Single-disease clinical pathway refers to a scientific (or reasonable) and sequential patient care plan formulated by medical, nursing and related personnel for a disease or an operation after the disease diagnosis is clear.
Second, the hospital departments to carry out single disease clinical pathway must abide by this system.
Third, the formulation of clinical pathway of single disease in each department should follow the principles of science, safety, standardization, effectiveness, economy and ethics, and adapt to the functions and tasks of the department, which requires qualified professional and technical personnel, corresponding equipment, facilities and quality control system; Medical staff at all levels should strictly implement the norms and routines of diagnosis and treatment of related diseases and optimize the quality of diagnosis and treatment of quality control diseases.
Fourth, set up organizations to strengthen supervision. Under the leadership of the dean and the director in charge, establish a three-level medical control system responsible for the quality of single diseases and clinical pathways, and be responsible for the management and supervision of this work. The hospital set up a leading group for single disease quality and clinical pathway management, which belongs to the hospital medical quality management committee, and is mainly responsible for the relevant rules and regulations of single disease quality and clinical pathway management, guiding, monitoring and evaluating the single disease quality and clinical pathway management in our hospital, and coordinating the problems encountered in the implementation of clinical pathway. Relevant departments set up a single disease quality and clinical pathway implementation team, with the clinical director as the team leader and medical staff as members. The chief physician is mainly responsible for the implementation of clinical pathway, the evaluation and analysis of the effect of the implementation process of clinical pathway, and the medical department is responsible for the collection, recording and collation of relevant information and information reporting.
Verb (abbreviation of verb) Quality control, evaluation and improvement (1) Entry path Medical record selection requirements: 1. The diagnosis is clear; 2. No other complications, complications and accompanying diseases; 3. The patient voluntarily (signed informed consent); 4. No other obvious complications or complications occurred during the diagnosis and treatment. (two) the implementation of process control and variation analysis; (3) Single disease quality control index 1, diagnostic quality index: the coincidence rate of admission and discharge diagnosis, the coincidence rate of diagnosis before and after operation, and the coincidence rate of clinical and pathological diagnosis. 2. Treatment quality indicators: cure rate, improvement rate, unhealed rate, complication rate, antibiotic use rate, mortality rate and readmission rate within one week. 3. Length of stay: average length of stay and average length of stay before operation. 4. Cost indicators: average hospitalization expenses, hospitalization expenses per bed, operation expenses, medicine expenses and examination expenses. (4) Main measures for quality control of single diseases 1. According to the requirements of clinical pathway management formulated by the Ministry of Health, strictly implement the routine and technical process of diagnosis and treatment; 2. Improve the implementation of diagnosis, treatment and nursing system; 3. Reasonable examination, adopting appropriate technology, and improving the level of diagnosis and treatment; 4. Rational drug use and hospital infection control: 5. Strengthen the management of critically ill patients and perioperative patients; 6. Adjust the service process of medical department to control the invalid hospitalization days.
Six, all clinical departments should attach great importance to single disease quality control, refine the work plan, determine the specific work objectives and implementation steps, establish an information reporting system, complete the case registration after each single disease diagnosis and treatment, fill in the single disease quality control statistics, earnestly implement the work responsibilities, and ensure the smooth development of single disease quality and clinical pathway management.
Seven, the provisions from the date of promulgation, by the single disease quality and clinical pathway management leading group is responsible for the interpretation and explanation.