Work plan of nursing quality control center. Recognize the goal and define the position.
Our unique, warm and comfortable 7,500 square meters office building and the special functions of maternal and child health care in our hospital will bring us unlimited development space. At the same time, the fierce competition in the medical market and the current economic situation have also brought us great pressure. In the face of the coexistence of hope and difficulties, opportunities and challenges, all staff in our hospital should continue to carry forward the spirit of unity, harmony, dedication and innovation, overcome difficulties, seize opportunities, correctly locate the development direction of maternal and child health hospitals in accordance with the policy of medical and health system reform, give full play to their own functional characteristics and advantages, and seek development in the reform. We will fully implement a new scientific management model with medical care as the center, clinical support and management as the guarantee, service as the feature, and maternal and child health needs as the guide, seize opportunities by projects, shape the image with integrity, and take performance as the driving force, vigorously improve the medical level, improve the hospital service ability, improve the overall quality of all staff, and strive to build a characteristic department. Inspired to make our hospital a well-known hospital with characteristics, specialties and expertise, make our hospital the most professional medical and health care center for women and children in our city, achieve greater breakthroughs in economic and social benefits, and provide high-quality, healthy, satisfactory and assured medical and health care services for women and children in our city.
Second, clear objectives and make plans.
(1) goal:
1, improve the quality of medical care and build a hospital that people can rest assured of.
2. Strengthen high-quality service and create a hospital with patient satisfaction.
3. Highlight medical characteristics and create characteristic hospitals.
4. Innovate and develop technology to build brand hospitals.
5, the implementation of performance appraisal, scientific management of hospitals.
6. Strengthen external publicity and create a good image.
7. Strengthen safety measures to create a safe hospital.
8, unity, hard work, progress, and constantly develop the hospital.
(2) Scheme:
1, improve the quality of medical care and build a hospital that people can rest assured of.
Medical quality and safety is related to the health and safety of patients, the lifeline of medical services, and the core content and eternal theme of hospital management. "Take patients as the center, quality as the core and safety as the theme", conscientiously implement various rules and regulations, post responsibilities, strictly implement various diagnosis and treatment technical routines, and implement various systems in all links. Ensure the safety of patients, so that patients are safe, satisfied and assured.
(1) It is necessary to improve various management systems and quality control systems, strengthen the two-level management of hospitals and departments, and further improve the safety awareness of hospital employees. Set up a two-level medical quality management team, composed of business presidents and functional department heads, to control the quality of the whole hospital; Department quality management organization is composed of department directors, head nurses and related members, which comprehensively manages the medical quality of departments.
(2) Strengthen business training. For the development of the hospital and the safety of patients, it is necessary to strengthen the consolidation of professional knowledge and the study of new knowledge. In 20xx, the hospital will organize the examination of basic theoretical knowledge 12 and the examination of medical and nursing technical knowledge 1 2, and organize medical staff to study once a month, using multimedia teaching methods, focusing on practical skills and basic knowledge. If the individual assessment is unqualified, the qualification of the department will be cancelled and linked to the performance appraisal results of the department.
(3) Ensure the writing quality of medical nursing documents. Write medical and nursing documents in a timely, serious and rigorous manner.
(4) Strengthen the management of daily nursing quality and strive to improve the quality of nursing.
(5) Implementing dynamic management of professional and technical titles: those who have participated in study at ordinary times, obtained examination results, mastered new knowledge, new technology, professional level, contribution, performance, democratic evaluation and patient evaluation are preferred.
2. Strengthen high-quality service and create a hospital with patient satisfaction.
Strengthening high-quality service, improving service quality, strengthening the construction of medical ethics, practicing medicine in good faith and being polite to others are the important foundations for establishing a harmonious doctor-patient relationship, reducing disputes between doctors and patients, improving the reputation of hospitals and departments, and then creating a hospital where patients are satisfied. Only by improving patient satisfaction can hospitals achieve sustainable development in today's increasingly competitive medical market.
(1) Facilitate the medical treatment process, optimize the medical treatment environment and provide convenience measures. (1) There are consultation areas on all floors of the hospital, and the consultation personnel introduce the department characteristics and attending doctors to patients, and provide help to the elderly and patients with mobility difficulties; Hospitalized patients are accompanied by nurses during admission and discharge procedures, and various small items are checked in the ward during hospitalization. Make sure that someone (car) will pick you up when you enter the hospital, check that someone is staying, check that someone is accompanying you, send you (car) when you leave the hospital, and visit you when you go home. ② A clean, tidy, warm, comfortable, quiet and orderly medical environment can leave a satisfactory first impression on patients. The leaders in charge of the hospital check and urge the cleanliness of the hospital environment every day; The staff of the whole hospital maintain and promote the good environment of the hospital. ③ Actively promote people-oriented family-oriented and characteristic services.
(2) Carry out smile service, use civilized language and pay attention to communication with patients. A warm smile and a cordial greeting can make patients feel at home, and a relaxed atmosphere is conducive to communication between doctors and patients and improve patients' trust in medical staff. Medical staff greet patients with a smile! Please sit down! Further diagnosis, treatment and nursing operation; Strengthen communication between doctors and patients, improve communication content and improve communication methods. In the process of diagnosis and nursing, we should change from waiting to asking, actively communicate with patients and ask about their situation, pay attention to gentle tone, easy-to-understand language, and pay attention to the use of non-verbal communication methods such as eyes and gestures. In the process of diagnosis and nursing, we should express our concern and respect for patients in time to meet their psychological needs and gain their trust.
(3) Strengthen the construction of medical ethics. Noble professional ethics is the basis of preventing medical disputes and improving the quality of medical care and service. If a hospital wants to gain an advantage in the competition and make great progress, it must establish a team of medical staff with high professional ethics, consciously resist all kinds of unhealthy trends, establish a good social image, comprehensively enhance the comprehensive competitiveness of the hospital and lay a solid foundation for the sustainable development of the hospital. With strict management measures and performance appraisal regulations, the hospital restricts all employees to abide by the rules and regulations of the hospital, take up their posts on time, dress neatly and neatly, and provide enthusiastic, timely and accurate diagnosis, treatment and nursing services for patients. They are not allowed to shirk and contradict patients, charge fees, accept red envelopes, issue false medical certificates and inspection reports without permission. The upsurge of striving for "quality service window" and "quality service model" has been set off in the whole hospital.
Work plan of nursing quality control center 2 I. Work objectives
1, improve the nursing quality standard system, and all work indicators meet the requirements of secondary hospitals.
2. Improve the quality of nursing service in an all-round way, and the patient satisfaction rate is over 95%.
3, do a good job of writing nursing documents, meet the requirements of the specification.
4, strengthen business training, improve business ability.
Second, the implementation measures
1, sort out the nursing work standards and distribute them to all nursing units.
2, quality control committee members and department quality control personnel regularly carry out nursing quality management knowledge training.
3. The nursing department conducts comprehensive target inspection and assessment on the nursing quality of the whole hospital every quarter, and the results are linked to the benefit salary.
4, the nursing department and the quality control committee to determine the focus of weekly inspection, the whole hospital nursing unit ward survey, the results are linked to the benefit salary.
5. The quality control team will check the ward 3-4 times a month, summarize the inspection results and attend the head nurse's regular meeting.
6, the head nurse to do a good job of weekly self-inspection, and fill in the work self-inspection form.
7, continue to implement the system of nurses' long night rounds, and check the quality of care at night and holidays.
8. Conduct a patient satisfaction survey once every quarter, and feedback the results at the head nurse's regular meeting, and give timely answers and solutions to the problems reflected by patients.
9, hold a nursing error and accident analysis seminar once a month.
10, pointing out nursing defects on the spot, correcting them immediately, and reporting major problems to the nursing department in time.
1 1. Strengthen business training, standardize technical operation and standardize basic theory assessment.
12 years, if an individual makes mistakes more than three times in a year, the nursing department will give him a face-to-face warning and financial punishment.
Work plan of nursing quality control center 3 1. Basic nursing and specialty, primary, secondary and tertiary nursing.
1, strengthen the quality of ward layout in the morning and evening, strengthen the implementation of basic nursing contents, and continuously improve the ward environment.
2, strengthen the nurse on duty to inspect the ward, ask to master the eight tips in charge of patients.
3. Strengthen the supervision, inspection, rectification and feedback of the nursing team leader on the implementation of basic nursing.
Second, the ward, drug management
1. Strengthen the management of wards, nurses' stations and warehouses, and implement the responsibility to people, high-risk drugs and spare drugs.
2. Drugs in the refrigerator are special, and sundries are strictly prohibited. Check the temperature of the refrigerator every shift every day and make records.
3, strengthen the daily ward bedside table, pager, bedside equipment cleaning work, do a good job of patient's belongings.
Third, first aid drugs and equipment.
1. Record the shift change of emergency medicine and equipment. The responsible nurse makes daily inspections and the head nurse makes weekly inspections to ensure that the first-aid drugs and equipment are in an emergency state at any time.
2. Nurses should be familiar with the names, functions and usage of various first-aid drugs.
3, put an end to the existence of expired drugs and articles, strengthen the management of drugs and equipment.
Fourth, quality care.
1. The responsible nurses should strengthen the health education for patients, and publicize the disease-related knowledge and complications.
2, the implementation of the overall nursing responsibility system, the responsibility of nurses to master the patient's condition, psychology, treatment and so on and so forth.
3. Strengthen the spot check on the implementation of holistic nursing, and analyze and rectify the problems existing in the inspection.
4, daily telephone follow-up, public holidays discussion, satisfaction evaluation and other methods, collect suggestions from patients during hospitalization, actively grasp the needs of patients, solve problems in time, and improve patient satisfaction.
Five, nursing document writing
1, strengthen the supervision and inspection of quality control management team, strengthen the responsibility of responsible nurses, reduce the rate of missed doctor's orders, and strengthen the timely and accurate writing of nursing documents.
2. Strengthen the training of nursing document writing and improve the connotation quality of nursing document writing.
3, completes the patient's health education, key, special education content fully reflected in the nursing documents.
4, the head nurse strictly control the quality of medical records, timely check the medical records, the existing problems in a timely manner to hold department meetings, the implementation of improvement measures.
Six, safety management
1. Regularly train nursing staff on safety knowledge, strengthen their safety awareness, and conscientiously implement patient safety target management.
2. Strengthen the study and evaluation of management knowledge, processes and measures for pressure ulcers, bed falling and falls, implement nursing measures, and improve nurses' overall nursing ability for patients.
3. Strengthen the research of wristband identification system, strengthen the application of safety warning signs and warm tips, and implement refined management, such as safety warnings such as falling off the bed and falling.
4, strictly implement the grading nursing management system, especially the night shift, holiday ward patrol, timely find problems and solve them in time.
5, conscientiously implement the system of succession, strengthen the content, method and rigor of succession, reduce the link security risks.
6, strengthen the safety management of perioperative patients, strict surgical handover, do a good job of skin, heart, tube, medicine, vital signs and so on.
7. Strengthen the quality management of critical value projects, carefully register and report in time.
8. Improve the real-name signature of various treatment execution forms, implement the system of who executes and who signs, and complete the daily and weekly inspections of nurses.
9, strengthen the ward oxygen, electricity safety, public toilet ` water safety and the whole ward anti-theft safety awareness, do a good job in hospitalization education.
10. Strengthen the safe use of various instruments in the department, such as ECG monitors and electrocardiographs, and conduct regular tests.
1 1, strengthen the management of nursing defects and nursing disputes, strictly supervise all work links, find potential safety hazards, handle them in time, and nip nursing errors in the bud. Departments timely discuss and analyze nursing defects and errors.
12, strengthen communication and cooperation between nurses and patients, nursing skills and medical care, reduce obstacles and ensure safety.
Work plan of nursing quality control center. The service of nursing work is ultimately embodied in ensuring the life safety of patients. According to the requirements of "quality, safety, service and cost" in hospital quality management, quality management must run through the nursing work. Therefore, this plan must closely focus on the main line of quality, according to the hospital and nursing work plan:
First, the quality control principle of nursing quality:
Our hospital implements quality management monitoring under the leadership of head nurses, continuous improvement of nursing quality, full implementation of quality control forward, strengthening special quality control, implementing dispute defect management, implementing safety early warning management, and continuously carrying out group activities.
Second, the nursing quality management implementation plan:
(A) to further improve the nursing quality standards and workflow.
1, combined with clinical practice, constantly improve the quality control system, and further improve the assessment content and scoring standard of nursing quality, such as basic nursing, disinfection and isolation, writing of nursing documents, nursing quality in supply room and operating room, etc. Ward management, basic nursing, special first-class nursing, disinfection and isolation, writing of nursing documents, management of first-aid articles, nursing safety management, etc. , monthly nursing quality evaluation and analysis, and formulate corresponding corrective measures.
2. The head nurse should supervise and urge to correct the problems existing in nursing work at any time, and announce the outstanding problems at the morning meeting, so that the nurses can understand the existing problems and solutions.
3. Check all kinds of articles and medicines and ambulances regularly every month, and find out expired articles and medicines in time. Ensure medical safety.
(2) Establish an effective nursing quality management system and cultivate a good nursing quality management team.
1, play the role of nursing quality monitoring group, pay attention to link quality control and track the rectification effect of key problems. The principle of combining peacetime inspection with quarterly inspection and combining key inspection with comprehensive inspection shall be implemented. The nursing department scores the quality control summary once a month and puts forward solutions.
2. Strengthen the implementation, supervision and inspection, and pay attention to the quality supervision of nurses' operation process. Pay special attention to three-level quality control management, so that everyone can participate, manage at different levels, ensure quality, give full play to the role of nursing quality controllers, and all staff can participate in nursing management, with inspection records, analysis, evaluation and improvement measures.
3. Improve the system and responsibilities of nursing quality control management committee, discuss and analyze the difficult problems existing in nursing, and put forward effective rectification measures.
4, strengthen the management of nursing defects, nursing disputes, adhere to strict supervision of the quality of work in all aspects, find potential safety hazards, and take timely measures to eliminate nursing errors and accidents in the bud. The nursing department discusses and analyzes nursing defects and errors in time.
5, strengthen the training of medical and nursing laws and regulations, in order to improve the legal awareness of nursing staff, nursing according to law, and protect the legitimate rights and interests of patients and nurses.
6, establish and improve the safety early warning work, timely find hidden dangers in the work, and put forward improvement measures.
7. Check the writing of nursing documents every day. The discharge medical records will be reviewed by the head nurse, and finally submitted to the medical record room by the head nurse.
8, strengthen the normal operation and assessment of nursing staff. Find the problems in operation and correct them in time.
Work plan of nursing quality control center 5 In order to improve the quality of outpatient nursing service in our hospital and ensure the safety of patients, this year's outpatient nursing service will be carried out around the implementation plan of "further improving medical service action plan" and the construction of Ping 'an Hospital. Provide people with safe, effective, convenient and cheap basic medical and nursing services. Let the people seek medical treatment conveniently, safely, effectively and clearly. According to the detailed rules of the hospital nursing quality management committee, the medical quality evaluation standard of the secondary general hospital, and the 20xx nursing quality and safety management work plan of the nursing department, the outpatient nursing quality and safety management work plan was formulated.
First, the principle of quality control
Implement the second-level quality monitoring of nursing department-head nurse under the leadership of the director, strengthen special quality control and safety management, and promote the continuous improvement of nursing quality.
Second, the work objectives
1, the qualified rate of "three basics" assessment for nursing staff (qualified score is 70 points) ≥ 100%.
2, nursing technology operation qualified rate (90 points) 95% or higher.
3, nursing staff to participate in continuing education qualified rate of 95% or higher.
4, high quality nursing quality examination qualified rate (qualified score 90 points or higher) 95%.
6. The intact rate of first aid articles 100%.
7. The qualified rate of disinfection and isolation is 100%.
8. Health education coverage rate 100%
9. The effective rate of health education is ≥90%.
10, qualified rate of medical waste treatment 100%
1 1, one person, one needle, one tube, one towel, one belt and one disinfection implementation rate 100%.
12, qualified rate of nursing quality assessment standard in injection room (qualified score is 90 points) 100%.
13, hand hygiene coincidence rate ≧90%
14, core system implementation rate 100%
15, the patient's satisfaction with nursing work is ≥90%.
16, nursing error rate
17, and the attendance rate of guiding doctors 100%.
Three, nursing quality nursing safety management implementation plan is as follows:
According to the requirements of "Evaluation Standard of Nursing Quality in Secondary General Hospitals", "Action Plan for Further Improving Medical Services", "Ten Safety Goals for Patients" and "Construction of Safe Hospitals", we will further improve various quality standards and improve the level of outpatient service.
1, strengthen the training of the service ability of the nurses who guide doctors and triage, and reflect the good spirit of our hospital. Dress neatly and regularly, wear badges, and the medical staff are easy to understand, friendly and enthusiastic, showing respect for patients and good medical ethics. Reasonable allocation of outpatient hall staff, effective guidance and diversion of patients.
2. Keep the environment clean and tidy, and create a warm medical environment. Do a good job in improving the environmental sanitation of the treatment area, strengthen the environmental management of the waiting area, consulting room and bathroom, and keep it quiet, clean, safe and comfortable. Meet the requirements of smoking ban in public places.
3. Set up eye-catching signs. Street signs, floors, departments and safety signs are eye-catching and easy to identify.
4. Provide facilities. Improve self-service reservation, registration, inquiry and other services, and provide patients with drinking water, emergency telephone, wheelchair, pen and paper and other facilities; Improve barrier-free facilities.
5, continuous improvement of nursing service, the implementation of quality nursing requirements. Full coverage of outpatient service: In the departments of medical guidance, triage, injection room, etc., the responsible nurses fully perform their nursing duties and provide holistic physical and mental care for patients according to their disease characteristics and physiological, psychological and social needs. Pay attention to humanistic care and psychological counseling. Strengthen humanistic education and training for medical staff, and improve communication skills and service awareness.
6, triage nurses to do triage work. The implementation of the "one room, one doctor and one patient" diagnosis and treatment system, in the outpatient clinic, treatment room, examination room set up privacy protection facilities. Protect patient privacy.
7. Strengthen the services of social workers and volunteers. Cooperate with hospitals to improve the professional construction of social workers and volunteers. Actively carry out social workers and volunteer services, giving priority to providing guidance and consultation, maintaining order, psychological consultation, health guidance, rehabilitation and other services for the elderly, young people and disabled pregnant women. Give full play to the role of social workers as a bridge and link in doctor-patient communication.
8. Properly resolve medical disputes and build a harmonious doctor-patient relationship. Standardize the management of outpatient complaints. Provide effective channels to facilitate patients to complain. The outpatient director and the head nurse are responsible for handling and feedback of patients' complaints, timely handling and feedback of patients' strong problems, and urging rectification and continuous improvement of patients' concentrated problems.
9. Strengthen hospital infection control knowledge training, conscientiously implement disinfection and isolation measures, and strengthen hospital infection management in several key departments such as dermatology treatment room, outpatient surgical examination room and outpatient injection room. Strictly implement the medical core system and technical operation norms to prevent hospital feeling and accidents.
10, extensive health education. Educate and publicize the knowledge of prevention and treatment of common diseases, frequently-occurring diseases, chronic diseases and various infectious diseases that seriously affect people's health.
1 1, strengthen the management of production safety. Set eye-catching safety warnings for dangerous, flammable, explosive, toxic and harmful substances and radioactive sources. Increase emergency ability and first aid knowledge and skills training. Carry out extensive safety education to improve the personal safety awareness of outpatients. Notify the police and complain about the phone. The emergency treatment of outpatient service mainly includes sudden fire, earthquake, water cut-off, power cut-off, public health emergencies and outbreak of infectious diseases. First of all, do a good job in emergency training, so that once an emergency occurs, it can be handled correctly and the harm can be minimized. According to the requirements of the overall management leading group, formulate the annual nursing safety management work plan, and constantly improve the outpatient nursing safety management system and various emergency plans.
12, strengthen the three-basic training and first-aid ability training of nursing staff at all levels, improve the working ability and professional technical level of nursing staff and their ability to cooperate with critical illness rescue.
13, conscientiously implement the functions and responsibilities of two-level quality control. The quality control team of the department checks the quality weekly, the head nurse checks it once a month, and the nursing department conducts a comprehensive nursing quality inspection once a month. Every inspection has records, feedback and improvement measures, and the key issues are follow-up inspection to ensure the continuous improvement of nursing quality.
14, in strict accordance with the requirements of writing medical documents, improve the registration of various documents and forms.
15, strengthen the ability training of quality control personnel and head nurses, and apply five-routine method, QCC, PDCA and other quality management tools to continuously improve the quality of nursing.
16, further implement the performance appraisal system. Use the incentive mechanism to fully mobilize the work enthusiasm of each nursing staff.
17, the department held a discussion and analysis meeting on nursing adverse events once a month to discuss and analyze the potential safety hazards and nursing defects existing in the department, sum up experiences and lessons, and formulate rectification plans to prevent nursing errors and accidents. And timely feedback the spirit of the monthly meeting of the nursing quality and safety Committee and the discussion and analysis meeting of nursing adverse events held by the nursing department, share the experience and lessons of nursing work in the whole hospital with you, and play a warning role.