Self-inspection report of medical institutions 1 In order to improve the quality of medical services and the level of technical services, our service station has carried out strict self-inspection and self-correction according to the Detailed Rules for the Implementation of the Regulations on the Administration of Medical Institutions. The relevant self-inspection report is as follows:
First, leaders attach importance to it and are well organized.
Our service station held a meeting and made strict arrangements for self-inspection. At the meeting, a self-examination leading group was set up to carry out self-examination and self-correction in strict accordance with the Detailed Rules for the Implementation of the Regulations on the Administration of Medical Institutions, and achieved remarkable results.
Second, the basic situation of self-examination
(1) Institutional self-inspection: What is the full name of the organization? Keyuan Street Fengyuan Community Health Service Station? , private non-enterprise, located in; Legal representative: person in charge: Medical Institution Practice License issued by District Health Bureau, with the practice license number of 20xx65438+February 23rd. Our service station has strictly managed the practice license of medical institutions and has never altered, bought, sold, transferred or rented it. 6 beds, including preventive health care and general medical treatment; The business building area is 320 square meters.
(2) Personnel self-examination: attending physician 1 person, practicing physician 1 person, 2 assistant physicians and 3 nurses in our service station. Our service station has never been registered to carry out practical activities on a large scale; Persons who have not obtained the qualifications of practicing doctors or nurses or doctors registered with one license and many places shall not be used to engage in medical activities. All medical staff are listed for posts, and a supervision column is set up in the hall to make it public.
(3) Improve service quality: strengthen medical quality management and implement medical quality assurance scheme according to relevant regulations and standards of health administrative departments; Regularly check and assess the implementation of various rules and regulations and post responsibility system for personnel at all levels, ensure medical safety and service quality, and continuously improve service level.
(4) Cross-infection management in hospitals: A leading group for cross-infection management in service stations was established, with members including. Relevant personnel often receive education and training, and establish and improve relevant rules and regulations such as medical waste treatment management, nosocomial infection and disinfection management, and waste leakage treatment plan. The source, type and quantity of medical waste shall be completely recorded by special personnel, and the disinfection effect shall be regularly monitored by key departments and parts. The label of the prepared disinfectant is clear, complete and standardized.
(5) Disposal of solid medical wastes: All medical wastes have been collected by classification, the temporary storage time of the wastes has been marked with warning signs according to regulations, and the containers of the wastes have been sealed against stab. Is the temporary storage of dirt realized? Five defenses? The transportation and transfer of medical wastes shall be the responsibility of a special person, with a signature record.
(6) Disposal of disposable medical supplies: All disposable medical supplies are collected by the medical waste treatment station after soaking, disinfection and destruction.
(VII) Epidemic Management Report: Our service station has established a strict epidemic management and reporting system, and designated a special person to be responsible for epidemic management. The contents of the epidemic situation register are complete, and the epidemic situation report card is standardized. The epidemic situation report is checked once a month, without omission or delay.
(8) Self-inspection of drug management: After investigation, our service station has never used counterfeit drugs, expired, invalid or illegal drugs. Strictly implement the provisions of the antibacterial drug system.
Third, there are shortcomings.
First, due to lack of funds, some medical equipment can not be maintained or updated in time, which affects the in-depth development of related businesses to a certain extent and has insufficient development potential; Second, limited by the establishment, the staff is tight, the workload is heavy, there are not many opportunities for further study in provincial medical institutions, and the knowledge updating cycle is long, which has affected the service level to a higher level to some extent.
Fourth, the direction of future efforts.
Our service station must take this self-examination as an opportunity, under the leadership of the superior business department, conscientiously implement the spirit of the superior meeting, strictly abide by the Regulations on the Management of Medical Institutions, strengthen management measures, optimize the quality of personnel, be pragmatic, pioneering and innovative, and constantly improve the quality of medical services and technical services.
Self-inspection report of medical institutions 2 In order to further strengthen the management of the designated medical institutions of the new rural cooperative medical system in our district, standardize the diagnosis and treatment service behavior, control the unreasonable increase of medical expenses, ensure the safety of the new rural cooperative medical system fund, promote the fine management of the new rural cooperative medical system and promote the evaluation of the health system, according to the spirit of the document Notice of the General Office of the Provincial Health Department on Carrying out the Behavior Inspection Activities of the New Rural Cooperative Medical System in Designated Medical Institutions, the District Health Bureau issued the Notice on Carrying out the Behavior Inspection Activities of the New Rural Cooperative Medical System in Designated Medical Institutions (No.20x55), and arranged the deployment of the designated medical The District Health Bureau organized special classes to conduct special inspections on medical institutions at all levels in the jurisdiction from September 5 to 9. The inspection activities are summarized as follows:
I. Achievements made
District people's hospitals and township health centers attach great importance to the new rural cooperative medical system, strengthen internal management, strictly implement the new rural cooperative medical system policy, and fully serve the participating people, ensuring the smooth progress of the new rural cooperative medical system, improving the benefit level of the participating people, and ensuring the safety of the new rural cooperative medical system fund. The main performance is as follows:
(A) the basic establishment of internal control mechanism
All township hospitals have established a new rural cooperative medical system with a clear division of responsibilities; Strengthen basic management, improve rules and regulations, strictly assess rewards and punishments, and ensure that all system provisions are implemented.
(2) The hospitalization expenses decreased steadily.
After the implementation of the reform of paying by bed, township hospitals have strengthened cost control and medical services, and achieved good results in reducing costs and not discounting services. In 20xx1-August, the average hospitalization expense of Penglian Township Health Center was 1200 yuan, which was 272 yuan lower than the same period of last year, with a decrease rate of 18.48%.
(3) Outpatient total prepayment has achieved remarkable results.
After the implementation of the reform of outpatient prepayment payment method, township hospitals have strengthened the overall management of outpatient service, formulated management plans, strengthened daily management, and strictly supervised and assessed, ensuring the benefit of the participating people and the safety of outpatient fund. Qiaobian Town Health Center strengthened systematic supervision, quarterly assessment and household inspection, and reduced the illegal subsidy funds of village clinics by 4 140.80 yuan from June 5438+0 to August, effectively curbing the phenomenon of fictitious diagnosis and treatment and ensuring the safe and effective use of the total prepaid funds of outpatient clinics.
Second, the existing problems
(1) District People's Hospital
First, the internal management system of the new rural cooperative medical system needs further improvement. As the District People's Hospital is incorporated into the integrated management of Yichang Central Hospital, the District People's Hospital has no independent and perfect grading management organization of the new rural cooperative medical system, the management function of the medical insurance office needs to be further strengthened, and the internal control and assessment mechanism needs to be further improved.
Second, the implementation of admission standards is not strict. Is the District People's Hospital implementing it? First time in the community? 、? Step by step introduction? The phenomenon of referral after admission in the system; The admission standard is not strict, and there is a phenomenon that outpatient service is transferred to hospitalization and minor illness treatment.
Third, rational drug use needs to be strengthened. District People's Hospital uses the drug list of tertiary hospitals, and the overall drug price is on the high side, and the management regulations on the graded use of antibacterial drugs are not strictly enforced.
Fourth, reasonable inspection needs to be standardized. District People's Hospital has strengthened the management of large-scale examinations such as color Doppler ultrasound and ct, and the pertinence and rationality of the examinations have been improved. However, there are still over-examination behaviors such as unconventional examinations unrelated to major diseases and unnecessary examinations that are of little significance to diagnosis and treatment.
(2) Township hospitals
The outpatient management of the new rural cooperative medical system in township hospitals is basically standardized, the basic drug policy is implemented, and the compensation is in place in time. There is no phenomenon of fictitious medical services taking funds, and the participants are highly satisfied and have a good social response.
Township hospitals in the new rural cooperative medical system hospitalization management mainly has the following problems:
First, the proportion of critical illness in individual hospitals is too high. From June 5438 to August, the proportion of patients in emergency and critical care management in Tucheng Health Center reached 28.78%, which was nearly 10 percentage point higher than the regional average.
Second, the overall service capacity of township hospitals is insufficient. Due to the influence of talents, equipment, technology, management and other factors, the medical service capacity of township hospitals has been declining, some common and frequently-occurring diseases in rural areas can not be treated in primary medical institutions, and the proportion of patients' outflow has been increasing, which has affected the benefit level of participating farmers and the security of the new rural cooperative medical fund.
Third, the average cost of some township hospitals is high. Compared with the same period of last year, the average cost of Ai Jia Town Health Center and Pengli 'an Township Health Center decreased obviously, and the reform of the new rural cooperative medical system based on bed-day payment achieved remarkable results. The average cost of Tucheng township health center 1583 yuan is relatively high.
Fourth, reasonable inspection needs to be standardized. Some tests have nothing to do with the main disease, and some tests (such as blood sugar) are repeated too frequently.
(3) Village clinic
First, the implementation of the basic drug policy is not in place. There are still non-essential drugs in village clinics, which can not be included in compensation, affecting the benefits of participating farmers.
Second, Chinese medicine in some village clinics was not included in the scope of reimbursement.
Third, the utilization rate of total prepaid funds in some township clinics is low. From June 5th to August, the utilization rate of funds in Aijia Town was 72.93%, and that in Peng Lian Town was 70.25%. Too much funds are deposited, and the benefit rate of participating farmers is low.
Fourth, the phenomenon of fictitious medical services still exists to varying degrees. Some village clinics do not implement the small ticket signature system and collect fees at random; It is difficult to fundamentally put an end to the phenomenon of under-reporting, over-reporting, fictitious person-times and so on.
Third, the rectification requirements
(1) Strengthen leadership and implement responsibilities. The District People's Hospital should correctly handle the relationship between the development of the hospital and the interests of the masses, effectively strengthen the management responsibility of the new rural cooperative medical system, straighten out the relationship, establish and improve the internal control mechanism, and implement the responsibility of fee control to departments and doctors. Township health centers should further implement the president responsibility system, implement the president responsibility system, implement the management responsibility to departments, extend to village clinics, and strictly implement the accountability system.
(2) Establish rules and regulations to regulate behavior. District people's hospitals and township health centers should start with system construction, implement refined management, standardize the service behavior of the new rural cooperative medical system, and improve the benefit level of participating farmers. The District People's Hospital should establish relevant management systems that are in line with the reality of Jiangnan Hospital and highlight the responsibilities of the District People's Hospital, and strengthen the system management from the aspects of admission (discharge) standards, standardized diagnosis and treatment, and reasonable cost control, and include the average cost of each case, the average bed day cost, the proportion of drugs, the positive rate of large-scale inspection, the actual compensation ratio, the utilization rate of drugs outside the catalogue, and the average length of stay in the hospital. Township health centers should establish various systems suitable for the reform of payment methods to ensure that the reform achieves the expected results.
(3) Strengthen supervision and discipline. The new rural cooperative medical fund is the life-saving money of the participating people, and it is strictly forbidden for medical institutions and medical personnel at all levels to cheat, cheat, misappropriate or illegally occupy it. The district joint management office shall perform its supervisory duties, carefully examine relevant compensation materials, strengthen online supervision, on-site supervision, telephone follow-up, and household verification, and reduce fees and informed criticism for violations found. Cases of violations with outstanding problems, serious circumstances and strong social repercussions shall be reported to the District Health Bureau for handling. Township health centers should strengthen the dynamic supervision of village clinics under their jurisdiction, implement daily supervision and quarterly assessment, further standardize medical reimbursement, and ensure that medical services are not discounted and farmers' benefit level is not reduced.
Self-inspection report of medical institutions. Self-inspection report of designated medical institutions for medical insurance Under the correct leadership of the higher authorities, according to the Notice of Heilongjiang Provincial Department of Human Resources and Social Security on Printing and Distributing the Implementation Measures for Classified Management of Designated Medical Institutions for Basic Medical Insurance in Heilongjiang Province, our hospital strictly abides by the relevant national, provincial and municipal laws and regulations on medical insurance, and conscientiously implements the medical insurance policy. We are now carefully inspecting ourselves, and the self-inspection report is as follows:
First, attach great importance to it, strengthen leadership and improve the responsibility system for medical insurance management.
After receiving the notice, our hospital immediately set up a self-inspection leading group with the main leaders as the team leader and the leaders in charge as the deputy team leader. According to the relevant standards, we found the shortcomings and actively rectified them. We know that basic medical care is an important part of the social security system. Deepening the basic medical insurance system and policy is an inevitable requirement for the development of socialist market economy and an important measure to ensure basic medical care for employees and improve their health level. Our hospital has always attached great importance to medical insurance, with specialized management by hospital leaders and a sound management system. We have held many special meetings to study and deploy, and regularly trained doctors in medical insurance. At the beginning of the year, the medical insurance work plan was formulated, the medical insurance work was summarized regularly, and the medical care and expenses of the insured patients were analyzed.
Two, standardize management, realize the standardization, institutionalization and standardization of medical insurance services.
In recent years, under the correct leadership and guidance of the District Labor Bureau and the District Medical Insurance Office, various rules and regulations such as basic medical insurance referral management system, hospitalization process, medical insurance work system, fee bill management system and outpatient management system have been established and improved. Settings? Basic medical insurance policy bulletin board? And then what? Complaint box? ; Announce the consultation and complaint telephone number 3298794; Enthusiastic to provide consulting services for insured persons and properly handle complaints from insured patients. Announce the medical insurance process in a prominent position in the hospital to facilitate the insured patients to seek medical treatment and purchase medicines; Set up a special window for the registration and settlement of medical insurance patients. Simplify the process and provide convenient and high-quality medical services. Insured employees should strictly identify themselves when they are hospitalized, and put an end to false medical treatment and false hospitalization, and to false hospitalization and broken hospitalization. Strictly grasp the admission, discharge and admission standards of patients and the admission standards of intensive care units, implement the principle of treatment due to illness, and ensure reasonable examination, treatment and medication; Medical records shall not be forged or altered. Actively cooperate with the medical insurance office to supervise and audit the diagnosis and treatment process and medical expenses, and provide medical files and related materials that need to be consulted in time. Strictly implement the charging standards set by relevant departments, and there is no case of charging for independent projects or raising the charging standards.
Strengthen the publicity of medical insurance policies, and organize regular study of the Administrative Measures for the Settlement of Medical Insurance Expenses for Urban Employees in Yichun City, the Detailed Rules for the Implementation of Basic Medical Insurance for Employees, and the Catalogue of Drugs for Basic Medical Insurance, Work Injury Insurance and Maternity Insurance in Heilongjiang Province, so that every medical staff can become more familiar with the catalogue and become a propagandist, interpreter and executor of medical insurance policies. The satisfaction rate questionnaire was distributed on the spot, and the satisfaction rate of service quality reached 98%, which was well received by the majority of insured people.
Three, strengthen management, to provide quality assurance for the insured medical treatment.
A, strictly implement the diagnosis and treatment of nursing routine and technical operation procedures. Conscientiously implement the medical core systems such as the first-visit physician responsibility system, the three-level physician rounds system, the handover system, the difficult, critical and dead case discussion system, the preoperative discussion system, the medical record writing system, the consultation system, the graded operation management system and the technical access system. Second, on the basis of strengthening the implementation of the core system, pay attention to the improvement and continuous improvement of medical quality. We have generally improved the medical quality management control system, assessment system and incentive and restraint mechanism, implemented the three-level medical quality management responsibility system in hospitals, departments and groups, decomposed the medical quality management objectives layer by layer, put the responsibility on people, moved the inspection and supervision barrier forward, went deep into the clinical front line, and found and solved problems and hidden dangers in medical work in time. Standardize the process of morning shift, chief rounds and case discussion. Third, employees should memorize the core medical system and strictly implement it in actual clinical work. Actively learn advanced medical knowledge, improve their professional and technical level, improve medical quality, serve patients well, and at the same time strengthen the study and cultivation of humanistic knowledge and etiquette knowledge to enhance their communication skills. Fourth, strengthen safety awareness, and the relationship between doctors and patients is becoming increasingly harmonious. Our hospital has continuously strengthened medical safety education, raised the awareness of quality responsibility, standardized medical operation procedures, established and improved the communication system between doctors and patients, adopted various ways to strengthen communication with patients, and patiently and meticulously explained or explained the illness to patients. Be careful before operation, be skilled in operation and be strict after operation. Further optimize the service process to facilitate patients to seek medical treatment. By adjusting the layout of departments, the integration of computer network in the whole hospital can be increased, the links of medical treatment can be simplified and the waiting time of patients can be shortened. The lobby is equipped with information desk and complaint desk, which are managed by special personnel and equipped with green.
Access to ambulance, stretcher, wheelchair and other service facilities. Through a series of caring services, the average satisfaction rate of patients is over 96%.
Fourth, strengthen hospitalization management, standardize hospitalization procedures and expense settlement.
In order to strengthen the standardized management of medical insurance and fully implement medical insurance policies and regulations, according to the requirements of the district medical insurance department, the medical insurance certificates and cards of insured patients are strictly audited. The doctors who received the consultation all managed to treat the disease, make a reasonable examination and use drugs rationally. Strengthen the quality management of medical records, strictly implement the responsibility system for first-time doctors, and standardize clinical medication. Attending doctors should consciously use safe, effective and reasonably priced drugs in the drug list according to clinical needs and medical insurance policies. Because of illness, it is really necessary to use self-funded drugs outside the drug list, and [special needs] order drugs. Class b? For drugs, medical materials and related self-funded items that need to bear part of the expenses, the attending physician shall explain the reasons to the insured and fill in the form? Informed consent? , with the consent of patients or their families, attached to the hospital medical records, the proportion of out-of-directory services in the total cost is controlled below 25%.
Five, strictly implement the provincial and municipal price departments of the charges.
Medical expenses are another concern of insured patients. Our hospital adheres to the expense list system, and the daily expenses are sent to patients. The patient can only be transferred to the inpatient department after confirmation, so that the insured can clearly understand the consumption.
Maintenance and management of intransitive verb system
The hospital attaches great importance to the maintenance and management of the insurance information management system, and promptly eliminates the obstacles of the hospital information management system to ensure the normal operation of the system. In accordance with the requirements of Yichun Medical Insurance Agency and Friendly Forestry Bureau, the computer technology administrator is responsible, and the special computer for medical insurance is required to be used in strict accordance with the regulations. If there is any problem, contact in time, and the medical expenses cannot be settled due to procedural problems, so as to ensure that the insured person can settle in time and quickly.
Always adhere to the patient-centered, quality-centered, and wholeheartedly serve patients as the starting point, strive to standardize the establishment of rules and regulations, the concept of humanized service, standardize medical quality, consciously correct professional ethics, and actively provide high-quality, efficient and inexpensive medical services and a warm medical environment for the insured, which has been well received by the majority of insured people and received good social and economic benefits.
According to the document "Implementation Measures for Graded Management of Designated Medical Institutions of Basic Medical Insurance in Yichun City", strict self-examination was carried out, and it was found that the establishment of designated medical institutions of medical insurance in our hospital met the requirements of Grade A.
?