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. Seriously do a good job in writing nursing documents to meet the requirements of the specification.

4. Strengthen business training and improve business ability.

Second, the implementation measures

1. Organize to formulate various nursing work standards and distribute them to all nursing units.

2. Members of the quality control committee and quality control personnel of departments should receive regular training on nursing quality management knowledge.

3. The nursing department carries out 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 determine the key points of weekly inspection, and conduct a general survey of the nursing units in the lower wards, and the results are linked to the benefit salary.

5. The quality control team shall inspect the ward 3-4 times a month, summarize the inspection results and report them at the head nurse's regular meeting.

6. The head nurse completes the weekly work self-inspection and fills in the work self-inspection form.

7. Continue to implement the system of nurses' long night rounds, and check the quality of nursing at night and holidays.

8. Conduct a patient satisfaction survey every quarter, and feedback the results at the head nurse's regular meeting. Respond and solve the problems reflected by patients in time.

9. Hold a nursing error and accident analysis seminar once a month.

10. point out nursing defects on the spot, correct them immediately, and report major problems to the nursing department in time.

1 1. Strengthen business training, standardize technical operation and standardize basic theory assessment.

12. 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.

Nursing quality work plan 2 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.

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 nursing quality.

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.

Work plan of nursing quality. 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 be firmly based on the main line of quality, according to the hospital and nursing work plan:

First, the quality control principle of nursing quality

Implement the quality management monitoring system under the leadership of the competent dean, comprehensively organize the implementation of nursing quality control measures, strengthen special inspection, supervision and rectification, realize continuous improvement of nursing quality and ensure patient safety.

Second, the nursing quality management implementation plan

(1) Complement and improve the nursing quality and safety management system, and cultivate a quality nursing quality management team.

(two) to further improve the nursing quality standards and workflow.

1. According to the clinical practice, constantly improve the nursing rules and regulations, and further improve the assessment content and scoring standards of nursing quality such as specialist and first-class nursing; Basic nursing; Disinfection and isolation; Writing of nursing documents; Quality evaluation standards such as supply room, operating room and ten safety targets of patients; Revision of nursing technical operation process.

2. Organize nurses to learn rules and regulations and new standards, strengthen the training of medical and nursing laws and regulations, improve the legal awareness of nursing staff, care according to law, protect the legitimate rights and interests of patients and nurses, and strengthen the safety awareness of nurses and the awareness of quality management of all staff.

3. Give play to the role of the secondary quality monitoring team of nursing department and department and the backbone of nursing, and attach importance to link quality control and tracking the rectification effect of key topics. The principle of combining routine examination of departments with supervision of nursing department, focusing on comprehensive examination. The nursing department holds a nursing quality analysis meeting once a month to report the monthly nursing quality inspection, analyze the reasons and put forward corrective measures.

4. Take the potential safety hazards in monthly quality analysis as the key content of quality inspection next month, strengthen inspection and supervision, and attach importance to the actual rectification effect. And there are inspection records, analysis, evaluation and improvement measures.

5. Strengthen the management of key links and critical periods, such as fair scheduling and scientific management of night shifts, holidays and new employees.

6. Do a good job in basic nursing and specialist nursing for critically ill patients and patients after major surgery, strengthen health education and improve the quality of life of patients.

7. Organize the study of "Top Ten Safety Targets for Patients", formulate quality evaluation standards, and inspect and supervise the contents of the top ten safety targets every month; Continuously evaluate high-risk factors such as falls and pressure ulcers, and follow up nursing measures in time.

8. Strengthen the management of nursing defects and nursing disputes, adhere to strict supervision of all aspects of work quality, find potential safety hazards, and take timely measures to eliminate nursing negligence accidents in the bud. The nursing department discusses and analyzes nursing defects and faults in time.

9. Establish and improve the safety early warning work, find hidden dangers in the work in time, and put forward improvement measures.

(3) Strengthen the professional skills training of nurses to ensure the safety of patients.

1. The nursing department sends officers to be responsible for nursing skills training, and draws up the annual work plan for nursing staff training at all levels, adopting the principle of teaching first, then organizing training by the head nurse, and combining sampling examination with compulsory examination in the nursing department.

2. The nursing department organizes nursing theory study 1~2 times a month according to the "Dimethyl" standard rules, and conducts assessment, paying attention to the implementation of rules and regulations in clinical work.

3. Strengthening the training of specialized nurses and continuing education for nurses: 8 nurses are planned to participate in the training of specialized nurses in the fields of trauma, rehabilitation, severe illness and newborn. 3~4 nursing backbones were selected to study in provincial hospitals and Huaxi hospitals for 3 months.