Time flies and the work has come to an end. Looking back at the efforts during this period, there are defects. At this time, we need to write a self-inspection report. I believe everyone is worried about writing a self-inspection report again! The following is the hospital self-examination report (generally 5 articles) I collected for you, hoping to help you.
Hospital self-inspection report 1 according to the spirit and regulations of the relevant documents of the higher authorities, our hospital immediately conducted a major medical quality inspection and made the following summary:
First, strictly control the quality of medical care to ensure medical safety.
1, carry out clinical work in strict accordance with the process and diagnosis and treatment guidelines to ensure medical quality and safety.
2. Strictly implement the doctor's rounds system, and make detailed rounds on the illness records: records of illness analysis, medical treatment and the next diagnosis and treatment plan.
3, strictly implement the management system of medical practitioners.
4, strictly implement the doctor on duty system,
5. Do a good job of "night rounds". "Night rounds" include the follow-up of newly admitted patients and critically ill patients, the results after medical treatment during the day, the analysis and processing of test results, the results of special examinations, the communication of informed consent forms (especially for patients who are about to undergo surgery or invasive examinations), the arrangement of patients who will be discharged tomorrow, and the handling of patients who have been consulted. And hand over the work with the doctor on duty.
6, do a good job of succession. The morning shift and afternoon shift before going to work are particularly important, and critically ill patients must be handed over at the bedside. The doctor on duty every day must refer to the checklist of undergraduate patients in detail after taking over, and handle and review the abnormal results.
7, a consultation system.
8, the department set up a doctor who is responsible for the quality inspection of medical records, spot-check medical records and do a good job of quality control, and correct mistakes in time.
9, according to the feedback information of patient rounds, put forward opinions, found the problem, timely rectification, to avoid making the same mistake.
10, led by the department director every month, learning business, updating new knowledge and progress in diagnosis and treatment.
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12, set up a consultation and discussion system for difficult cases, aiming at improving the overall academic level of all subjects while solving the diagnosis and treatment of difficult cases, and at the same time training doctors and improving their clinical professional ability and level.
Second, implement various systems, strengthen communication between doctors and patients, and enhance understanding between doctors and patients.
1, communication is a very important link.
(1) Do a good job of communication when entering the hospital: let the patients and their families know about the patient's current condition, ask the doctor to explain the condition in detail for critically ill patients, and sign a notice of serious illness (danger) if necessary. Let patients and their families know the names of doctors and nurses and the time of communication.
(2) Communication during hospitalization: illness change, examination results and treatment plan; Especially when there are major changes in diagnosis and treatment, it is necessary to communicate in time. For patients who can't come to the hospital in time during the day, they must give their illness to the doctor on duty, so that the family members of the patients can understand the illness with the doctor on duty.
(3) Communication before discharge: the diagnosis and treatment results of the disease, the time of outpatient follow-up and the possible side effects of drugs, the treatment methods when the condition may change, and the examination items that need to be reviewed.
(4) Communication with outpatients: diagnosis and treatment of diseases, effects and side effects of drugs, follow-up time, etc.
(5) Communication between doctors and nurses: timely implementation of medical behaviors, timely inspection, and timely handling of patient's condition changes, with medical hidden dangers or disputes.
2. Conscientiously implement the signed informed consent. For related treatment, the person in charge must communicate face to face with the family members and patients, explain the necessity, indications, possible risks and complications, medical expenses and time of medical observation or treatment to the family members of patients, and sign an informed consent form.
3. For patients with potential safety hazards, such as critically ill patients, patients with large fluctuations, patients with mental disorders, patients who do not cooperate with medical operations, patients who go out casually, etc., we must do a good job in explaining and obtain the cooperation and understanding of patients' families. When necessary, they should set up full-time escorts and do a good job of handover.
4. The rational allocation of extra beds in departments must have clear goals and directions for the sustainable development of departments on the premise of improving medical quality and ensuring medical safety.
Hospital self-examination report 20xx, under the leadership of the superior health department, our hospital organized the medical staff of the whole hospital to seriously carry out the work of establishing a safe hospital. Strengthen the basic management of hospitals, improve the quality and technical level of medical services, and significantly reduce disputes between doctors and patients; By gradually improving the mediation mechanism of doctor-patient disputes, the doctor-patient relationship will develop more harmoniously and promote the sustained and healthy development of health in our town. According to the requirements of Detailed Rules for Assessment and Scoring of Establishing "Safe Hospital" in Guangdong Province, our hospital specially organized personnel to conduct self-examination and self-assessment, and now the results of self-examination are reported as follows:
Through the development of this work, the practice environment of our hospital has been obviously improved. Our hospital has carried out a number of founding activities this year, and changed the contents of the publicity column of the founding activities in time. Our hospital customized the medical and health report and sent it to the village health station in time at the relevant regular meeting.
First of all, our hospital will check the quality of medical services every month. The medical staff in the hospital have good medical ethics and basic management is in place. Very few medical staff are not standardized in medical documents and need to be improved. In terms of medical services, our hospital adheres to all patient-centered service concepts. Solve problems for patients in time. For medical safety and medical charges, strictly implement the provisions of the higher authorities. The management of drugs and medical devices is also strictly implemented in accordance with relevant laws. Strictly implement the management of job classification and grading, and make records.
Second, there were no internal disputes between doctors and patients, criminal cases and public security cases in our hospital. Safety management related measures are put in place. Our hospital also organized personnel to conduct drills on public emergencies and public health emergencies. And prepare relevant plans.
Third, the internal security organization of our hospital needs to be strengthened, and this work has not yet been put in place. In order to further improve, our hospital has strengthened the contact and cooperation with the local police station.
Fourthly, the special group set up in our hospital regularly investigates the problems between doctors and patients, and the hospital affairs are open, and we are perfect for the reasonable requirements of patients. Respect the relevant rights of patients and implement them after obtaining the written informed consent of patients in relevant aspects. The job satisfaction of patients in our hospital is over 95%.
5. Our hospital has established and improved the long-term mechanism of establishing rules and regulations with hospitals as the main body and system construction as the core, equipped with medical accident prevention system and treatment plan, held lectures on relevant legal knowledge twice a year, regularly conducted annual safety target assessment, held medical safety meetings and kept relevant records.
Six, for some work that has not been done for the time being, our hospital is actively improving.
According to the detailed rules of assessment and scoring for the establishment of "Ping An Hospital" in Guangdong Province, the self-evaluation result of our hospital is basically good!
Hospital self-inspection report 3 According to the Notice of Beijing Municipal Health Planning Commission on Special Supervision of Hospital Infection in District Medical Centers and Primary Medical Institutions issued by the superior, our community health service center organized personnel to conduct a serious self-inspection of all departments. The summary report is as follows:
First, the results of self-examination
1. Our hospital has established a hospital infection management team, which is fully responsible for the monitoring and management of hospital infection, formulated a three-level management system of hospital infection, defined the post responsibilities of each team member, formulated a hospital infection management system, monitoring measures and on-the-job training of hospital infection, organized and implemented hospital infection monitoring measures, and monitored hospital infection regularly or irregularly. Conduct hospital quality control once a month and register.
2. Strengthen the quality control of infection in key departments, such as treatment room, injection room, dressing room, laboratory, stomatology, gynecology and other departments.
3. Disinfect and sterilize all kinds of articles in strict accordance with the disinfection and sterilization operation specifications. And earnestly and regularly carry out disinfection and sterilization effect monitoring, and urge relevant departments to do a good job in the registration and record of disinfection solution replacement, ultraviolet lamp wiping and ultraviolet disinfection.
4. According to the standard of medical waste disposal, we signed a medical waste transfer agreement with Beijing Qing Er Group, collected, temporarily stored and transferred medical waste according to the standardized process, and made handover records to ensure that the medical waste disposal process in our hospital was in place.
5. The treatment room, dressing room and injection room should be cleaned and disinfected daily and registered. Strictly implement the rules and regulations and operating procedures at work, and do a good job in aircrew training every month.
6. The Department of Stomatology strictly abides by the disinfection specifications of stomatology and the disinfection and isolation system of dental diagnosis and treatment instruments, so that one person has one machine, and all the diagnosis and treatment instruments entering the oral cavity must meet the requirements of one person, one use and one disinfection, and the staff should do a good job in personal protection.
7. Hospital infection management team shall perform supervision and inspection duties on the procurement, management and post-treatment of disposable medical supplies. The disposable medical and health care products purchased and used in our hospital have complete "three certificates" with disinfection and sterilization marks, and the production date, expiration date and product packaging meet the requirements. A register should be set up in the drug storehouse, and the articles should be stored in a cool, dry and well-ventilated shelf. Disposable medical supplies should be destroyed and disinfected after use.
Second, the main problems of hospital infection management in our hospital
1. Hand hygiene compliance is not high.
2. The hand drying equipment is not perfect.
3. Lack of medical fabric management system
4. Lack of hospital infection management committee meeting minutes.
Third, the hospital infection management next work plan and corrective measures:
1. Further do a good job in publicity, education and training, strengthen the basic knowledge of hospital infection and hand hygiene knowledge, and improve the hand hygiene compliance of medical staff.
2. Equipped with disposable dry towels
3. Formulate the washing system and management system of medical fabrics.
4. Hold hospital infection committee meetings regularly, and make records in time.
Hospital self-examination report 4 Since the medical and health units in our city launched the anti-smoking activities, our hospital has formulated a series of work plans and systems to publicize the knowledge that smoking is harmful to health through health education theme meetings and hospital staff meetings, so that the staff in the hospital can fully realize the harm of smoking and the significance of smoking ban, and strictly implement the hospital anti-smoking system. No one smokes in public places in hospitals, and the awareness of no smoking is enhanced. The specific report on self-examination of smoking ban in our hospital is as follows:
First, set up a leading group to implement the duty of banning smoking.
In order to promote the implementation of "xx Medical and Health System Comprehensive Smoking Ban Implementation Plan", the leaders of our hospital held a smoking ban mobilization meeting, calling on the staff of the whole hospital to quit smoking and smoking. At the same time, a leading group for banning smoking was set up, with President xx as the leader, Vice President as the deputy leader and functional section chief as the member. There is an office under the leading group, with xx as the director and xxxx as the member. The leading group strictly implemented the smoking ban in our hospital in accordance with the smoking ban regulations of the higher authorities, which effectively controlled the smoking phenomenon in the hospital.
Two, combined with the actual, formulate a smoking ban system.
In order to thoroughly implement the smoking ban implementation plan, create a smoke-free environment for patients and hospital staff, and ensure the health of hospital staff, the smoking ban system of xx hospital in xx city, the smoking ban reward and punishment standard of xx hospital in xx city and the smoking ban evaluation record of xx hospital in xx city are formulated. The smoking ban system clearly points out that all employees in our hospital are forbidden to smoke, and ashtrays are forbidden in all workplaces in our hospital. All employees in our hospital have the obligation to carry out peer education and mutual supervision, and have the obligation to publicize tobacco control for patients and their families. At the same time, reward departments and individuals who have outstanding performance in tobacco control, and punish departments and individuals who violate the system. The establishment of the smoking ban system enables hospital smokers to exercise self-discipline and self-control in the work area according to the regulations, and strive to create a smoke-free environment.
Third, vigorously publicize and improve health knowledge.
Make full use of health education conferences, study sessions, training sessions and other forms, actively carry out anti-smoking publicity and education, improve the anti-smoking awareness of all cadres and workers, cultivate good behavior habits of cadres and workers not to smoke and discourage others from smoking in time, enhance the health awareness and self-protection ability of "inhaled" people, and further improve tobacco control. Incorporate tobacco control publicity materials into outpatient and hospitalization guides, publicize medical knowledge that smoking is harmful to health, warn patients, family members and visitors not to smoke in hospitals, vigorously publicize the harm of smoking, and enhance the effect of tobacco control. Let smokers with a history of smoking quit smoking slowly in a smoke-free environment. Since the launch of the activity, more than 5,000 publicity materials on smoking prohibition and quitting have been distributed to patients and their families.
Four, strict supervision and inspection, rewards and punishments.
In order to ensure the implementation of the smoking ban, the whole hospital will realize a smoke-free environment. The anti-smoking office organizes spot checks and surprise inspections every week, focusing on the establishment and implementation of the anti-smoking system in various departments, and timely issues the problems found in the inspection to all departments for timely rectification. For example, if a hospital employee is found smoking in the workplace, he will be given a verbal warning for the first time, a serious warning for the second time, and a bonus will be deducted for the third time (the initial amount is 50 yuan, and the deducted amount will be 2 times of the previous amount every time, which will be accumulated every month and deducted from the personal bonus of that month); Those who violate the tobacco control regulations for more than three times (including three times) within one year will be recorded in the tobacco control evaluation reward and punishment record form, and the evaluation qualification of that year will be cancelled. In addition, our hospital has also set up the "Outstanding Smoke-free Department Award", which gives 500 yuan an annual award to departments that have not violated relevant regulations.
Since the "smoke-free" activity in our hospital, the effect of smoking ban is very obvious. It not only promoted health education and spiritual civilization construction, but also improved the awareness of workers and social smokers on the health hazards of tobacco, and improved the self-control of hospital workers to refuse cigarettes. In order to create a good smoke-free environment and promote the physical and mental health of all hospital staff, some achievements have been made. In the future work, we will continue to do a good job in smoking ban and strive to open up a clean, beautiful and pure healthy environment.
Hospital self-inspection report 5 (1), organization and management
1. Hospitals practicing according to law strictly implement medical and health laws, regulations and rules, and engage in diagnosis and treatment activities in strict accordance with the subjects specified in the Practice License of Medical Institutions. There is no out-of-range practice except that health technicians are engaged in diagnosis and treatment activities, and practicing doctors and nurses have been registered according to regulations. The hospital has no external rental or contracting departments, and there are no false and illegal medical advertisements.
The hospital has established and improved the rules and regulations, the job responsibilities of employees at all levels and the core medical system. Most staff members are familiar with their job responsibilities and related rules and regulations, and have established and improved 13 medical core systems. The hospital has compiled medical and health laws, regulations and rules and distributed them to all departments, and organized regular or irregular study. All staff members are trained at least once a year.
Medical staff can follow the main laws, regulations, rules, norms and conventions related to their practice in clinical diagnosis and treatment activities. The hospital carried out an inspection of the laws and regulations of the department and their implementation, and rectified them in time when problems were found.
2. Hospital administrative organization and management mechanism The hospital implements the president responsibility system and the hospital is managed at two levels. The president and vice president have clear division of labor, clear responsibilities of all functional departments, and perfect management systems and processes. The organization chart can reflect the management level of hospital leaders, functional departments and clinical departments, and establish a unified coordination mechanism for all functional departments with coordination records. The management organization is set up reasonably and runs efficiently, which can meet the needs of various hospitals.
The hospital has established and improved the open system of hospital affairs and the system of workers' congress. Major issues have been discussed and approved by the workers' congress. According to the requirements of the Ministry of Health and the Provincial Health Department, the system of open hospital affairs and open branch affairs is implemented. The survey of employees' praise for management organizations and hospital leaders is ≥85%.
3. The number of doctors, nurses and other health technicians in the human resources hospital meets the specified requirements, and the third-level doctors' rounds and the first-and second-line duty personnel can meet the clinical needs. The ratio of beds to nurses in wards is 1:0.53 (the ratio of beds to nurses in orthopedics is 1:0.6), and the ratio of beds to nurses in ICU is 0.04: 1. The ratio of nurses who have received professional training meets the specified requirements.
The educational background, professional title and age structure of health technicians are reasonable. The ratio of beds to health technicians is 1: 1.06, and medical, inspection and release professionals have corresponding academic qualifications and titles. The proportion of on-the-job professional and technical personnel to the number of employees and the proportion of middle and senior technical personnel to the number of health technical personnel basically meet the specified requirements.
All major professional departments have academic leaders with deputy senior titles or above; The hospital strengthens talent management, strengthens the training of young and middle-aged backbones, and ensures that experts can enter, stay and use. In recent years, there has been no phenomenon of experts and young and middle-aged backbone leaving their jobs.
Implement and improve the system of continuing education for medical staff, the management of continuing education meets the requirements of superiors, and implement the pre-job training for new employees to ensure the smooth development and completion of continuing education for medical staff.
4. Scientifically plan the development, new construction, reconstruction and expansion of the hospital, which is proved to be in line with the regional health planning and approved by the health administrative department. According to the level, function and task of the hospital, the development plan and annual plan of the hospital for 3-5 years are formulated and effectively implemented. The annual work summary can accurately reflect the completion of the plan.
(2) Information management
The hospital established and improved the hospital management information system and realized the hospital information management. The hospital information system can timely, accurately and systematically collect, sort out, analyze and feed back relevant medical quality, safety, service and cost information, and can meet the needs of hospital management, clinical work and health administrative departments at all levels for hospital statutory statistical information.
The operation of hospital information system is basically stable and safe, which can not completely guarantee that the workstations connected to LAN can meet the requirement of "avoiding direct connection with the Internet". Anti-virus measures have been established, anti-virus and firewall software and hardware have been installed, anti-virus software has been upgraded regularly, and backups have been made in different places. Establish technical consultation channels between telemedicine and superior hospitals.
(3), financial management
1), hospital finance adheres to the principle of "unified leadership and centralized management", and all financial revenue and expenditure activities are brought into the unified management of the financial department. In accordance with the Accounting Law, Hospital Accounting System, Hospital Financial Formulation and relevant state regulations, set up accounting subjects, establish accounting books, conduct accounting and prepare accounting statements.
There are no off-balance-sheet accounts and "small treasury" in various departments within the hospital. The audit department of the superior competent unit regularly and irregularly inspects the "small treasury", and the on-the-job financial personnel are qualified and have the post responsibility system for accounting personnel. Open and use bank card numbers in accordance with financial regulations. Established the hospital financial accounting management information system.
2) Major projects shall be submitted for approval according to the prescribed procedures after collective discussion. The implementation of the leadership responsibility system and accountability system for major economic issues, the responsibility lies with people. An effective internal control system for financial accounting has been established and improved.
3), the implementation of hospital internal cost accounting, strengthen the management of drugs, materials, equipment and other materials, and gradually standardize the hospital internal cost accounting system, and strive to reduce the cost of medical services and the consumption of drugs and materials. There is a procurement management system for drugs, equipment, reagents and consumables. A leading group for cost accounting led by college leaders was established. In order to set up cost accounting separately, the consumption of drugs, sanitary materials, low-value consumables and other materials can follow the accrual basis principle and can basically be calculated according to the actual amount of the month. Be able to clearly define the business income and cost expenses corresponding to accounting entities, cost centers and their economic activities.
(4), safety management
(1) equipment management implements scientific equipment management, and the purchase of large-scale equipment has undergone strict feasibility demonstration.
Large-scale medical equipment that belongs to Class A and Class B as stipulated in the Measures for the Administration of Configuration and Use of Large-scale Medical Equipment shall apply for configuration license in accordance with regulations. The hospital has formulated the Measures for the Management of Medical Equipment, which strictly follows the regulations to purchase, put in storage, maintain, repair, update and scrap equipment (including consumables). The intact rate of rescue equipment (emergency department, ICU, operating room, etc.). ) is 100%. Ask the clinical department for equipment management opinions regularly and irregularly, and make timely improvement.
(2) Logistics management Logistics support can meet the needs of clinical work, and can provide water, electricity, gas, clothing and related facilities for the hospital actively and timely, and carry out timely maintenance. Seriously implement the national environmental protection laws and regulations, set up a sewage purification system, and the domestic water meets the national standards without secondary water use.
Can provide nutritional dietary guidance. Capital construction projects shall be submitted for approval, bid invitation and organized for implementation in accordance with state regulations. There is no dangerous building in the workshop of the whole hospital.
(III) Drug Administration The layout of pharmacies and patient waiting areas in hospitals is basically reasonable and the management is standardized. Set up a consultation desk to provide medical consultation services. The hospital has compiled a list of essential drugs and formulated an emergency management plan for sudden drug incidents. Drug management information system can dynamically reflect the use, quality and safety of drugs in real time.
It can provide patients with safe, timely and humanized services.
The hospital formulates and implements relevant systems, such as drug procurement management, selection principles and approval procedures for the introduction of new drugs, and approval management for temporary drug purchases. All hospital drugs are purchased through provincial bidding platform, and the qualification files of drug suppliers are established. The warehousing link was carefully checked and registered, and the blood products with batch numbers, inspection reports and other related materials were filed. No drugs without batch number, expired, deteriorated or invalid were found.
The drug storage meets the standards, there is a drug storage maintenance management system, and drugs are stored in strict accordance with the prescribed conditions. Formulate and implement a system for regularly checking the storage and use of Chinese and western medicine warehouses, outpatient and ward pharmacies, small medicine cabinets in ward treatment rooms, ward rescue vehicles, anesthesiology departments, operating rooms and other medicines.
(IV) Teaching and scientific research management Establish and improve the hospital teaching management organization and management system, undertake the clinical teaching internship tasks of students in Liaodong University, formulate the intern management system, and uniformly manage interns.
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