二级乙等医院评审标准(1)

二级乙等医院评审 标准 excel标准偏差excel标准偏差函数exl标准差函数国标检验抽样标准表免费下载红头文件格式标准下载 (1) 二级综合医院评审标准(2012年版) 发表者:徐江 为全面推进深化医药卫生体制改革和公立医院改革，逐步建立我国医院评审评价体系，促进医疗机构加强自身建设和管理，持续改进医疗质量，保证医疗安全，改善医疗服务，更好地履行社会职责和义务，提高医疗行业整体服务水平与服务能力，满足人民群众多层次的医疗服务需求，在总结我国第一周期医院评审和医院管理年活动等工作经验基础上制定本标准。用于二级综合性医院，其他各类二级医院参照使用。 设置7章69节356条标准与监测指标。 第一章至第六章共63节321条标准，用于医院自我评价与改进，并作为对二级综合医院实地评审。 第七章共6节35条监测指标，用于对二级综合医院的日常运行、医疗质量与安全指标的监测与评审后的追踪评价。 说明: 1.二级医院是向含有多个社区的地区(人口一般在数十万左右)提供医疗为主，兼顾预防、保健和康复医疗服务并承担一定教学和科研任务的综合或专科的地区性医疗机构;本标准中，“县医院”为政府举办的县域内医疗卫生中心，应结合当地疾病谱特点，重点加强严重危及当地人民群众健康的疑难病救治及危急重症患者抢救能力。同时，承担对乡镇卫生院、村卫生室的业务技术指导和卫生人员的进修培训。 2.本标准中引用的疾病名称与ICD-10编码采用《疾病和有关健康问 题 快递公司问题件快递公司问题件货款处理关于圆的周长面积重点题型关于解方程组的题及答案关于南海问题 的国际统计分类》，人民卫生出版社，第十次修订本第二版(北京协和医院、世界卫their own conditions to develop the correct road, the maximum to avoid investment risk, gain profit.(three) vigorously promote the brand. To establish brand awareness, awareness of the use of brand, brand value, brand acquisition performance, enhance the competitive strength. Concentrated manpower, careful planning, packaging and publicity of a number of unique, market influence and coverage of the brand, the implementation of key breakthroughs, to enhance the competitive strength, walking business road the competition of alienation and characteristics, the pursuit of stability and development of the market.(four) to promote the integration of resources. To further broaden their horizons, effective integration of resources within the group, the city resources, other industries and regional resources, mutual trust, mutual benefit, seeking win-win principle, in the framework of national policies and regulations, strict inspection and argumentation, legal consultation, examination and approval procedures, strict regulation of economic activities, attract injection the social investment to the industry group, to achieve leveraging the development, ensure that the value of state-owned assets.(five) to strengthen the construction management personnel. Strengthen the management of education and training of cadres and workers of the existing business, firmly establish the concept of the market, enhance the sense of crisis to adapt to market competition, the sense of urgency, improve the ability to respond to market competition, improve management and operation of the market. At the same time, according to the need of industrial development, vigorously the introduction of high-quality management management personnel, and strive to build a high-quality professional management team, hard work, and promote the entire workforce knowledge structure, age structure, structure optimization and upgrading ability, enhance core competitiveness, adapt to the need of market competition.(six) seriously study the policy for policy. Serious research about social support the development of cultural undertakings in the country and the XX policy, especially the policy of industrial development, financial investment policy, financial policy and tax policy, and actively seek policy, projects and funds, enterprise and industry group mission to promote leapfrog development. 生组织、国际分类家族合作中心编译)。 3.本标准中引用的手术名称与ICD-9-CM-3编码采用《国际疾病分类手术与操作》，人民军医出版社，第九版临床修订本2008版(刘爱民主编译)。 第一章 医院功能任务 一、医院设置、功能和任务符合区域卫生规划和医疗机构设置规划的定位和要求 (一)医院的功能、任务和定位明确，保持适度规模。 (二)主要承担常见病、多发病、部分疑难病的诊疗工作，兼顾预防、保健、康复功能，可提供24小时急危重症诊疗服务。 (三)临床科室诊疗科目设置、人员梯队与诊疗技术能力达到省级卫生行政部门规定的二级医院标准。 (四)医技科室服务能满足临床科室需要，项目设置、人员梯队与技术能力达到省级卫生行政部门规定的二级医院标准。 二、科学规范的内部管理机制 (一)坚持公立医院公益性，把维护人民群众健康权益放在第一位。 (二)按照省级卫生行政部门规定，实施住院医师规范化培训工作。 (三)将推进规范诊疗、临床路径管理和单病种质量控制，作为推动医疗质量持续改进的重点项目。 (四)提高工作绩效，优化医疗服务系统与流程，缩短平均住院日、缩短患者就医等候时间。 (五)按照《国家基本药物临床应用指南》、《国家基本药物处方集》及医疗机构药品使用管理有关规定，规范医师处方行为，确保基本药物得到优先合理使用。 ition,s of the existing business, firmly establish the concept of the market, enhance the sense of crisis to adapt to market competto strengthen the construction management personnel. Strengthen the management of education and training of cadres and workerowned assets.(five) -social investment to the industry group, to achieve leveraging the development, ensure that the value of stateon, legal consultation, examination and approval procedures, strict regulation of economic activities, attract injection the win principle, in the framework of national policies and regulations, strict inspection and argumentati-mutual benefit, seeking winective integration of resources within the group, the city resources, other industries and regional resources, mutual trust, s, efft of stability and development of the market.(four) to promote the integration of resources. To further broaden their horizonghs, to enhance the competitive strength, walking business road the competition of alienation and characteristics, the pursuikthroung, packaging and publicity of a number of unique, market influence and coverage of the brand, the implementation of key breaof brand, brand value, brand acquisition performance, enhance the competitive strength. Concentrated manpower, careful plannie the brand. To establish brand awareness, awareness of the use their own conditions to develop the correct road, the maximum to avoid investment risk, gain profit.(three) vigorously promot2leapfrog development. nancial policy and tax policy, and actively seek policy, projects and funds, enterprise and industry group mission to promotecy, firal undertakings in the country and the XX policy, especially the policy of industrial development, financial investment poliarket competition.(six) seriously study the policy for policy. Serious research about social support the development of culture optimization and upgrading ability, enhance core competitiveness, adapt to the need of mquality professional management team, hard work, and promote the entire workforce knowledge structure, age structure, structu-t personnel, and strive to build a highquality management managemen-t the same time, according to the need of industrial development, vigorously the introduction of highthe sense of urgency, improve the ability to respond to market competition, improve management and operation of the market. A (六)严格控制公立医院开展特需服务。 三、承担政府指令性任务 (一)根据政府指令承担对口支援基层医疗机构的工作，纳入院长目标责任制与医院年度工作 计划 项目进度计划表范例计划下载计划下载计划下载课程教学计划下载 ，有实施方案，专人负责。 (二)根据《中华人民共和国传染病防治法》和《突发公共卫生事件应急条例》等相关法律法规承担传染病的发现、报告、救治、预防等任务。 (三)开展健康教育、健康咨询等多种形式的公益性社会活动。 (四)根据《统计法》与卫生行政部门规定，完成医院基本运行状况、医疗技术、诊疗信息和临床用药监测信息等相关数据报送工作，数据真实可靠。 四、应急管理 (一)遵守国家法律、法规，严格执行各级政府制定的应急预案。服从指挥调度，承担本县域内突发公共事件的紧急医疗救援任务和配合突发公共卫生事件防控工作。 (二)建立医院应急工作领导小组，落实责任，建立并不断完善医院应急管理机制。 (三)医院有明确的应对主要突发事件策略，建立医院应急指挥系统，制定和完善各类应急预案，提高快速反应能力。 (四)开展应急培训和演练，提高各级、各类人员的应急素质和医院的整体应急能力。 (五)合理进行应急物资和设备的储备。 五、临床医学教育及科研 (一)承担政府分配的培养基层医疗机构(乡镇卫生院、村卫生室)人 -, to achieve leveraging the development, ensure that the value of stategroup on and approval procedures, strict regulation of economic activities, attract injection the social investment to the industryle, in the framework of national policies and regulations, strict inspection and argumentation, legal consultation, examinatiwin princip-ithin the group, the city resources, other industries and regional resources, mutual trust, mutual benefit, seeking winarket.(four) to promote the integration of resources. To further broaden their horizons, effective integration of resources wthe mrength, walking business road the competition of alienation and characteristics, the pursuit of stability and development of of unique, market influence and coverage of the brand, the implementation of key breakthroughs, to enhance the competitive st numberisition performance, enhance the competitive strength. Concentrated manpower, careful planning, packaging and publicity of a it.(three) vigorously promote the brand. To establish brand awareness, awareness of the use of brand, brand value, brand acqutheir own conditions to develop the correct road, the maximum to avoid investment risk, gain prof3actively seek policy, projects and funds, enterprise and industry group mission to promote leapfrog development. XX policy, especially the policy of industrial development, financial investment policy, financial policy and tax policy, and d thestudy the policy for policy. Serious research about social support the development of cultural undertakings in the country an ure optimization and upgrading ability, enhance core competitiveness, adapt to the need of market competition.(six) seriouslyquality professional management team, hard work, and promote the entire workforce knowledge structure, age structure, struct-quality management management personnel, and strive to build a high-of industrial development, vigorously the introduction of high e neede ability to respond to market competition, improve management and operation of the market. At the same time, according to thblish the concept of the market, enhance the sense of crisis to adapt to market competition, the sense of urgency, improve thof cadres and workers of the existing business, firmly estaowned assets.(five) to strengthen the construction management personnel. Strengthen the management of education and training 才的指令性任务，制定相关的制度、培训方案，并有具体措施予以保障。 (二)承担医学院校医学生的临床教学和实习任务或承担本地区全科医师培养任务。 (三)有制度保障开展卫生技术人员的继续医学教育工作。 (四)有制度支持鼓励医务人员参与，开展与本区域常见病、多发病相关的调查研究，并提供适当的经费、条件与设施，取得成果。 六、具有承担公立医疗卫生中心功能任务的能力和资源(可选，县医院为必选) (一)承担公立医疗卫生中心的功能和任务。 (二)在主管部门组织下，承担建立与完善以乡镇卫生院、村卫生室为基础的农村三级医疗卫生服务网络。 (三)学科专业设置与诊疗技术能力在同级医院中具有明显优势。 (四)根据政府指令，接受城市三甲医院对口支援的医院，力争达到二级甲等级别，应将“达标工作”任务作为院长目标责任制与医院年度 工作计划 幼儿园家访工作计划关于小学学校工作计划班级工作计划中职财务部门工作计划下载关于学校后勤工作计划 ，有实施方案，专人负责。 第二章 医院服务 一、预约诊疗服务(可选，县医院为必选) (一)实施多种形式的预约诊疗与分时段服务，对门诊和出院复诊患者实行中长期预约。 (二)有预约诊疗工作制度和规范，有操作流程，逐步提高患者预约就诊比例。 (三)有改善门诊服务、方便患者就医的绩效考评和分配政策，支持医务人员从事晚间门诊和节假日门诊。 s of the existing business, firmly establish the concept of the market, enhance the sense of crisis to adapt to market competto strengthen the construction management personnel. Strengthen the management of education and training of cadres and workerowned assets.(five) -social investment to the industry group, to achieve leveraging the development, ensure that the value of stateon, legal consultation, examination and approval procedures, strict regulation of economic activities, attract injection the win principle, in the framework of national policies and regulations, strict inspection and argumentati-mutual benefit, seeking winective integration of resources within the group, the city resources, other industries and regional resources, mutual trust, s, efft of stability and development of the market.(four) to promote the integration of resources. To further broaden their horizonghs, to enhance the competitive strength, walking business road the competition of alienation and characteristics, the pursuikthroung, packaging and publicity of a number of unique, market influence and coverage of the brand, the implementation of key breaof brand, brand value, brand acquisition performance, enhance the competitive strength. Concentrated manpower, careful plannie the brand. To establish brand awareness, awareness of the use their own conditions to develop the correct road, the maximum to avoid investment risk, gain profit.(three) vigorously promot4leapfrog development. nancial policy and tax policy, and actively seek policy, projects and funds, enterprise and industry group mission to promotecy, firal undertakings in the country and the XX policy, especially the policy of industrial development, financial investment poliarket competition.(six) seriously study the policy for policy. Serious research about social support the development of culture optimization and upgrading ability, enhance core competitiveness, adapt to the need of mquality professional management team, hard work, and promote the entire workforce knowledge structure, age structure, structu-t personnel, and strive to build a highquality management managemen-t the same time, according to the need of industrial development, vigorously the introduction of highthe sense of urgency, improve the ability to respond to market competition, improve management and operation of the market. A ition, (四)建立与上级对口支援医院以及挂钩合作的基层医疗机构的预约转诊服务。 二、门诊流程管理 (一)优化门诊布局结构，完善门诊 管理制度 档案管理制度下载食品安全管理制度下载三类维修管理制度下载财务管理制度免费下载安全设施管理制度下载 ，落实便民措施，减少就医等待，改善患者就医体验。 (二)公开出诊信息，保障医务人员按时出诊，遇有医务人员出诊时间变更应提前告知患者。提供咨询服务，帮助患者有效就诊。 (三)根据门诊就诊患者流量调配医疗资源，做好门诊和辅助科室之间协调配合。 (四)根据门诊就诊患者流量配套医疗资源。有改善门诊服务、方便患者就医的绩效考评和分配政策。支持医务人员从事晚间门诊和节假日门诊。 三、急诊绿色通道管理 (一)合理配置急诊资源，配备经过专业培训、胜任急诊工作的医务人员，配置急救设备和药品，符合《急诊科建设与管理指南(试行)》的基本要求。 (二)落实首诊负责制，与基层医疗机构建立急诊、急救转接服务制度。 (三)加强急诊检诊、分诊，急危重症患者与一般急诊患者分区救治，及时救治急危重症患者，有效分流非急危重症患者。 (四)建立急诊住院和手术的“绿色通道”，建立创伤、农药中毒、急性心肌梗死、脑卒中、高危妊娠孕产妇等重点病种的急诊服务流程与规范，需紧急抢救的危重患者可先抢救后付费，保障患者获得连贯医疗服务。 (五)开展急救技术操作规程的全员培训,实行合格上岗制度。 (六)科主任、护士长与具备资质的人员组成质量与安全管理小组，能 owned assets.(five) to strengthen the construction management personnel. Strengthen the management of education and training -, to achieve leveraging the development, ensure that the value of stategroup on and approval procedures, strict regulation of economic activities, attract injection the social investment to the industryle, in the framework of national policies and regulations, strict inspection and argumentation, legal consultation, examinatiwin princip-ithin the group, the city resources, other industries and regional resources, mutual trust, mutual benefit, seeking winarket.(four) to promote the integration of resources. To further broaden their horizons, effective integration of resources wthe mrength, walking business road the competition of alienation and characteristics, the pursuit of stability and development of of unique, market influence and coverage of the brand, the implementation of key breakthroughs, to enhance the competitive st numberisition performance, enhance the competitive strength. Concentrated manpower, careful planning, packaging and publicity of a it.(three) vigorously promote the brand. To establish brand awareness, awareness of the use of brand, brand value, brand acqutheir own conditions to develop the correct road, the maximum to avoid investment risk, gain prof5actively seek policy, projects and funds, enterprise and industry group mission to promote leapfrog development. XX policy, especially the policy of industrial development, financial investment policy, financial policy and tax policy, and d thestudy the policy for policy. Serious research about social support the development of cultural undertakings in the country an ure optimization and upgrading ability, enhance core competitiveness, adapt to the need of market competition.(six) seriouslyquality professional management team, hard work, and promote the entire workforce knowledge structure, age structure, struct-quality management management personnel, and strive to build a high-of industrial development, vigorously the introduction of high e neede ability to respond to market competition, improve management and operation of the market. At the same time, according to thblish the concept of the market, enhance the sense of crisis to adapt to market competition, the sense of urgency, improve thof cadres and workers of the existing business, firmly esta 用核心制度、岗位职责、诊疗规范与质量安全指标来加强急诊质量全程监控管理与定期评价，促进持续改进。 四、住院、转诊、转科服务流程管理 (一)完善患者入院、出院、转科服务管理工作制度和标准，改进服务流程，方便患者。 (二)为急诊患者入院制定合理、便捷的收入院制度与程序。危重患者应先抢救并及时办理入院手续。 (三)在国家基本医疗保障制度框架内，在主管部门组织下，医院应建立与实施双向转诊制度。 (四)加强转诊、转科患者的交接管理，及时传递患者病历与相关信息，为患者提供连续医疗服务。 (五)加强出院患者健康教育和随访预约管理，提高患者健康知识水平和出院后医疗、护理及康复措施的知晓度。 五、基本医疗保障服务管理 (一)有各类基本医疗保障服务的管理制度和相应保障措施，严格服务收费管理，方便患者就医。 (二)公开医疗服务收费标准，公示基本医疗保障支付项目。 (三)保障各类基本医疗保障制度参加人员的权益，强化参保患者知情同意。 六、保障患者的合法权益 (一)医院有相关制度保障患者及其家属充分了解其权利。 (二)主管医师应采取恰当方式、使用易懂语言，向患者、家属或委托代理人说明病情及治疗方式、特殊治疗及处置，并获得其同意，说明内容应 s of the existing business, firmly establish the concept of the market, enhance the sense of crisis to adapt to market competto strengthen the construction management personnel. Strengthen the management of education and training of cadres and workerowned assets.(five) -social investment to the industry group, to achieve leveraging the development, ensure that the value of stateon, legal consultation, examination and approval procedures, strict regulation of economic activities, attract injection the win principle, in the framework of national policies and regulations, strict inspection and argumentati-mutual benefit, seeking winective integration of resources within the group, the city resources, other industries and regional resources, mutual trust, s, efft of stability and development of the market.(four) to promote the integration of resources. To further broaden their horizonghs, to enhance the competitive strength, walking business road the competition of alienation and characteristics, the pursuikthroung, packaging and publicity of a number of unique, market influence and coverage of the brand, the implementation of key breaof brand, brand value, brand acquisition performance, enhance the competitive strength. Concentrated manpower, careful plannie the brand. To establish brand awareness, awareness of the use their own conditions to develop the correct road, the maximum to avoid investment risk, gain profit.(three) vigorously promot6leapfrog development. nancial policy and tax policy, and actively seek policy, projects and funds, enterprise and industry group mission to promotecy, firal undertakings in the country and the XX policy, especially the policy of industrial development, financial investment poliarket competition.(six) seriously study the policy for policy. Serious research about social support the development of culture optimization and upgrading ability, enhance core competitiveness, adapt to the need of mquality professional management team, hard work, and promote the entire workforce knowledge structure, age structure, structu-t personnel, and strive to build a highquality management managemen-t the same time, according to the need of industrial development, vigorously the introduction of highthe sense of urgency, improve the ability to respond to market competition, improve management and operation of the market. A ition, 有记录，并履行书面知情同意手续。 (三)开展实验性临床医疗(临床人体试验)应严格遵守国家法律、法规及部门规章，有审核管理程序，并征得患者书面同意。 (四)保护患者的隐私权，尊重民族习惯和宗教信仰。 (五)医院针对医务人员开展维护患者合法权益、医患沟通等培训，相关医务人员能够知晓并遵循。 七、投诉管理 (一)贯彻落实《医院投诉管理办法(试行)》，实行“首诉负责制”，设立或指定专门部门统一接受、处理患者和医务人员投诉，及时处理并答复投诉人。 (二)公布投诉管理部门、地点、接待时间及其联系方式，同时公布上级部门投诉电话。建立健全投诉档案，规范投诉处理程序。 (三)根据患者和医务人员投诉，持续改进医疗服务。 (四)对全体员工进行纠纷防范及处理的专门培训。 八、就诊环境管理 (一)为患者提供就诊接待、引导、咨询服务。 (二)急诊与门诊候诊区、医技部门、住院病区等均有明显、易懂的标识。 (三)就诊、住院的环境清洁、舒适、安全。 (四)有保护患者的隐私设施和管理措施。 (五)执行《无烟医疗机构标准(试行)》及《关于2011年起全国医疗卫生系统全面禁烟的决定》。 (六)落实创建“平安医院”有措施，构建和谐医患关系、优化医疗执 owned assets.(five) to strengthen the construction management personnel. Strengthen the management of education and training -, to achieve leveraging the development, ensure that the value of stategroup on and approval procedures, strict regulation of economic activities, attract injection the social investment to the industryle, in the framework of national policies and regulations, strict inspection and argumentation, legal consultation, examinatiwin princip-ithin the group, the city resources, other industries and regional resources, mutual trust, mutual benefit, seeking winarket.(four) to promote the integration of resources. To further broaden their horizons, effective integration of resources wthe mrength, walking business road the competition of alienation and characteristics, the pursuit of stability and development of of unique, market influence and coverage of the brand, the implementation of key breakthroughs, to enhance the competitive st numberisition performance, enhance the competitive strength. Concentrated manpower, careful planning, packaging and publicity of a it.(three) vigorously promote the brand. To establish brand awareness, awareness of the use of brand, brand value, brand acqutheir own conditions to develop the correct road, the maximum to avoid investment risk, gain prof7actively seek policy, projects and funds, enterprise and industry group mission to promote leapfrog development. XX policy, especially the policy of industrial development, financial investment policy, financial policy and tax policy, and d thestudy the policy for policy. Serious research about social support the development of cultural undertakings in the country an ure optimization and upgrading ability, enhance core competitiveness, adapt to the need of market competition.(six) seriouslyquality professional management team, hard work, and promote the entire workforce knowledge structure, age structure, struct-quality management management personnel, and strive to build a high-of industrial development, vigorously the introduction of high e neede ability to respond to market competition, improve management and operation of the market. At the same time, according to thblish the concept of the market, enhance the sense of crisis to adapt to market competition, the sense of urgency, improve thof cadres and workers of the existing business, firmly esta 业环境有成效。 第三章 患者安全目标 一、确立查对制度，识别患者身份 (一)对就诊患者施行唯一标识(如医保卡、新型农村合作医疗卡编号、身份证号码、病历号等)管理。 (二)在诊疗活动中，严格执行“查对制度”，至少同时使用姓名、年龄、床号等2项核对患者身份，确保对正确的患者实施正确的操作。 (三)完善关键流程(急诊、病房、手术室、ICU、产房、新生儿室之间流程)的患者识别措施，建全转科交接登记制度。 (四)使用“腕带”作为识别患者身份的标识，主要针对ICU、新生儿科(室)，手术室、急诊室等重点科室，以及意识不清、抢救、输血、不同语种语言交流障碍、传染病、药物过敏的患者等。 二、确立在特殊情况下医务人员之间有效沟通的程序、步骤 (一)在住院患者的常规诊疗活动中，应以书面方式下达医嘱。 (二)在实施紧急抢救的情况下，必要时可口头下达临时医嘱;护士应对口头临时医嘱完整重述确认，在执行时双人核查;事后及时补记。 (三)接获非书面的患者“危急值”或其他重要的检查(验)结果时，接获者必须规范、完整、准确地记录患者识别信息、检查(验)结果和报告者的信息，复述确认无误后方可提供医师使用。 三、确立手术安全核查制度，防止手术患者、手术部位及术式发生错误 (一)择期手术的各项术前检查与评估工作全部完成后方可下达手术医嘱。 (二)有手术部位识别标示制度与工作流程。 ition,s of the existing business, firmly establish the concept of the market, enhance the sense of crisis to adapt to market competto strengthen the construction management personnel. Strengthen the management of education and training of cadres and workerowned assets.(five) -social investment to the industry group, to achieve leveraging the development, ensure that the value of stateon, legal consultation, examination and approval procedures, strict regulation of economic activities, attract injection the win principle, in the framework of national policies and regulations, strict inspection and argumentati-mutual benefit, seeking winective integration of resources within the group, the city resources, other industries and regional resources, mutual trust, s, efft of stability and development of the market.(four) to promote the integration of resources. To further broaden their horizonghs, to enhance the competitive strength, walking business road the competition of alienation and characteristics, the pursuikthroung, packaging and publicity of a number of unique, market influence and coverage of the brand, the implementation of key breaof brand, brand value, brand acquisition performance, enhance the competitive strength. Concentrated manpower, careful plannie the brand. To establish brand awareness, awareness of the use their own conditions to develop the correct road, the maximum to avoid investment risk, gain profit.(three) vigorously promot8leapfrog development. nancial policy and tax policy, and actively seek policy, projects and funds, enterprise and industry group mission to promotecy, firal undertakings in the country and the XX policy, especially the policy of industrial development, financial investment poliarket competition.(six) seriously study the policy for policy. Serious research about social support the development of culture optimization and upgrading ability, enhance core competitiveness, adapt to the need of mquality professional management team, hard work, and promote the entire workforce knowledge structure, age structure, structu-t personnel, and strive to build a highquality management managemen-t the same time, according to the need of industrial development, vigorously the introduction of highthe sense of urgency, improve the ability to respond to market competition, improve management and operation of the market. A (三)有手术安全核查与手术风险评估制度与工作流程。 四、执行手卫生规范，落实医院感染控制的基本要求 (一)按照《医务人员手卫生规范》，正确配置有效、便捷的手卫生设备和设施，为执行手卫生提供必需的保障与有效的监管措施。 (二)医务人员在临床诊疗活动中应严格遵循手卫生相关要求。 五、加强特殊药物管理，提高用药安全 (一)高浓度电解质、易混淆(药品名称相似、药品外观相似)药品有严格的贮存要求，要严格执行麻醉药品、精神药品、放射性药品、医疗用毒性药品及药品类易制毒化学品等特殊管理药品的使用与管理规章制度;对高浓度电解质、易混淆(听似、看似)药品应有严格的贮存要求，高危药品如在病区储存，则必须做到专柜加锁，有高危药品的标识。 (二)处方或用药医嘱在转抄和执行时有严格的核对程序，并由转抄和执行者签名确认。 六、临床“危急值”报告制度 (一)有临床“危急值”报告制度与流程，确定“危急值”项目。 (二)建立“危急值”评价制度。 七、防范与减少患者跌倒、坠床等意外事件发生 (一)评估有跌倒、坠床风险的高危患者，要主动告知跌倒、坠床危险，采取措施防止意外事件的发生。 (二)有跌倒、坠床等意外事件报告制度、处理预案与的工作流程。 八、防范与减少患者压疮发生 (一)有压疮风险评估与报告制度，有压疮诊疗及护理规范。 (二)实施预防压疮的护理措施。 owned assets.(five) to strengthen the construction management personnel. Strengthen the management of education and training -, to achieve leveraging the development, ensure that the value of stategroup on and approval procedures, strict regulation of economic activities, attract injection the social investment to the industryle, in the framework of national policies and regulations, strict inspection and argumentation, legal consultation, examinatiwin princip-ithin the group, the city resources, other industries and regional resources, mutual trust, mutual benefit, seeking winarket.(four) to promote the integration of resources. To further broaden their horizons, effective integration of resources wthe mrength, walking business road the competition of alienation and characteristics, the pursuit of stability and development of of unique, market influence and coverage of the brand, the implementation of key breakthroughs, to enhance the competitive st numberisition performance, enhance the competitive strength. Concentrated manpower, careful planning, packaging and publicity of a it.(three) vigorously promote the brand. To establish brand awareness, awareness of the use of brand, brand value, brand acqutheir own conditions to develop the correct road, the maximum to avoid investment risk, gain prof9actively seek policy, projects and funds, enterprise and industry group mission to promote leapfrog development. XX policy, especially the policy of industrial development, financial investment policy, financial policy and tax policy, and d thestudy the policy for policy. Serious research about social support the development of cultural undertakings in the country an ure optimization and upgrading ability, enhance core competitiveness, adapt to the need of market competition.(six) seriouslyquality professional management team, hard work, and promote the entire workforce knowledge structure, age structure, struct-quality management management personnel, and strive to build a high-of industrial development, vigorously the introduction of high e neede ability to respond to market competition, improve management and operation of the market. At the same time, according to thblish the concept of the market, enhance the sense of crisis to adapt to market competition, the sense of urgency, improve thof cadres and workers of the existing business, firmly esta 九、妥善处理报告医疗安全(不良)事件 (一)有主动报告医疗安全(不良)事件与隐患缺陷的制度与可执行的工作流程，并让医务人员充分知晓。 (二)有激励措施，鼓励医务人员通过《医疗安全(不良)事件报告系统》开展网上报告工作。 (三)对重大不安全事件要有根本原因分析，将安全信息与医院实际情况相结合，从医院管理体系、运行机制与规章制度上进行有针对性的持续改进。 十、患者参与医疗安全 (一)针对患者疾病诊疗，为患者及其家属提供相关的健康知识教育，协助患方对诊疗方案做出正确理解与选择。 (二)主动邀请患者参与医疗安全活动，如身份识别、手术部位确认、药物使用等。 第四章 医疗质量安全管理与持续改进 一、医疗质量管理组织 (一)有医院、科室的医疗质量管理责任体系，院长为医疗质量管理第一责任人，负责制定医疗质量与医疗安全管理和持续改进方案，定期专题研究医疗质量和医疗安全工作，科主任全面负责科室医疗质量管理工作，执行医疗质量与医疗安全管理和持续改进相关任务。 (二)医院有适当的质量管理组织，包括医疗质量管理、药事管理、护理管理、医院感染管理、病案管理、输血管理等组织，定期研究医疗质量管理等相关问题，记录质量管理活动过程，为院长决策提供支持。 (三)医疗、护理等职能部门负责组织实施医院医疗质量与医疗安全管 s of the existing business, firmly establish the concept of the market, enhance the sense of crisis to adapt to market competto strengthen the construction management personnel. Strengthen the management of education and training of cadres and workerowned assets.(five) -social investment to the industry group, to achieve leveraging the development, ensure that the value of stateon, legal consultation, examination and approval procedures, strict regulation of economic activities, attract injection the win principle, in the framework of national policies and regulations, strict inspection and argumentati-mutual benefit, seeking winective integration of resources within the group, the city resources, other industries and regional resources, mutual trust, s, efft of stability and development of the market.(four) to promote the integration of resources. To further broaden their horizonghs, to enhance the competitive strength, walking business road the competition of alienation and characteristics, the pursuikthroung, packaging and publicity of a number of unique, market influence and coverage of the brand, the implementation of key breaof brand, brand value, brand acquisition performance, enhance the competitive strength. Concentrated manpower, careful plannie the brand. To establish brand awareness, awareness of the use their own conditions to develop the correct road, the maximum to avoid investment risk, gain profit.(three) vigorously promot10leapfrog development. nancial policy and tax policy, and actively seek policy, projects and funds, enterprise and industry group mission to promotecy, firal undertakings in the country and the XX policy, especially the policy of industrial development, financial investment poliarket competition.(six) seriously study the policy for policy. Serious research about social support the development of culture optimization and upgrading ability, enhance core competitiveness, adapt to the need of mquality professional management team, hard work, and promote the entire workforce knowledge structure, age structure, structu-t personnel, and strive to build a highquality management managemen-t the same time, according to the need of industrial development, vigorously the introduction of highthe sense of urgency, improve the ability to respond to market competition, improve management and operation of the market. A ition, 理工作，并落实持续改进方案，承担指导、检查、考核和评价医疗质量管理工作，严格记录，定期分析，及时反馈，落实整改，并建立多部门质量管理协调机制。 二、医疗质量管理与持续改进 (一)有医疗质量管理和持续改进方案，并组织实施。 (二)建立与执行医疗质量管理制度、操作规范、诊疗指南。 (三)坚持“严格要求、严密组织、严谨态度”，强化“基础理论、基本知识、基本技能”培训与考核;每二年一次组织卫生技术人员考核。 (四)建立医疗风险防范确保患者安全的机制，按规定报告医疗安全(不良)事件与隐患缺陷，不瞒报、缓报和漏报。 (五)医院领导班子、职能部门、各临床与医技科室的质量管理人员能够应用全面质量管理的原理，通过适宜质量管理改进的方法及质量管理技术工具开展持续质量改进活动，并做好质量改进效果评价。 (六)定期进行全员医疗质量和安全教育，牢固树立医疗质量和安全意识，提高全员医疗质量管理与改进的参与能力。 (七)建立医疗质量控制、安全管理信息数据库，为制订质量管理持续改进的目标与评价改进的效果提供依据。 三、医疗技术管理 (一)医院提供与功能和任务相适应的医疗技术服务，符合法律、法规、部门规章和行业规范的要求，符合医院诊疗科目范围，符合医学伦理原则，技术应用安全、有效。 (二)医疗技术管理符合《医疗技术临床应用管理办法》规定，不应用未经批准或已经废止和淘汰的技术。建立医疗技术目录，并根据医院开展医 -, to achieve leveraging the development, ensure that the value of stategroup on and approval procedures, strict regulation of economic activities, attract injection the social investment to the industryle, in the framework of national policies and regulations, strict inspection and argumentation, legal consultation, examinatiwin princip-ithin the group, the city resources, other industries and regional resources, mutual trust, mutual benefit, seeking winarket.(four) to promote the integration of resources. To further broaden their horizons, effective integration of resources wthe mrength, walking business road the competition of alienation and characteristics, the pursuit of stability and development of of unique, market influence and coverage of the brand, the implementation of key breakthroughs, to enhance the competitive st numberisition performance, enhance the competitive strength. Concentrated manpower, careful planning, packaging and publicity of a it.(three) vigorously promote the brand. To establish brand awareness, awareness of the use of brand, brand value, brand acqutheir own conditions to develop the correct road, the maximum to avoid investment risk, gain prof11actively seek policy, projects and funds, enterprise and industry group mission to promote leapfrog development. XX policy, especially the policy of industrial development, financial investment policy, financial policy and tax policy, and d thestudy the policy for policy. Serious research about social support the development of cultural undertakings in the country an ure optimization and upgrading ability, enhance core competitiveness, adapt to the need of market competition.(six) seriouslyquality professional management team, hard work, and promote the entire workforce knowledge structure, age structure, struct-quality management management personnel, and strive to build a high-of industrial development, vigorously the introduction of high e neede ability to respond to market competition, improve management and operation of the market. At the same time, according to thblish the concept of the market, enhance the sense of crisis to adapt to market competition, the sense of urgency, improve thof cadres and workers of the existing business, firmly estaowned assets.(five) to strengthen the construction management personnel. Strengthen the management of education and training 疗技术状况实行动态管理、分级分类管理、监督评价和档案管理制度，临床应用新技术应按规定报批。 (三)有医疗技术风险预警机制和医疗技术损害处置预案，并组织实施。对新开展医疗技术的安全、质量、疗效、经济性等情况进行全程追踪管理和评价，及时发现并降低医疗技术风险。 (四)开展科研项目符合法律、法规和医学伦理原则，按规定审批。在科研过程中实行全程质量管理，充分尊重患者的知情权和选择权，签署知情同意书，保护患者安全。 (五)对实施手术、介入、麻醉等高风险技术操作的卫生技术人员实行“分级管理”和“准入制”，定期进行技术能力评价与“再授权”机制。 四、临床路径、单病种质量管理与持续改进(可选，县医院为必选) (一)按照《外科10个病种县医院版临床路径》要求开展临床路径、单病种质量管理，作为推动医疗质量持续改进的重点项目，规范临床诊疗行为的重要内容之一;有开展工作所必要的组织体系与明确的职责，建立部门协调工作机制。 (二)根据医院医疗资源情况，以常见多发病为重点，参照卫生部发布的临床路径管理文件，遵照循证医学原则，制定医院执行文件，实施教育培训。 (三)在医院信息系统中建立实时监测平台，监控临床路径应用与变异情况。 (四)建立临床路径统计工作制度，定期对进入临床路径患者进行平均住院日、住院费用、药品费用、出院30天内出住院率、非预期再手术率、并发症与合并症、死亡率等质量与安全指标进行统计分析。 s of the existing business, firmly establish the concept of the market, enhance the sense of crisis to adapt to market competto strengthen the construction management personnel. Strengthen the management of education and training of cadres and workerowned assets.(five) -social investment to the industry group, to achieve leveraging the development, ensure that the value of stateon, legal consultation, examination and approval procedures, strict regulation of economic activities, attract injection the win principle, in the framework of national policies and regulations, strict inspection and argumentati-mutual benefit, seeking winective integration of resources within the group, the city resources, other industries and regional resources, mutual trust, s, efft of stability and development of the market.(four) to promote the integration of resources. To further broaden their horizonghs, to enhance the competitive strength, walking business road the competition of alienation and characteristics, the pursuikthroung, packaging and publicity of a number of unique, market influence and coverage of the brand, the implementation of key breaof brand, brand value, brand acquisition performance, enhance the competitive strength. Concentrated manpower, careful plannie the brand. To establish brand awareness, awareness of the use their own conditions to develop the correct road, the maximum to avoid investment risk, gain profit.(three) vigorously promot12leapfrog development. nancial policy and tax policy, and actively seek policy, projects and funds, enterprise and industry group mission to promotecy, firal undertakings in the country and the XX policy, especially the policy of industrial development, financial investment poliarket competition.(six) seriously study the policy for policy. Serious research about social support the development of culture optimization and upgrading ability, enhance core competitiveness, adapt to the need of mquality professional management team, hard work, and promote the entire workforce knowledge structure, age structure, structu-t personnel, and strive to build a highquality management managemen-t the same time, according to the need of industrial development, vigorously the introduction of highthe sense of urgency, improve the ability to respond to market competition, improve management and operation of the market. A ition, (五)医院定期进行临床路径管理相关的医务人员和患者满意度调查。总结分析影响病种实施临床路径的的因素,不断完善和改进路径标准。 (六)制定相关的制度与程序保障卫生部文件规定上报的单病种质量指标信息，做到正确、可靠、及时。 五、住院诊疗管理与持续改进 (一)由有法定资质的医师和护士按照制度、程序与病情评估结果为患者提供规范的同质化服务。 (二)应用疾病诊疗规范和药物临床应用指南，规范临床检查、诊断、治疗和使用药物及植(介)入类医疗器械的行为。 (三)由上级医师负责评价与核准住院诊疗(检查、药物治疗、手术/介入治疗等)计划/方案的适宜性，并记入病历。 (四)规范院内会诊管理，明确院内会诊职责，提高会诊质量和效率。 (五)为出院患者提供较详细的出院医嘱和康复指导意见。 (六)科主任、护士长与具备资质的人员组成科室质量与安全管理小组，用质量与安全管理核心制度、岗位职责、诊疗指南与质量安全指标，对住院时间超过30天的患者，进行管理评价，优化医疗服务流程。 (七)对开展新生儿住院诊疗活动的医院，应当按照《新生儿病室建设与管理指南(试行)》的要求，建立符合规范的新生儿病室。 (八)应按《市、县级医院常见肿瘤规范化诊疗指南(试行)》要求，规范肿瘤诊疗活动。 六、手术治疗管理与持续改进 (一)实行手术医师资格准入制和手术分级授权管理制度，有定期手术医师资格和能力评价与再授权的机制。 of cadres and workers of the existing business, firmly estaowned assets.(five) to strengthen the construction management personnel. Strengthen the management of education and training -, to achieve leveraging the development, ensure that the value of stategroup on and approval procedures, strict regulation of economic activities, attract injection the social investment to the industryle, in the framework of national policies and regulations, strict inspection and argumentation, legal consultation, examinatiwin princip-ithin the group, the city resources, other industries and regional resources, mutual trust, mutual benefit, seeking winarket.(four) to promote the integration of resources. To further broaden their horizons, effective integration of resources wthe mrength, walking business road the competition of alienation and characteristics, the pursuit of stability and development of of unique, market influence and coverage of the brand, the implementation of key breakthroughs, to enhance the competitive st numberisition performance, enhance the competitive strength. Concentrated manpower, careful planning, packaging and publicity of a it.(three) vigorously promote the brand. To establish brand awareness, awareness of the use of brand, brand value, brand acqutheir own conditions to develop the correct road, the maximum to avoid investment risk, gain prof13actively seek policy, projects and funds, enterprise and industry group mission to promote leapfrog development. XX policy, especially the policy of industrial development, financial investment policy, financial policy and tax policy, and d thestudy the policy for policy. Serious research about social support the development of cultural undertakings in the country an ure optimization and upgrading ability, enhance core competitiveness, adapt to the need of market competition.(six) seriouslyquality professional management team, hard work, and promote the entire workforce knowledge structure, age structure, struct-quality management management personnel, and strive to build a high-of industrial development, vigorously the introduction of high e neede ability to respond to market competition, improve management and operation of the market. At the same time, according to thblish the concept of the market, enhance the sense of crisis to adapt to market competition, the sense of urgency, improve th (二)实行患者病情评估与术前讨论制度，遵循诊疗规范制订诊疗和手术方案，依据患者病情变化和再评估结果调整诊疗方案，均应记录在病历中。 (三)患者手术前的知情同意包括术前诊断、手术目的和风险、高值耗材的使用与选择，以及其他可选择的诊疗方法等。 (四)医院建立重大手术报告审批制度，有急诊手术管理措施，保障急诊手术及时与安全。 (五)按照《外科手术部位感染预防和控制技术指南(试行)》要求指导并规范外科手术部位感染的预防与控制工作，手术预防性抗菌药物应用的选择与使用时机符合规范。 (六)手术的全过程情况和术后注意事项及时、准确地记录在病历中;手术切除组织必须做病理学检查，明确术后诊断。 (七)做好患者手术后治疗、观察与护理工作,并记录在相应的医疗文书中。 (八)科主任、护士长与具备资质的人员组成质量与安全管理小组，有适用质量与安全管理核心制度、岗位职责、操作规范与质量安全指标，加强围手术期管理，保障患者安全，建立“非计划再次手术”的监测、原因分析、反馈、改进和控制体系。 七、麻醉管理与持续改进 owned assets.(five) -social investment to the industry group, to achieve leveraging the development, ensure that the value of stateon, legal consultation, examination and approval procedures, strict regulation of economic activities, attract injection the win principle, in the framework of national policies and regulations, strict inspection and argumentati-mutual benefit, seeking winective integration of resources within the group, the city resources, other industries and regional resources, mutual trust, s, efft of stability and development of the market.(four) to promote the integration of resources. To further broaden their horizonghs, to enhance the competitive strength, walking business road the competition of alienation and characteristics, the pursuikthroung, packaging and publicity of a number of unique, market influence and coverage of the brand, the implementation of key breaof brand, brand value, brand acquisition performance, enhance the competitive strength. Concentrated manpower, careful plannie the brand. To establish brand awareness, awareness of the use their own conditions to develop the correct road, the maximum to avoid investment risk, gain profit.(three) vigorously promot14leapfrog development. nancial policy and tax policy, and actively seek policy, projects and funds, enterprise and industry group mission to promotecy, firal undertakings in the country and the XX policy, especially the policy of industrial development, financial investment poliarket competition.(six) seriously study the policy for policy. Serious research about social support the development of culture optimization and upgrading ability, enhance core competitiveness, adapt to the need of mquality professional management team, hard work, and promote the entire workforce knowledge structure, age structure, structu-t personnel, and strive to build a highquality management managemen-t the same time, according to the need of industrial development, vigorously the introduction of highthe sense of urgency, improve the ability to respond to market competition, improve management and operation of the market. A ition,s of the existing business, firmly establish the concept of the market, enhance the sense of crisis to adapt to market competto strengthen the construction management personnel. Strengthen the management of education and training of cadres and worker