Head nurses-department nursing quality controllers-all nurses participate in quality management monitoring, implement continuous improvement of nursing quality, and comprehensively implement quality control work.
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 ward management, basic nursing, specialist and first-class nursing, disinfection and isolation, nursing document writing, first-aid articles management, nursing safety management, etc. , evaluate and analyze the quality of nursing every month, and formulate corresponding corrective measures.
2, the head nurse, department head of nursing quality supervision at any time to correct the problems existing in the nursing work, will highlight the problem in the morning meeting notice, let the nurse know 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 set up a group of experienced nurses to participate in nursing quality control to ensure the quality of nursing work.
1, implement the quality control network of head nurses and department quality controllers, gradually implement everyone's participation in quality management, and achieve the goal of total quality control.
2, play the role of nursing quality monitoring group, pay attention to link quality control and key problems of the rectification effect tracking. The principle of combining normal inspection with monthly inspection and giving priority to comprehensive inspection.
3. Strengthen the implementation, supervision and inspection, and pay attention to the quality supervision of nurses' operation process. Pay special attention to quality control management, make everyone participate, * * ensure quality, give full play to the role of nursing quality control personnel, all staff participate in nursing management, and have inspection records, analysis, evaluation and improvement measures.
4. Improve the nursing quality control management system and responsibilities, discuss and analyze the difficult problems existing in nursing, and put forward effective rectification measures.
5, strengthen the management of nursing defects, nursing disputes, adhere to strict supervision of the quality of each link, find safety hazards, and take timely measures to eliminate nursing errors and accidents in the bud.
6, 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.
7, strengthen the normal operation and assessment of nursing staff. Find the problems in operation and correct them in time.
8. The nurses in each class check the doctor's advice in each class, and the head nurse checks it every week to ensure the correct implementation of the doctor's advice.
9. Check the writing of nursing documents every day. The discharge medical records will be reviewed by the attending nurse, and finally submitted to the medical record room by the head nurse.
10, establish nursing safety management, conduct nursing safety knowledge training every month, and explain nursing problems inside and outside the hospital, so as to strengthen the safety awareness of nursing staff, improve safety early warning, find out nursing safety hidden dangers in time, conduct weekly centralized search for safety problems, analyze and propose improvement measures.
Quality Control Work Schedule (Part II) 1. Three-level nursing quality control management in departments
(1) The head nurse, nursing backbone and quality controller form the nursing quality control network of the department, and implement the three-level quality control management of the department. Set up six nursing quality control groups, gradually implement everyone's participation in quality management and realize the goal of total quality control. Each management team regularly completes the work plan, inspection records, summary and analysis, as well as feasible improvement measures and training plans.
(2) Quality control team training department personnel assessment standards and scoring rules, especially the team leader should do a good job of mentoring, assist the head nurse to do a good job of supervision and guidance, and the liaison should play the role of uploading and distributing. * * * The head nurse should do a good job of nursing quality control and regularly assess the liaison.
(3) The head nurse organizes a "nursing quality analysis meeting" once a month. The leaders of each quality control team will summarize and discuss the problems existing in last month, and put forward rectification measures through general discussion. The contents of the meeting will be recorded in the "nursing quality analysis meeting", and those who did not attend will read and sign it themselves within one week to let all employees know.
Second, the department each quality control team specific work plan
(a) nursing safety management team:
1, system implementation:
(1) Continue to organize the study of various core systems and emergency plans, and put them in convenient places for regular study and reference;
(2) the first question responsibility system is implemented, and patients have problems to solve in time, and they can't shirk;
(3) Strictly check seven to three, double check and execute the doctor's advice;
(4) the doctor's advice class BANCHA is right. If you don't check the wrong doctor's advice, you will find that the right person and the agent bear the same responsibility;
(5) Give full play to the role of the chief inspector in supervising the doctor's orders in time, and the head nurse will always check twice a week to comprehensively check the contents of the doctor's orders;
(6) Strictly implement the doctor's advice processing flow, and do not perform oral doctor's advice during non-rescue time, and the supervision and management are in place;
2, fall, pressure sore:
(1) Make timely and correct assessment according to the fall and pressure sore assessment system, and follow up continuously;
(2) Monitor the high-risk groups and high-risk links in the department, find them in time and handle them in time;
(3) The team leader controls the score of falls and pressure sores of undergraduate course room patients daily, and gives guidance to junior nurses;
(4) When a fall or pressure sore occurs, there is an emergency plan and you know how to handle and report it;
3. Adverse events:
(1) Training on reporting and handling system of adverse events and categories of adverse events;
(2) Master the reporting and handling procedures of adverse events;
(3) The head nurse should timely review the adverse events reported by the nurses, determine the classification and grading, help the nurses analyze the reasons, and make rectification within the department;
(4) Do a good job in the construction and publicity of safety culture in departments, regularly carry out safety warning case studies or small lectures, and cultivate nurses' risk awareness and prevention awareness;
The quality controller completes the contents of the quality checklist every week as required, and completes the data summary at the end of each month, summarizes the main problems existing in nursing safety management, analyzes the reasons, and puts forward corrective measures. After the head nurse approves the corrective measures, she will inform all the staff, and the quality controller will follow up the implementation of the corrective measures.
(2) Nursing Documentation Department:
1, organize the study and training of nursing documents related systems, and conduct assessment;
2. There is no omission in the temperature list, and the use of ECG monitoring and the heart rate, breathing and defecation times of critically ill patients must be consistent with the nursing record list;
3, the doctor's advice should be confirmed in time, without omission;
4, nursing records require concise and smooth description of the condition, the use of medical terms, focused, timely records, consistent with the condition, special medication, treatment and changes in the condition should be recorded in a timely and accurate manner;
5. The responsible team leader should control a small shift of nursing documents before coming off work every day, and inform and correct them in time when problems are found;
6、N
Quality control 5 nursing documents per shift every day, register them, and hand over at the early meeting to attract the attention of nurses;
7. When the patient is discharged from the hospital, the responsible class carries out preliminary quality control on the documents, and timely modifies the obvious errors and informs the responsible person;
8. The quality control team randomly selects at least 5 medical records every month for full supervision. If there is any problem with the written record, organize the personnel of the department to discuss and analyze the reasons in time, put forward corrective measures and put them on record. Examination results are linked to personal behavior assessment, and good nursing writing in all aspects is praised by the head nurse at the nurses' meeting;
Require daily quality control records, rectification and tracking, by n.
Class nurses consult at least 5 medical records every day and register. The quality controller completes the contents of nursing documents on time every week, and completes the data summary at the end of each month.
(3) Drug (including blood) management group:
1, drugs are classified and placed, managed by special personnel, and registered in special books;
2, A6 drugs inventory every day, to ensure the drug base and quality;
3, drug administrators regularly check the types and quantities of drugs every month, whether there is precipitation, discoloration, near-effect, fuzzy labels and other phenomena. , timely replacement;
4. Drugs are classified according to their types and properties, such as oral administration, external use and injection, which are clearly marked. Daily inspection shows that similar oral drugs with the same color and similar injections with different doses are not allowed to be mixed. Drugs with obvious warning signs are packaged in the same category, drugs of the same category, and stored in multiple specifications or doses for one product;
5. High-risk drugs shall be implemented according to the high-risk drug management system, with special storage areas and correct identification and storage methods;
6, emergency medicine in standby state, regular inspection records, handover registration is complete;
7, training related system of safe blood use;
8, organize training in the event of a transfusion reaction emergency plan, so that everyone knows;
The nurses in A6 treatment class check high-risk drugs every day, affix the high-risk seal of "anti-extravasation" on the bottle label and infusion card, put a red warning tape on the infusion bottle, and clip it on the red infusion card with "high-risk drugs patrol card". The nurse in charge should patrol at least once an hour to ensure the safety of medication. When department patients need blood transfusion, Class A6 nurses are responsible for blood collection, and the blood collection box is cleaned and disinfected every week. The quality inspector completes the inspection of drugs and blood transfusion every week, and completes the data summary at the end of each month.
(four) emergency medical equipment management group:
1, rescue vehicles are clearly marked, managed by five rules, closed as required, and registered;
2, rescue vehicle drugs within the validity period, the quality is qualified, all kinds of items within the validity period;
3, all kinds of equipment in good condition, in a state of emergency, oxygen bag volume is sufficient;
4. All first-aid medicines and articles should be replenished in time after use;
5. There is no omission in the handover register of the rescue vehicle, and the head nurse should check it once a week;
6. The administrator of the rescue vehicle regularly organizes training on the use, function and side effects of drugs in the rescue vehicle;
7, equipment classification, cleanliness, number management, daily inventory of equipment handover per shift;
8. The equipment manager regularly organizes training on the use of equipment;
9. There are emergency plans and measures for the failure of instruments and equipment, so that all staff can know;
Every day, the A5 nurse in the main class will check and register the rescue vehicle and life support instruments, and the quality controller will check the first-aid medical instruments at least once a month to avoid the damage of expired drugs and the first-aid instruments in the department, and ensure that the first-aid instruments 100% are in good and standby condition.
(5) Quality nursing management team:
1, the head nurse's scheduling reflects the energy level correspondence, realizes flexible scheduling, and nurses know the flexible allocation scheme of human resources;
2, the implementation of the tube bed responsibility system and bedside work system, each responsible class is responsible for a certain number of patients, the implementation of holistic nursing;
3, ward environment clean and quiet, such as found that the problem timely rectification;
4, nursing staff dress code, language civilization, warm reception of patients;
5. Nurses know the connotation and goal of quality nursing;
6. The department provides convenient service measures, such as disposable cups, paper towels, sewing boxes, microwave ovens, etc.
7, basic nursing:
(1) The morning care requires that the bed unit be neat and flat, the bedside table items should be placed neatly, and the stool should be placed neatly, which shall be the responsibility of the responsible nurse;
(2) The drainage tube is placed reasonably, fixed correctly, all kinds of catheters are unobstructed, and the observation records meet the requirements. It should be replaced every Tuesday and Saturday, and the principle of aseptic operation should be observed;
(3) Oral care should keep the patient's oral cavity clean and moist, and keep the oral mucosa intact, once a day 1-2 times;
(4) The responsible nurse should ensure that all patients are clean (fingers, nails, short hair and beard) and clean (hair, mouth, skin, perineum, toes and bed), and the bedside monitor should provide graded nursing and diet according to the doctor's advice, so that the nursing staff can understand the patient's dietary requirements and assist the patient to eat;
(5) The head nurse does not regularly check the quality of life care;
(6) Handover of skin, oral mucosa and drainage tube. Care should be taken. If there are defects caused by unclear handover, the successor nurse shall bear the responsibility;
8, specialist care:
(1) Organize and train the department's disease nursing routine, and nurse patients according to the routine;
(2) The nurse in charge knows the patient's "Ten Knows";
(3) The responsible nurse timely and accurately evaluates the risks of patients and tracks them;
(4) Health education can be given to patients according to their different stages of illness;
Every month, the quality controller will join hands with doctors to organize patients to hold public holiday seminars and keep the meeting records. Complete the nursing quality inspection every week, summarize the data at the end of each month, summarize the existing problems, analyze the reasons and put forward the rectification measures.
(6) Nursing training group:
1, nurses know their respective job responsibilities;
2, according to the training plan at all levels, organize learning and training related content;
3. Nurses at all levels have their own tutors to guide their study;
4. Organize business study twice a month, so that trainers can do well.
T to explain;
5. Organize 1 nursing rounds or case discussions every month;
6. Operational evaluation:
(1) Complete the operation training according to the operation plan, and conduct basic and professional operation demonstrations by operators on a regular basis every month;
(2) After the demonstration by the operator, the head nurse and the operator conduct spot check and assessment;
(3) 65438+ 0-2 times of first aid skills training and assessment according to the characteristics of undergraduate course;
(4) Give full play to the enthusiasm and potential of each nurse and improve the nursing operation ability;
Quality Control Work Schedule (Part III) 1. Objective: The qualified rate of basic nursing ≧ 100%, first-class nursing ≧90% and critically ill patients ≧90%.
Implementation measures:
1. The Nursing Quality Management Committee conducts a comprehensive quality evaluation on wards, ICU and CCU of the whole hospital every quarter, and gives timely feedback at the head nurse's regular meeting for analysis, evaluation and improvement.
2, the head nurse daily inspection, found that the problem is solved in time.
Second, the goal: the number of nursing errors per year is ≦0.5 hundred beds.
Implementation measures:
1, often stressed at the head nurse's regular meeting, strengthen nursing safety education and improve safety awareness.
2, the department has a safety education plan and measures, the head nurse is responsible for the implementation.
3. Department. Errors and defects should be reported in time, discussed and handled, and reported on time every month.
4. Nursing errors and accidents management committee regularly analyzes and evaluates nursing defects and errors and accidents in the whole hospital, and puts forward improvement measures.
Three. Objective: The intact rate of first aid articles is 65,438+000%, and the intact rate of first aid facilities is 65,438+000%.
Implementation measures:
1. First-aid drugs and articles should be carefully handed over in each shift, and replenished in time after use, so as to achieve "four guarantees".
2, the department personnel responsible for, check twice a week, the head nurse check and sign every week.
3, the nursing department quarterly inspection and assessment.
Four. Objective: The number of bedsores per year is 0 (except in special circumstances).
Implementation measures:
1, strengthen the care of critically ill patients, establish a turn-over card for bedridden patients, and make a record of bedside handover.
2, the head nurse daily supervision and inspection.
3, the nursing department spot check.
5. Objective: The qualified rate of nursing technique operation is 100%, the qualified rate of disinfection and isolation is 100%, and the recovery rate of disposable medical supplies is 100%.
Implementation measures:
1, strictly implement one person, one needle, one tube, one bed, one towel, one table and one cloth.
2, strictly distinguish between treatment room, dressing room clean area, pollution area.
3. Strengthen "three basics" training and standardize nursing technical operation.
4, nursing department regular inspection and evaluation.
5, regular monitoring work, to prevent cross infection in the hospital.
6. Strictly implement the classified collection, unified storage and disposal of disposable medical supplies.
Objective: The coincidence rate between admission assessment and patients' condition is ≥80%, and the coincidence rate of nursing diagnosis problems is ≥90%.
Implementation measures:
1, which requires that the collected data be comprehensive, timely and accurate, in line with the patient's condition.
2. All subjects list the nursing diagnosis of common diseases for nurses to learn, master and use.
3, nursing head nurse according to the patient's situation, ask the responsible nurse, check the nursing medical records, records, etc.
4, check the nursing problems, evaluate whether it is accurate and consistent with the patient's condition, and timely guidance and correction.
Objective: The implementation rate of nursing plan was 100%, and the effect was evaluated.
Implementation measures:
1, formulate specific, timely, effective and scientific nursing measures to facilitate nurses' operation.
2, guide the head nurse to master the nursing measures consistent with the patient's problems.
3. Ask the nurse to evaluate the effect in time.
4, the nursing department, the head nurse supervision and inspection.