妇保院考核标准

妇保院考核 2011年上半年妇保院考核标准,1500分, 项目 指标 分值 检查考核标准 得分 考核记录 1. 认真执行市卫生局规章制度。严格以市卫生局记录为准～会议迟到、早退一次扣2 落实会议制度～设备购臵、土建工程分/次～缺席一次扣5分/次,设备购臵、土建工程50 审批制度等规定。 审批核对单位资料及卫生局的批复～缺一次扣5 分～扣完为止。 2.1根据卫生局工作记录。一次未完成扣2分。 2.1按时完成市卫生局临时指令性任 2.2查检查记录～每缺一次扣5分。和上级医院定务。 40 向技术协作得10分,无合作单位扣10分。 2.2对基层技术指导～每季一次考核,一 向上合作情况。 行 3.建立健全医疗安全工作制度～定期查看制度～缺一项扣4分,查看会议记录～缺一次 召开会议每月至少1次,层层签订安扣2分,查看责任书～未签订者扣5分,毒麻药品政 全目标责任书～落实一岗双责,加强无专用保险柜、双人双锁管理的扣5分,治安案件、50 危险化学品、毒麻药品的管理使用～安全事故发生其中任何1件此项都不得分。 管 保证行车、消防安全,单位治安案件、 安全生产事故为零。 理 4.严格落实24小时值班制度及领导带查值班记录～无值班表扣5分～查制度～缺制度扣 班制度～制定详细值班表～实行院,站、30 2分～发生空岗一次扣5分～以市局抽查为准～扣 400 所、校,长行政带班制。 完为止。 分 5.严格工作程序～依法处臵突发公共违反工作程序～导致负面影响的～扣15分,不依 卫生事件。严格落实日报告和零报告法处臵的扣10分。报告制度每减少一次扣0.5分～ 制度～报告及时～信息准确～无瞒报、30 发生瞒报、迟报、漏报不得分。不服从调度一次扣 漏报、迟报。服从政府或卫生局对处5分。 臵突发公共卫生事件的调度。 6.工作人员着装整洁规范～佩带胸牌～现场抽查～发现一人着装不规范或不带胸牌者扣2 10 态度亲切。 分～扣完为止。 consciousness of malfeasance at catching good honest, practical action into ideas and County, the County discipline Inspection Commission of the deployment and requirements, adhere to the County and the County discipline Inspection Commission report implementation of clean two responsibilities. 2. clear a gang two accountability responsibilities. Early each year organize conferences, in charge of the leadership, departments, units of the town clean and studied anti-corruption work deployments, according to a gang dual accountability requirements, clear roles and responsibilities for members of the leading body of the Party Committee, put a gang two accountability targets, develop work plans, organizations honest responsibility, urged the team members to actively fulfil a gang double duty. Urged the first responsibility of grass-roots party branch secretaries to perform duties, efforts to form a team in unison, and the linkage of the work of the Party Committee. 3. pay close attention to the construction of a clean and honest government regulations implemented. Conscientiously implement the responsibility of uncorrupted, really formed by system in politics, according to the rules, effective mechanisms for the management of the system. First, build and improve the conversation reminded party members and cadres education system, auditing system of cadres, 18, for the full implementation of responsibility of uncorrupted to provide favorable institutional safeguards. Second, persist in combining focused inspections and special inspections, paying careful attention to supervision, implementation of the special inspection and the system of democratic appraisal of 单位: 考核人签字: 时间: 得分: 项目 指标 分值 检查考核标准 得分 考核记录 7.设有档案室～并有专人收发公文及无档案室扣2分～无专人收发公文及从事档案管理工作 从事档案管理工作～制度健全～管理20 扣3分～无制度扣2分～扣完为止。 规范。 8.卫生宣传成效显著～设有宣传栏,稿件每少一篇扣0.5分～最多扣5分,无宣传栏、版面 门诊、病房有健康教育版面,每年至扣2分,年内无面向社会的健康教育活动扣1分～院内一 少三次面向社会的健康教育活动～院未定期开展健康教育工作扣2分～发生反面典型、负面行 内定期开展健康教育与活动。按质按报道影响大的事件或上级部门通报批评的不得分。信息 量及时上报卫生信息、宣传稿件～每20 缺少一篇扣0.5分～最高扣10分。完不成订阅任务的 月至少2篇,无反面典型、负面报道扣5分。潍坊级一篇加3分～省级加5分～国家级加10 事件发生。在潍坊市级以上新闻媒体分～加分最多不超过10分。 政 报道稿件逐级加分。及时完成各类党 报党刊、业务报刊订阅。 管 9.树立市级先进典型至少1件,人和经主管部门认可～并经县、市、省级新闻媒体宣传报道～ 事,。 在县、市、省范围内每推出1件典型分别得6、8、1030 分～最高不超过10分。,报纸以原件为准～电台、电视理 台以节目播出单为准,。 10 、按照医院建设标准～合理规划查看现场～病房设施齐全得5分～缺一项扣1分,卫生 400 医院建设～改善就医环境。病房配套整洁无死角得5分～发现一处卫生死角扣1分～扣完为20 分 设施齐全～环境整洁卫生、无死角～止。 为病人提供良好的就医条件和环境。 11、门窗桌椅等基本设施完好～整洁查看现场。门窗玻璃、椅凳等缺一页,把,扣1分,警 并正常使用～各种警示标识,如禁烟、20 示标识一处不全～扣1分～扣完为止。 导医及科室标牌等,齐全、清楚。 e system of democratic appraisal ofinspections and special inspections, paying careful attention to supervision, implementation of the special inspection and thcused mplementation of responsibility of uncorrupted to provide favorable institutional safeguards. Second, persist in combining fond improve the conversation reminded party members and cadres education system, auditing system of cadres, 18, for the full iild areally formed by system in politics, according to the rules, effective mechanisms for the management of the system. First, bu uction of a clean and honest government regulations implemented. Conscientiously implement the responsibility of uncorrupted,Committee. 3. pay close attention to the constrroots party branch secretaries to perform duties, efforts to form a team in unison, and the linkage of the work of the Party -Urged the first responsibility of grass to actively fulfil a gang double duty. embersy Committee, put a gang two accountability targets, develop work plans, organizations honest responsibility, urged the team mding to a gang dual accountability requirements, clear roles and responsibilities for members of the leading body of the Partcorruption work deployments, accor-conferences, in charge of the leadership, departments, units of the town clean and studied anti t implementation of clean two responsibilities. 2. clear a gang two accountability responsibilities. Early each year organizen Commission of the deployment and requirements, adhere to the County and the County discipline Inspection Commission reporconsciousness of malfeasance at catching good honest, practical action into ideas and County, the County discipline Inspectio2 12、计生工作领导小组健全～成立机无领导小组扣5分～未成立计生科、无专(兼)职计生干 构～有专,兼,职计生干部。各项计部各扣2分。责任书未签订或未落实扣5分。计生工作 生工作规章制度完善。《人口与计生无、无措施、无落实各扣1分～会议、检查无记录 目标管理责任》签订率100,。定期40 或不全各扣1分。计生信息不真实或上报不及时扣5分。 召开计生专题会议～计生工作有计B超未签订或私自进行胎儿性别鉴定的该项不得 划、有措施、有落实～并定期检查～分。私自为符合法定生育条件妊娠14周以上妇女作引 计生会议、检查有记录。计生簿 卡产手术的不得分。发生1例恶性节育手术事故不得分。 齐全～计生信息数据真实准确～上报 及时。加强B超执机管理～严禁非医 学需要鉴定胎儿性别～《B超执机管 理合同》签订率100,。除急症外～ 非指定单位禁止为 符合生育条件妊娠,,周以上的妇一 女施行引产。接受产妇时审验身份 证、《计生服务手册》或《生育证》～行 审验率100,～无证人员立即告知计 生局。无恶性节育手术事故发生。 政 查医院1个普通病房和1个市级护理示范病房～临床一 13.护理人员配备情况 10 线护士数量/实际开放床位数比?0.6:1得10分～0.6 ,0.5:1得8分～0.5,0.4:1得5分～,0.4不得分。 管 14.聘任制护士保障政策落实到位～ 每缺少一项保险扣2分。聘任制护士教育培训管理不到医疗保险、社会养老保险、失业保险10 理 位扣3分。 购臵齐全～在职培训及管理到位。 400 分 15.医院设立警务室 5 未设立警务室不得分。 16.贯彻落实《劳动合同法》。 10 抽查聘用工作人员10名～1人不落实扣1分～扣完为止。 工会组织健全得2分～建立院务公开制度～形式内容规17.工会组织建设 5 范得3分。否则～酌情扣分。 tation. Second, persist in combining focused inspections and special inspections, paying careful attention to supervision, implementem of cadres, 18, for the full implementation of responsibility of uncorrupted to provide favorable institutional safeguardsng sysanagement of the system. First, build and improve the conversation reminded party members and cadres education system, auditihe responsibility of uncorrupted, really formed by system in politics, according to the rules, effective mechanisms for the mment te. 3. pay close attention to the construction of a clean and honest government regulations implemented. Conscientiously implerty branch secretaries to perform duties, efforts to form a team in unison, and the linkage of the work of the Party Committeroots pa-Urged the first responsibility of grass responsibility, urged the team members to actively fulfil a gang double duty. s of the leading body of the Party Committee, put a gang two accountability targets, develop work plans, organizations honestrcorruption work deployments, according to a gang dual accountability requirements, clear roles and responsibilities for membe-antiilities. Early each year organize conferences, in charge of the leadership, departments, units of the town clean and studied onsibdiscipline Inspection Commission report implementation of clean two responsibilities. 2. clear a gang two accountability resp d County, the County discipline Inspection Commission of the deployment and requirements, adhere to the County and the Countyconsciousness of malfeasance at catching good honest, practical action into ideas an3of the special inspection and the system of democratic appraisal of 4e system of democratic appraisal ofinspections and special inspections, paying careful attention to supervision, implementation of the special inspection and thcused mplementation of responsibility of uncorrupted to provide favorable institutional safeguards. Second, persist in combining fond improve the conversation reminded party members and cadres education system, auditing system of cadres, 18, for the full iild areally formed by system in politics, according to the rules, effective mechanisms for the management of the system. First, bu uction of a clean and honest government regulations implemented. Conscientiously implement the responsibility of uncorrupted,Committee. 3. pay close attention to the constrroots party branch secretaries to perform duties, efforts to form a team in unison, and the linkage of the work of the Party -Urged the first responsibility of grass to actively fulfil a gang double duty. embersy Committee, put a gang two accountability targets, develop work plans, organizations honest responsibility, urged the team mding to a gang dual accountability requirements, clear roles and responsibilities for members of the leading body of the Partcorruption work deployments, accor-conferences, in charge of the leadership, departments, units of the town clean and studied anti t implementation of clean two responsibilities. 2. clear a gang two accountability responsibilities. Early each year organizen Commission of the deployment and requirements, adhere to the County and the County discipline Inspection Commission reporconsciousness of malfeasance at catching good honest, practical action into ideas and County, the County discipline Inspectio 项目 指标 分值 检查考核标准 得分 考核记录 1.加强质量管理～有全院,站,总体质量控制和重点无方案扣5分～机构、人员和重点环节控制措 环节控制措施～设臵专门机构～配备专职人员监督医务人40 施缺一处扣2分。无检查及考核记录每次扣3 员的医疗服务工作～每月一次检查本单位业务工作。 分～扣完为止。 2. 完善业务培训～认真开展“三基三严”培训～培训计查业务培训计划及记录～无“三基三严”培训 划系统、规范～新上岗人员培训率100,,加强继续医学50 计划及继续医学教育计划分别扣3分～业务讲 教育～每月一次业务讲座～提高工作人员的业务素质。 座每少一次扣3分～扣完为止。 3. 严格医疗卫生技术人员准入管理～规范执业行为～依查各专业执业资格～随机调出部分人员名单～ 法开展各种业务活动。 进行查对。超范围执业发现一次扣5分～执业二 50 范围不符发现一次扣3分～使用未取得执业资 格人员执业的～每人次扣5分～扣完为止。 业 4.加强信息管理～各种医疗护理等文书书写认真、及时、现场抽查3个科室～10份病历～甲级病历>90%～ 务 规范～保存完好。 40 每降低一个百分点扣5分,缺一项文书、登记 扣5分,书写不规范每项扣3分～扣完为止。 管 5.强化医院感染管理～建立专门组织及制度～每月监测一查看制度及登记～无制度及组织扣5分～监测 次,严格医疗废物管理～各项指标符合要求,重视传染病每少一次扣3分,传染病例及死亡病例、中毒理 管理～登记处臵规范～传染病例及死亡病例、急性中毒病40 病例处臵不当1例扣3分～报告不及时1例扣2 例报告及时准确。 分～漏报、瞒报1例扣5分～无登记1例扣3400分 分～扣完为止。 6.对医务人员开展艾滋病、梅毒和乙肝防治知识培训～有未开展培训扣2分～无试卷、小结扣1分,未 内容、有试卷、有小结,开展对全部手术病人、产妇、受30 开展HIV抗体检测扣3分～发现1例未检测扣5 血者、性病病人和结核病人的HIV抗体检测。 分～扣完为止。 7.加强医疗安全管理～杜绝医疗纠纷发生～医疗事故发生发生医疗纠纷每赔偿1万元扣1分。发生医疗 50 率为零。 事故此项不得分。 8.医疗单位院长坚持行政查房制度 每周查房一次～每少一次扣1分 20 5of the special inspection and the system of democratic appraisal of tation. Second, persist in combining focused inspections and special inspections, paying careful attention to supervision, implementem of cadres, 18, for the full implementation of responsibility of uncorrupted to provide favorable institutional safeguardsng sysanagement of the system. First, build and improve the conversation reminded party members and cadres education system, auditihe responsibility of uncorrupted, really formed by system in politics, according to the rules, effective mechanisms for the mment te. 3. pay close attention to the construction of a clean and honest government regulations implemented. Conscientiously implerty branch secretaries to perform duties, efforts to form a team in unison, and the linkage of the work of the Party Committeroots pa-Urged the first responsibility of grass responsibility, urged the team members to actively fulfil a gang double duty. s of the leading body of the Party Committee, put a gang two accountability targets, develop work plans, organizations honestrcorruption work deployments, according to a gang dual accountability requirements, clear roles and responsibilities for membe-antiilities. Early each year organize conferences, in charge of the leadership, departments, units of the town clean and studied onsibdiscipline Inspection Commission report implementation of clean two responsibilities. 2. clear a gang two accountability resp d County, the County discipline Inspection Commission of the deployment and requirements, adhere to the County and the Countyconsciousness of malfeasance at catching good honest, practical action into ideas an 项目 指标 分值 检查考核标准 得分 考核记录 9.按要求开展单病种限价收费～综合医院不少10 查看文件、查住院处收费登记和住院病历～每减 于20种～专科医院不少于5种。 少1种扣2分。有文件未实施不得分。 10.积极开展惠民医疗服务～惠民政策落实到10 查看文件、有关资料～一项政策未落实扣2分。 位。 11.1平均住院日?6.5天, 5 11.1查～每增加1个住院日扣1分, 11.2门急诊、住院人次增长12,? 10 11.2每降低1,扣1分。 11.3 门诊、住院患者人均医疗费用增长率? 11.3高于GDP增长率～每高出0.1个百分点扣2 GDP增长率 10 分～低于GDP增长率得10分。 12.卫生科技成果推广转化数。 10 推广转化卫生部“十年百项”每项2分～卫生厅 “五年百项”每项1分～最高得10分。 业 务 13.获省,部,级、潍坊市、高密市科技奖励数。 10 获省,部,级科技奖励一、二、三等奖分别记10、 管 8、6分,获潍坊市级科技奖励一、二、三等奖分理 别记8、6、4分,获高密市级科技奖励一、二、400分 三等奖分别记6、4、2分。最高得10分。 14.积极开展贯标认证工作 5 通过ISO质量管理体系第三方认证得5分～建立 质量管理体系文件得2分。未开展不得分。 15.标准化创建工作 10 标准化护理示范病房:二级医疗机构达标率30,, 标准化门诊、急诊科、ICU、手术室:二级综合医 院达标率100,,其他医疗机构达标率50,,开 展血液透析的二级医疗机构达标率100,。 16.开展公共卫生服务～完城目标任务。有项目 查看公共卫生服务项目、办公室设臵、工作场所 质控方案～进行季度自查质控。 设备配备是否利于开展工作。各种工作资料是否 齐全～工作流程是否规范～服务是否到位。一项 达不到扣1分。 6e system of democratic appraisal ofinspections and special inspections, paying careful attention to supervision, implementation of the special inspection and thcused mplementation of responsibility of uncorrupted to provide favorable institutional safeguards. Second, persist in combining fond improve the conversation reminded party members and cadres education system, auditing system of cadres, 18, for the full iild areally formed by system in politics, according to the rules, effective mechanisms for the management of the system. First, bu uction of a clean and honest government regulations implemented. Conscientiously implement the responsibility of uncorrupted,Committee. 3. pay close attention to the constrroots party branch secretaries to perform duties, efforts to form a team in unison, and the linkage of the work of the Party -Urged the first responsibility of grass to actively fulfil a gang double duty. embersy Committee, put a gang two accountability targets, develop work plans, organizations honest responsibility, urged the team mding to a gang dual accountability requirements, clear roles and responsibilities for members of the leading body of the Partcorruption work deployments, accor-conferences, in charge of the leadership, departments, units of the town clean and studied anti t implementation of clean two responsibilities. 2. clear a gang two accountability responsibilities. Early each year organizen Commission of the deployment and requirements, adhere to the County and the County discipline Inspection Commission reporconsciousness of malfeasance at catching good honest, practical action into ideas and County, the County discipline Inspectio 项目 指标 分值 检查考核标准 得分 考核记录 1.行业作风建设、党风廉政建设组织健全～有查看资料～无专人负责扣2分,缺制度、措施扣 专人负责～制度、措施完备～对商业贿赂等有30 2分,无专项治理办法扣2分,无处理记录扣2 专项治理办法～并有落实处理记录。 分～扣完为止。 2.有计划、有步骤地对医务人员进行职业道德查看教育计划、记录等资料。每缺一项扣2分。 20 教育～每年不少于2次。 调查走访～缺一次扣1分～扣完为止。 3.建立完善投诉处理机制～设立举报箱、监督查看现场及资料～每缺一项扣2分。查投诉记录 台、公布投诉、监督电话及对社会承诺～及时20 未及时处理的1件扣1分～扣完为止。 三 处理病人投诉等。 4.医务和政务公开。坚持收费公示制度～收费检查有关公示资料～无电子显示屏、触摸屏分别 行 规范～住院费用一日清单制,建有政务公开栏～扣3分。无收费价目表扣3分～未及时更换扣1 向职工公示单位重要事项～定期公示科室、医30 分～收费不规范、未实行一日清单制扣1分,无风 生的抗生素使用情况。 公开栏扣2分,重要事项未公布扣2分,未定期 公示抗生素使用情况扣2分～扣完为止。 建 5.服务对象满意度。 随机抽取10-30名近期出院患者或服务对象～电 30 话回访～满意得15分、较满意得10分～不满意设 不得分～取其平均分值为本单位得分。 6.开展行业自律及优质服务教育活动～成效显查看资料～职工未签订服务承诺书的扣5分～缺 200 著。 1人扣1分～扣完为止,开展警示教育、纪律讲20 分 座、廉洁行医与优质服务倡议活动～缺一项扣2 分。 7. “双评”活动措施得力～通过座谈、走访等现场抽查被考核单位走访企业总数的20%～发放 形式～征求规模以上企业负责人和市级人大代20 征求意见打分表,满意20分、基本满意15分、 表、政协委员的意见。 不满意不得分,～取其平均分即为该项得分。 8、精神文明建设成效显著。 市级10分～潍坊市级20分～省级30分。无文明 30 单位称号不得分。 tation. Second, persist in combining focused inspections and special inspections, paying careful attention to supervision, implementem of cadres, 18, for the full implementation of responsibility of uncorrupted to provide favorable institutional safeguardsng sysanagement of the system. First, build and improve the conversation reminded party members and cadres education system, auditihe responsibility of uncorrupted, really formed by system in politics, according to the rules, effective mechanisms for the mment te. 3. pay close attention to the construction of a clean and honest government regulations implemented. Conscientiously implerty branch secretaries to perform duties, efforts to form a team in unison, and the linkage of the work of the Party Committeroots pa-Urged the first responsibility of grass responsibility, urged the team members to actively fulfil a gang double duty. s of the leading body of the Party Committee, put a gang two accountability targets, develop work plans, organizations honestrcorruption work deployments, according to a gang dual accountability requirements, clear roles and responsibilities for membe-antiilities. Early each year organize conferences, in charge of the leadership, departments, units of the town clean and studied onsibdiscipline Inspection Commission report implementation of clean two responsibilities. 2. clear a gang two accountability resp d County, the County discipline Inspection Commission of the deployment and requirements, adhere to the County and the Countyconsciousness of malfeasance at catching good honest, practical action into ideas an7of the special inspection and the system of democratic appraisal of