Maternal and Child Health Hospital 1 The work plan is guided by the evaluation criteria of the third-level maternal and child health hospital, patient-centered, and the theme of continuously improving quality and ensuring medical safety, and earnestly carries out various medical and nursing work. Through the "new two programs" maternal and child health indicators, we will steadily promote maternal and child health and people's livelihood projects and public health and major public health services.
I. Guiding ideology
Hospital work should continue to deepen the reform of public hospitals in accordance with the Measures for the Administration of Maternal and Child Health Care Institutions, the Regulations on the Administration of Medical Institutions and the Detailed Rules for Grade Evaluation of Third-level Maternal and Child Health Hospitals in Anhui Province. Adhere to the patient-centered, constantly improve the quality of medical services, and comprehensively strengthen the construction and development of hospitals.
II. Objectives and tasks
Constantly strengthen the construction of a clean and honest government, consolidate the cornerstone of work style construction, strengthen the construction of medical ethics, take the reform of public hospitals as the starting point, and combine the specific requirements of "three good and one satisfaction" activities and the objectives and tasks of the city's health work in 20xx to carry out the work in a down-to-earth manner. As the first responsible person, the president takes the overall responsibility, and the deputy secretary, vice president and heads of relevant functional departments are responsible for the specific implementation. In practical work, all departments are required to plan, implement and record well, and feedback and coordinate the problems in inspection in time to ensure the smooth implementation of the annual work plan. Those who fail to perform well will be investigated for responsibility until they are removed from office.
Third, the specific requirements
(1) Party Affairs and Government Affairs
1 deepen the building of a clean and honest government and constantly improve the medical ethics and professional ethics of medical staff. Adhere to the system of "three sessions and one lesson" and the political study system of government organs, and improve the ability of cadres and medical personnel in party member to resist corruption and change.
2. Strengthen the construction of morals, formulate feasible rectification measures, and ensure the implementation of medical service commitments. Medical staff are required to firmly establish the purpose of serving the people wholeheartedly and advocate the spirit of loving their posts and being dedicated.
3. Carry out the main responsibility, correct the outstanding problems that harm the interests of the masses, implement the "eight regulations", create a clean and healthy development environment, stimulate the thoughts and feelings of employees who love hospitals, work and patients, mobilize the enthusiasm and creativity of employees in the hospital, and raise the hospital work to a new level.
4. Actively promote the open system of hospital affairs, improve the effective supervision mechanism inside and outside the hospital, and ensure the sustained and stable development of the hospital.
(two) functional departments, general affairs and safety work.
1. All functional departments of the organ should closely embody the three functions of management, service and guarantee, earnestly carry out work around the clinical front line, and put an end to the phenomenon of buck passing and departmental supremacy. Satisfy patients and employees.
2, the insurance department should conscientiously do a good job in hospital logistics, always pay attention to the hospital water, electricity, gas use safety, especially the safety of pressure vessels. Do a good job of communication and coordination with the property, and guarantee clinical logistics services at any time. Security personnel should conscientiously do a good job in the propaganda, supervision and inspection of fire prevention and theft prevention in the hospital, combine technical defense with civil air defense, and effectively protect the life and property safety of patients who come to the hospital. The training of comprehensive management of law popularization is not relaxed, and the work of maintaining stability should be done in handling medical disputes and complaints.
(3) Basic medical work
We will continue to devote ourselves to establishing a tertiary maternal and child care hospital. Based on the evaluation requirements of grade hospitals, organize all departments to carry out self-examination and self-correction activities of medical quality, focus on implementing the core system of medical quality, and ensure the medical safety of hospitals.
1, strengthen medical quality and medical safety supervision, and strictly implement quality assessment and reward and punishment measures.
1) Implement whole-process quality monitoring, strengthen key links, key departments and important positions of basic quality such as operating room, delivery room, neonatal ward, infusion room and laboratory, and continuously improve medical quality through inspection, analysis, evaluation and feedback. According to the inspection and analysis results of medical quality and safety in 20xx, combined with the actual implementation of reward and punishment measures, it is necessary to revise the reward and punishment measures for medical quality and safety assessment formulated in July of 20xx in the first quarter of 20xx, increase the intensity of rewards and punishments, and ensure the continuous improvement of medical quality.
2) Continue to strengthen the supervision of "Three Rationalities". Although efforts have been made in the management of rational examination, rational drug use and rational use of consumables in 20xx, the work has not improved, especially the supervision of rational drug use and rational use of consumables is weak, the utilization rate of antibacterial drugs and medical consumables are high, and the rationality and standardization of clinical drug use are not enough. There is an urgent need to formulate strict reward and punishment measures. It is planned to formulate specific improvement plans in the first quarter of 20xx, and score them in combination with hospital performance appraisal.
3) Improve clinical pathway management. On the basis of 5 clinical disciplines 17 diseases and 1026 cases in 20xx, the clinical pathway management of 57 diseases in the whole hospital will be fully covered in 20xx. Improve relevant systems, strictly implement reward and punishment measures, supervise once a month, and link it with performance appraisal every quarter.
4) Strengthen the management of clinical blood transfusion. According to the Technical Specification for Clinical Blood Transfusion, combined with the actual situation of clinical blood transfusion in our hospital in 20xx years and the problems existing in the supervision of the municipal clinical blood transfusion quality control center, we will further strengthen the training of medical staff's mathematical knowledge, focusing on strengthening the management of clinical blood use indications, blood transfusion process and curative effect evaluation after blood transfusion. Carry out a special inspection of clinical blood use every quarter, analyze the evaluation results in time, report the inspection results, formulate the rectification plan, and make continuous improvement to ensure the safety of clinical blood use.
2. Strengthen the supervision of discipline construction.
According to the discipline construction requirements in our business development plan, we will focus on building some two disciplines and applying for provincial key disciplines:
1) Continue to carry out the construction of the two disciplines, and actively assist the leaders of various disciplines to complete specific matters such as talent echelon training and the application of science and technology projects in the development of various disciplines according to the development steps of the two disciplines in 20xx.
2) Strengthen the construction of key disciplines and assist neonatology department to complete the application of key disciplines in Anhui Province in the first quarter of 20xx.
3) Strictly implement the system of continuing medical education, and complete six municipal continuing medical education training courses in cooperation with various disciplines. Ensure the training time and quality according to the training plan. After the training, after passing the on-site examination, enter the following teaching information.
3, "three basics" training and assessment
1) Complete the training and assessment of basic knowledge and basic theory in the first half of 20xx, and organize a training and assessment of basic skills in the second half.
2) Organize a knowledge contest on core medical system in the first half of the year. Through the competition, the initiative of medical staff to consciously learn the core medical system is improved, and the relevant contents of 18 core medical systems are skillfully used to carry out various medical activities, thus promoting the continuous improvement of medical quality.
4. Foreign medical cooperation
Strengthen the cooperation work under the framework of medical consortium, continuously expand the field of business cooperation, and rapidly improve the technical level of each specialty in our hospital.
1) Continue to promote all-round cooperation with the Department of Pathology of Huainan First People's Hospital, train technical teams, dynamically monitor the training effect, and make timely improvements.
2) Expand the cooperation fields with other disciplines of the First People's Hospital of the city, and establish close business relations, that is, responsibilities and rights are consistent. Continue to strengthen cooperation with Anhui Children's Hospital.
3) While continuing to carry out multidisciplinary business cooperation, we will strengthen cooperation in scientific research projects in 20xx, and plan to carry out cooperation in clinical research projects of congenital dislocation of hip joint.
4) Do a good job of counterpart support. On the basis of consolidating the work of pediatrics, obstetrics and gynecology and ultrasound counterpart support in Sanhe Township Health Center in 20xx, graded diagnosis and treatment management, appointment registration and two-way referral will be carried out in 20xx.
(4) Basic nursing work
1. Strengthen nursing quality and safety management, continuously improve the quality of nursing service, and ensure nursing safety.
Nursing quality management is the eternal theme and the core content of nursing management. In the nursing work of 20xx years, the nursing department will carefully assess, analyze, evaluate and rectify according to various quality assessment standards, reflecting continuous improvement and implementing target management.
1) Organize members of the assessment team of the Nursing Quality Management Committee to supervise the nursing quality of the whole hospital every quarter, summarize and report, and achieve performance; Each nursing unit carries out self-examination of nursing quality every month, tracks the existing problems in time, revises nursing quality standards (nursing quality assessment and reward and punishment methods) in time, improves systems and norms, puts forward improvement measures, and promotes the continuous improvement of nursing quality; Strengthen nurses' long night rounds to ensure the quality of night shift and middle shift nursing.
2) Do a good job in nursing quality management of key links, key time periods, key populations and key departments (disinfection supply room, operating room, neonatal department, delivery room, etc.). ), the nursing department will supervise the department from time to time to ensure nursing safety.
3) Further strengthen infection control, strictly abide by the disinfection and isolation system, strengthen occupational protection, ensure the safety of nursing staff, and do a good job in the management, use and treatment of disposable articles and medical wastes. It is planned to set up a hospital-wide nursing emergency team to ensure the implementation of the emergency plan.
4) Establish and improve the patient risk assessment system, timely assess high-risk patients such as falls, bed falls and pressure ulcers, and take effective measures to prevent accidental injuries. Gradually establish various sensitive nursing quality indicators to guide clinical nursing work. Continue to play the role of the static treatment group to ensure the quality and safety of intravenous treatment in hospitals.
5) Strengthen the management of critically ill patients and nursing adverse events, encourage active reporting of adverse events, and timely coordinate the reporting of critically ill patients and adverse events to wards.
6) Do a solid job in three-level quality control of nursing records, regularly analyze and improve the defects of nursing records, and improve the quality of medical record writing. Strengthen the management of medical equipment and first-aid medical instruments, with responsibilities assigned to people and clear responsibilities, and be on standby at any time.
2. Strengthen the connotation of high-quality nursing and implement the overall nursing responsibility system.
Carry out the service concept of "patient-centered", implement holistic nursing with responsibility system according to the standards of graded nursing and specialized nursing, strengthen health education, and provide safe, high-quality, efficient and satisfactory services for patients and their families.
1) Strengthen the management of nursing human resources, implement the post management of nurses, and adopt the graded APN scheduling system for clinical nursing in the whole hospital to meet the clinical nursing needs as much as possible.
2) In order to further strengthen the assessment of high-quality nursing service, the head nurse will hold special meetings, public holidays and symposiums on a regular basis to listen to opinions from all sides. Through continuous summary, clinical nursing work is improved, service attitude and service quality are improved, and patients are satisfied.
3. Strengthen post management and performance management of nurses.
1), to further implement the hierarchical management of nursing staff, to correspond the needs of nursing posts with the abilities of nursing staff, to embody the employment mechanism of "giving full play to the talents" and to provide patients with higher professional nursing services.
2), improve and refine the workflow, system, standards, responsibilities, routines, norms, etc. By integrating into the process and strengthening the detail management, the nurse work has execution and operability.
4. Strengthen the training of head nurses and nurses' working ability, and effectively improve the overall quality of the nursing team.
1) The assessment of head nurses will be strengthened in 20xx. Nursing system, responsibilities, procedures and emergency plan training are added to the head nurse assessment. Encourage head nurses to actively participate in various forms of learning and improve their academic level and management level.
2) Strengthen the training of specialized nurses, arrange for further study, and speed up the construction and development of specialized nursing; Improve the specialized nursing level of high-risk pregnant women and high-risk infants. Give full play to the leading role of nursing backbone, specialist nurses and nursing service stars.
3) The learning and training objectives of nursing business are clear, focusing on "what is lacking in learning (training)" and emphasizing practical results. According to the grading training plan for nurses, the grading management and assessment of nurses should be carefully revised. Strengthen the examination of new nurses and junior nurses through the three-base examination question bank system purchased by the hospital.
4) Hold two municipal nursing follow-up classes.
5) Strengthen the teaching of interns (advanced students), and require 1 teacher (nurse) to have lifelong tenure.
5. Carry out nursing work with innovative thinking, and support all disciplines to carry out new work.
Strengthen the study of new theory, knowledge and technology of nurses, explore the extended nursing service mode, encourage all departments to carry out new work, and strive to carry out new work projects in the following departments in 20xx:
Pediatrics:
1, strengthen the construction of intensive care specialty.
2. Develop the indwelling technology of medium and long catheters.
Neonatal department: establish patient WeChat group to master the prognosis of children.
Operating room: perform blood gas analysis.
Gynecology: pelvic floor muscle function exercise
Obstetrics: outpatient service: network management during pregnancy, and setting up a second child consultation clinic.
Rehabilitation center:
1. Establish a model school for pregnant women.
2. Expand early education.
3. Carry out treatment to remove stretch marks.
(5) Equalization of livelihood projects and basic health services.
1. Take the "two cardinal guides" as the main line, promote the implementation of "two cardinal guides", implement the "two cardinal guides" indicators, and complete the evaluation of "two cardinal guides" indicators.
2, continue to implement the "improve the health level of women and children" provincial livelihood project, increase social propaganda and mobilization, optimize the service environment and service process, and further strengthen cooperation with civil affairs departments, the city's premarital check-up rate is stable at more than 90%, and complete the tasks assigned by superiors. The rural hospital delivery subsidy should be supplemented to complete the subsidy task of 20xx years.
3, the implementation of basic public health services and major public health services, and promote the gradual equalization of maternal and child health services.
1) In 20xx, we will continue to do a good job in promoting the "demonstration counties and key counties" for the systematic health care management of pregnant women and children, and further improve the health management level of pregnant women and children aged 0-6. Ensure that the coverage rate of "two tubes" reaches over 90%, and the management rate of maternal health care and children under 3 years old health care system reaches over 85%. Continue to carry out hearing testing, neonatal genetic and metabolic disease screening and prenatal screening.
2) Supplement the folic acid service standards for rural women of childbearing age, further improve the distribution of folic acid supplements for rural women of childbearing age, and ensure the completion of the tasks assigned by the Provincial Health Department.
3) Strengthen the management of maternal and child health monitoring projects and prevent mother-to-child transmission of AIDS, syphilis and hepatitis B..
5) Continue to carry out maternal death and neonatal death assessment, maternal critical illness monitoring, strive to reduce maternal mortality, and make maternal death assessment institutionalized and standardized.
6) Continue to carry out the free "two cancers" screening project for rural women aged 35-64.
7) Strengthen supervision, continue to do a good job in obstetric construction, further reduce the cesarean section rate, and strive to reduce it to 30%.
(six) hospital infection prevention and control management and preventive health care work.
Hospital infection management part:
1. Improve the hospital infection management system, implement quality control and strengthen infection monitoring.
1) Give full play to the role of the three-level hospital infection management system, conscientiously implement the hospital infection management meeting system, publish a quarterly hospital infection information feedback, and make statistics, summary and timely feedback on the hospital infection monitoring index data, medical record examination, disinfection and isolation inspection in the last quarter. Formulate rectification measures for specific problems existing in the department. The inspection results are linked to the performance of the department.
2) Actively assist the medical department and pharmacy department to supervise and manage the rational use of antibacterial drugs and do a good job in pathogen monitoring. Strengthen the supervision of multi-drug resistant bacteria monitoring, so as to strengthen the awareness of pathogen monitoring in various departments and find the epidemic trend of multi-drug resistant bacteria as soon as possible. Do a good job in the supervision and management of outsourced sterilized medical devices and disposable medical and health supplies, and continue to monitor the disinfection and sterilization effect of environmental sanitation and hospital infection. Through the monthly statistics and summary of hospital infection cases in all departments of the hospital, the clinical departments are urged to report and summarize hospital infection cases and feedback them to the clinical departments in time.
2. Strengthen hospital infection management in key departments and hand hygiene of medical staff.
1) according to the relevant national laws and regulations to develop key departments of hospital infection prevention and control system, and earnestly implement and supervise. To adapt to the relevant national policies, strengthen the management of hospital sense in key departments such as delivery room, maternal and child room and abortion room. Strengthen the management of supply room. In particular, the construction of organization, equipment and quality has been further enriched. Start the disinfection and sterilization work centered on the disinfection supply room. Supervise the quality of infection regularly or irregularly, and inspect and evaluate the quality of nosocomial infection in various departments of the hospital.
2) Continue to implement the hand hygiene management system of medical staff, strengthen the publicity, education and training activities of hand hygiene, enhance the awareness of preventing hospital infection, and conduct regular or irregular spot checks on the knowledge and implementation of hand hygiene of medical staff every month to ensure the effect of hand washing and hand disinfection.
3, to carry out hospital infection knowledge training, improve the awareness of hospital infection prevention and control.
Organize members of the hospital infection management team to participate in various training courses on hospital infection control and management, and strive to improve their professional level and their own quality, and improve the level of hospital infection management. Make the hospital infection knowledge training plan, and test the hospital infection management knowledge according to the training content.
Preventive health care work:
1, strictly implement the relevant provisions of infectious disease reporting.
Strictly manage the epidemic situation of infectious diseases and do a good job in the registration, direct reporting and warehousing of infectious diseases. Actively carry out the knowledge training of standardized reporting of infectious diseases and the knowledge assessment of infectious diseases prevention and control in the whole hospital. Arrange the report of infectious diseases on holidays in advance, check the outpatient logs and medical records every day, find out the missing reports of infectious diseases in time, and make quarterly and annual analysis of the reported epidemic situation analysis reports of infectious diseases.
2, do a good job in infectious disease detection, virus sampling and epidemiology.
Do a good job in sampling and testing the pathogen of hand, foot and mouth disease in time; AFP-related cases were monitored and reported within 10 days. May-June 5438+ 10, do a good job of microscopic examination of plasmodium hemolyticum in patients with intestinal infectious diseases and fever. As a free voluntary AIDS screening point, do a good job in free AIDS screening and registration of case questionnaires. Do a good job in STD detection and reporting. Do a good job in disinfection and isolation of wards to prevent cross-infection of such diseases in the hospital.
3, prevention and health care and other related work.
1) Actively carry out publicity activities on various disease prevention publicity days (3.24 Tuberculosis Day, 4.25 Planned Immunization Publicity Day, 4.26 Malaria Prevention Day, 12. 1 World AIDS Day) and health knowledge education on different diseases in different seasons.
2) Do a good job in the registration, reporting and management of death and tumor cases in our hospital.
3) Do a good job in the delivery, storage, timely entry and submission of various reports and cold chain management of vaccines. Complete the first dose of hepatitis B and BCG vaccination for newborns delivered in our hospital within 24 hours.
(7) Strive to keep the number of hospital visits and hospitalizations at last year's level in the current environment for 20xx, so as to make the social benefits of the hospital grow steadily.
According to the requirements of the objectives and tasks of maternal and child health care, the second work plan of maternal and child health care hospital is to continuously optimize the working environment of maternal and child health care, further strengthen the basic work of maternal and child health care at the grass-roots level, strengthen the education of employees' ideas and service concepts, earnestly grasp the construction of their own connotation, strive to build a dynamic working operation mechanism, continuously improve the quality and two benefits of maternal and child health care, and actively complete various quality indicators of maternal and child health care, and formulate a work plan from the reality of the county.
I. Main indicators of maternal and child health in 20xx
1, and the maternal mortality rate should be controlled within 30/65438+ 10,000; infant mortality rate
2. The coverage rate of maternal health care is more than 70%, the delivery rate of pregnant women in hospital is more than 80%, and the delivery rate of high-risk pregnant women in hospital is100%;
3. Early pregnancy card establishment rate: 45% in rural areas and 70% in cities.
The rate of children aged 4.0-3 years >; 75%; The health care coverage rate of children under 7 years old is over 80%; The management rate of frail infants was100%;
5. The monitoring coverage rate of birth defects is100%; Incidence of birth defects
Second, the main work requirements
1. Continue to strengthen the study of laws and regulations such as the law on maternal and child health care and its implementation methods, further improve the understanding of maternal and child health care, and earnestly strengthen the leadership and organization of maternal and child health care.
2, strengthen management according to law, adhere to the practice and service according to law, hold relevant certificates, strictly abide by the norms and operating procedures of maternal and child care, and ensure the safety and health of mother and baby.
3. Strengthen the construction of standardized outpatient service. It is necessary to actively create conditions to complete the establishment of standardized perinatal health clinics and standardized child health clinics, and other towns and villages should also actively do the establishment work.
4. Strengthen and improve the information management of maternal and child health care, and gradually implement computer management of perinatal health care. Guidance and management of maternal and child health statistics; Strengthen the management of "Birth Medical Certificate", so that the special person is responsible. "Birth Medical Certificate" must be signed by the mother herself.
5, maternal system management, children's system management should pay close attention to, grasp the reality, grasp the details, improve the quality and level of work to a new level, the two management rates should ensure the indicators issued by superiors.
6. Keep abreast of the trends of women of childbearing age, further improve the household registration management, effectively grasp the situation of pregnancy and newborn birth, and improve the card-building rate of early pregnancy, the card-building rate of 42-day newborns and the system management rate.
5. Strengthen the follow-up management of high-risk pregnant women, improve the quality of high-risk screening at the county level, and improve the registration, treatment, reporting and follow-up system of high-risk screening for pregnant women. Strengthen hospitals and medical and health care institutions, manage severely high-risk pregnant women, and prohibit township hospitals from intercepting high-risk pregnant women.
6. Call on the health administrative department to strengthen the obstetric construction of designated delivery units and improve the rescue level of critically ill pregnant women and newborns; Illegal childbirth in rural areas is strictly prohibited, and maternal mortality and neonatal mortality have been effectively controlled and reduced.
7. Strengthen the screening and classified management of weak children and high-risk children, do a good job in screening and registration of weak children and high-risk children, and fill in the list of weak children.
Third, do a good job in publicity and education.
1. Strengthen the publicity of maternal and infant health care law and knowledge of prenatal and postnatal care, make publicity materials, strive to create an atmosphere in which the whole society cares about maternal and infant health care, and promote the implementation of prenatal and postnatal care measures.
2. Through radio and television, distributing publicity materials, training rural maternal and child health professionals and village clinic staff, and organizing the masses to go to the countryside to publicize the relevant policies of rural pregnant women's hospital delivery subsidies, every rural pregnant woman can enjoy the care of the government, improve the hospital delivery rate of rural pregnant women and reduce the maternal mortality rate in our county.
It is necessary to vigorously publicize pre-marital health care, strengthen publicity on the importance of pre-marital health care, actively strengthen communication with civil affairs departments and local governments, actively strive for government preferential policies, obtain government support, pay for pre-marital examination, strive to develop pre-marital health care services for newlyweds, conscientiously do a good job in pre-marital medical examination, and improve the rate of pre-marital examination.
Fourth, strengthen the management of kindergartens for young children.
1, children's health care institutions, to increase publicity, conscientiously do a good job in mobilization and organization, and strive to improve the quality and level of health care, expand the social and economic benefits of children's health care.
2, this work should be carefully organized, enthusiastic service, careful inspection, scientific guidance, timely processing, timely feedback, and constantly improve the quality of inspection, in view of the problems in the inspection timely put forward intervention measures.
3, strengthen the monitoring, management and supervision of health care and children's health examination in kindergartens.
Five, outpatient medical work
Actively bid for maternal and child health clinics, treat frail children, malnourished children, iron deficiency anemia children, pregnant women and high-risk pregnant women screened out in the management of two departments in time, actively carry out medical work according to the requirements of outpatient medical norms, and combine preventive health care with treatment to improve service quality and increase business income.