Looking back on the work in June, under the correct leadership of the board of directors and the superior departments, and with the joint efforts of Comrade Qi Xin, we adhered to the theme of taking patients as the center, comprehensively improved the quality of medical care, and paid close attention to the implementation of standardized management and medical core system. All the work was promoted in an orderly manner and achieved gratifying results, but there was still a gap from the requirements of the board of directors. I will report my work in June to the board of directors and the staff of the whole hospital as follows:
The first is the development of medical business and economic income.
1, medical business:
In June, the total number of inpatients 1, 7 1, discharge 1, 75, and 25 operations.
There were 400 outpatient visits, and 50 children were hospitalized to enjoy rehabilitation medical insurance.
2. Economic income:
The hospital's total income in June was * * million yuan, including medical insurance hospitalization income of nearly * * million yuan (municipal * * million yuan, development zone of * * million yuan, South New District of * * million yuan), medical insurance outpatient income of * million yuan, cash outpatient income of nearly * million yuan.
Medical business and economic income have increased compared with last month, but they have not yet reached the predetermined target.
Second, strengthen management and comprehensively improve the quality of medical care.
Medical quality is the core, lifeline and eternal theme of hospital management. Only by establishing this concept can the scientific development of hospitals be realized. In June, we will focus on medical quality, strengthen management, find out potential safety hazards and formulate medical safety measures.
1. Strengthen medical safety work, improve medical safety organization and management, formulate weekly rounds system, clarify responsibilities and requirements, and put measures in place to ensure medical quality and medical safety.
2. Strengthen training to improve the medical quality and safety awareness of medical staff. Take various forms, comprehensively carry out medical personnel training, focus on a medical record writing standard training, standardize medical record writing, strengthen medical record writing quality management, and report the problems existing in medical record examination. Although the quality of medical records has improved, there is still a certain gap according to relevant standards. At the same time, organize all nursing staff to learn business, the main content is the form, skills and methods of doctor-patient communication. Strive to improve the quality of nursing and establish a harmonious doctor-patient relationship. At the same time, organize the "three basics" examination for medical staff, and enhance the medical level and quality of medical staff through the examination.
Third, strengthen the construction of professional courses and highlight the characteristics of rehabilitation.
Rehabilitation department is a characteristic department of the hospital. In June, on the basis of previous achievements, the rehabilitation department further strengthened the management and service concept construction of the department. Regularly carry out professional study for all rehabilitation teachers, formulate the system of children's rehabilitation rounds, and improve the operational norms of rehabilitation technology. In June, adult rehabilitation treatment 18 1 person, including acupuncture treatment 145 people, rehabilitation treatment 180 people, fire treatment 15 people, massage treatment 60 people, and 65 children who are currently undergoing children's rehabilitation training actively welcome the children's rehabilitation organized by the Municipal Disabled Persons' Federation.
Fourth, strengthen pharmacy management.
A, clean up the pharmacy accounts, check the accounts, small inventory every day, the end of the month inventory, careful accounting, careful inventory, to ensure that the accounts and goods are consistent. The second is to establish and improve the drug procurement system and the management system of various rules and regulations, do a good job in the purchase, sale and storage of pharmacies, sort out accounts and calculate income.
Five, administrative logistics work, to provide protection for the development of the hospital.
Administrative logistics work around the clinical front line and establish the concept of "everything is a front line and everything is clinical". The first is to improve the diagnosis and treatment environment, strengthen the management and supervision of environmental sanitation, and achieve normalization. Second, large-scale medical equipment, such as DR, blood biochemical analyzer and coagulation analyzer, has been added, with an investment of nearly 500,000 yuan. At present, the equipment has been installed in place, which has played a great role in clinical medical service and expanded the external influence of the hospital. The third is to complete the removal of the prosthetic orthosis.
The financial department conscientiously implements the financial work system, actively participates in the management of medical cost accounting, and completes business revenue and expenditure, budget and economic accounting.
Problems and shortcomings of intransitive verbs
While affirming everyone, I have to point out that on the basis of May, the work of the hospital in June did not make much breakthrough and progress, and did not reach the expected state. There are some problems in the work of various departments, mainly including:
1, there is a big problem with medical documents:
1, the outpatient register is incomplete.
2, medical record writing is not timely, such as admission record is not completed within 24 hours, course record is not completed within 8 hours.
3. The principle error caused by the act of copying medical records, such as the patient's gender, and the superior doctor's rounds Zhang Moumou copied into Li Moumou, which led to the principle error.
4. The current medical history is too simple, 80 words is not enough, and there is no main symptom and diagnosis process of the disease.
5, doctor-patient communication is insufficient, the content is not substantial, not timely, should be finished within 2 hours.
6, doctor's advice prescription writing is not standardized, such as cefradine for injection, only write cefradine, etc.
7, superior physician rounds record Shen Qian is not timely, should be completed within 48 hours.
2. The shortcomings of nursing home feeling are:
1, some accounts have not been established, there is no quality control organization, and there is no self-inspection and record.
2, individual wards, bedside table is not neat, sundry, messy, bedside card placement is not standardized.
3. Health education is not in place, and admission education and discharge guidance are not in place.
For example, some patients adjust the infusion speed by themselves, and don't know what to pay attention to in the disease diet.
4. Individual nurses lack a sense of responsibility in their work and can't implement various rules and regulations well. At work, there is also the phenomenon of absent without leave and playing with mobile phones.
5. Individual nurses pay little attention to the examination of "Three Basics", and the qualified rate of theoretical examination is low, so the operation process still needs further practice.
Work ideas in July and July
1. Improve the humanistic quality of medical staff and strengthen the service concept.
Pay attention to the construction of hospital culture, create high-level service concept and humanistic care, and shape the brand of hospital culture. Change the service concept, adhere to the interests and convenience of patients as the center, and provide cordial and enthusiastic service. Resolutely put an end to the "three noes": put an end to the phenomenon of no language, no title and no expression in service, always establish and fully embody the service concept and requirements of "care, responsibility and technology" and build a hospital service brand.
2. Strengthen market expansion and mobilize all employees to carry out pain rehabilitation business.
At present, the marketing department has not been really developed. The hospital features orthopedics, pain department and rehabilitation department. The key work of the hospital in the next stage is to mobilize all staff to open up markets for pain patients and rehabilitation patients, and to carry out radio frequency, ozone and other treatment projects.
3, actively meet the health check, improve the ledger information.
4. Establish a general duty system, with the dean on duty every Sunday.
Over the past six months, under the correct leadership of the district party committee and county government, and under the care and guidance of the district health bureau, our hospital has conscientiously studied and implemented the spirit of the xx Congress of the Communist Party of China and the Third Plenary Session of the xx Congress, fully implemented the Scientific Outlook on Development, carried out in-depth activities such as "Hospital Management Year", improved service attitude, improved medical quality, standardized medical behavior, promoted the harmony between doctors and patients, successfully completed various objectives and tasks, and comprehensively promoted the scientific development of the hospital. Now it is reported.
I. Indicators of completed work
1, outpatient visits; Compared with the same period last year%;
2, emergency person-times; Compared with the same period last year%;
3. Receiving the number of inpatients; Compared with the same period of last year, it increased by 10%;
4. Number of operations; Compared with the same period of last year, it increased by 10%;
5. Bed utilization rate%, down% compared with the same period last year;
6. Average hospitalization days; Compared with the same period last year, it decreased by 20%;
Second, the main work carried out in the year
(a) improve the quality of medical services, improve the level of medical services.
The first is medical work. Continue to adhere to the medical management concept of "patient-centered, improve the quality of medical services", comprehensively strengthen medical quality work, firmly establish quality awareness, continuously improve the overall level of medical care, and improve hospital hardware construction (such as providing electronic anorectal mirror detector and hemorrhoid pph therapeutic instrument for clinical frontline); Combined with the actual work of the hospital, the medical system of 13 hospital has been further improved, and the monthly "three basics and three strictness" assessment has been strictly implemented, requiring medical staff to consciously implement such important systems as the first-visit doctor responsibility system, the third-level doctor rounds system, the preoperative discussion system for difficult and critical cases, and the three-check and seven-level medical care. Increased management supervision and evaluation of important departments and links, and conducted more than 20 medical rounds, each time 13 departments; Adhere to the weekly morning meeting system, summarize and analyze last week's work, arrange and deploy a new week's work, study and rectify specific problems, and effectively reduce medical errors; Strictly implement the "Medical Record Writing Standard", evaluate, publicize and file medical records once a month, and keep the rate of Grade A medical records above 96%; The Medical Department organized 9 short-term business trainings, participated in 2 medical academic seminars and hired experts to teach 4 times. Further improve the hospital infection management system, effectively control the adverse events in medical services, and ensure the treatment and treatment effect of patients.
The second is nursing work. In XX, the nursing department took the Detailed Rules for Comprehensive Evaluation of Hospital Management in Hubei Province as the standard, focused on nursing quality management, strengthened the quality education and professional skills training of nursing staff, started from the basis of nursing work, and insisted on holding a nursing quality analysis seminar every quarter to analyze the existing problems on time and put forward improvement measures, which was conducive to the effective development of nursing work. All the nursing quality indicators in the whole year have been improved compared with last year. For example, the compliance rate of basic nursing and critically ill patient care is 90%, the compliance rate of holistic nursing and ward management is 95%, and the compliance rate of various nursing technical operations and system implementation is 100%. Organize nursing business training and study 6 times and nursing business examination 6 times throughout the year. The qualified rate of nursing staff's mastery of nursing rules and regulations, post responsibilities and emergency plans reached 95%, and the implementation rate of nursing core system reached 96%.
The third is hospital infection. According to the evaluation standard of hospital infection management, the hospital infection department regularly evaluates and checks each department and feeds back the results to each department; Regularly check and supervise the implementation of disinfection and isolation system in clinical departments and the use of disposable medical and health supplies. Sampling tests were carried out in 2 18 clinical and key departments in our hospital throughout the year, and 2 18 were qualified, with the qualified rate of 100%.
(B) patient-centered, building a harmonious doctor-patient relationship.
The hospital always adheres to the principle of "patient-centered", and always regards the realization and maintenance of people's life, health and safety as the starting point and the end result of implementing Scientific Outlook on Development.
One is to hold a big discussion and speech contest on "If I were a patient" to promote medical staff to improve their working methods, change their service attitude and improve their service level.
The second is to carry out one-stop outpatient service, carry out the activities of "comparing speed, quality, service and evaluation results" and optimize the service process.
The third is to promote "humanized, personalized and affectionate" services. For example, patients who are treated with infusion in the outpatient clinic at noon will be given a free lunch to xx people; More than 600 free trips were provided for women who gave birth, so that patients could feel the care of their loved ones.
The third is to strictly implement the national drug price policy and medical service charging standards, so as to achieve "treatment due to illness, reasonable examination, rational drug use and reasonable charging" and let patients feel "open, transparent and honest service". More than 20 single-disease price-limiting services such as natural delivery, cesarean section, myomectomy, cholecystectomy for chronic cholecystitis with gallstones, simple appendicitis and nodular thyroid tumor resection were introduced to the society, with a cumulative reduction of 65.438+56 billion yuan.
(3) Strengthen the internal management of the hospital with scientific management mechanism.
Combined with the in-depth development of hospital management year activities, our hospital takes improving medical level and service quality as the main line, clearly implements post responsibilities and target responsibilities, and makes hospital management reach a new level, mainly in the following aspects.
1, continue to carry out the annual activities of medical service quality management. Through this activity, the staff of the hospital will further establish the consciousness of medical quality first, truly put the improvement of medical service quality in the first place in medical work, and take medical quality as the starting point and the foothold of all work, thus forming a good situation in which everyone in the hospital pays attention to medical quality everywhere. Further strengthen the rules and regulations of medical quality and medical safety, the responsibilities of personnel at all levels and various technical operating procedures, gradually institutionalize all work, clarify responsibilities, standardize technology, and establish a long-term mechanism to ensure the medical quality of our hospital to a new level.
2. Further strengthen and standardize system management. Focus on financial management, pharmacy and storeroom management, medical equipment and consumables management, and office logistics management, and do a good job of self-management while ensuring non-business functional departments and regulatory service functions.
3. Strengthen theoretical education and guidance, extensively carry out education on medical ethics, industry discipline, laws and regulations led by Scientific Outlook on Development in the whole hospital, constantly enhance the political awareness, overall situation awareness and responsibility awareness of the broad masses of cadres and workers, and actively promote the improvement of the overall quality of the broad masses of workers.
(4) Demonstrate public social responsibility and play the role of public service.
Based on the principle of basing itself on the society and repaying the society, our hospital always puts social benefits first, starts with public welfare undertakings, solves problems for the people, and strives to alleviate the problems of difficult and expensive medical treatment for the people.
First, more than 20 single-disease price-limiting services, such as natural delivery, cesarean section, myomectomy, cholecystectomy for chronic cholecystitis with gallstones, simple appendicitis and nodular thyroid tumor resection, were introduced to the society, and the accumulated fee was reduced by more than 280,000 yuan.
Second, in view of the three common high-risk diseases of women (hysteromyoma, mastopathy and cervical diseases) and the three major cancers (breast cancer, cervical cancer and endometrial cancer), our hospital and the Municipal Health Bureau jointly launched the "Women's Disease Prevention Project" during the "March 8" Women's Day, and carried out the "three high and three cancers" screening activities for more than 3,000 women free of charge, with a cumulative exemption amount of more than 600,000 yuan.
Third, during the "Labor Day" period, we jointly carried out a public welfare activity of "promoting dedication and caring for the health of model workers" with the * * Municipal Federation of Trade Unions, and provided free medical examination packages worth 380 yuan to model workers in the city, with a free amount of * * million yuan.
Fourth, in May 12, we jointly established the * * breast disease prevention and treatment charity fund and the * * charity clinic with the * * Charity Federation. More than 65,438+0,500 free breast examinations were provided to women, and more than 20 cases were assisted in surgery. The "charity clinic" provides free surgery for 5 poor households, five-guarantee households and laid-off workers, with a free amount of 6.5438+0.5 million yuan.
Fifth, effectively carry out public health and epidemic prevention work. The hospital has carried out in-hospital training and study on hand-foot-mouth disease, influenza A (h 1n 1), AIDS, tuberculosis and other infectious diseases for more than 20 times, set up six study columns, and publicized and educated the public on health prevention knowledge through irregular visits to community clinics and distribution of leaflets, so as to improve the public's awareness and prevention ability.
In short, through the unremitting efforts of the staff of the whole hospital, the work of the Fourth People's Hospital of * * has achieved good results in XX years. In the new year, the hospital has always adhered to the purpose of serving the people wholeheartedly, and carried out various medical service activities with a highly responsible attitude towards the party and the people to reassure and satisfy the people.
March xx is a month in which opportunities and challenges coexist. With the deepening of the theme of economic construction, western development and Qinghai development, the party's xx spirit and a series of lines, principles and policies are more deeply rooted in the hearts of the people. The reform of medical insurance system and the development of new rural cooperative medical care have made every hospital employee have cohesion and appeal. In the face of challenges, we rely on science, teamwork, unity and cooperation, which embodies the belief that unity is strength; Facing the opportunity, we correctly handle the relationship between reform, development and stability, adhere to the highest principle of "patient-centered", strive to promote the transformation of hospital management mode and create a new situation of hospital sustainable development.
I. Basic information
The hospital has employees 146, including 4 with senior titles and 30 with intermediate titles. There are 102 beds and 4 out-of-hospital clinics.
Second, the completion of medical economic indicators
By the end of xx, the hospital had completed 30,434 outpatient visits, including 865 emergency visits. 3092 cases were hospitalized, the cure rate was 50.40%, the improvement rate was 42.65%, and the mortality rate was 0.23%. The average hospitalization time of each patient was 4.2 1 day. Inpatients 1045, outpatients 132. Rescuing critically ill patients 137 people, the success rate of rescue was 98.78%, the coincidence rate of admission and discharge diagnosis was >: 96.69%, the bed utilization rate was 44%, and the number of bed turnover was 30.43 times/bed; The cure and improvement rate of single disease has reached the disease quality control standard promulgated by the Ministry of Health. The hospital business income is * * * ten thousand yuan, of which drug income accounts for 52.6%; Per capita outpatient expenses are * * * yuan, and per capita discharge expenses are * * * yuan. It can be seen from the proportion of medical income and drug income in business income and the decline of average hospitalization days that medical income has increased compared with last month, while drug income has dropped sharply, and the proportion of the two has gradually become reasonable, achieving the fundamental goal of "taking patients as the center and benefiting the majority of patients". The situation of "supporting doctors with medicine" has been obviously improved, the utilization rate of existing resources has been improved, the technical content has been reflected, input and output have been emphasized, and social benefits have been put first. It has achieved the goal of balance of payments, slight savings, reducing expenditure, reducing waste and improving efficiency.
Third, the level of medical quality management has been continuously improved.
First, quality is the core of all work. In order to truly put medical quality at the core of hospital management, this month, while continuing to improve and further implement hospital rules and regulations, we formulated the medical quality management standard of the Second People's Hospital of Huangzhong County, further established and improved the three-level quality control network of hospitals, departments and individuals, adjusted and enriched the quality control and business management institutions, strengthened the quality management of hospitals, formed a good situation in which both quality control and quality management were paid equal attention to in the whole hospital, and avoided the occurrence of serious accidents.
The second is to adhere to the two benefits as a guarantee. On the one hand, medical staff are required to have a high sense of service, not to regard themselves as "lifesavers", but to treat patients as "parents" and do their best to provide patient-centered services. On the other hand, administrative workers are required not to have the idea of "inferiority", but to have the idea of serving patients as the first line of clinical service, and firmly establish the idea of playing chess in the whole hospital and being a good master. The hospital correctly handled the relationship between the two benefits and achieved good results.
Third, all services are based on patient satisfaction. Seek the opinions of patients and the masses regularly, continue to hire social supervisors, and seriously study and solve the hot and difficult problems raised by the masses in combination with the actual situation of the hospital. Participating in medical bidding procurement can reduce costs, reduce losses and improve benefits. The hospital stay of patients is only four days, which lightens the burden of patients. In the process of examination, diagnosis and treatment, we insist on reasonable examination, rational drug use and reasonable charge, thus safeguarding the rights and interests of patients. In the outpatient and emergency work, actively explore and adjust the diagnosis and treatment process, standardize the guidance service, and basically alleviate the "three long and one short" problem. In the aspect of hospital affairs publicity, the system of selecting doctors for patients, listing hospitalization expenses, publicizing drugs and checking project expenses is implemented to protect patients' right to know and respect patients' right to choose. The activity of "patient-centered, quality-centered, so that patients can see clearly" has won the trust of patients. The fourth is to strengthen quality management and comprehensive management. Carry out the second theme activity of "Health Management Month" with "high quality, high efficiency and low consumption"
According to the quality system and assessment contents of "secondary" hospitals, the working system of quarterly assessment, monthly assessment and irregular in-depth visits by hospital leaders has been maintained, and a quality management mechanism has basically been formed, with the assessment results linked to performance pay and gradually improved. The qualified rate of basic nursing in the whole hospital reached 9 1.3%, the qualified rate of "three basics" examination reached 100%, no nursing accident occurred within one month, health education reached 100%, and the intact rate of first-aid drugs and articles reached 100%.
Fourth, personnel training and clinical medical education have achieved remarkable results. Two new businesses, color Doppler ultrasound, interventional therapy and cataract intraocular lens implantation, were developed. In clinical teaching, 20 interns and 4 doctors and nurses from primary health care centers were accepted throughout the month. In order to strengthen the construction of hospital talent team and human resources development, reserve the backbone of emergency department, and maintain and carry forward the advantages of county-level comprehensive teaching hospitals, 12 students were selected in XX month, and 56 people participated in continuing medical education; Organize in-hospital business lectures 12 times, invite experts and professors from provincial hospitals to make rounds, give lectures and guide operations for 22 times, and participate in academic activities for 48 times throughout the month; 35 people participated in academic education.
Verb (abbreviation of verb) is effective in hardware construction. In order to improve the level of hospital diagnosis and treatment, meet the medical needs of patients at different levels to the greatest extent, and improve the medical environment, the outpatient building project of our hospital was successfully implemented and put into use at the end of the month through the efforts of hospital leaders.
In the past four months, with the care and attention of hospital leaders, the leadership and support of nursing department and the joint efforts of nurses, the nursing work plan issued at the beginning of the year has been successfully completed. At the same time, actively participate in the "Hospital Management Year" activities, and do a good job of each work item by item according to the standards. Through this activity, the institutionalization and standardization of nursing management in our department and the improvement of nursing quality were effectively promoted.
1. The quality of nursing has improved steadily.
According to the requirements of nursing quality management norms, a nursing quality control group was established in our department at the beginning of the year, and the members of the group and the department were studied and trained, which enabled the quality control group to work well and promoted the improvement of nursing quality in the department.
The activities of "Hospital Management Year" in the second half of the year have greatly promoted the nursing work of departments, making nurses understand that strict implementation of various rules and regulations is the fundamental guarantee for improving nursing quality and ensuring medical safety. Nurses pay attention to themselves in their work, whether they have conscientiously implemented various systems and improved the quality of links. Significant progress has been made in ward management, basic nursing and graded nursing, disinfection and isolation work has been strengthened, and the quality of nursing documents has been improved from the connotation. There were no major mistakes and accidents throughout the year.
2. Improve the quality of nursing staff.
Completed the training and assessment requirements of nursing staff at all levels issued by the nursing department. While organizing to participate in business study and nursing rounds in the hospital, they seriously conduct business study and nursing rounds once a month, conduct theoretical questions and operation exams every month, and ask nursing staff to take notes carefully. Taking the "three basics" theory and operation examination organized by the nursing department, the qualified rate was 100%.
During the year, a nurse was sent to a district hospital for further study. After coming back from further study, I promoted the advanced nursing concepts and clinical nursing methods in higher hospitals, updated the concept of nurses, and gradually changed into "actively serving patients". Paying attention to the study of specialized theory and operational knowledge has greatly improved the technical level of nurses. The improvement of specialized theoretical knowledge also promotes the improvement of holistic nursing. Nurses can better understand the condition, carry out health education and nursing, and make patients get systematic guidance and complete services.
3. Strengthen the construction of medical ethics of nursing staff.
It is necessary to combine the professional ethics education of nursing staff with situation education and personnel system reform, pay attention to fully mobilize the enthusiasm of nursing staff, correct their attitude towards work and service, and enhance their confidence and pride in their work. This year, the personnel system reform was successfully completed, and nurses' mood was stable and their sense of crisis was enhanced.
Attach importance to the role of nursing backbones, such as the nurse in charge XXX, who is serious and responsible, actively and meticulously serving patients and has won praise from patients and their families for many times. At the same time, it also sets an example for general nursing staff. Patient satisfaction has also improved.
4. Strengthen the management of hospital infection.
Seriously implement the disinfection and isolation system, do a good job in the use and management of disposable articles, focusing on the disinfection management of disposable articles, endoscopes, ophthalmic equipment, otolaryngology equipment, attracting materials, oxygen-absorbing materials and sterile bags. Seriously carry out air monitoring and ultraviolet lamp intensity monitoring, and make records to ensure that the monitoring meets the health requirements.
Strengthen the training of nurses' occupational protection skills, strengthen their awareness of self-protection, and require everyone to be familiar with the relevant plans for occupational protection and strive to put an end to occupational injuries.
5. Basically complete scientific research and nursing teaching.
At the beginning of the year, a new nursing research project was formulated, and the project of "Diet research after tonsillectomy" was recorded and summarized, and a paper was formed. Through scientific research, nurses can improve their observation ability and research consciousness, record and enjoy their own work experience, and improve their nursing level. During the year, each nurse wrote more than 1 paper, and 3 XXX nurses' papers were developed in China and the province, and won the excellent paper award in XX city. The teaching work of nursing students has been completed very well.
6. Successfully completed the nursing task.
Adhere to "patient-centered" and "quality-centered" to provide quality services for patients. Earnestly complete all tasks assigned by superiors and actively participate in the activities of creating "Hospital Management Year". This year, the number of people discharged from our department reached a record high, exceeding XXXX, and the workload was very heavy. Especially during the government sunshine project "cataract recovery project", more than XXX cataract recovery operations were completed in less than one month, and the number of other patients in the department increased instead of decreasing. The nursing staff made great efforts without complaint, which made the work well completed.
7. There is a problem
(1) The overall quality of nursing staff still needs to be further improved, and the study of "three basics" and professional theoretical knowledge still needs to be strengthened.
(2) The quality of nursing still needs to be further improved.
(3) Individual nurses have a weak sense of crisis and lack initiative in their work.
(4) Two general nursing mistakes occurred during the year, and medical safety needs to be strengthened.
(5) Holistic nursing, especially health education needs to be further strengthened.
Over the past year, nursing work has made some achievements in nursing quality and professional ethics construction, but there are also some shortcomings that need further improvement.
I recommend it carefully.