医疗管理 (2)课件

1、培训内容医疗组分管条款检查方法检查路径、特点各科对应条款项目案例等级评审的内涵以评促改重在内涵以评促建评建并举服务（C级） 质量、安全管理（B级）绩效（A级）医院评审方针等级评审主题评审组专家以病人和评审员双重身份评价医院的系统性的服务质量。追踪患者就医全过程考评服务环节流程是否合理、安全、有效（各科急诊、危重）侧重于医院整体管理是否全面有效。考察医院各个部门履职是否规范、紧密衔接、协调配合，流程是否顺畅高效。评审组检查方法 追踪法 个案追踪系统追踪系统个案综合追踪各科评审重点内容制度 职责流程 规范指南预案落实情况核心制度重中之重核心条款评审重点质控小组活动改进制度培训考核过关 核心制度人人

2、知晓 核心条款缺一不可 质控活动改进有效 现场检查过程Reality 以病人为中心聚焦医疗护理质量与安全是找出问题帮助医院提高Creativity 观察询问为主非仅资料检查检视医院整体系统追溯病人就医过程对标准融会贯通并非按标准逐条打分体现团队精神与医院是合作关系现场评审检查方法与特点现场检查特点围绕条款看、问、查、追 查到什么追什么 看到什么问什么听到什么查（问）什么检查方法现场查看处理寻找切入点病历患者流程谈做法、找问题、问相关管理与制度、走访患者急危重症、薄弱环节、多科协作、重要内容多发伤、急性心梗、大出血、病情较重医疗质量管理委员会三级质控工作医疗医技医务科质控科急诊科、内科、外科、妇

3、产科、儿科、麻醉、门诊、影像科室、检验、输血、病案室、病理、 医疗检查重点路径 急 诊 科11.3.4.1建立院前急救与院内急诊绿色通道，有效衔接的工作流程2.3.1.2急诊科已配备足够受过专业训练掌握急诊医学知识与技能、具备独立工作能力的医护人员急诊科2.3.2.2突发事件应急组织指挥、职责协调、流程培训、演练落实、有职能监管和改进。1.2.2.1承担常见病、多发病、部分疑难病诊疗，可提供4小时急诊诊疗服务。2.3.1.1诊科布局设备符合急诊科建设与管理指南2.3.2.1实首诊负责制与基层医疗机构建立急诊、急救转介服务制度2.3.1.3急诊医务人员经过专业培训胜任工作，医护专业考核达到要求2

4、.3.1.4急诊抢救由主治医师以上（含主治）主持负责、服务及时、安全便捷、有效，提高急诊分诊能力。 急诊现场检查观看患者抢救全过程1、查看问病史、查体、作心电图、是否交待告知病情等过程。6、各种记录本7、提问什么是绿色通道2、抢救车布局、抢救台药品分类及放置4、急会诊医师资质，口头医嘱执行情况。5、接诊医师及会诊医师急诊处理流程及操作是否熟练6、各种记录本7、提问什么是绿色通道3、询问药物应用方法、注意事项、治疗原则、处理是否规范。制度职责培训考核现场急救会诊Title in hereTitle in hereTitle in here1.急诊分诊环境与急救设备；2.现场急救能力、协调能力；3

5、.制度职责落实与改进效果；4、是否依法？ 是否及时？ 是否规范？查看急救意识、急救能力急诊检查中现场发现情况医生处理 不规范不熟悉追踪 必备操作技术诊疗规范常规情况处理流程重症医学科三大核心要素.布局、设施、设备符合管理指南要求床位与人力资源配置符合建设与管理指南要求制度职责技术规范操作规程监护指征院感防控危重评估各科重症监护室ICU于急诊科危重症登记本上发现一位收住ICU患者 - ThemeGallery is a Design Digital Content & Contents mall developed by Guild Design Inc.观察入住过程（电梯间情况）了解出入通道流

6、程、接待过程对特定患者的护理目前病情及诊断病情观察要点哪些情况需要立即汇报医生主要诊断更衣询问护士各科重症监护室ICU目前重要检查结果目前存在什么问题还要观察什么 目前如何评估，分值多少询问病人转入转出标准病史情况住院时间CT、X线等检查结果及报告规范相关知情同意书、病危通知书会诊单、危重患者讨论输血规范、评估询问医生查阅患者病历资料麻醉科4.7.1.1 实行麻醉师分级授权管理，有明确制度4.7.1.2 麻醉师定期职业能力再评价和再授权制度4.7.1.3 麻醉师经过严格的专业理论和技能培训，完成继续教育4.7.1.4 手术麻醉人员配置合理4.7.2.1 有患者麻醉前评估和麻醉前讨论4.7.2.

7、2 具有资质和授权的麻醉医师进行麻醉风险评估4.7.3.1 履行麻醉知情同意4.7.4.1 执行手术安全核查，麻醉全程在病历/麻醉单上得到充分体现4.7.4.2 有麻醉意外与并发症处理规范4.7.4.3 有麻醉效果评定4.7.5.1 全麻后复苏管理措施到位，实施规范的全程监测4.7.5.2 全麻复苏监护结果和处理均有记录麻醉科 4.7.6.1 术后镇痛治疗规范管理制度与流程 4.7.7.1 术中用血制度、流程、适应症、输血前评估 4.7.8.1 科室质量与安全管理小组，制度、职责、评估、改进 4.7.8.2 开展质量与安全管理培训：核心制度、职责、诊疗操作规范 4.7.8.3 定期开展麻醉与镇

8、痛质量评价 4.7.8.4 建立麻醉与镇痛质量管理数据库临床路径和单病种4.4.1.1 按照外科10个病种县医院版临床路径实施质量管理4.4.2.1 遵照循证医学原则制定本院文件并实施培训4.4.3.1 临床路径和单病种信息平台，定期联席会议，总结分析4.4.4.1平均住院日、疗效、30日内再住院率、再手术率、并发症等有监测4.4.5.1执行临床路径相关医务人员和患者进行满意度调查4.4.6.1单病种质量指标信息台账4.4.6.2人负责上报单病种质量信息1.2.3.1 将临床路径和单病种质控作为持续改进的重点项外 科4.3.1.1 依法开展医疗技术服务，与功能任务相适应4.3.1.2 医学伦理

9、委员会承担医疗技术伦理审核【可选】4.3.2.1 实行医疗技术分级分类管理，有管理制度4.3.3.1 有医疗技术风险预警机制和技术损害处置预案，并组织实施4.3.3.2 有新技术准入与风险管理4.3.5.1 对手术、麻醉、介入、腔镜等有创操作人员有授权制度4.3.5.2 建立相应的资格许可授权制度及考评标准，实施动态管理4.6.4.1 有重大手术审批制度4.6.4.2 有急诊手术管理措施保障急诊手术及时安全科室任务项目操作举例1科室任务项目操作举例2病案室出院病例分类编码资质、制度、流程、培训、首页、登记 服务流程、安全措施、电子病历、质控改进DiagramDescription of the

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