Service self-inspection report

Service self-inspection report

According to the unified deployment of the health authorities, our hospital has seriously carried out the "Year of Quality Service" activities. Since the launch of the activity, our hospital has combined the actual situation of the hospital and focused on innovation and development to effectively strengthen the hospital's work style, continuously improve service levels, continuously improve medical quality, vigorously promote noble medical ethics, build a harmonious doctor-patient relationship, and strive to become a hospital that satisfies the people. Strive to provide the people with safe, effective, convenient and affordable medical and health services.

1. Strengthen leadership, carefully organize, and widely publicize

After the "Quality Service Year" activity plan was issued, our hospital responded actively and formulated the " "Excellent Service Year Activities Implementation Plan", established the "Quality Service Year" activity work leading group and activity office, forming a unified leadership team of the department. The dean is responsible for the overall responsibility, team members are responsible for the division of labor, each functional department is responsible for its own responsibilities, and cadres The leadership mechanism and work pattern of joint management with extensive participation of employees and the masses. Timely convene a mobilization meeting for the "Year of Quality Service" activities to convey the spirit of superior documents, deploy activities, and unify ideological understanding. In order to make all employees understand the content of the activities and implement them conscientiously, we hung promotional slogans in prominent places in the hospital, and vigorously publicized the content, purpose, meaning, good practices, and good practices of the "Quality Service Year" activities through printed materials and bulletin boards. Experience and good models create a good public opinion atmosphere that is conducive to improving service levels, improving medical quality, promoting noble medical ethics, and building a harmonious doctor-patient relationship.

2. Improve the medical environment, optimize service processes, and continuously improve service levels

1. Strengthen hospital infrastructure construction. The first phase of the comprehensive ward building of the city and county's key construction project and its supporting ancillary projects have been fully put into use, further expanding the scale of the hospital, further optimizing the internal medicine system, pediatric system, blood purification treatment, 120 emergency center, medical clinical examination and other projects, and the hospital The infrastructure environment, comprehensive service functions and overall image have been fundamentally improved, providing stronger support for the construction of the county medical service system.

2. Improve convenience service measures. Set up in the outpatient hall the hospital layout plan, department distribution schematic, floor department identification system, expert introductions, admission and admission procedures, new rural cooperative medical insurance verification and medical insurance policy publicity, common medical service charging standards, Chinese and Western drug prices and other service information; Facilities such as waiting chairs, drinking water stations, and convenience telephones have been set up. Boiled water, wheelchairs, stretchers, and carts are provided free of charge, and health education and life guidance are provided. A medical insurance office has been established, with full-time staff providing services to New Rural Cooperative Medical Care and medical insurance patients, and service management measures such as instant review and reimbursement of New Rural Cooperative Medical Care and medical insurance fees have been implemented.

3. Improve the service process. Further improve the information system, add doctor and nurse workstations, improve service efficiency, facilitate patients to wait for medical treatment in an orderly manner, and eliminate the phenomenon of "three longs and one short". Various medical technical inspections are carried out to ensure that reports on large equipment inspection items are issued within 24 hours. Routine inspections, electrocardiograms, general imaging, and ultrasound inspections are carried out on-site, and diagnostic reports are provided in a timely manner; in order to solve the problem of people's difficulty in seeing a doctor, all-weather outpatient clinics are carried out Services to ensure patient treatment on weekends and holidays.

4. Provide high-quality nursing services. Conscientiously implement the "Quality Nursing Service Demonstration Project" activities, effectively change the concept of "emphasis on professionalism, emphasis on basics, emphasis on technology, and emphasis on services", use basic nursing as a breakthrough, comprehensively strengthen clinical nursing work, and change patients' medical experience. Major hospital service improvement actions to achieve “patient satisfaction, social satisfaction, and government satisfaction”. The "Leading Group for Quality Nursing Service Demonstration Project Activities" has been established successively, with the internal medicine ward as the pilot department, establishing a basic nursing responsibility system, strictly implementing the overall nursing work system, further consolidating basic nursing, improving nursing quality, and improving the ward nursing environment.

5. Build a harmonious doctor-patient relationship. Further improve the system for publicizing medical expense lists, medical service charges, drug prices and service commitments, establish and improve systems for consultation and consultation, doctor-patient agreements, doctor-patient communication, and statutory notifications; actively promote service management measures such as patient interviews and discharge follow-up visits. Strictly implement the "first consultation responsibility system" and "first inquiry responsibility system", and promote the attending physician responsibility system in an orderly manner.

Improve the medical ethics evaluation system and regular physician evaluation system; implement the "Hospital Complaint Management Measures", continue to promote the disclosure of hospital affairs, constantly improve the patient complaint handling mechanism, effectively safeguard the legitimate rights and interests of patients, ensure medical quality and medical safety; strengthen service and safety Dynamically monitor, promptly discover service deficiencies, correctly handle service complaints, listen humbly to patients' opinions on hospital service improvement, further improve service attitude and work style, and strive to build a harmonious doctor-patient relationship.

3. Strengthen quality management, standardize diagnosis and treatment behavior, and continuously improve medical quality

1. Strengthen basic medical quality management. Strictly abide by health management laws and regulations and diagnosis, treatment and nursing standards, practice law and conduct according to law; improve the secondary quality control system of the hospital, formulate medical care quality plans and assessment standards, and improve medical quality control inspection tracking, feedback supervision, analysis and evaluation , guidance and assessment, quality management system for key links, key departments, and important positions; hold regular special meetings on medical quality and medical safety, strengthen medical safety education, implement link quality and terminal quality management, and implement 14 core systems for medical quality and medical safety ; Strictly follow the requirements of the "Basic Standards for Writing Medical Records" formulated by the Ministry of Health to further improve the quality of medical records; explore clinical path management, strengthen medical quality management responsibilities, and promote continuous improvement of medical care and quality.

2. Carry out special rectification activities for the clinical application of antibacterial drugs. Conscientiously implement the essential drug system, standardize the procurement, distribution and use of drugs; establish and improve the clinical drug supervision, guidance and evaluation system, carry out drug safety monitoring, adverse drug reaction monitoring and antimicrobial clinical application monitoring, strengthen prescription management, and implement prescription reviews , improve the quality of prescriptions, carry out analysis and reporting on the top 10 drugs and top 10 doctors for large-amount cases, large prescriptions, antibacterial drug use and specialist drugs, so that disease-based treatment, rational use of drugs, and reasonable inspection systems can be effectively implemented.

4. Strengthen the education of medical ethics and medical styles, promote noble medical ethics, and strictly enforce industry disciplines

1. Strengthen the education of medical ethics and medical styles. Strengthen the education of medical staff on honest medical practice, strictly implement various regulations on medical staff's honest medical practice, carry out in-depth education on the socialist concept of honor and disgrace, medical ethics and medical ethics, publicity and education on health laws and regulations, and enhance medical staff's professional ethics and awareness of compliance with laws and regulations. Strengthen the construction of a harmonious medical culture in hospitals and establish a good ethos of practicing medicine with integrity and in accordance with the law.

2. Actively promote the disclosure of academic affairs. In accordance with the arrangements for the disclosure of academic affairs by superior departments, we will further improve various measures for disclosure of academic affairs, standardize the content of academic disclosure, and insist on disclosing to the public and patients policies, regulations, systems, medical service information, convenience measures, and policies that are closely related to the interests of the masses. Basic information such as medical charging items and standards, drug prices, etc.; disclose major hospital decision-making matters, hospital operation and management, personnel management, financial revenue and expenditure, pharmaceutical equipment, infrastructure project bidding, and relevant information related to the vital interests of employees to internal employees, and proactively Accept the supervision of the masses, truly win the trust of the people, and ensure and implement the people's rights to know, participate, and supervise.

3. Improve the medical ethics evaluation system. With the goal of improving the professional ethics of medical staff, regular assessment and recording of the medical ethics behavior of medical staff as a means, and the prominent tasks of improving medical service attitudes, optimizing the medical service environment, standardizing medical service behavior and improving the quality of medical services, we will conduct in-depth development of medical staff Medical ethics assessment activities, improve the doctor-patient communication system, medical service accountability system, service complaint handling system and medical ethics and medical ethics assessment reward and punishment system, improve the medical ethics and medical ethics assessment files of medical staff, and incorporate the medical ethics assessment of medical staff into the comprehensive target management of the department, as a medical The prerequisites for the annual assessment of personnel, the assessment results are linked to department and individual performance salary distribution, annual assessment evaluation and professional title promotion, etc., giving full play to the incentive and restraint role of medical ethics assessment.

4. Carry out in-depth volunteer service activities. Adhering to the theme of "dedication of love, serving patients, and serving the masses" and the main content of "serving the overall situation, facilitating people's medical treatment and improving health quality", we carry out in-depth "volunteer service" activities. Actively carry out activities such as free clinics on the streets, health care in the countryside, and health check-ups for people in residential communities and special care recipients throughout the county, which have been well received by all walks of life and the general public.

5. Existing problems and next steps

1. Since the launch of the "Three Good and One Satisfactory" campaign, although our hospital has achieved certain results in various tasks, it is still far from the expectations of superiors. There is still a certain gap between the requirements and the people's expectations, mainly as follows: first, the results of the high-quality nursing service demonstration project activities are not obvious, and the human resources allocation of nurses is insufficient to meet the needs of actual clinical work; second, the establishment of Ping An Hospital is not solid enough, and the quality of medical care There are also safety flaws and hidden dangers. Third, the clinical pathway work is not intensive and progress is slow. Fourth, the implementation of service measures is not in place, and the service attitude and service level of a few departments and individual medical staff cannot meet the requirements and satisfaction of the people.

2. In future work, we will strive to improve in the following aspects. The first is to improve outpatient services, enrich outpatient services, strengthen emergency green channel management, and implement "three first, three last", that is, treatment first and then examination, first rescue and then division, and first rescue and then payment, to ensure that the "green channel" for emergency rescue is unimpeded and smooth. Provide timely and effective treatment, improve hospitalization, transfer, hospital transfer, and discharge service processes to ensure that patients receive convenient, fast, continuous and personalized medical services. The second is to solidly promote high-quality nursing services, conscientiously implement the "Quality Nursing Service Demonstration Project" activity plan and implementation plan, steadily advance the work of pilot wards, formulate nursing staff performance appraisal plans, establish and improve the nursing support system, and promote nursing work to be close to patients and close to patients. Clinical and close to society, we provide patients with safe, effective, convenient and satisfactory nursing services and enhance doctor-patient harmony. The third is to increase the intensity of clinical pathway work and increase the number of diseases entering clinical pathway management. The fourth is to strengthen the construction of medical ethics and medical ethics, further improve the professional ethics of medical personnel, effectively correct unhealthy tendencies in medical services, and better safeguard the health interests of the people.