Annual work plan for quality management 1 1. Strengthen the construction of medical quality office team and improve various medical quality systems and assessment standards.
Establishing a perfect quality management system and standardizing medical behavior are the core. Establish a quality management system in line with the actual situation of the hospital. The hospital has set up a quality management committee and a leading group for quality control assessment, with the executive vice president, medical department and clinical department as members, to be responsible for the quality management of the hospital. The whole hospital formed the main leaders to personally grasp; In charge of leadership; Functional departments grasp every day; Clinical departments have been paying attention to medical quality and medical safety management mode. Strengthen clinical pathway management, improve medical quality and ensure medical safety through medical business management during probation period.
Two, strengthen medical quality management, ensure and improve the quality of medical services.
Medical quality management is the core of hospital management, and improving medical quality is the fundamental purpose of hospital management. Medical quality is the lifeline of the hospital. On the basis of improving the medical management system, it is the most important thing to reduce medical quality defects, timely investigate and eliminate medical safety hazards, reduce medical disputes and prevent medical accidents. Strictly control the quality of medical care, requiring all departments to strictly implement various rules and regulations, standardize diagnosis and treatment behavior, and adhere to the responsibility system of first diagnosis, three-level rounds, consultation system for difficult patients, consultation system for critically ill patients and discussion system before and after operation. Strengthen the sense of responsibility, pay attention to the dynamic analysis in medical activities, and take various preventive measures to nip in the bud. In view of patients' increasing demand for medical information, various information systems should be improved. Strengthen quality control management. In-patient medical records shall be written in accordance with the Medical Records Writing Standard, the Basic Standard for Electronic Medical Records (Trial), the Basic Standard for Medical Records Writing in China and the grading standards issued by the Ministry of Health, and prescription writing shall be executed in accordance with the Prescription Management Measures and the Provisions on Drug Quality and Spiritual Management.
Third, according to the problems found in the actual operation during the probation period, optimize the medical service process and improve the medical quality.
The identification of departments and services is standardized, clear, eye-catching and easy to understand. Adhere to the patient-centered, make great efforts to optimize the medical treatment process and facilitate patients to seek medical treatment, seek practical results, enhance service awareness, optimize the development environment, and strive to provide warm, convenient and high-quality medical services for patients.
Four, the implementation of medical quality, medical safety education, is the basis of strengthening medical quality.
Strengthen the quality education of medical staff in the hospital, so that all staff in the hospital have a correct outlook on life, values and professional ethics; Need a strong sense of responsibility, dedication and compassion; Establish a solid awareness of medical quality and medical safety; Carry out high-quality service and "safety is saving, accidents are wasting" activities in hospitals in an all-round way, stimulate employees' professionalism in learning and work, and form a good atmosphere for learning and catching up. Cooperate with the medical department and the science and education department to carry out "three basics and three strictness" education and training for medical staff in the hospital.
Annual Work Plan for Quality Management 2 I. Implementation Basis:
1, 20xx medical service quality and safety special rectification plan and other documents.
2, the superior medical management department management document requirements.
Second, improve the quality management organization system to meet the needs of quality management and continuous improvement.
1, improve the hospital medical management organization and implement the two-level responsibility system. Dean and department director are the first responsible persons for the quality and safety management of hospitals and departments, and the leading group should regularly study the medical quality and medical safety issues. This department has quality control personnel.
2. The person in charge of medical quality management shall organize the implementation of medical quality and safety management, be responsible for guiding, supervising, assessing, analyzing and evaluating medical quality and safety work, and regularly check and analyze medical quality and safety indicators and supervise their implementation. Supervision and inspection must be planned, recorded, analyzed, fed back, rectified and effective.
3. Improve the medical quality management organization: medical quality management, pharmacy management, hospital infection management, medical record management, nursing management, etc. Regularly study medical quality and safety management issues, keep activity records, and attach importance to work effectiveness.
The third is to strengthen the education of medical quality and medical safety for all staff, improve the ability of all staff to participate in quality and safety, and incorporate quality and safety training into the annual training plan for all staff and conduct it regularly to ensure the training effect.
Four, strengthen the "three basics" training, to carry out clinical medicine, nursing, imaging, testing, pharmacy, hospital infection and other professional training activities. Do a good job in first aid, serious illness rescue, resuscitation technology, surgery, clinical skills, medical record writing and other basic training. , strengthen the ability to practice according to law and the communication ability between doctors and patients.
Five, strictly implement the core system of medical quality and medical safety management and continuous improvement, improve and implement the rules and regulations, technical operation procedures and the responsibilities of all kinds of personnel. Establish and improve medical technology risk prevention, medical safety incidents, medical accident prevention plans and treatment processes, and improve preventive measures against accidental injuries caused by non-medical factors. Report and handle medical accidents, disputes and other adverse events as required.
Six, strengthen the management of key departments and key positions. Focus on finding hidden dangers and weak links in medical safety, strengthen rectification, and have monthly inspection and monitoring records.
Seven, fully study and apply the clinical pathway to ensure and continuously improve the quality of medical care.
Eight, adhere to the patient-centered, strengthen the people-oriented service concept, enhance patient service awareness, continuously improve medical services, improve work efficiency, strengthen communication and follow-up, improve the doctor-patient relationship, safeguard the interests of patients, and realize the standardization and humanization of medical services.
Nine, strengthen the quality of medical services in departments to ensure safety and effectiveness. According to the implementation plan of hospital medical quality and safety management and continuous improvement, combined with the actual work of our department, each department makes feasible medical quality and safety management and continuous improvement plans, and constantly improves them in the implementation process.
Annual work plan for quality management. Gradually improve the organizational structure construction system of the quality control center, and establish and improve the quality evaluation standards.
(a) to establish and improve the quality control center expert group.
(two) to assist all localities to establish medical quality control sub-centers.
In accordance with the requirements of the Ministry of Health's Administrative Measures for Medical Quality Control Centers (Trial) and the Notice of Sichuan Provincial Health Department on Building a Medical Quality Control Network, we will improve the construction of pediatric quality control sub-centers in various cities and States and comprehensively and effectively carry out pediatric quality control.
(3) Drafting the quality control standard of pediatrics in Sichuan Province.
Gradually complete the drafting of quality control standards for newborns, children's infectious diseases, children's digestive system, children's respiratory diseases, children's heart diseases, children's nephropathy, children's hematological diseases, children's neuropathy, children's endocrinology, children's hereditary diseases, children's immunity and other1/professional diseases, and formulate and improve the quality management and control standards for pediatric medical care; Strive to build a pediatric team in the province; Escort the health of children aged 0- 18.
Two, the province's pediatric management, quality control, operation research, using various forms of on-site supervision and inspection.
Comprehensively sort out the current situation of pediatric specialty, discipline development, talent team, diagnosis and treatment technology level and ability in the province; Carry out disease spectrum investigation, such as the incidence of nephrotic syndrome in children, to provide basis for health administrative departments and government decision-making; Measures or methods related to the collection, summary, analysis, evaluation, feedback, guidance and rectification of 20xx quality control information; Experts from the Provincial Pediatric Quality Control Center will go to cities and states together with experts from sub-centers to conduct spot checks on the inspection and guidance of pediatric quality control in relevant medical institutions in the province, find out the existing problems and propose improvement methods; Provide daily monitoring result data for hospital grade evaluation and evaluation.
Three, strengthen the construction of technical personnel, fully implement the technical training work.
1. Hold a training meeting for experts to strengthen standardized guidance and training for primary medical institutions. In 20xx, Sichuan Pediatric Quality Control Center plans to hold at least two provincial expert group meetings to strengthen standardized guidance and training for primary medical institutions.
2. Compile the training materials of Sichuan Pediatric Quality Control Center. According to the training objectives, the 1 training textbook for diagnosis and treatment of neonatal diseases was compiled, and relevant personnel were trained according to the contents of the textbook.
3. Training members of Sichuan Pediatric Quality Control Center. With the help of national and provincial continuing medical education projects and the provincial center as the platform, the standardized construction of pediatric departments, the promotion of appropriate technologies and the introduction of new technologies in the province were carried out; In order to standardize and improve the level of diagnosis and treatment of neonatal diseases by pediatric medical staff, the center's goal this year is to strengthen and standardize the construction, management and diagnosis and treatment of neonatal diseases.
Four, establish and improve the medical quality control center information system construction.
(a) to carry out relevant disease information report.
Gradually establish a pediatric diagnosis and treatment case information reporting system, designate a person to be responsible for information reporting and entry, and provide necessary equipment and technical conditions for information reporting; The center will collect, sort out, count, analyze, evaluate and feedback the quality control information of pediatric diseases reported by our province, and guide relevant measures or methods for rectification. At the same time, the quality control center should strengthen the technical guidance to medical institutions, and regard the timeliness, completeness and safety of information submission as an important index of medical quality control of pediatric diagnosis and treatment in medical institutions; Provide daily monitoring result data for hospital grade evaluation and evaluation.
(two) the establishment of medical quality control center adverse event information reporting system.
Gradually establish the adverse event information reporting system of medical quality control center, make full use of the platform of adverse event information reporting system of medical quality control center, exchange and share risk prevention experience, enhance risk prevention awareness and improve risk prevention ability, and finally achieve the purpose of protecting patients' health and medical safety.
(3) Improve the information construction of quality control center and build an information exchange platform.
Using the established website of Sichuan Pediatric Quality Control Center, we will expand the propaganda of pediatric quality control in the whole province, use the convenience and openness of the network to hang training courseware, related forms and other materials, strengthen communication with sub-centers, continuously improve the network construction of pediatric quality control centers, open remote consultation channels for difficult diseases, and organize experts to carry out various forms of appropriate technology promotion lectures, rounds, discussion of difficult patients, deaths and other activities to effectively improve medical quality and ensure medical safety.
Verb (short for verb) Other jobs
Assist and support the construction of pediatrics in cities and States, and promote the construction of provincial or municipal clinical key specialties. CC: Department of Medical Administration and Department of Medical Management of the National Health and Family Planning Commission, Provincial Administration of Traditional Chinese Medicine, Provincial Health Law Enforcement Supervision Corps, Provincial Clinical Quality Control Center, and Provincial Bayi Rehabilitation Center.
Annual Work Plan for Quality Management 4 This plan is formulated to strengthen the construction of medical quality control system, promote the standardization and standardized management of medical quality, establish and improve the long-term mechanism of medical safety and quality control in our province, improve medical quality and safeguard people's health, and build provincial medical quality control centers (hereinafter referred to as "quality control centers") by stages.
I. Work objectives
In accordance with the requirements of the annual hospital management activities of the Ministry of Health and state administration of traditional chinese medicine "patient-centered, with the theme of improving medical quality", we should strengthen medical quality management, improve the medical quality control system, ensure medical safety, improve medical quality and safeguard people's health.
Second, the job responsibilities and functions
(a) the provincial health department is fully responsible for the province's medical quality control work, and co-ordinate the province's medical quality control activities; Guangdong Provincial Hospital Association is entrusted by the Provincial Health Department to undertake daily management.
The Provincial Health Department is responsible for the planning, coordination and management of quality control centers, organizing quality control centers to formulate professional medical quality control standards, establishing evaluation systems and quality information systems, and coordinating quality control activities of quality control centers.
The provincial health department strengthens the medical quality control of tertiary hospitals in the province, focusing on provincial and subordinate hospitals; According to the requirements of medical quality in the whole province, referring to the implementation measures for the construction of provincial medical quality control centers, and combining with local conditions, cities organize the implementation of medical quality control in their respective jurisdictions.
Entrusted by the Provincial Health Department, Guangdong Provincial Hospital Association accepted the application materials, collected and summarized the quality control information, analyzed the medical quality control situation in the province, and put forward suggestions for improvement.
(two) according to the needs of medical quality management, according to different professional disciplines or professional technology to set up a specialist quality control center, the provincial health department will be based on the progress of medical quality control in our province from time to time to announce the name of the proposed specialist or professional quality control center.
(three) the quality control center affiliated unit conditions:
1. In principle, the quality control center belongs to three-level medical institutions at or below the provincial level, entrusted by the provincial health department, and is responsible for the medical quality control of this specialty, and an expert group composed of several experts from the whole province is established to provide professional and technical guidance on quality control;
2, quality control center affiliated medical institutions, the relevant professional level should be in the national or provincial status, with good political quality, professional quality and management level;
3, affiliated medical institutions should provide office space, equipment and necessary full-time or part-time staff and other support for the quality control center;
(four) professional quality control center under the leadership of the provincial health department, perform the following duties:
1, according to the current situation of professional quality management and quality control requirements in the province, formulate professional quality control plans, and provide professional business guidance to medical institutions at all levels according to the plans;
2, according to the medical management standards and medical quality standards promulgated by the Ministry of health and the provincial health department, formulate the professional medical quality control standards and technical specifications;
3, responsible for the development of the province's professional quality evaluation system and assessment plan, organization of professional quality control supervision and quality evaluation of medical institutions at all levels; Responsible for the review of special medical technology access of related majors;
4, the province's professional medical quality analysis, research, and regularly report to the provincial health department, put forward opinions and suggestions to improve the quality;
5. Organize technical training for relevant professionals, organize academic exchanges, and popularize new theories, technologies and methods of this major; Continuously improve the quality of professional teams;
6, the establishment of relevant professional information database, strengthen the collection, collation and analysis of relevant professional information;
7. Give full play to the technical guidance role of professional experts;
8. Undertake other medical quality management tasks entrusted by the Provincial Health Department.
(5) The quality control center has a director 1 person, two or three deputy directors and two secretaries 1-2; The quality control center has an expert group with 7- 10 members, both full-time and part-time. The members of the expert group of quality control center include hospital management and clinical medicine experts, and in principle, they are composed of members of national and provincial societies (branches/groups) of related majors.
(six) the quality control center implements the director responsibility system, and the organizational structure is confirmed by the provincial health department.
Iii. Application and confirmation of quality control center
According to the provincial medical quality control center construction plan and the annual special construction plan, eligible units may apply to the provincial health administrative department. Applicants must submit the following materials:
(1) Application Form for the Construction of Guangdong Medical Quality Control Center;
(two) the feasibility report, including the basic situation of the unit, professional advantages and working ideas;
(3) Copies of relevant technical materials, scientific and technological projects, achievements, patents and important papers, and letters of appointment of academic/technical leaders and technical backbones of academic institutions;
Annual Work Plan for Quality Management 5 I. Purpose:
According to the company's quality policy and quality objectives, formulate and organize the implementation of the department's quality management plan and objectives, and organize subordinates to improve and maintain the standardization system, as well as product standard management and product quality accident handling; Organize subordinates to inspect and test raw and auxiliary materials, finished products and production processes, ensure the fairness, accuracy and timeliness of inspection results, control inspection costs, and improve work efficiency and service quality to meet the needs of businesses and customers of various departments of the company.
Second, the organizational structure
Due to the gradual expansion of the company's scale, there are more and more products and business volume, and the focus of work will change accordingly. In order to meet the current production needs, the temporary organizational structure is shown in the following figure 1, and inspectors need to be added later.
I hope the quality of inspectors is higher. The existing quality inspector retraining can only prevent the delivery of defective products, and cannot plan the development needs of the organization in the later stage. The quality department also needs to establish supplier quality management and delivery inspection. Therefore, quality management needs to be systematized and standardized more and more.
Third, personnel planning:
The planned number of people is 5:
The number of entry inspectors in 1 and IQC has increased from the current 2 to 5. And set up a special IQC incoming inspection team.
2. The target of the number of bad batches of 2.IQC incoming materials is ≥94%. In order to achieve this goal, a professional SQM engineer is needed to provide guidance on supplier management, and this person also serves as the leader of IQC team.
3. In order to strengthen the data analysis and improvement ability of the quality department and improve the company's ISO procedures, it is necessary to add a quality clerk who will also serve as a document controller.
4. The quality supervisor is directly responsible for reducing potential quality hazards in product development, improving process quality control ability, reducing customer complaints, and handling anomalies in the outsourcing production process.
5. Each foreign factory needs to be equipped with 1 skilled foreign supervisor and 2 quality inspectors to achieve the purpose of monitoring the quality of foreign factories.
Fourth, regional planning:
With the continuous growth of the company, the company's quality management system is becoming more and more perfect, and there are more and more people in the quality department. The existing work area of the quality department can no longer meet the needs of constant change and development, so the quality department needs a relatively independent work area that can accommodate enough people.
Verb (abbreviation for verb) department responsibility
In order to implement the quality management system, promote the company's product quality management and quality improvement activities, ensure to provide customers with satisfactory products and quality services, and realize the company's interests, the following duties are tentatively set:
1, implement the company's quality policy, constantly improve the company's quality assurance system documents, and ensure that the ISO900 1:20xx: 20xx quality management system can run continuously and be effectively implemented;
2. According to the company's quality objectives, supervise all departments to establish relevant quality objectives, be responsible for evaluating the quality management of all departments, and organize review and planning according to the actual performance and orders;
3. Be responsible for the formulation and implementation of various quality management systems of the company, and organize and promote various quality improvement activities.
4. Establish a quality management responsibility system, implement it in all relevant departments (people), establish and improve the quality assessment system, and implement "strict control of each working procedure, so that everyone is responsible, everything is based, the operation is standard, and there is supervision at all levels";
5. Formulate departmental assessment system and organize the implementation of performance management; And provide statistical data of various quality problems, and cooperate with the administrative department to supervise the performance appraisal process of various departments;
6. Formulate quality management training program and carry out comprehensive quality management education activities. Regularly organize quality education and training for inspectors, managers, business personnel, operators and other different positions, strengthen quality management, and improve the quality awareness and quality management level of all employees of the company;
7. Strengthen the collection and collation of information on international, national or industrial standards and technical requirements, and then distribute them to relevant departments and personnel for learning and mastering, and implement them;
8. Participate in the review of special orders and product designs, and formulate corresponding inspection specifications and quality control plans;
9. Responsible for sample inspection, feedback inspection results to relevant departments, promote project improvement, and file relevant documents according to the quality control plan;
10. Implement supplier quality management and participate in the evaluation of qualified suppliers of the company;
1 1. Inspect raw and auxiliary materials, processed products, semi-finished products and finished products according to the specified operation flow and with reference to inspection standards or specifications, conduct inspection tour, form written inspection records and feed them back to relevant departments;
12. Cooperate with the Ministry of Commerce to handle customer complaints, lead the analysis of abnormal reasons and effectively implement and verify improvement measures to reduce internal and external customer complaints and continuously improve customer satisfaction;
13, responsible for compiling annual, quarterly and monthly product quality statistical reports, and establishing and standardizing original inspection records, statistical reports and quality statistical audit procedures; Statistics, analysis and assessment of product quality indicators, put forward measures to improve product quality.
14, responsible for regular quality work report. Regularly make oral or written reports at production meetings, organize special analysis meetings of major quality accidents, and report special emergencies to superiors.
15, responsible for the investigation and handling of the company's quality accidents according to the Regulations on Handling Quality Accidents.
16, responsible for the management of relevant documents, records and information to ensure the traceability of the product realization process.
17, coordination and management of related work with other departments.
18, complete the tasks assigned by the superior temporarily.
Annual Work Plan of Quality Management 6 There have been several quality accidents in the production department. Although there are various reasons such as the prototype equipment of real stone paint and the transformation of transportation pipeline, it is difficult to achieve 100% water washing, and the production equipment is insufficient. Part of the equipment removed by Jinding has been used for a long time, and its function and performance are unstable, which leads to the alternate use of existing equipment, which leads to the alternate production of some products on the designated 1 2 machine. For example, there are also cases where the skills of color mixing personnel are different, which also leads to problems in some color mixing products.
Through the analysis of product quality problems, the 20xx quality management work plan is as follows:
1. Strengthen employees' awareness of inferior quality;
At present, some employees still have the attitude that quality is irrelevant and indifferent, and they only care about production and ignore quality; This is related to employees' poor quality awareness, strong sense of quality crisis and inadequate implementation of product quality responsibility system. Next year, we should begin to implement the quality management system and increase control over the production process.
2, establish the concept of full participation in quality:
What we lack now is the quality consciousness of full participation, and there is also the wrong idea that product quality is detected, not produced, and that quality problems do not analyze the reasons and find solutions in time; Sometimes there will be a phenomenon that the production site is managed but not implemented in place. In a word, it seems impossible to achieve perfection if the product quality is managed by only a few people, which requires the active cooperation and participation of managers at all levels. Therefore, the production department should strengthen the assessment of process control in the future production process to improve the qualified rate of products.
3. Lack of quality record control:
In the whole manufacturing process of products, it is particularly important to completely record the quality status of products. If there is a perfect quality record, it will provide accurate basis for product design change, technical analysis and data search. Strengthen the control and assessment of the execution process of engineering orders, but a lot of work still needs the assistance of technical departments to strengthen the management of details.
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