importance to put forward clearly to 2017 years into the ranks of the "national civilized city" create the target. This year is also the county of a new round of urban civilization created the first year, we not only bear the city to create a "National Civilized City" in the work of the task, also do a good job of "provincial and civilized county Ying check evaluation, work responsibility for a large, heavy task. To the county at all levels and departments cooperate closely, grab get right on the job really, to tight style and promote the implementation of the work, ensure that a city made outstanding achievements. 1, the leadership to strengthen. The county at all levels and departments to the urban civilization was founded on the top of the agenda, and the development of economy and society, the focus of the work together to study the deployment of, together organization and implementation, together with the supervision and inspection, improve and perfect the county, the unified leadership of the county government, a county, a city office coordinated, create liability units of duties, the joint participation of society as a whole leadership system andWorking mechanism. This year, according to the city, a city leading group and special working group to adjust the arrangement, we adjusted the a city the work of the leading group members, the addition of the administrative environment and the effectiveness of the steering group, excellent culture communication group two special 7、实行医疗服务价格公示制度，向社会公开收费项目和标准，建立完善价格查询机制、费用清单机制，提高收费透明度。及时答复患者的费用查询，处理价格投诉。 8、费用结算方式便捷。 (八)建设、设备和后勤保障管理 1、医院基本建设符合规划要求，按国家法律、法规和相关规定组织实施。 2、建筑布局体现“以病人为中心”的服务理念，满足医疗服务流程需要。 3、水、电、气、物资供应等后勤保障满足医院运行需要。 4、建立健全设备、设施论证、招标、采购、保养、维修、更新和应用分析制度，设备处于完好状态。 5、按照《大型医用设备配置与使用管理办法》的规定，配置使用甲乙类大型医疗设备。 6、为员工提供餐饮服务，为患者提供治疗饮食，满足患者治疗需要。 7、医疗废物和污水处理符合国家规定。 8、安全保卫组织健全，制度完善，人员、设备、设施满足要求。 二、医疗质量管理与持续改进 医疗质量管理是医院管理的核心内容和永恒的主题，是不断完善、持续改进的过程。医院应当建立医疗质量管理体系。要建立健全医疗质量管理组织，严格执行规章制度、技术操作规范、常规、标准，加强基础质量、环节质量和终末质量管理，建立和完善可追溯制度、监督评价和持续改进机制，提高医疗服务能力，为患者提供优质、安全的医疗服务，提高医院核心竞争力。 (一)建立健全院、科二级质量管理组织 1、建立院、科二级质量管理体系，院长作为医疗质量管理第一责任人，定期专题研究医疗质量和医疗安全工作，科主任全面负责本科质量管理工作。 2、量管理职能部门组织实施全面质量管理，指导、检查、考核、评价和监督质量管理工作，建立多部门质量管理协调机制。 3、建立医疗质量管理组织，包括医疗质量管理委员会、伦理委员会、药事管理委员会、医院感染管理委员会和输血管理委员会，定期研究质量管理等相关问题。 (二)全程医疗质量与安全管理与持续改进 1、制定医疗质量与安全管理和持续改进方案并组织实施。 2、定期进行全员质量和安全教育，牢固树立质量和安全意识，提高全员质量管理与改进的意识和参与能力。 3、强化“基础理论、基本知识、基本技能”培训，严格执行医疗技术操作规范，遵循诊疗常规。 Municipal City Government for the work of a city attaches great importance to put forward clearly to 2017 years into the ranks of the "national civilized city" create the target. This year is also the county of a new round of urban civilization created the first year, we not only bear the city to create a "National Civilized City" in the work of the task, also do a good job of "provincial and civilized county Ying check evaluation, work responsibility for a large, heavy task. To the county at all levels and departments cooperate closely, grab get right on the job really, to tight style and promote the implementation of the work, ensure that a city made outstanding achievements. 1, the leadership to strengthen. The county at all levels and departments to the urban civilization was founded on the top of the agenda, and the development of economy and society, the focus of the work together to study the deployment of, together organization and implementation, together with the supervision and inspection, improve and perfect the county, the unified leadership of the county government, a county, a city office coordinated, create liability units of duties, the joint participation of society as a whole leadership system andWorking mechanism. This year, according to the city, a city leading group and special working group to adjust the arrangement, we adjusted the a city the work of the leading group members, the addition of the administrative environment and the effectiveness of the steering group, excellent culture communication group two special 4、认真执行医疗质量和医疗安全的核心制度，包括首诊负责制度、三级医师查房制度、疑难病例讨论制度、会诊制度、危重患者抢救制度、手术分级制度、术前讨论制度、死亡病例讨论制度、分级护理制度、查对制度、病历书写基本规范与、交接班制度、临床用血审核制度等。 5、完善各类会诊制度，医师外出会诊严格执行《医师外出会诊管理暂行规定》。 6、建立医疗风险防范、控制和追溯机制，按规定报告不良医疗事件，开展医疗质量检查和评价，建立和完善监管记录，定期分析，及时反馈，落实整改。 7、实行医疗质量责任追究制，及时妥善处理医疗纠纷。 (三)医疗技术管理 1、医院的医疗技术服务应与其功能和任务相适应，符合伦理道德规范，具备相应专业技术人员和支持系统，确保技术应用的安全、有效。开展的医疗技术应当是其执业诊疗科目内的成熟技术，符合国家有关规定。 2、医疗技术管理符合国家有关规定。根据《医疗技术临床应用管理办法》建立健全医疗技术和人员资质准入、分级管理、监督评价和档案管理制度。 3、建立医疗技术风险预警机制，制定和完善医疗技术损害处置预案，并组织实施。对新开展的医疗技术的安全、质量、疗效、费用等情况进行全程追踪管理和评价，及时发现医疗技术风险，采取相应措施，降低、避免医疗技术风险。 4、不应用未经批准或明令禁止和淘汰的技术。 (四)主要专业部门质量管理与持续改进 1、非手术科室质量管理与持续改进 (1)对患者进行评估，制定符合诊疗规范要求的诊疗计划。 (2)规范临床药物治疗，严格执行《抗菌药物临床应用指导原则》。 (3)加强运行病历监控与管理，落实核心制度和规范要求，提高诊疗质量，保障治疗安全、及时、有效、经济。 (4)开展高风险的有创诊疗操作按手术诊疗管理。 (5)开展单病种质量管理。 2、手术科室质量管理与持续改进 (1)对患者进行评估，制定符合诊疗规范要求的诊疗计划。 (2)实行手术分级管理制度，重大手术报告、审批制度。 (3)加强运行病历的监控与管理，落实核心制度和规范要求，提高诊疗质量，保障治疗安全、及时、有效、经济。 (4)严格执行大中型手术术前讨论制度，重点是:术前诊断、手术适应证、术式、麻醉与输血选择、Municipal City Government for the work of a city attaches great importance to put forward clearly to 2017 years into the ranks of the "national civilized city" create the target. This year is also the county of a new round of urban civilization created the first year, we not only bear the city to create a "National Civilized City" in the work of the task, also do a good job of "provincial and civilized county Ying check evaluation, work responsibility for a large, heavy task. To the county at all levels and departments cooperate closely, grab get right on the job really, to tight style and promote the implementation of the work, ensure that a city made outstanding achievements. 1, the leadership to strengthen. The county at all levels and departments to the urban civilization was founded on the top of the agenda, and the development of economy and society, the focus of the work together to study the deployment of, together organization and implementation, together with the supervision and inspection, improve and perfect the county, the unified leadership of the county government, a county, a city office coordinated, create liability units of duties, the joint participation of society as a whole leadership system andWorking mechanism. This year, according to the city, a city leading group and special working group to adjust the arrangement, we adjusted the a city the work of the leading group members, the addition of the administrative environment and the effectiveness of the steering group, excellent culture communication group two special 预防性应用抗菌药物、手术风险及处理预案等。 (5)围手术期管理措施到位。加强围手术期质量控制，重点是术前讨论、手术适应症、风险评估、术前查对、操作规范、术后观察及并发症的预防与处理，医患沟通制度的落实。术前:诊断、手术适应证明确，术式选择合理，患者准备充分，与患者签署手术和麻醉同意书、输血同意书等。手术前查对无误;术中:手术操作规范，意外处理措施果断、合理，术式改变等及时告知家属或代理人;术后:观察及时、严密，早期发现并发症并妥善处理。提高术前诊断与病理诊断相符率。 (6)麻醉安全管理:麻醉工作程序规范，术前麻醉准备充分，麻醉意外处理及时，输血合理，麻醉复苏实施全程观察。 (7)采取有效措施，缩短择期手术患者术前平均住院日。 (8)开展单病种质量管理。 3、门诊工作质量管理与持续改进 (1)门诊环境布局合理，符合医院感染控制要求。 (2)强化诊疗质量控制，实行首诊负责制，建立门诊科间会诊制度。 (3)依据工作量及需求，合理配置专业技术人员，提高门诊确诊能力，保证门诊诊疗质量。 (4)规范门诊医疗文书。 (5)制定突发意外紧急情况处理预案，提高反应能力。 4、急诊质量管理与持续改进 (1)急诊科作为重点科室独立设置，急诊专业队伍稳定，人员相对固定，设备设施完备，布局合理，满足急诊工作需要。 (2)急诊医务人员经过专业培训，能够胜任急诊工作，急诊抢救工作由主治医师以上指导或主持，不断提高急危重症患者抢救成功率。 (3)急救设备、药品齐备完好，处于备用状态，急诊医护人员能够熟练、正确使用各种抢救设备，心肺复苏达到高级水平。 (4)加强急诊质量全程监控与管理，重点落实核心制度，尤其落实首诊负责制，建立急诊、入院、手术“绿色通道”，急诊服务及时、安全、便捷、有效，科间紧密协作，保障患者获得连贯医疗的可及性。 (5)加强急诊留观患者管理，急诊留观时间平均不超过72小时。 (6)急诊抢救医疗文书书写规范、及时、完整，医患沟通充分。 5、传染病管理: (1)严格执行传染病防治的法律、法规、规章和技术操作规范、常规。建立健全规章制度并组织实施，有效预防和控制传染病的传播和医源性感染。 Municipal City Government for the work of a city attaches great importance to put forward clearly to 2017 years into the ranks of the "national civilized city" create the target. This year is also the county of a new round of urban civilization created the first year, we not only bear the city to create a "National Civilized City" in the work of the task, also do a good job of "provincial and civilized county Ying check evaluation, work responsibility for a large, heavy task. To the county at all levels and departments cooperate closely, grab get right on the job really, to tight style and promote the implementation of the work, ensure that a city made outstanding achievements. 1, the leadership to strengthen. The county at all levels and departments to the urban civilization was founded on the top of the agenda, and the development of economy and society, the focus of the work together to study the deployment of, together organization and implementation, together with the supervision and inspection, improve and perfect the county, the unified leadership of the county government, a county, a city office coordinated, create liability units of duties, the joint participation of society as a whole leadership system andWorking mechanism. This year, according to the city, a city leading group and special working group to adjust the arrangement, we adjusted the a city the work of the leading group members, the addition of the administrative environment and the effectiveness of the steering group, excellent culture communication group two special (2)有专门部门或人员负责传染病疫情报告工作，并按照规定进行网络直报。 (3)感染性疾病科或传染病科建设符合规定。 (4)定期对工作人员进行传染病防治知识和技能的培训。 6、临床检验质量管理与持续改进: (1)贯彻落实《病原微生物实验室生物安全管理条例》、《医疗机构临床实验室管理办法》等有关规定。临床检验实验室集中设置，统一管理，资源共享。实验室管理统一标准，统一质控，保证质量。 (2)临床检验实验室布局与流程安全、合理，符合医院感染控制和生物安全要求。 (3)开展检验项目符合卫生行政部门公布的目录和方法，不开展淘汰和未经批准的项目。特殊实验室取得审批许可。 (4)临床检验项目满足临床需要，并能提供24小时急诊检验服务，实施“危急值报告”的运行机制。 (5)落实全面质量管理与改进制度，包括分析前、分析中和分析后的质量控制，按照规定开展室内质控、参加室间质评。对床旁检验项目进行严格比对。 (6)检验报告及时、准确、规范，严格审核制度。 (7)遵守检验项目和检测仪器操作规程，定期校准检测系统，并及时淘汰经检定不合格的设备与试剂。不使用未经批准的设备与试剂。 )患者、医师与护理人员对检验部门服务满意。 (8 7、医学影像质量管理与持续改进 (1)贯彻落实《放射性同位素与射线装置安全和防护条例》、《放射诊疗管理规定》等相关法律、法规和规章，依法取得《放射诊疗许可证》、《大型医用设备配置许可证》等。 (2)专业设置、人员配备及其设备、设施符合医院功能任务要求，满足临床需要，能提供24小时急诊检查服务。 (3)执行技术操作规范，实行科学的质量控制标准，开展临床随访，定期进行质量评价。 (4)提高医学影像资料质量，报告及时、准确、规范，严格审核制度。 (5)环境保护、操作人员与患者个人防护达到标准。 (6)患者、医师与护理人员对医学影像部门服务满意。 8、药事质量管理与持续改进: (1)贯彻落实《药品管理法》、《医疗机构药事管理暂行规定》、《处方管理办法》和《抗菌药物临床应用指导原则》等有关规定。 (2)药学部门布局、设施和工作流程合理，管理规范，能为患者提供安全、及时、人性化的服务。 (3)建立突发事件药品供应与药事管理机制。 Municipal City Government for the work of a city attaches great importance to put forward clearly to 2017 years into the ranks of the "national civilized city" create the target. This year is also the county of a new round of urban civilization created the first year, we not only bear the city to create a "National Civilized City" in the work of the task, also do a good job of "provincial and civilized county Ying check evaluation, work responsibility for a large, heavy task. To the county at all levels and departments cooperate closely, grab get right on the job really, to tight style and promote the implementation of the work, ensure that a city made outstanding achievements. 1, the leadership to strengthen. The county at all levels and departments to the urban civilization was founded on the top of the agenda, and the development of economy and society, the focus of the work together to study the deployment of, together organization and implementation, together with the supervision and inspection, improve and perfect the county, the unified leadership of the county government, a county, a city office coordinated, create liability units of duties, the joint participation of society as a whole leadership system andWorking mechanism. This year, according to the city, a city leading group and special working group to adjust the arrangement, we adjusted the a city the work of the leading group members, the addition of the administrative environment and the effectiveness of the steering group, excellent culture communication group two special (4)药学部门要建立“以病人为中心”的药学管理工作模式，开展以合理用药为核心的临床药学工作。制定、落实药事质量管理规范、考核办法并持续改进。 (5)建立临床药师制，开展临床药学工作。健全临床用药的监督、指导、评价制度，开展药物安全性监测、药物不良反应与药害事件的监测和报告、抗菌药物临床应用监测，协助做好细菌耐药监测。提供合理用药咨询服务，积极推广个体化给药方案。不使用非药学专业技术人员从事药学技术工作。 (6)加强处方管理，落实处方点评制度，提高处方质量，保障合理用药。 (7)加强特殊管理药品的管理，包括毒性药品、麻醉药品、精神药品、放射药品购置、使用与安全保管。 (8)患者与医师、护理人员对药学部门服务满意。 9、输血质量管理与持续改进 (1)落实《献血法》和《临床用血管理办法》、《临床输血技术规范》等有关规定。 (2)设立输血科，具备为临床提供24小时供血服务的能力，满足临床需要，医院无非法自采供血。 (3)建立输血质量全程监控，严格掌握输血适应证，科学、合理用血。 (4)制定、实施控制输血感染的方案，严格执行输血技术操作规范。 (5)落实临床用血申请、登记制度，履行用血报批手续，执行输血前检验和核对制度。完善输血反应及输血感染疾病的登记、报告和调查处理制度。 10、医院感染管理与持续改进 )根据国家有关的法律、法规，按照《医院感染管理办法》，制定并落实医院感染管理的各项规章(1 制度。 (2)医院的布局、设施和工作流程符合医院感染预防与控制的要求。 (3)落实医院感染的监测、诊断和报告制度。 (4)加强对医院感染控制重点部门的管理，包括感染性疾病科、口腔科、手术室、重症监护室、新生儿病房、产房、内窥镜室、血液透析室、导管室、临床检验部门和消毒供应室等。 (5)加强对医院感染控制重点项目的管理，包括呼吸机相关性肺炎、血管内导管所致血行感染、留置导尿管所致感染、手术部位感染、气管插管操作性肺炎、透析相关感染等。 (6)医务人员严格执行无菌技术操作、消毒隔离工作制度、手卫生规范。 (7)按规定可以重复使用的医疗器械，应当进行严格的消毒或者灭菌。 (8)加强职业暴露管理，保障职工安全。 11、病案质量管理与持续改进 (1)贯彻落实《医疗事故处理条例》、《病历书写基本规范(试行)》和《医疗机构病历管理规定》等有关规定。 Municipal City Government for the work of a city attaches great importance to put forward clearly to 2017 years into the ranks of the "national civilized city" create the target. This year is also the county of a new round of urban civilization created the first year, we not only bear the city to create a "National Civilized City" in the work of the task, also do a good job of "provincial and civilized county Ying check evaluation, work responsibility for a large, heavy task. To the county at all levels and departments cooperate closely, grab get right on the job really, to tight style and promote the implementation of the work, ensure that a city made outstanding achievements. 1, the leadership to strengthen. The county at all levels and departments to the urban civilization was founded on the top of the agenda, and the development of economy and society, the focus of the work together to study the deployment of, together organization and implementation, together with the supervision and inspection, improve and perfect the county, the unified leadership of the county government, a county, a city office coordinated, create liability units of duties, the joint participation of society as a whole leadership system andWorking mechanism. This year, according to the city, a city leading group and special working group to adjust the arrangement, we adjusted the a city the work of the leading group members, the addition of the administrative environment and the effectiveness of the steering group, excellent culture communication group two special (2)医疗文书书写及时、准确、完整、规范。 (3)建立、健全病历全程质量监控、评价、反馈制度，重点加强运行病历的实时监控与管理，提高病历质量。 (4)建立病案管理制度并组织落实，病案保存时限符合规定。 (5)严格执行借阅、复印或复制病历资料制度，按规定保护患者隐私。 (五)护理质量管理与持续改进 1、医院有健全的护理管理组织体系，责任明确 (1) 根据医院的功能任务，建立完善的护理管理组织体系。 (2) 护理管理部门实行目标管理责任制，职责明确。 (3) 护理管理部门结合医院实际情况，制定护理工作制度，并有相应的监督与协调机制。 2、护理人力资源管理 (1)对护士的管理有明确的规定。 (2)对各级各类护士的资质、各岗位的技术能力有明确要求。 (3)对各护理单元护士人力的配置有明确的原则与标准，确保满足实施等级护理的质量与患者安全的需要，病房护士与床位比至少达到0.4:1，重症监护室护士与床位比达到2.5,3:1，医院护士总数至少达到卫生技术人员的50,。 (4)有紧急状态下对护理人力资源调配的方案。 (5)有各级各类护士的在职培训计划。 3、建立健全护理工作制度、护士的岗位职责和工作标准、各科疾病的护理常规和技术操作规程 (1)有健全的护理工作制度、岗位职责、护理常规、操作规程等文件或手册，并保证实施。 (2)护士知晓并落实相关护理工作制度、岗位职责、护理常规、操作规程。 (3)各护理岗位护士明确岗位职责和工作标准。 4、制定并落实护理质量考核标准、考核办法和持续改进方案 考核内容: (1)建立并实施基础护理质量评价标准。 (2)建立并实施专科护理质量标准。 (3)建立质量可追溯的机制，定期与不定期对护理质量标准进行效果评价，并体现在持续改进的过程中。 (4)按照《病历书写基本规范(试行)》进行护理文件书写，有定期的质量评价。 (5)有重点护理环节的管理、应急预案与处理程序。 Municipal City Government for the work of a city attaches great importance to put forward clearly to 2017 years into the ranks of the "national civilized city" create the target. This year is also the county of a new round of urban civilization created the first year, we not only bear the city to create a "National Civilized City" in the work of the task, also do a good job of "provincial and civilized county Ying check evaluation, work responsibility for a large, heavy task. To the county at all levels and departments cooperate closely, grab get right on the job really, to tight style and promote the implementation of the work, ensure that a city made outstanding achievements. 1, the leadership to strengthen. The county at all levels and departments to the urban civilization was founded on the top of the agenda, and the development of economy and society, the focus of the work together to study the deployment of, together organization and implementation, together with the supervision and inspection, improve and perfect the county, the unified leadership of the county government, a county, a city office coordinated, create liability units of duties, the joint participation of society as a whole leadership system andWorking mechanism. This year, according to the city, a city leading group and special working group to adjust the arrangement, we adjusted the a city the work of the leading group members, the addition of the administrative environment and the effectiveness of the steering group, excellent culture communication group two special 5、临床护理工作以病人为中心，为患者提供基础护理服务和护理专业技术服务，密切观察患者病情变化，正确实施各项治疗、护理措施，提供康复和健康指导，保障患者安全和提高护理工作质量。 (1)临床护理工作体现人性化服务，要体现患者知情同意与隐私保护的责任。 (2)基础护理与等级护理的措施到位。 (3)护士对住院患者的用药、治疗提供规范服务。 (4)对实施围手术期护理的患者有规范的术前访视和术后支持服务制度与程序。 (5)提供适宜的康复和健康指导。 (6)各种医技检查的护理措施到位。 (7)密切观察患者病情变化，根据要求正确记录。 6、保证对危重症患者的护理质量考核内容: (1)对危重患者有护理常规，措施具体，记录规范完整。 (2)护理管理部门对急诊科、重症监护病房、手术室、血液净化等部门进行重点管理，定期检查、改进。 (3)能够保证监护仪的有效使用。 (4)保证对危重患者实施安全的护理操作。 (5)保证呼吸机使用、管路消毒与灭菌的可靠性。 (6)建立与完善护理查房、护理会诊、护理病例讨论制度。 7、制定并实施护理差错报告和管理制度 (1)建立与实施护理差错报告和管理制度。 (2)完善专项护理质量管理制度，如各类导管脱落、患者跌倒、压疮等。 (3)能够应用对护理差错评价的结果，改进相应的运行机制与工作流程、工作制度。 8、手术室与中心供应室的管理 (1)手术室与中心供应室工作流程合理，符合预防和控制医院感染的要求。 (2)制定并实施相关的工作制度、程序、操作常规。 (3)与临床保持良好的沟通机制，满足住院患者的需要。 三、医院安全 医院应当采取有效措施，加强医疗服务全程的安全监督管理，保障就诊者、工作人员以及其他来院人员的安全。特别是要有效预防医疗事故以及其他意外事故造成的人身损害。 (一)医疗服务安全 1、制定重大医疗过失行为、医疗事故防范预案和处理程序，及时报告、分析、处理重大医疗过失行为和医疗事故。 Municipal City Government for the work of a city attaches great importance to put forward clearly to 2017 years into the ranks of the "national civilized city" create the target. This year is also the county of a new round of urban civilization created the first year, we not only bear the city to create a "National Civilized City" in the work of the task, also do a good job of "provincial and civilized county Ying check evaluation, work responsibility for a large, heavy task. To the county at all levels and departments cooperate closely, grab get right on the job really, to tight style and promote the implementation of the work, ensure that a city made outstanding achievements. 1, the leadership to strengthen. The county at all levels and departments to the urban civilization was founded on the top of the agenda, and the development of economy and society, the focus of the work together to study the deployment of, together organization and implementation, together with the supervision and inspection, improve and perfect the county, the unified leadership of the county government, a county, a city office coordinated, create liability units of duties, the joint participation of society as a whole leadership system andWorking mechanism. This year, according to the city, a city leading group and special working group to adjust the arrangement, we adjusted the a city the work of the leading group members, the addition of the administrative environment and the effectiveness of the steering group, excellent culture communication group two special 2、严格执行查对制度，提高医务人员对患者身份识别的准确性 3、提高用药安全 4、建立与完善在特殊情况下医务人员之间的有效沟通，做到正确执行医嘱 5、严格防止手术患者、手术部位及术式发生错误 6、严格执行手部卫生，落实医院感染控制的基本要求 7、防范与减少患者坠床与滑倒事件的发生 8、鼓励主动报告医疗安全(不良)事件 (二)建筑、设备、设施安全 1、建筑应当符合《综合医院建筑设计规范》。 2、设备、设施安全运行，防止漏电、漏气、漏水等。 3、消防通道畅通，无障碍物。消防设备齐全，标志醒目，专人管理，设有消防预警系统。有火灾事故的应急预案并定期演练。遇紧急状态时有与外界通讯联络的可靠方式和安全畅通的疏散路线。 4、具有双路供电系统和自备发电配送能力，保证手术室、导管室、产房、重症监护病房、急诊科、血液透析室、输血科(血库)等重点部门的用电需要。 (三)危险物品及要害部门安全 1、建立医用放射性物质、剧毒试剂等危险物品的安全管理制度并认真落实。 2、有处理放射事故等意外事件的预案。 3、加强对放射科、检验科、氧气供应室、、配电室、电梯等重要部门的安全管理。 四、医院服务 坚持“以病人为中心”，树立良好的服务理念和意识，加强职业道德和医德医风建设，充分体现尊重患者、关爱患者、方便患者、服务患者的人文精神。要不断改善服务态度，转变服务作风，做到服务形式多样化和规范化，服务流程合理、便捷，医疗收费合理、透明，并持续改进。尊重和维护患者的合法权益，构建和谐的医患关系，不断满足患者的医疗服务需求。 (一)维护患者合法权益 1、充分发挥伦理委员会在维护患者合法权益的作用。 2、尊重和维护患者的知情同意权、隐私权、选择权等权利。按照法律、法规、规章等有关规定，进行临床试验、药品试验、医疗器械试验、手术、麻醉、输血以及特殊检查、特殊治疗等，应当获得患者的书面知情同意。在医疗服务过程中，应当保护患者的隐私。 3、建立并实施院务公开制度，按规定及时发布有关医疗服务信息。 4、建立并落实医患沟通制度。进行医患沟通时，应当使用患者及其家属易于接受的方式和理解的语言。 Municipal City Government for the work of a city attaches great importance to put forward clearly to 2017 years into the ranks of the "national civilized city" create the target. This year is also the county of a new round of urban civilization created the first year, we not only bear the city to create a "National Civilized City" in the work of the task, also do a good job of "provincial and civilized county Ying check evaluation, work responsibility for a large, heavy task. To the county at all levels and departments cooperate closely, grab get right on the job really, to tight style and promote the implementation of the work, ensure that a city made outstanding achievements. 1, the leadership to strengthen. The county at all levels and departments to the urban civilization was founded on the top of the agenda, and the development of economy and society, the focus of the work together to study the deployment of, together organization and implementation, together with the supervision and inspection, improve and perfect the county, the unified leadership of the county government, a county, a city office coordinated, create liability units of duties, the joint participation of society as a whole leadership system andWorking mechanism. This year, according to the city, a city leading group and special working group to adjust the arrangement, we adjusted the a city the work of the leading group members, the addition of the administrative environment and the effectiveness of the steering group, excellent culture communication group two special 5、公开患者投诉渠道和流程，及时、妥善处理和反馈患者的投诉。 6、尊重患者的民族风俗习惯及宗教信仰。 (二)服务行为和医德医风 1、贯彻落实《医德考核办法》贯彻落实法律、法规、规章等有关规定。尊重、关爱患者，主动、热情、周到、文明服务患者。 2、有医德医风建设的制度、奖惩措施并认真落实。 3、严禁使用无批号、过期、变质、失效药品，或者擅自生产、销售、使用未经批准的制剂。 4、医院及其工作人员不得通过职务便利谋取不正当利益。 5、严禁推诿、拒诊患者。 6、患者和社会对医疗服务比较满意。 7、能够提供多层次的医疗护理服务，满足患者不同层次的需求。 (三)服务环境和服务流程 1、门诊应当提供就诊咨询、导诊以及其他便民服务。 2、服务环境和设施清洁、舒适、温馨，服务标识规范、清楚、醒目。 3、入院与出院、诊断与治疗、转科与转院等连续性服务流程合理、便捷。 4、优化流程，简化环节。挂号、划价、收费、取药、采血等服务窗口的数量、布局合理，缩短患者等候时间。 5、采取有效措施，提高医技科室工作效率，缩短出具检验、检查报告时间。 五、教学与科研管理 1、建立教学、科研部门，制定管理制度并组织实施。 2、制定教学、科研发展规划和年度工作计划，落实情况良好。 3、设施、设备满足教学、科研需要，带教教师教学能力符合医学本科教育以上要求。 4、医院承担继续医学教育和进修教育工作，为市级培训基地。 5、科研设施、设备、实验室以及科研资金满足临床科研需要。 6、具备与其功能、任务相适应的教学和科研水平，有一定数量的学术论文和科研成果。 六、医院绩效 医院应当遵循社会主义市场经济和医疗卫生事业发展的内在规律，始终把社会效益放在首位，履行社会责任和义务。加强科学、规范管理，建立良好的激励与约束机制，开源节流，加强成本核算，充分利用现有资源，不断提高医院的效率，保障人民健康。 评价指标 (一)社会效益考核内容: Municipal City Government for the work of a city attaches great importance to put forward clearly to 2017 years into the ranks of the "national civilized city" create the target. This year is also the county of a new round of urban civilization created the first year, we not only bear the city to create a "National Civilized City" in the work of the task, also do a good job of "provincial and civilized county Ying check evaluation, work responsibility for a large, heavy task. To the county at all levels and departments cooperate closely, grab get right on the job really, to tight style and promote the implementation of the work, ensure that a city made outstanding achievements. 1, the leadership to strengthen. The county at all levels and departments to the urban civilization was founded on the top of the agenda, and the development of economy and society, the focus of the work together to study the deployment of, together organization and implementation, together with the supervision and inspection, improve and perfect the county, the unified leadership of the county government, a county, a city office coordinated, create liability units of duties, the joint participation of society as a whole leadership system andWorking mechanism. This year, according to the city, a city leading group and special working group to adjust the arrangement, we adjusted the a city the work of the leading group members, the addition of the administrative environment and the effectiveness of the steering group, excellent culture communication group two special 1、在医疗服务过程中，始终把社会效益放在首位，履行相应的社会责任和义务。 2、认真完成卫生下乡、支农，积极参加政府组织的社会公益性活动。 3、承担突发公共卫生事件和重大灾害事故紧急救治任务。 4、积极开展健康教育、科普宣传，普及防病知识，不断提高公民健康意识。 (二)工作效率 考核内容: 1、医院年门诊人次、急诊人次、急诊抢救人次、手术人次、入出院人次。 2、医师人均每日担负诊疗人次，医师年均出院人次，医师人均每日担负住院床日。 3、平均住院日、平均开放病床数、实际开放总床日数、实际占用总床日数、出院者占用总床日数、病床使用率、病床周转次数。 4、门诊患者人均医疗费用、门诊患者人均药品费用、住院患者人均医疗费用、住院患者人均药品费用、住院床日平均费用、门诊处方人均费用，与上年度的比较。 (三)经济运行状态 考核内容: 1、药品收入及占总收入的百分比，药品进销差价收入及占总收入的百分比，与上年度的比较。 2、单价在200元以上的一次性耗材收入占医疗收入的百分比。 3、医疗服务收入占业务收入的百分比及与上年度的比较。 4、百元业务收入的业务支出、每职工平均业务收入、人员经费占业务支出比例。 5、资产负债率、固定资产净值率、固定资产增长率、净资产增长率、固定资产收益率、流动资产收益率。 6、流动比率和速动比率。 7、成本核算。 六、部分统计指标 1、法定传染病报告率100, 2、重大医疗过失行为和医疗事故报告率100, 3、手术、麻醉、特殊检查、特殊治疗履行患者告知率100, 4、完成政府指令性任务比例100, 5、年门(急)诊患者中外埠患者比例?15, 6、年出院患者中外埠患者比例?30, 7、入出院诊断符合率?95, 8、手术前后诊断符合率?95, Municipal City Government for the work of a city attaches great importance to put forward clearly to 2017 years into the ranks of the "national civilized city" create the target. This year is also the county of a new round of urban civilization created the first year, we not only bear the city to create a "National Civilized City" in the work of the task, also do a good job of "provincial and civilized county Ying check evaluation, work responsibility for a large, heavy task. To the county at all levels and departments cooperate closely, grab get right on the job really, to tight style and promote the implementation of the work, ensure that a city made outstanding achievements. 1, the leadership to strengthen. The county at all levels and departments to the urban civilization was founded on the top of the agenda, and the development of economy and society, the focus of the work together to study the deployment of, together organization and implementation, together with the supervision and inspection, improve and perfect the county, the unified leadership of the county government, a county, a city office coordinated, create liability units of duties, the joint participation of society as a whole leadership system andWorking mechanism. This year, according to the city, a city leading group and special working group to adjust the arrangement, we adjusted the a city the work of the leading group members, the addition of the administrative environment and the effectiveness of the steering group, excellent culture communication group two special 9、临床主要诊断、病理诊断符合率?60, 10、CT检查阳性率?70, 11、MRI检查阳性率?70, 12、大型X光机检查阳性率?70, 13、急危重症抢救成功率?80, 14、疑难病症好转率?90, 15、无菌手术切口甲级愈合率?97, 16、无菌手术切口感染率?0.5, 17、麻醉死亡率?0.02, 18、医院感染率?10, 19、医院感染漏报率?10, 20、临床化学室间质评全年平均及格(VIS?120) 21、血液学室间质评全年平均及格(改良偏离指数DI?2) 22、免疫室间质评全年平均成绩在全国平均水平以上 23、普通门诊具有副主任医师以上专业技术职务任职资格的本院医师比例?60, 24、院内急会诊到位时间?10分钟 25、急诊留观时间?48小时 26、急救物品完好率100, 27、甲级病历率?90, 28、处方合格率?95, 29、开展成分输血比例?85, 30、全血和成分输血适应证合格率?90, 31、挂号、划价、收费、取药等服务窗口等候时间?10分钟 32、检验、心电图、影像常规检验检查项目自检查开始到出具结果时间?30分钟 33、超声自检查开始到出具结果时间?30分钟 34、平均住院日?16天 35、择期手术患者术前平均住院日?3天 36、病床使用率?90, 37、病床周转次数?19次,年 38、药品收入占总收入比例?45, 39、基础护理合格率?90, Municipal City Government for the work of a city attaches great importance to put forward clearly to 2017 years into the ranks of the "national civilized city" create the target. This year is also the county of a new round of urban civilization created the first year, we not only bear the city to create a "National Civilized City" in the work of the task, also do a good job of "provincial and civilized county Ying check evaluation, work responsibility for a large, heavy task. To the county at all levels and departments cooperate closely, grab get right on the job really, to tight style and promote the implementation of the work, ensure that a city made outstanding achievements. 1, the leadership to strengthen. The county at all levels and departments to the urban civilization was founded on the top of the agenda, and the development of economy and society, the focus of the work together to study the deployment of, together organization and implementation, together with the supervision and inspection, improve and perfect the county, the unified leadership of the county government, a county, a city office coordinated, create liability units of duties, the joint participation of society as a whole leadership system andWorking mechanism. This year, according to the city, a city leading group and special working group to adjust the arrangement, we adjusted the a city the work of the leading group members, the addition of the administrative environment and the effectiveness of the steering group, excellent culture communication group two special 40、危重患者护理合格率?90, 41、医疗器械消毒灭菌合格率?100, 42、病房床位与病房护士比例1:0.4 43、职工对医院管理组织机构和领导工作满意度?80, 44、患者、医师与护理人员对检验科服务满意度?90, 45、患者、医师与护理人员对医学影像部门服务满意度?90, 46、患者与医师、护理人员对药学部门服务满意度?90, 47、患者、医务人员对医院后勤服务满意度?90, 48、社会对医疗服务满意度?90, 注:部分统计指标计算方法及说明 病床使用率:指“实际占用总床日数”与“实际开放总床日数”之比。 病床周转次数:指“出院人数”与“平均开放床位数”之比。 平均住院日:指“出院者占用总床日数”与“出院人数”之比。 实际开放总床日数:指年内医院各科每日夜晚12点钟开放病床数之总和，不论该床是否被患者占用，都应计算在内。包括因故(如消毒、小修理等)暂时停用的病床，不包括因医院病房扩建、大修理或粉刷而停用的病床及临时增设的病床。 实际占用总床日数:指医院各科每日夜晚12点钟实际占用病床数(即每日夜晚12点钟的住院人数)之总和。包括实际占用的临时床位，患者入院后于当晚12点钟以前死亡或因故出院所占用的床位。 平均开放病床数:即实际开放总床日数,本年日历日数(365)。 出院者占用总床日数:指出院者(包括正常分娩、未产出院、住院经检查无病出院、未治出院及健康人进行人工流产或绝育手术后正常出院者)住院日数的总和。 急危重症抢救成功率:指急危重患者抢救成功人次数与抢救总人次数之比。 入出院诊断符合率:诊断符合患者数,(出院患者数,疑诊患者数)×100, 手术前后诊断符合率:指手术前后诊断符合人数与手术患者总人数之比。 CT检查阳性率:指CT检查中检出阳性的人次数与CT检查总人次数之比。 药品收入占总收入比例:指药品收入与总收入之比。 总收入:指单位为开展业务及其他活动依法取得的非偿还性资金。总收入包括财政补助收入、上级补助收入、医疗收入、药品收入和其他收入等。 药品收入:指医疗机构在开展医疗业务活动中所取得的中、西药品收入。 门诊患者人均医疗费用:又称每诊疗人次医疗费用。即(医疗门诊收入，药品门诊收入),总诊Municipal City Government for the work of a city attaches great importance to put forward clearly to 2017 years into the ranks of the "national civilized city" create the target. This year is also the county of a new round of urban civilization created the first year, we not only bear the city to create a "National Civilized City" in the work of the task, also do a good job of "provincial and civilized county Ying check evaluation, work responsibility for a large, heavy task. To the county at all levels and departments cooperate closely, grab get right on the job really, to tight style and promote the implementation of the work, ensure that a city made outstanding achievements. 1, the leadership to strengthen. The county at all levels and departments to the urban civilization was founded on the top of the agenda, and the development of economy and society, the focus of the work together to study the deployment of, together organization and implementation, together with the supervision and inspection, improve and perfect the county, the unified leadership of the county government, a county, a city office coordinated, create liability units of duties, the joint participation of society as a whole leadership system andWorking mechanism. This year, according to the city, a city leading group and special working group to adjust the arrangement, we adjusted the a city the work of the leading group members, the addition of the administrative environment and the effectiveness of the steering group, excellent culture communication group two special 疗人次数。住院患者人均医疗费用:又称出院者人均医疗费用。即(医疗住院收入，药品住院收入) ,出院人数。 医师人均每日担负诊疗人次:即诊疗人次数,平均医师人数,251. 医师人均每日担负住院床日:指实际占用总床日数,平均医师人数,365. 法定传染病报告率:指医疗机构在某一时期内法定传染病报告病例数占总病例数(漏报病例数， 已报告病例数)的百分比 Municipal City Government for the work of a city attaches great importance to put forward clearly to 2017 years into the ranks of the "national civilized city" create the target. This year is also the county of a new round of urban civilization created the first year, we not only bear the city to create a "National Civilized City" in the work of the task, also do a good job of "provincial and civilized county Ying check evaluation, work responsibility for a large, heavy task. To the county at all levels and departments cooperate closely, grab get right on the job really, to tight style and promote the implementation of the work, ensure that a city made outstanding achievements. 1, the leadership to strengthen. The county at all levels and departments to the urban civilization was founded on the top of the agenda, and the development of economy and society, the focus of the work together to study the deployment of, together organization and implementation, together with the supervision and inspection, improve and perfect the county, the unified leadership of the county government, a county, a city office coordinated, create liability units of duties, the joint participation of society as a whole leadership system andWorking mechanism. This year, according to the city, a city leading group and special working group to adjust the arrangement, we adjusted the a city the work of the leading group members, the addition of the administrative environment and the effectiveness of the steering group, excellent culture communication group two special