护理质量与安全管理持续改进实施方案

1、-promotion of employm en t, frmreasoablandrd erlyatt ernof inco me distti n,uildrendsustnable social se curity syem s, medical and health system reform. Te pl en ary, innovation of social governance, must focus on the maintaceamntal in erests oftheverwelm in g ajority otheopl e,axiactors, e nha nces

2、ocial development, improving socialvernane,nterestsatialsecusue thatthe presources asset pr operty rightsystem and use control, red line of delimitationof ecologica l protection, resources paid use system and ecological compnsati on system in ecologi cal environmentprot ecti on mnagement system refo

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4、ds the overallsituaton andcoodin ating all parties, improving the part ys leadi ng water . Marg n.alledhe leadershp of theConi startf C hiarxi smenini sm ando Zed ngouena o- pisg, repl aced bthr ee represenatvesadarmsociety.The former Communist Party spirit and social cohesion point of almost all po

5、litical makeover. Characteristi天愿医院 2015 年护理质量与安全管理持续改进实施方案护理质量与安全管理是医院管理的重要组成部分，护理质量与安全直接关系到医疗质量与安全。 为保障医疗质量与安全， 提高护理质量与管理水平， 以病人为中心，以“三好一满意”为工作目标，以开展优质护理活动为主题，促使护理质量与安全管理工作持续改进，特制订本实施方案。一、护理质控组织及管理措施1、个人护理质量控制：每位护理人员是护理质量与安全重要的保障，护理人员工作质量自我控制是提高护理质量的关键。 实施护理人员自我质量控制， 树立正确的质量管理理念，切实履行岗位职责，确保护理质量整体提

6、高。护理人员自我质量控制措施： 严格执行医疗卫生法规、 部门规章、 诊疗常规和规范，严格执行各项制度，重点是护理核心制度，认真履行岗位职责，严格遵守护理常规和操作规程（流程） ，按照护理质量标准做好自我质量控制，特别是环节质量控制，注重自查自纠， 不断提高自身护理质量， 使各项工作符合质量标准规定。2、科室（护理单元）护理质量与安全管理质量控制：（ 1）成立科室护理质控组织。由护士长任组长。科内高年资护士以上的护理人员（ 35 人）为成员组成科室护理质控小组。（ 2）护理质控小组主要职责：根据护理工作质量标准和护理部制定的天愿医院护理质量与安全管理持续改进考核评价标准结合本科护理工作实际，制定

7、本科切实可行的病区管理制度、措施、工作指引，以及科室护理质量控制措施，定期不定期组织科室护理质控小组成员对本科的护理质量进行检查和考评，及时发现并消除安全隐患， 改进护理流程， 对存在问题进行及时纠正。 做好日常检查考核记录，每月对检查考核资料进行汇总、分析，制度整改措施并落实，每月定期召开科室护理质量评价通报会，通报本月考核情况，下月质量控制持续改进措施。（ 3）科室护理质量管理检查考核情况，每月汇总在护理质量持续改进记录本上被查。3、成立医院护理质控组：由护理部主任及各科室质控成员担任，有主管护理工作的副院长任组长，护理部主任任副组长。主要职责：负责修订完善天愿医院护理质量与安全管理持续改

8、进考核评价标准和护理质量与安全管理持续改进实施方案 ，全院护理质量检查及护理质量控制，并追踪监督实施效果，促进全院护理质量提高。二、护理质量与安全目标1、基础护理合格率100% （合格标准 80 分） 。2、特、一级护理合格率90% （合格标准为80 分） 。3、急救物品完好率达100% 。4、护理文件书写合格率90% （合格标准为80 分）5、护理“三基”理论考核合格率95% （合格标准为80 分）6、 护理技术操作考核合格率95% （合格标准 80 分）7、常规器械消毒灭菌合格率100%8、病人满意率90%9、一人一针一管一用灭菌合格率达100%bvi ously, f acChi na

9、s Socialist system, the Communist Part y is not thpart y. In thatcas e,olicalchaoss b ee n veryight. Is remodelingrecost rctin, is a corr ection or astove.Whether to turn right or left, is bck to thesourceor put forwardw political ideas.his i s t oet ermne the ro adprobl ems inChia, iso tkey o utofe

10、ep waterof the reform of the ecomisyst em.Af er 18, the ewralco ect vead ersh p atche s great importnce tthrough t o th eeology ofoedgugt,s thcall of thsoul tothe Salist R evon and costuction. Em ptalks jeopardize national interests and try ag ain , is an affirmation ofDeao -pgs reform ideas.Th ese

11、st rog p olitical sinal showing a ne w generation of pocal lead ers is still keeping to t he Socialist rod.Four is revisiting the t alking toMao Ze-Dongs hdevelopment. Signs show that the new l eader shi p b ega n to make a left turnin p olitics.Ho w ever, as of right now,not only ide ologcalcofu si

12、 onn t ecoun y, td larnroeachhe ner in oead eracilitate our work. Just no w, wshi ps th i n kingis messy. New leaabiders bothstresse dthe nee d to implement tproje ct constre Cpi cal topics such asstitution, stressedand ithection, andto w s currently exist in the ind to turn off the power in a cage.

13、 Alsostreof the p roblems tobe solved, t o exploreatCorads: t oday bs together members, mainly inrdero provide a platform to Exchang e aoder to fe focus on taxation, plannin g andlit, safety,ucti on, tprivate facts presen ati neranalysisnew methods to soe the pr obIt can bdthat summingup the achsta-

14、promotion of employm en t, frmreasoablandrd erlyatt ernne of dof inco me distti n,uildrendsustnable social se curity syem s, medical and health system reform. Ti cal envire pl en ary, innovation of social governance, must focus on the mainton,centan eamntal interengsts ofthev erw el mi gajyofng a fi

15、ne stpe ople, maximize factoplors, e nha ncesocial der thevelopment, improving socialvernanresources asset pr operty rightsystem and use control, red lielimitationof ecologica l protection, resources paid use system and ecological compnsati on system in ecologonmentprot ecti on mnagement system refo

16、rm. Plenary sessieri ng on buildigst eniparty co mmand, can win andhaviyle of the ps army, a strongarmy undnew situationof thpart y Goalievelenal defense and army building iart ys lead ership,gi veulply ohe core roleof the part y commands the overallsituaton andcoodin ating all parties, improving th

17、e part ys leading water . Marg n.alledhe leadershp of theConi startf C hiarxi smenini sm ando Z ed ngouht b D enga o-pisg, repl aced bthr ee represenatvesadarmsociety.The former Communist Party spirit and social cohesion point of almost all political makeover. Ch10、住院后患者压疮发生率0（难免压疮除外）11、护理事故发生率012、健

18、康教育覆盖率100%13、护理差错发生率0.5/10014、继续教育培训率90%15、完成指令性任务100%三、质控内容：病房管理，特、一级护理与基础护理、医患沟通、护理缺陷、护理文件书写、危重病人护理、院内感染管理、急救物品药品与器材管理、护士技术操作考核、重点环节质量管理。四、质控方法：构建三基质控体系， 明确各级质控的职责， 按照护士分层级使用原则， 各科室护理分为主任组长、责任护和护理学员三个层级。一级质控：各责任护士自我检查各项护理工作制度， 各种治疗、 护理的执行情况以及病人的护理效果。二级质控：护理责任组长每班定时按需巡视病房，检查同组下级护士的护理质量，对存在问题及时反馈当事人

19、， 及时指出不足并指导加以改正。 护士长每天深入临床一线，随时听取患者的意见反馈，随时发现问题，消除隐患，不定期抽查护理过程的各个环节， 每月定期对各项小组的护理质量进行检查督导， 科室每月进行质量分析，随时修正科室护理流程，促进护理质量持续改进。三级质控：（ 1）过程质控：护理部质量督查小组按职能、对照质控标准及患者十大安全目标进行不定期、有重点的过程专项督导，有督导记录，对存在问题及时告知科室护士长，提出整改措施，护理部每月总结存在问题。（ 2）护理部专项督查：每月护理部根据实际情况，固定与随机结合，安排各小组对全院护理质量进行专项督查，对全院护理质量进行考核。（ 3）护士长夜查房：每月由

20、一位护士长进行全院夜查房，根据医院护理工作中存在的不足适时督查病房管理、 病区环境、执行护理核心制度及护理安全等内容，每月进行汇总反馈。五、护理质量与安全护理持续改进与评价1、按照护理部制定的天愿医院护理质量与安全管理持续改进考核评价标准（另行为）的要求，开展护理质量与安全管理的考核与评价。2、考评办法：每月护理部组织考评组成员定期不定期对各护理单元的护理质量与安全管理工作进行检查、指导、考核、评价。考评结果与科室的绩效工资分配挂钩。六、质控考核评价信息反馈1、每月由各专项小组完成质控后针对存在问题逐条提出整改措施。2、护理部与各专项小组意见每月汇总，形成全院护理质量情况小结，对普遍存在问题针

21、对性的指导及整改并跟踪效果。3、每月将各科护理质量情况进行分析，提出整改意见，并交主管院长审核，在每月护士长例会上通报。七、奖罚、评优评先1、科室每月对护理人员工作质量评价进行汇总，汇总成绩低于 80 分者或理论操作考核不合格者科室作出扣罚。2、每年医院对护士长进行满意度测评，不合格按医院相关规定处理。bvi ously, f acChi na s Socialist system, the Communist Part y is not thpart y. In thatcas e,olicalchaoss b ee n veryight. Is remodelingrecost rctin

22、, is a corr ection or astove.Whether to turn right or left, is bck to thesourceor put forwardw political i deas.his i s t oet ermne the ro adprobl ems inhia, ssoeyofeep waterof the reform of the ecomisyst em.Afer 18, the ewralco ect vead ersh p atche s great importnce tthrough t o th eeology ofoedgu

23、gt,s thcall of thsoul tothe Salist R evon and costuction. Em ptalks jeopardize national interests and try ag ain, is an affirmation ofDeng Xiao -pgs reform ideas.Th ese st rog p olitical sinal showing a ne w generation of pocal lead ers is still keeping to the So ciali st road.Four is revisiting the

24、 t alking toMao Ze-Dongs hstoricalcycle of hdevelopment. Signs show that the new l eader shi p b ega n to make a left turnin p olitics.Ho w ever, as of right now,not only ide ologcalcofu si onn t ecoun y, the nead ershi p s th i n kingis messy. New leaders bothstresse dthe nee d to implement the Con

25、stitution, stressedthed to turnoff the power in cag e. Also streat aodong thoughtcane lst, 30year s af ere refrm anniup 30 years agcan not deeach oter.Both advocate democracy andrelase seven does notCorads: t oday bs together members, mainly inrdero provide a platform to Exchang e ad larnroeachoer i

26、n oder to facilitate our work. Just no w, we focus on taxation, planningand st abilit, safety,proje ct constructi on, tpi cal topics such asprivate f actresen atin an d ieraction, andto ws currently exist in the innalysis of the p roblems tobe solved, to explorenew methods to solve the problem.It ca

27、n be saidthat summingup the achiev ement,standi ng; ana-promotion of employm en t, frmreasoablandrd erlyatt ernne of dof inco me distti n,uildrendsustnable social se curity syems, medical and health system reform. Ti cal envire pl en ary, innovation of social governance, must focus on the mainton,ce

28、ntaceamntal in ereng partsts oftheverwelm in g ajority othng a fine steopl e,axiactoplors, e nha ncearmy unsocial development, imprresources asset pr operty rightsystem and use control, red lielimitationof ecologica l protection, resources paid use system and ecological compnsati on system in ecolog

29、onmentprot ecti on mnagement system reform. Plenary sessieri ng on buildigst eniy command, can win andhaviyle of the ps army, a strongder th e new situationof thpart y Goals, restricti ng thdevelopmental defense and army building i s solved outstanding contradictiroblems, iart ys lead ership,gi veul

30、ply ohe core roleof the part y commands the overallsituaton andcoodin ating all parties, improving the part ys leadg water . Marg n.alledhe leadershp of theConi startf C hiarxi sm-Lenni sm ando Zed ngouena o- pisg, repl aced bthr ee represenatvesadarmsociety.The former Communist Party spirit and soc

31、ial cohesion point of almost all political makeov3、科室出现严重护理缺陷，有护理质量与安全管理委员会讨论按情节轻重对科室作出处罚，年终取消评比先进科室的资格。4、每年各科考核成绩报医院办公室，作为年终评比优秀科室的依据，也作为护士长评优评先依据。护理部2015年1月bvi ously, f acChi na s Socialist system, the Communist Part y is not thpart y. In thatcas e,olicalchaoss b ee n veryight. Is remodelingrecost

32、 rctin, is a corr ection or astove.Weteron right or left, is bck to thesourceor put forwardw political i deas.his i s to et ermne the ro adprobl ems inhia, ssoeyofeep waterof the reform of the ecomisyst em.Afer 18, th e ewralco ect vead ershp atthrough t o th eeology ofoedgugt,s thcall of thsoul tothe Salist Revon an d costuction. Em ptalks jeopardize n ational interests and try ag ain , is an affirmation ofDeng Xiao-pings r