護理質(zhì)量與安全管理持續(xù)改進實施方案

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

3、rm. Plenary session,cent ering on buildigst ening party command, can win andhaving a fine style of the popls army, a strongarmy under thnew situationof thpart y Goalrestingevelenof national defense and army building isol ved utst andincoart ys lead ership,gi veulply ohe core roleof the part y comman

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天愿醫(yī)院 2015 年護理質(zhì)量與安全管理持續(xù)改進實施方案護理質(zhì)量與安全管理是醫(yī)院管理的重要組成部分，護理質(zhì)量與安全直接關(guān)系到醫(yī)療質(zhì)量與安全。 為保障醫(yī)療質(zhì)量與安全， 提高護理質(zhì)量與管理水平， 以病人為中心，以“三好一滿意”為工作目標，以開展優(yōu)質(zhì)護理活動為主題，促使護理質(zhì)量與安全管理工作持續(xù)改進，特制訂本實施方案。一、護理質(zhì)控組織及管理措施1、個人護理質(zhì)量控制：每位護理人員是護理質(zhì)量與安全重要的保障，護理人員工作質(zhì)量自我控制是提高護理質(zhì)量的關(guān)鍵。 實施護理人員自我質(zhì)量控制， 樹立正確的質(zhì)量管理理念，切實履行崗位職責(zé)，確保護理質(zhì)量整體提

6、高。護理人員自我質(zhì)量控制措施： 嚴格執(zhí)行醫(yī)療衛(wèi)生法規(guī)、 部門規(guī)章、 診療常規(guī)和規(guī)范，嚴格執(zhí)行各項制度，重點是護理核心制度，認真履行崗位職責(zé)，嚴格遵守護理常規(guī)和操作規(guī)程（流程） ，按照護理質(zhì)量標準做好自我質(zhì)量控制，特別是環(huán)節(jié)質(zhì)量控制，注重自查自糾， 不斷提高自身護理質(zhì)量， 使各項工作符合質(zhì)量標準規(guī)定。2、科室（護理單元）護理質(zhì)量與安全管理質(zhì)量控制：（ 1）成立科室護理質(zhì)控組織。由護士長任組長。科內(nèi)高年資護士以上的護理人員（ 35 人）為成員組成科室護理質(zhì)控小組。（ 2）護理質(zhì)控小組主要職責(zé)：根據(jù)護理工作質(zhì)量標準和護理部制定的天愿醫(yī)院護理質(zhì)量與安全管理持續(xù)改進考核評價標準結(jié)合本科護理工作實際，制定

7、本科切實可行的病區(qū)管理制度、措施、工作指引，以及科室護理質(zhì)量控制措施，定期不定期組織科室護理質(zhì)控小組成員對本科的護理質(zhì)量進行檢查和考評，及時發(fā)現(xiàn)并消除安全隱患， 改進護理流程， 對存在問題進行及時糾正。 做好日常檢查考核記錄，每月對檢查考核資料進行匯總、分析，制度整改措施并落實，每月定期召開科室護理質(zhì)量評價通報會，通報本月考核情況，下月質(zhì)量控制持續(xù)改進措施。（ 3）科室護理質(zhì)量管理檢查考核情況，每月匯總在護理質(zhì)量持續(xù)改進記錄本上被查。3、成立醫(yī)院護理質(zhì)控組：由護理部主任及各科室質(zhì)控成員擔(dān)任，有主管護理工作的副院長任組長，護理部主任任副組長。主要職責(zé)：負責(zé)修訂完善天愿醫(yī)院護理質(zhì)量與安全管理持續(xù)改

8、進考核評價標準和護理質(zhì)量與安全管理持續(xù)改進實施方案 ，全院護理質(zhì)量檢查及護理質(zhì)量控制，并追蹤監(jiān)督實施效果，促進全院護理質(zhì)量提高。二、護理質(zhì)量與安全目標1、基礎(chǔ)護理合格率100% （合格標準 80 分） 。2、特、一級護理合格率90% （合格標準為80 分） 。3、急救物品完好率達100% 。4、護理文件書寫合格率90% （合格標準為80 分）5、護理“三基”理論考核合格率95% （合格標準為80 分）6、 護理技術(shù)操作考核合格率95% （合格標準 80 分）7、常規(guī)器械消毒滅菌合格率100%8、病人滿意率90%9、一人一針一管一用滅菌合格率達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、住院后患者壓瘡發(fā)生率0（難免壓瘡除外）11、護理事故發(fā)生率012、健

18、康教育覆蓋率100%13、護理差錯發(fā)生率0.5/10014、繼續(xù)教育培訓(xùn)率90%15、完成指令性任務(wù)100%三、質(zhì)控內(nèi)容：病房管理，特、一級護理與基礎(chǔ)護理、醫(yī)患溝通、護理缺陷、護理文件書寫、危重病人護理、院內(nèi)感染管理、急救物品藥品與器材管理、護士技術(shù)操作考核、重點環(huán)節(jié)質(zhì)量管理。四、質(zhì)控方法：構(gòu)建三基質(zhì)控體系， 明確各級質(zhì)控的職責(zé)， 按照護士分層級使用原則， 各科室護理分為主任組長、責(zé)任護和護理學(xué)員三個層級。一級質(zhì)控：各責(zé)任護士自我檢查各項護理工作制度， 各種治療、 護理的執(zhí)行情況以及病人的護理效果。二級質(zhì)控：護理責(zé)任組長每班定時按需巡視病房，檢查同組下級護士的護理質(zhì)量，對存在問題及時反饋當事人

19、， 及時指出不足并指導(dǎo)加以改正。 護士長每天深入臨床一線，隨時聽取患者的意見反饋，隨時發(fā)現(xiàn)問題，消除隱患，不定期抽查護理過程的各個環(huán)節(jié)， 每月定期對各項小組的護理質(zhì)量進行檢查督導(dǎo)， 科室每月進行質(zhì)量分析，隨時修正科室護理流程，促進護理質(zhì)量持續(xù)改進。三級質(zhì)控：（ 1）過程質(zhì)控：護理部質(zhì)量督查小組按職能、對照質(zhì)控標準及患者十大安全目標進行不定期、有重點的過程專項督導(dǎo)，有督導(dǎo)記錄，對存在問題及時告知科室護士長，提出整改措施，護理部每月總結(jié)存在問題。（ 2）護理部專項督查：每月護理部根據(jù)實際情況，固定與隨機結(jié)合，安排各小組對全院護理質(zhì)量進行專項督查，對全院護理質(zhì)量進行考核。（ 3）護士長夜查房：每月由

20、一位護士長進行全院夜查房，根據(jù)醫(yī)院護理工作中存在的不足適時督查病房管理、 病區(qū)環(huán)境、執(zhí)行護理核心制度及護理安全等內(nèi)容，每月進行匯總反饋。五、護理質(zhì)量與安全護理持續(xù)改進與評價1、按照護理部制定的天愿醫(yī)院護理質(zhì)量與安全管理持續(xù)改進考核評價標準（另行為）的要求，開展護理質(zhì)量與安全管理的考核與評價。2、考評辦法：每月護理部組織考評組成員定期不定期對各護理單元的護理質(zhì)量與安全管理工作進行檢查、指導(dǎo)、考核、評價?？荚u結(jié)果與科室的績效工資分配掛鉤。六、質(zhì)控考核評價信息反饋1、每月由各專項小組完成質(zhì)控后針對存在問題逐條提出整改措施。2、護理部與各專項小組意見每月匯總，形成全院護理質(zhì)量情況小結(jié)，對普遍存在問題針

21、對性的指導(dǎo)及整改并跟蹤效果。3、每月將各科護理質(zhì)量情況進行分析，提出整改意見，并交主管院長審核，在每月護士長例會上通報。七、獎罰、評優(yōu)評先1、科室每月對護理人員工作質(zhì)量評價進行匯總，匯總成績低于 80 分者或理論操作考核不合格者科室作出扣罰。2、每年醫(yī)院對護士長進行滿意度測評，不合格按醫(yī)院相關(guān)規(guī)定處理。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、科室出現(xiàn)嚴重護理缺陷，有護理質(zhì)量與安全管理委員會討論按情節(jié)輕重對科室作出處罰，年終取消評比先進科室的資格。4、每年各科考核成績報醫(yī)院辦公室，作為年終評比優(yōu)秀科室的依據(jù)，也作為護士長評優(yōu)評先依據(jù)。護理部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