The days passed silently and ushered in a new starting point. Let's sit down and write the annual hospital work plan. The following is a practical annual hospital work plan that I have carefully arranged for you, hoping to help you.
Article 1 on the practicality of the annual hospital work plan. In order to ensure the safety of hospital personnel and property, the security department should give full play to its supervisory role, fully penetrate the security work and safety awareness into grass-roots departments and individuals, better complete the hospital security work, and ensure the prosperity and development of the hospital, this plan is specially formulated.
Unify understanding and strengthen quality. In the new year, the security department should strengthen its own study, improve its professional quality and ability, standardize management according to relevant rules and regulations, improve the quality and level of work, and complete various tasks assigned by the hospital.
The second is to strengthen public security and fire control management, maintain order, ensure hospital safety, and consolidate the results of comprehensive management.
1, fire safety management:
(1) Adhere to the principle of "prevention first, combining prevention with elimination", do a good job in safety and fire prevention, continue to carry out daily inspection, weekly inspection and monthly inspection, keep a close eye on key parts, grasp hidden danger parts, ensure that supervision is in place and rectification is thorough.
(2) Strengthen the implementation of the responsibility system, further improve the regulatory rectification measures, implement the preventive responsibility, and resolutely do three things: "The cause of the fire is unclear; The responsible person does not handle it; Don't learn lessons, don't take measures, don't let go "; Continue to improve and implement other fire safety work, and establish and improve fire protection files. To ensure the fire safety of the hospital.
(3) According to the requirements of the fire department, the personnel on duty in the fire control room must have excellent work skills. Once a fire breaks out, the personnel on duty in the fire control room should participate in the fire fighting and the operation of corresponding equipment at the first time to ensure timely fighting.
2, public security and safety management:
(1) Adhere to the combination of attack and prevention, play a functional role, implement the responsibility system, strengthen public security management, implement safety education, and ensure good public order in hospitals.
(2) Safeguard Section shall improve the layout design of video monitoring system on each floor, and increase video monitoring points to ensure full coverage.
(3) Strengthen the management of the doorman and parking lot to ensure the orderly and stable public security environment of the hospital.
(4) continue to cooperate with the local police station to crack down on illegal acts such as "medical troubles" and safeguard the rights and interests of hospitals.
(5) Implement the safety responsibility system, strengthen the sense of responsibility of department heads, improve employees' safety awareness and legal concept, and at the same time strengthen the management of family visits of hospitalized patients to control the occurrence of various cases.
_ _ Hospital
20/2000 1 Month
On the practice part of the hospital's annual work plan II. The overall goal of department development: on the existing basis, formulate and improve the department management system, improve the professional and technical level, and realize the standardization, standardization and professional management goals of the department; Relying on the relevant departments to improve the scientific research level and discipline status of departments, so that anesthesiology becomes the key discipline of medical treatment, teaching and scientific research in _ _ province.
First, standardize management.
Department management depends on: one is the idea of department director, and the other is leadership. Because the director of the department has no idea, the department will inevitably lose the hospital orientation and move completely in the direction of personal interests; If interests overwhelm ideas, the department will definitely go backwards. Therefore, the management of the department must be that ideas overwhelm interests, and all correct ideas that can stand the social test must be adhered to. We know that in fact, vested interests are far more powerful than ideas, but although people are dominated by interests, interests themselves and all human affairs are dominated by ideas.
The department has a clear ideal: to ensure our success in the construction of key disciplines in the province, thus bringing brand effect to the hospital. This is the concept of the department. Correcting the current situation that money has the upper hand and highlighting the highlights of the department are the goals. Creating a provincial key discipline may make everyone in the general practice make more efforts, even if life is not rich, but it will certainly enrich your life, so that you will not fall into a material and spiritual loss after your busy work. The ideal of the department is the height, brightness and depth of anesthesiology department.
Second, clinical safety.
Clinical medical treatment is the top priority of hospital work, and medical safety is the foundation of department work. Only by completing medical tasks on time with good quality and quantity can we establish the position of departments in hospitals and peers. We will continue to improve and implement various management systems and quality standards, strictly implement various operating procedures, and minimize various safety risks.
We should make full use of our own advantages to promote the wide application of perioperative blood protection and gradually form our own clinical characteristics and theoretical system. It is necessary to establish a key discipline with first-class talents, first-class technology, first-class equipment and high reputation, which represents the image of the hospital and is the first choice for patients to seek medical treatment. So the key subject is the "brand" of the hospital. Ensuring the safety of patients during perioperative period is a comfortable medical brand sincerely created by anesthesiology department.
Third, scientific research brand.
Scientific research is the most important link to improve the academic status of departments. At present, isovolemic hemodilution, especially autologous blood transfusion in elective surgery, has reached 88%, and the blood reserve has entered the world's advanced ranks; Last year, two scientific research projects were included in the municipal science and technology support projects, one of which has been approved by the Health Department; At the same time, there are eight projects in this department. At present, scientific research technology is the true embodiment of strengthening the cultivation of scientific research quality in departments.
This year, we will scientifically evaluate the clinical application of autologous blood transfusion in elective surgery. Our research direction must be blood protection and related organ protection and drug metabolism. We should make use of our own advantages, attach importance to clinical research and strengthen drug metabolism research, so as to establish and enhance the status of blood protection in perioperative research in domestic counterparts.
All departments should publish more high-level professional articles, especially core journal articles. At present, it is one of the important conditions for hospitals to attract patients that anesthesiology scientific research leads the health system and builds the brand awareness of scientific research.
Fourth, teaching benefits from each other.
It is planned to recruit 2-3 undergraduate students majoring in anesthesia,/kloc-0 graduate students majoring in anesthesia, or attending physicians majoring in anesthesia with certain clinical experience. In particular, it is necessary to strengthen the standardized training of specialists and undergraduate teaching. At present, the standardized training of residents has become the highlight of the city. The department insists on organizing business study three times a week, which is actually the embodiment of the department's emphasis on teaching and learning, and is of great significance to the department's sustainable development.
Optimize the workflow and bring anesthesia nurses into the management scope of anesthesia department. Strengthen the standardized management of anesthesia recovery room according to the quality control standard of anesthesia medical treatment and the basic requirements of hospital three-level evaluation. The main content is to implement the process and system of recovery room, plan the corresponding staffing and training, and plan the purchase of corresponding equipment. It is planned to organize the province to continue the project this year and hold the second anesthesiology director's study class and the city's anesthesiology academic conference.
Fifth, talents promote science.
The sustainable development of departments can not be separated from the construction of talent team. It is necessary to train talents in a planned way through various channels, so that everyone in the department can give full play to their potential, so that everyone can give full play to their intelligence and value, and finally establish a talent team with reasonable structure, excellent quality and both ability and political integrity, especially with morality, ability and performance as the guidance, so as to truly develop talents into practice.
A doctor in the department plans to practice in Singapore Central Hospital for half a year during the year to enrich the backbone and reserve force of the department. Going abroad for further study is not only to learn advanced technology and management level, but also to learn advanced service concept and humanistic development concept beyond ideology. Departments always need vitality and sunshine, and advanced social concepts are an endless treasure for us to learn.
Sixth, strengthen exchanges.
Strengthening external publicity and promoting international and domestic academic exchanges are important contents of discipline development. Use the hospital's network platform and various channels to strengthen external publicity, use existing resources to strengthen external academic exchanges, and use the opportunity to participate in important international and domestic academic conferences to publicize and enhance the brand and influence of departments.
Seven, comfortable medical care.
This year, the department promotes comfortable medical care, because we are the leading discipline in promoting comfortable medical care. In the process of promoting comfortable medical care, we put special emphasis on respecting patients and ensuring their dignity. All patients who come to the department for surgery should, in principle, take off their pants and have a catheterization after anesthesia. When some patients are worried about strangers, can they use more humane methods and wait for anesthesia before taking some methods or measures that may hurt their self-esteem?
Some languages: "Go to bed, take off your pants and stretch your legs" are languages that violate basic human rights and hurt your self-esteem. If we use more intimate language, or use anesthesia, the assistant will complete these actions and help the patient put on clothes and trousers at the end of the examination, and her dignity will be guaranteed when the patient is awake. Is this more humane? We often say: there is no difference in technology from developed countries in Europe and America, but our culture is quite shallow and there is no respect for patients.
As we all know, we are a vast country with 5,000 years of culture. Why should we abandon the traditional excellent culture of the Chinese nation? Whether there is contempt for patients in the practice process is worth pondering. In the process of promoting comfortable medical care, ensure that patients' human rights and psychology are respected. It is very important to improve the service quality and brand image of the department.
In this work, the department must not ignore the significance of asking the anesthesiologist to talk with the patient in detail: the purpose is to improve his/her quality of life, ensure basic human rights, make him/her more dignified and reduce complications. This is an important content to avoid hospital disputes.
The pursuit of anesthesiology is based on the perspective of strategic thinking, from refined strategy to refined operation. Only in this way can we lead the market with talents, technology and academics and lay a good foundation for the re-evaluation of key departments in this year's department! Promote the construction of provincial anesthesia key disciplines and anesthesia brands. This is a typical performance of a strong cultural subject.
We believe that under the correct leadership of the hospital leaders and the unremitting efforts of the general department, we have successfully passed the acceptance of the first-class key specialty of anesthesiology in Hangzhou, and it is just around the corner to contribute all our strength to the development of the hospital.
Practical article 3 1 on the annual work plan of the hospital. Give full play to the main role of employees with the theme of building a harmonious hospital.
Under the leadership of the Municipal Federation of Trade Unions, the County Federation of Trade Unions and the General Party Branch of the Institute, the trade unions in our hospital mobilized the staff of the whole hospital to make clear the objectives and requirements, and earnestly made various preparations. In this year's "three good and one satisfaction" activities, the hospital trade union will cooperate with the hospital administration, pay close attention to the quality and safety of medical care, do a good job in all the work and successfully complete the task. Fully stimulate the creativity of the broad masses of workers. With the goal of "three good and one satisfaction", we will mobilize the employees to actively participate in a series of interactions, condense the wisdom and strength of employees, and give full play to the role of employees as the main force. Further improve the system, highlight the theme, strengthen the assessment, carry out various competitions, and strengthen medical safety, personal safety of employees and environmental safety. Comprehensively improve the overall quality of the workforce. Advocate employees to study business knowledge hard, strengthen skills training, and continue to carry out various activities in the hospital. With good service attitude and superb business technology, we can relieve patients' pain, restore health, ensure medical quality and safety, and prevent medical accidents.
Two, to coordinate labor relations as the main line, and earnestly safeguard the legitimate rights and interests of workers.
Harmonious labor relations are the foundation of social harmony. The working theme of this year's hospital is "building a harmonious hospital". Trade unions should firmly establish the concept of trade union rights protection in Socialism with Chinese characteristics, focus on promoting the implementation of labor contract law, labor law, trade union law and labor dispute mediation and arbitration law, further improve the rights protection mechanism, increase the power of maintaining rights, improve the effectiveness of rights protection, unite and mobilize the broad masses of workers to effectively build * * * in * * and enjoy * * *. Strive to become a bridge and link between the hospital party Committee, hospital administration and staff, create a harmonious atmosphere and promote the development of the hospital.
Third, with the purpose of serving employees wholeheartedly, we strive to do practical things for employees.
The trade union is the "mother's family" of workers, and it is the unshirkable responsibility of the trade union to solve problems for workers, which is also one of the foundations of "building a harmonious hospital".
1, continue to do a good job in send warm. Understand the life and difficulties of employees in detail, warmly receive letters and visits from employees, give timely answers, sympathize with hospitalized employees and retired veteran comrades, sympathize with deceased employees and their families, and help employees who have difficulties in life solve their difficulties. At the same time, carry forward the fine tradition of the Chinese nation of "providing for the old, providing for the young, and providing for the young", actively respond to the call of superiors, lend a helping hand to poor and needy families and affected compatriots, and offer sincere love.
2. Continue to carry out health-related cultural and sports activities. In order to enliven the amateur cultural life of employees, enhance the friendship between employees and enhance the sense of collective honor, the trade union will hold a poker competition to welcome the New Year and draw a lottery. Celebrate the 385 plan? A "five"? Four ""five? In the "Twelfth", "July 1st", "August 1st" and "National Day" festivals, speech contests, calligraphy contests, knowledge contests, large-scale get-together activities and sports activities were held in combination with the actual work of the hospital. Cooperate with the Health Bureau to form a team to participate in various cultural and sports activities organized by county government departments. Organize a cultural and sports activity for retired veteran comrades to enrich the lives of the old people and make them healthy. Invite experts to give lectures to the staff of the hospital, conduct political and ideological training and professional knowledge training, so that the staff can further establish self-confidence, self-reliance, self-reliance and self-love, strengthen their study, improve their own quality and become qualified medical workers. Carry out large-scale publicity and education activities with the theme of "fire safety".
3, continue to do a good job of "health check-up" and "subsistence allowances" free clinic work. The trade union will continue to publicize the "physical examination", contact the reception work, and publicize the good service and exquisite technology of our hospital to all units, departments and communities through the window of "physical examination". Continue to carry out the free clinic work of "low-income workers", deliver medicines to the relatively poor people in need, make contributions to solving the problem of "expensive and difficult medical treatment" among the people, publicize medicine while serving the people, and create social and economic benefits for the hospital.
In the new year, in combination with the Law of People's Republic of China (PRC) on Medical Practitioners, the Regulations on the Administration of Medical Institutions and the Detailed Rules for the Administration of Medical Institutions, we will give full play to the role of the functional departments of the Medical Department: under the leadership of the Chairman and the Dean, we will organize and implement the medical treatment, teaching and scientific research, preventive health care (physical examination) and other work in the whole hospital. The work plan for 20__ years is as follows:
One is to organize the hospital management committee to carry out the hospital round, which is fixed every Wednesday morning, and only one department is checked in the whole morning, except for holidays or special circumstances. The clinical departments of the hospital take turns to circulate. Attend the handover of the department at eight o'clock in the morning, and attend the routine three-level rounds of a patient in the department after the handover. This is a ward round mode including teaching ward round and chief ward round, which lasts about 40 ~ 80 minutes. Then spot-check the quality of inpatient medical records, check the necessary record books stipulated by the hospital, and focus on the implementation of systems such as critical case discussion, death discussion, business learning, and medical quality management team activities. The time is about 15 minutes. After entering the report discussion stage, the hospital staff who participated in the ward round gathered with the department director. The department director first reported the problems existing in medical operation, quality management, scientific research and teaching, and personnel ideological trends at this stage, and put forward opinions on hospital service guarantee and problems that need to be solved; Then, the staff of the hospital department reported the usual inspection situation on the same day, made a decision to solve the problem on the spot, and made suggestions on the construction of the department; The discussion time is about 1 half an hour to 2 hours. The whole round lasts for one morning. Some unsolvable problems are brought back to the dean's office for discussion and decision.
Second: the chief and deputy chief of medical education stay in each department for one week (morning), contact relevant departments or personnel to help solve problems in time, and report to the hospital leaders in time if they can't solve them. Details are as follows:
(1) Clinical departments
Focus on the quality of medical records (including inpatient medical records and archived medical records), the rational use of antibiotics, and the prevention of medical errors and accidents. And organize medical quality management team to discuss and formulate inspection and assessment rules and reward and punishment system;
1, medical record quality: In strict accordance with the Zhejiang Medical Record Writing Standard, further standard requirements are put forward for the writing of inpatient medical records, course records and related materials.
(1) On the afternoon of the first Monday of each month, organize the management team to carry out clinical work, check the quality of current medical records and make an evaluation. Check the 5- 10 medical record every time;
(2) Spot check and compare the quality of archived medical records every 3 months. The required grade A rate is 100%. Every department can submit the medical records of the previous month before the 5th of each month.
2. Rational use of antibiotics: According to the Administrative Measures for Rational Use of Antibiotics in Zhejiang Province, check whether clinicians use antibiotics rationally. On Monday of the second week of each month, organize the drug supervision committee to conduct inspection.
① Indications and contraindications for use;
(2) the principle of preventive use of antibiotics;
③ the course of antibacterial treatment;
④ Therapeutic dose and route of administration of antibacterial drugs;
⑤ Combined medication and incompatibility.
3, prevent medical errors, accidents and disputes:
(1) emphasizes the writing of admission notice, power of attorney and informed consent for various medical treatments;
(2) Emphasize the true and accurate records of death case discussion records, critical and difficult case discussion records, critical patient rescue discussion records and doctor's logs;
(3) the department organization diagnosis and treatment norms and related laws and regulations.
Every month, the medical education department goes to various departments from time to time to check all records and disease records. If one item is missing or incomplete, it shall be handled according to the performance appraisal method.
(2) Emergency Department
1, further improve the outpatient function of each department, set up a fever triage office at the outpatient door, and set up an independent infectious disease pre-inspection triage department.
2. Set up and arrange an expert column in the outpatient department, and announce the professional expertise and visiting time of experts, so as to facilitate patients to see a doctor.
3. Organize quality management team to discuss and formulate inspection and assessment rules and reward and punishment system. On the afternoon of the first Monday of each month, check and evaluate the outpatient medical records. On Monday of the second week of each month, organize the Drug Administration Committee to check and evaluate the outpatient medical records and prescriptions.
(3) Medical technical assistance department
Organize medical quality management team to check and evaluate once a month.
Third, assist the hospital to set up a medical record room, reading room and nutrition department.
The fourth is to assist the hospital to improve the setting of triage points for infectious diseases and arrange the medical staff reasonably.
Fifth, strengthen the work of the new rural cooperative medical system, coordinate social security work, do a good job in medical services, so that patients can actually get the benefits brought by cooperative medical care, and further realize a win-win situation for doctors and patients and a double harvest of two benefits through the new rural cooperative medical system.
In the past 5 20 years, the nursing department has followed the requirements of "Dimethyl" hospital standards and combined with the overall work objectives of the hospital. Work closely around the new standards of "quality, safety, service, management and performance", and specific plans are hereby formulated as follows:
I. Work objectives:
1, improve the project management system of nursing quality, safety, service and management, and make all work institutionalized, scientific and standardized.
2. Strengthen connotation construction and continuously improve the overall quality of nursing team.
3. Improve and implement professional training and three-basic assessment (including: laws and regulations, rules and regulations, professional theory, operational skills, etc.). ) Provide graded training for nurses at all levels to improve their three basic theories and operational level.
4. Adhere to the "people-oriented" service principle, make the nursing service closer to the masses and society, continuously meet the people's growing demand for medical services, and create high-quality nursing benefits.
Second, the work indicators
1, and the qualified rate of basic nursing is ≥90%
2. The qualified rate of specialized nursing is ≥90%
3, grading nursing qualified rate of 90% or higher.
4, critically ill patients nursing qualified rate of 90% or higher.
5. The intact rate of first-aid articles 100%.
6. The qualified rate of disinfection and sterilization of conventional instruments is 100%.
7. The qualified rate of nursing document writing is ≥95%.
8, the patient's satisfaction with nursing work 90% or higher.
9, "three basics" assessment pass rate 100% (score ≥90)
10, and the qualified rate of nursing technology operation is ≥90% (including TCM operation)
1 1, nursing error rate "0", pressure sore rate "0"
12, qualified rate of medical waste treatment 100%
13, one needle and one tube for one person, and the disinfection qualified rate reached 100%.
15, disposable syringes, blood transfusion (blood) instruments, the type loss rate reached 100%.
15, health education coverage rate 100%
16, the success rate of health education ≥95%.
17, and the coverage rate of quality nursing service is ≥50%.
18, the overall nursing qualification rate of responsibility system ≥ 100%.
Third, specific measures.
(1) Strengthen the management of nursing quality and safety, 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 20__ year nursing work, the nursing department will follow the pdca cycle mode, and carry out assessment, analysis, evaluation, rectification, tracking and re-evaluation according to various quality assessment standards, reflecting continuous improvement and implementing target management.
1. Re-adjust the division of labor among members of the nursing quality management committee, supervise the nursing quality every month, and each nursing unit conducts self-examination on the nursing quality every week, promptly rectify and track the existing problems, revise the nursing quality standards in time, improve the system, and propose improvement measures to promote the continuous improvement of nursing quality.
2. Strengthen the nursing quality management of key links, key periods, key people and key departments (disinfection supply room, operating room and emergency room), and the nursing department will supervise the departments irregularly according to the requirements of dimethyl standard 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 disposal of disposable articles and medical wastes.
4. Improve the patient risk assessment system, strengthen the management of critically ill patients and adverse nursing time, timely check critically ill patients and adverse events reported by wards, and put forward reasonable suggestions to avoid medical disputes.
(two) to speed up the training of head nurses, nursing backbones and nurses' working ability, and effectively improve the overall quality of the nursing team.
1, strengthen the assessment of head nurses' work. Increase the training of basic technology, specialist technology and Chinese medicine skills; The nursing department conducts monthly assessment on the operation of traditional Chinese and western medicine for head nurses, continuously improves the operation ability of head nurses, strengthens the ability of correctly guiding nurses, and standardizes the operation of nursing skills in various subjects.
2. The nursing department organizes the hospital business study once every quarter, organizes the skill examination once a month, and organizes the hospital sex skill examination twice a year, with a total of * * * eight items (four skills of Chinese and Western medicine). The department organizes business study once a month.
3. According to the nurse grading training plan, revise the nurse grading management and assessment manual.
4. Strengthen the training and assessment of nursing management system, responsibilities, processes and emergency plans.
5, the nursing department regularly and irregularly organize nursing rounds, teaching rounds, nursing consultation, difficult case discussion. Organize department nursing rounds once a month, arrange discussion and analysis, find out the weak links in the work, and formulate corrective measures. Every day, the nursing department goes deep into the ward to give on-site guidance on daily work, and holds regular exchange meetings on the management experience of head nurses to improve the management level of the ward.
6. Strengthen the training of specialist nurses, arrange for further study abroad, and plan to arrange backbone nurses to study Chinese medicine, operating room and emergency specialist nursing in 20 years to speed up the construction and development of specialist nursing.
7. Encourage nurses and head nurses to participate in various forms of learning, and improve their academic level and management level. This year, it is planned to eliminate 5- 10 business backbones and head nurses and go out for further study.