Level III hospital: (The number of beds is within 100, including 100. [Author's Note] The same below) is a grass-roots hospital and health center that directly provides prevention, medical care, health care and rehabilitation services for communities with a certain population.
Secondary hospital: (the number of beds is between 10 1-500) a regional hospital that provides comprehensive medical and health services for many communities and undertakes certain teaching and scientific research tasks.
Third-level hospital: (the number of beds is more than 50 1 `) a hospital above the regional level that provides high-level specialized medical and health services for several areas and performs higher education and scientific research tasks. The level of hospitals run by enterprises, institutions, collectives and individuals can be delineated by analogy. (Note: In practice, tertiary hospitals are not divided into three levels ... The classification of hospital levels is based on the technical strength, management level, equipment conditions and scientific research ability of the hospital. , score 1000.
Hospitals at all levels should establish and improve the two-way referral system and step-by-step technical guidance relationship.
Third-class first-class hospital
Remarkable achievements have been made in hospital construction, and the comprehensive assessment of department setting, staffing, management level, technical level, work quality and technical facilities has reached more than 900 points according to the grading standards.
Three-level and two-level hospital
The achievements of hospital construction are still good, and its department setting, staffing, technical level, work quality and technical facilities have reached 750-899 points according to the grading standards.
Tertiary and tertiary hospitals
Some achievements have been made in hospital construction, and the basic standards have passed the examination, but there is still a big gap with the requirements of this standard. According to the grading standard, the comprehensive assessment is 749 points or less. Third-class and third-class hospitals should have practical improvement measures. Three-level specialized hospitals and three-level first-class hospitals are the most authoritative hospitals in grade hospitals. Evaluation criteria of tertiary general hospitals
A, hospital functions and tasks (50 points)
(a) medical services (20 points)
Can provide comprehensive and continuous medical care, preventive health care and rehabilitation medical services.
1. Provide high-level specialized services on the basis of high-quality comprehensive medical services. Undertake the task of diagnosis and treatment of critical and difficult diseases and carry out two-way referral.
2, there is enough radiation ability of medical services, and a certain proportion of discharged patients should come from areas or provinces outside the hospital.
3, according to the relevant provisions of the state, to participate in the local emergency medical network, under the leadership of the health administrative department, can cooperate with the emergency center to make emergency response quickly, undertake the emergency rescue task of disasters and accidents, and can accept a group of patients for hospital emergency treatment.
4, to carry out mental health, gene search outpatient service and support, to guide community medical care, nursing, rehabilitation medical services.
(2) Teaching and scientific research (15)
1, undertake clinical teaching and practice in medical colleges and universities, and train senior clinical medical talents. And undertake the clinical professional training task of technical backbone in secondary hospitals.
2, undertake national and provincial (autonomous regions and municipalities directly under the central government) scientific research projects.
(3) Business technical guidance (10)
It is the duty and obligation of the hospital to provide technical guidance to lower-level medical institutions, establish regular technical guidance and cooperative relations, help develop new technologies and projects, solve difficult problems, and cultivate health technology and management talents. Complete the health or supporting agriculture work of the local health administrative department.
(four) prevention and health care (5 points)
1, carry out health education.
2. To undertake preventive health care, clinical epidemiological investigation and prevention of major chronic non-communicable diseases (cardiovascular and cerebrovascular diseases, malignant tumors) assigned by the local health administrative department.
3. Participate in urban primary health care.
Two departments (30 points)
The establishment of hospital departments should adapt to their functions, tasks and scale. The establishment of functional departments should conform to the principle of streamlining and high efficiency and meet the needs of management. Under the guidance of the planning of medical institutions, business departments should strengthen the construction of specialties on the basis of overall development, and some first-level departments should implement secondary division to highlight the advantages of specialties.
(a) clinical departments (20 points)
1, a professional department
Should comply with the "basic standards of medical institutions" and local regulations.
2. Secondary professional departments
Internal medicine: there must be at least 7 departments, among which 3 departments are required: cardiovascular, digestive, respiratory, blood, neurology, nephrology, endocrinology and other professional departments.
Surgery: General surgery, cardiothoracic surgery, neurosurgery, urology, orthopedics and other professional departments should be established.
Obstetrics and Gynecology: There should be specialties such as gynecology, obstetrics and family planning.
Pediatrics: specialties such as pediatrics and newborns should be set up.
3. Key majors
Key specialties should be established according to the planning of medical institutions.
The hospital should have more than 3 key specialties.
Each key specialty has 20 beds.
4. Comprehensive intensive care unit (ICU or comprehensive intensive care unit) or specialized intensive care unit (or specialized intensive care unit) should be set up.
(2) Medical departments and other business departments (10)
In addition to the conference room, an information statistics room (reference room) should also be set up.
Three staffing (30 points)
Hospitals should be equipped with health technicians and other professional technicians who are suitable for their functions, tasks and scale. In addition to the introduction, it should also meet the basic standards of medical institutions and meet the following conditions:
(1) The number of nurses actually engaged in clinical nursing work shall not be less than 50% of the total number of health technicians, the ratio of beds to ward nurses shall not be less than 1:0.4, and the number of nurses with nursing professional college degree or above shall not be less than 20% of the total number of nurses. Head nurses in nursing department, internal medicine department, gynecology department, pediatrics department, emergency department, operating room and key departments should have technical positions of deputy director and above.
(2) The director, deputy chief physicians, attending physicians and resident offices are reasonable. (6 points)
(three), the first-level departments and key secondary departments should have the technical position of chief physician, and the general director of secondary departments should have the technical position of deputy chief physician or above. (7 points)
(4). The ratio of nutrition personnel (technical personnel with a master's degree or above in nutrition) to beds is 1:200 (4 points).
(5), blood transfusion professionals according to the number of hospital beds, surgery cases, blood consumption and the actual situation to carry out the work. (3 points)
Affiliated hospitals and teaching hospitals of medical colleges should appropriately increase the proportion of personnel.
Fourth Hospital Management (140)
(a), organization and management (25 points)
1, the hospital should have a sound scientific management system, with full-time or part-time staff responsible for all management work.
2. Conscientiously implement the relevant national laws and regulations, the Regulations on the Administration of Medical Institutions issued by the State Council and the Detailed Rules for the Implementation of the Regulations on the Administration of Medical Institutions issued by the Ministry of Health, the relevant national regulations on hospital work, the hospital work system and the responsibilities of hospital staff, and carefully formulate and constantly combine the actual situation of the hospital.
Improve the hospital work system, job responsibilities and pre-job education system for business personnel at all levels, organize their implementation, and strengthen standardized management.
3, the hospital implements target management, should make long-term development plan and annual plan. Coordinate, inspect, assess and evaluate the implementation progress.
4. Establish and improve the supervision system inside and outside the hospital, and regularly evaluate the quality of hospital work and medical services.
5. The dean should fully grasp the knowledge and skills of hospital management, understand the domestic hospital management trends, and strengthen scientific management awareness; Hospital leaders must receive management professional post training from national, provincial (autonomous regions and municipalities directly under the Central Government) health administrative departments and obtain training certificates. Leaders of functional departments should also receive on-the-job training.
6, on-the-job personnel training plan and funds.
7. The hospital staff's satisfaction with the hospital leadership structure, cooperation and work is ≥80%.
(two), information management (22 points)
1, with a sound information management organization and related work system.
2. Chinese and foreign medical books and periodicals in the library can meet the needs of medical teaching and scientific research.
3, file management according to the "measures for upgrading the archives management of science and technology institutions" (national level 2) standard.
4, using computers to manage medical treatment, medical record statistics, finance, personnel, pharmacies and books.
5, all kinds of statistics, analysis, coding and information must conform to the national and ministerial standards.
6, hospital information must be true, complete and accurate, and timely analysis, feedback and utilization.
(3) Financial management (15)
1, strictly implement the relevant national accounting system, and strengthen financial discipline.
2. Strictly implement the charging standards and clearly mark the main service items.
3, implement the policy of "running the hospital diligently", strengthen management and gradually carry out cost accounting.
(4) Equipment management (19)
1, with a sound equipment management and maintenance organization, equipped with certain engineering and technical personnel.
2, the hospital equipment management plan, establish and improve the medical equipment procurement, maintenance, repair and update system on a regular basis. Ensure the needs of medical work. Ensure the equipment is in good condition, improve the use efficiency and avoid repeated purchases.
3, the hospital should focus on ensuring the "basic standards for medical institutions" provisions of the equipment and other basic equipment, first aid equipment, monitoring equipment, the purchase of expensive instruments and equipment to be demonstrated. Relevant large-scale equipment shall be implemented according to the relevant regulations of the Ministry of Health.
4, expensive equipment to establish files, personnel management.
(5) Comprehensive management (19)
1, a sound comprehensive management system, job responsibilities and work system.
2. General materials shall be subject to quota management, with a sound system of procurement, acceptance, warehousing and scrapping.
3, active and timely service for medical teaching, scientific research and staff life. Do it three times (receiving, sending and repairing), ensure the three links (water supply, power supply and gas supply), deal with the three leaks (water leakage, electricity leakage and air leakage) in time, and achieve two satisfactions (employees and patients).
4. There are emergency power supply measures to ensure emergency needs.
(six), construction management (8 points)
1, the hospital construction should have a master plan, new construction, reconstruction and expansion should be feasible, and the data should be kept intact, in line with the Ministry of Health's Building Standards for General Hospitals and other building specifications.
2, the hospital outpatient department, inpatient department, medical department, operating room, disinfection supply room, emergency department and other departments of the building layout and people flow, logistics should be reasonable. Indoor lighting and color design meet the hygiene requirements.
3, the old hospital building has a regular maintenance plan, shall not engage in medical activities in dangerous buildings.
(7), safety management (15)
1, the hospital safety management organization is sound.
2, have a sound hospital safety management system, measures and implementation records and regularly evaluate the safety management.
3. Dangerous equipment and departments such as high-pressure system, oxygen supply room of hyperbaric oxygen chamber, dangerous goods warehouse, isotope room, power distribution room and bacteria room of operating room have special management measures.
Fire fighting equipment is complete, with eye-catching signs, regular inspection and replacement, and easy to use.
Strictly implement the management system of toxic drugs, narcotic drugs and psychotropic drugs for medical use.
(eight) environmental management (17 points)
1, keep the hospital clean]
2. Smoking is prohibited in clinics, wards and other medical places; Keep clean and quiet.
3, do a good job in hospital greening, beautification and road hardening.
4, sewage, dirt, radioactive substances, such as processing, toxic gas emissions and smoke suppression should comply with the relevant provisions.
Five medical management and technical level (480 points) _
(a) medical management (105)
1, establish and improve the medical management organization, with reasonable personnel and corresponding working system. There is a vice president in charge of business work.
2, formulate feasible hospital medical business construction plan and work plan, and organize their implementation.
3, establish and improve the medical work system diagnosis and treatment technical specifications, operating procedures and medical quality standards, and organize their implementation.
4. Establish and improve medical quality management organizations, formulate quality management plans, improve the internal restraint mechanism of quality management, conduct quality education for all employees, raise quality awareness, regularly supervise, inspect and evaluate the quality management of medical care, medical technology and medical records, and put forward suggestions for improvement. The necessary medical quality management institutions are: medical quality management committee, medical record management committee (which can be merged with medical quality management committee), pharmaceutical affairs management committee, hospital infection management committee and blood transfusion management committee.
5, adhere to the three-level doctor rounds and various case discussion system. Establish and improve the medical record quality inspection and assessment system, and strengthen the three-level inspection and assessment of hospitals, departments and attending physicians. Medical record writing should be clear, standardized, complete, correct, timely, focused, analytical and of good quality. Doctors at all levels should keep complete records of rounds, rescue consultations and discussion opinions, and must not resort to deceit.
6. Attach great importance to medical safety and enhance the medical safety awareness of hospital staff. Strengthen the management of medical defects, formulate preventive measures, and timely occur and correct errors and accident signs. The mistakes and accidents that have been found should be reported in time, handled correctly, learned lessons, summed up experience and improved.
Manage technical training and assessment of personnel, and establish technical files of medical personnel.
Outpatient management, improve service attitude, simplify procedures, facilitate the masses, strive to eliminate the phenomenon of "three long and one short" (registration, charging, long time to get medicine, short time to see a doctor), and take corresponding measures. Gynecology and pediatrics at home and abroad should have more than two deputy chief physicians on duty every day, among which internal medicine and surgery clinics should ensure that there are more than two deputy chief physicians on duty every day to undertake the task of guiding junior physicians to help solve difficult problems. The number of outpatients in our hospital should account for more than 65% of the total number of on-the-job outpatients.
Strengthen the construction of the emergency department, implement the responsibility system for the first diagnosis of emergency, and implement the organization and leadership, layout, personnel, beds, equipment, medicines, instruments, communication equipment and vehicle equipment in accordance with the provisions of the Ministry of Health and provinces, autonomous regions and municipalities directly under the Central Government to ensure the needs of medical treatment and patient transfer.
10, adhere to the bedside shift system for critically ill patients, closely observe the changes of the condition and stick to their posts.
1 1. Medical departments should establish and adhere to the idea of serving the clinical front line, strengthen management, ensure quality and improve work efficiency. Shorten the time for booking and sending reports. The laboratory must establish an indoor quality control system and participate in the ventricular interstitial assessment activities of the clinical laboratory center of the Ministry of Health or the local clinical laboratory center (3A hospitals must participate in the ventricular interstitial assessment activities of the clinical laboratory center of the Ministry of Health).
Supervision and guidance of bed research and clinical medication.
(two), nursing management (75 points)
1, implement the relevant regulations of the Ministry of Health on strengthening nursing management, and establish and improve the nursing management system.
2, the hospital nursing work under the leadership of the director of nursing department dean responsibility system. Pharmaceuticals actively create conditions to set up nursing vice presidents and implement three-level or two-level management.
3, conscientiously implement the relevant provisions of the Ministry of health "hospital staff responsibilities", give full play to the role of intermediate and above technical positions in nursing work, personnel at all levels according to technical positions.
4, to carry out holistic nursing, holistic nursing implementation plan, through the model ward gradually extended to the whole hospital.
5, establish the overall nursing record, and constantly improve.
6, improve the disease care routine and nursing technology operating procedures, and seriously implement.
7, specify and improve the nursing quality management scheme, strengthen nursing quality management.
8, the nursing department should be responsible for education and continuing education, the deputy director of the ward should be responsible for teaching nursing staff.
9, strengthen the training and assessment of nursing staff, establish business technical files, the annual training rate is not less than15%; Have graded training objectives and training plans, and organize their implementation; The training of nursing graduates above junior college level should be carried out by individuals who plan to use drugs.
10, strengthen the training of nursing managers. The management personnel above the head nurse must accept the management professional post training organized by the health administrative departments of the state and provinces (autonomous regions and municipalities directly under the Central Government) and obtain the certificate of completion.
(three) "three basics" and "three strictness" training and management (45 points)
1. Hospitals should insist on training health technicians in basic theory, basic knowledge and basic skills (referred to as "three basics"), and cultivate strict requirements, strict organization and rigorous attitude (referred to as "three strictness").
2, "three basics" training must be full participation, "three basics" assessment must be everyone up to standard.
3. Implement the "three strictness" style into all medical business activities and management.
4, medical staff to master the palm resuscitation first aid.
(four) hospital infection management (40 points)
1, implement the relevant provisions of the Ministry of Health on strengthening hospital infection, improve the hospital infection management organization, and strictly control hospital infection.
2, hospital infection control scheme and management system, monitoring records, effect, evaluation and improvement facilities.
3, establish strict disinfection, isolation and legal reporting of infectious diseases registration and reporting system.
4, there is a system of hospital infection education and training, medical staff must establish the concept of aseptic, strictly implement the correct aseptic technical operation.
5. There are management measures for rational use of antibiotics.
6, the management of special areas should comply with the Ministry of health "hospital infection management norms" requirements.
7, disinfection supply room should meet the Ministry of health "hospital disinfection supply room acceptance standard (Trial)" requirements.
8, disinfection items, surface, hands, air sampling inspection meets the requirements.
(5) Blood transfusion management (15)
1, strictly implement the Measures for Blood Collection and Supply Institutions and Blood Management of the Ministry of Health and relevant regulations, and bring blood transfusion into the unified management area of Grade III blood. Don't take blood, take blood yourself.
2, establish and improve the blood transfusion system, technical operation procedures and quality standards, establish quality assessment indicators and quality management information feedback system.
3, clinical blood transfusion should strictly implement the blood registration system and blood examination and approval procedures, before blood transfusion, must carry out the inspection and verification system before blood transfusion.
4, strictly grasp the indications of blood transfusion, there are reasonable blood and component blood transfusion management measures.
5, there is a strict control of transfusion infection scheme and management system, the establishment of transfusion reaction and transfusion infection disease registration report and investigation and handling system.
6, blood transfusion department should comply with the requirements of the relevant provisions of the Ministry of health.
(six) technical level (200 points)
The hospital should have the medical technology level suitable for its functions and tasks, and can accept referrals from secondary and partial tertiary hospitals. Can correctly handle complex and difficult diseases.
1, clinical departments (see Annex I) (60 points)
2, the medical department (see Annex II) (60 points)
3, key institutions (60 points)
(1), can carry out the diagnosis and treatment technology of key specialties listed in Annex I, and each key specialty should reach the advanced ranks in China or the province.
(2), the director or academic leader should have the technical position of deputy chief physician, and has a certain reputation in the academic field of this major in China.
(3) Professionals form an echelon.
(4) Be able to carry out experimental research corresponding to key points.
(5) Scientific research achievements at or above the provincial level.
(6) International academic exchanges.
(7) Publish ≥2 papers in national (core journals in this field) or provincial academic journals every year.
4, nursing (20 points)
(1), the key specialized nursing has reached the domestic advanced level.
(2), to carry out holistic nursing, and can provide technical guidance to lower hospitals.
(3) To undertake the clinical teaching of mutually beneficial specialty in secondary and higher health schools.
(4), to carry out nursing research, nursing research or innovation projects every year more than 2.
(5) Publish ≥3 papers in journals at or above the provincial level every year.
Six, teaching, scientific research management and level (105 points)
(a) teaching and scientific research management (45 points)
1, with sound teaching and scientific research management institutions suitable for functions and tasks. Hospital leaders should have special personnel in charge of teaching and scientific research management.
2, a practical teaching and research plan and work plan, and organize the implementation and evaluation.
3, have a sound teaching and scientific research work rules and regulations, so that there is supervision, inspection and evaluation.
4. Have a relatively stable team of teachers, and establish a system of preparing lessons, evaluating teachers and checking lectures.
5. Teaching materials (audio-visual teaching materials, self-compiled teaching materials, etc.). ), teaching equipment (instruments and equipment, charts and charts)
This model, experimental animals, etc. ) and the number of classrooms, demonstration classrooms, diseases and patients provided can meet the needs of clinical teaching.
6, the implementation of the provisions of the Ministry of health on the management of "teaching hospital".
(two), teaching and scientific research level (60 points)
A hospital should have a level of teaching and scientific research suitable for its functions and tasks.
1. Complete the clinical practice task in medical colleges.
2. Cultivate master's or doctoral students independently.
3. Post-graduation education, continuing education and continuing education are formal and strict, with good results.
4, undertake more than 2 scientific research projects at or above the provincial level every year.
5, statistical year, published more than 20 papers in national academic journals (core journals in this field); Participate in international academic exchanges ≥ 1 time.
6. According to the statistics of the three years before the review, there is a provincial scientific and technological progress (achievement) award ≥1; Ministries and provincial scientific and technological progress (achievements) awards ≥2.
Seven, ideological and political work and the construction of medical ethics (65 points)
(1) Implement the Party's line, principles and policies, adhere to the socialist policy of running schools, adhere to the purpose of serving the people, and put social benefits first. (10)
(2) Having corresponding management systems and education systems. (5 points)
(3) Adhere to patriotism, socialism, collectivism education, professional ethics education and legal education. (5 points)
(four), strengthen the construction of medical ethics, in line with the "medical ethics norms and implementation measures", establish and improve the clean medical practice measures, resolutely resist unhealthy practices, rewards and punishments are clear. (13)
(5), patient-centered, quality service. (13)
(6) Advocating professionalism, striving for perfection in technology and being conscientious and responsible in work. (6 points)
(seven), establish and improve the supervision system of the masses and the society, patients and contract units are more than 85% satisfied with the hospital. (13)
Eight, statistical indicators (100 points)
1, the coincidence rate of admission diagnosis and discharge diagnosis is ≥95%.
2. The coincidence rate before and after operation is ≥90%.
3. The coincidence rate between clinical diagnosis and pathology is ≥50%.
4.X-ray computed tomography (CT) positive rate ≥60% (if there is no CT, this item is not counted).
5. The positive rate of magnetic resonance imaging (MRI) is ≥70% (if there is no MRI, this item is not counted).
6, large X-ray machine check positive rate of 50% or higher.
7.X-ray nail removal rate ≥40%.
8. Average annual qualification rate of interstitial assessment in clinical chemistry room (VIS≤ 120).
9. Average annual qualified rate of interstitial blood room assessment (improved deviation index DI≤2).
10, and the annual average score of interstitial assessment of immune room is above the national average.
1 1, and the accuracy of national identification of bacterial cell interstitial assessment is ≥80%.
12, autopsy rate ≥ 10% (except for neonatal autopsy).
13, the success rate of emergency rescue for critically ill patients is ≥80%.
14, the success rate of rescuing critically ill patients in wards is ≥84%.
15, and the first-class healing rate of aseptic incision was ≥97%.
16, the readmission rate of the same case within one week (the disease type was determined during the examination, compared with the hospital at the same level) was at a low level.
17, and the maternal mortality rate in hospital is ≤0.02%.
18, and the mortality rate of live births is ≤0.5%.
19, and the anesthetic mortality was ≤0.02%.
20, outpatient prescription qualified rate of 95% or higher.
2 1, the qualified rate of writing format of outpatient medical records is ≥90%.
22, medical record writing rate of 90% or higher (no class C medical records).
23. Accompanying rate ≤5% (excluding maternity ward of baby-friendly hospital)
24. One person, one needle, one tube and one sterilization implementation rate 100%.
25. The eating rate of inpatients was 100%.
26, inpatient dining rate of 80% or higher.
27, hospital infection rate ≤ 10%.
28, hospital infection rate of 20% or less.
29, aseptic operation incision infection rate ≤.5%
30. The suitable range of hospital bed utilization rate is 85%-93%.
3 1, and the average hospitalization days were ≤ 18 days.
32, bed turnover times ≥ 17 times/year.
33, more than ten thousand yuan of medical equipment and instruments in good condition rate of 95% or higher.
34. Complete mandatory tasks 100%
35, health technical personnel "three basics" assessment qualified rate (80 points) 100%.
36, nursing technology operation qualified rate (qualified standard is 90 points) 100%.
37, basic nursing qualified rate (90 points) 100%
38, intensive care level nursing qualified rate (80 points) 90%
39. The qualified rate of nursing document writing (the qualified standard is 80 points) is ≥95% (according to the needs of nursing mode reform, nursing documents are determined by all localities themselves).
40, to carry out holistic nursing ward number 20% or higher.
4 1, and the intact rate of first aid items 100%.
42. The qualified rate of disinfection and sterilization of conventional instruments is 100%.
43, disposable syringes, transfusion (blood) after the destruction rate of 65438 000%.
44. The number of bedsores per year is 0 (except in special circumstances)
45, component transfusion rate of 70% calculation formula:
Annual blood consumption of each component (bag)+annual blood consumption of whole blood (bag) × 100%
46. The cure rate of single disease reached the disease quality control standard issued by the Ministry of Health.
47. The unit disease mortality rate is lower than the disease quality control standard promulgated by the Ministry of Health.
48. After ten days, the unit disease mortality rate is lower than the disease quality standard promulgated by the Ministry of Health.
49. The reporting rate of legal infectious diseases is 0.
50. The number of medical liability accidents is 0.
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