Article 1 Market Special Supervision and Self-inspection Report
In order to improve the quality of medical services and technical services, our hospital conducted a strict self-examination according to the Detailed Rules for the Implementation of the Regulations on the Administration of Medical Institutions. The self-inspection is now reported as follows: 1. The leaders attach great importance to it and the organization is strict.
Our hospital held a meeting and made strict arrangements for self-examination. At the meeting, a self-inspection leading group was set up, with Wang Bin as the leader and the heads of relevant business departments as members. According to their respective responsibilities, all business departments have carried out serious self-examination and self-correction in strict accordance with the Detailed Rules for the Implementation of the Regulations on the Administration of Medical Institutions, and achieved remarkable results.
Second, the basic situation of self-examination
(1) Institutional self-examination: The full name of the unit is "Kunming Tang Chi Hospital", xx is a private enterprise, located in Tangchi Town, the management committee of Yangzonghai Scenic Area in Kunming; Legal Representative: Gao Kaihong; Client: xx. It has the Practice License for Medical Institutions issued by xx Health Bureau, with the practice license number of xx and the validity period of xx. Our hospital strictly manages the practice license of medical institutions and has never altered, bought, sold, transferred or leased it. There are xx beds, and the diagnosis and treatment subjects are surgery, internal medicine, traditional Chinese medicine, obstetrics and gynecology, laboratory and imaging; The commercial building covers an area of xx square meters.
(2) Personnel self-examination: Our hospital has never registered to carry out large-scale practice activities or issued medical certificates in violation of regulations; Persons who have not obtained the qualifications of practicing doctors or nurses or doctors registered with one license and many places shall not be used to engage in medical activities. All medical staff are listed for posts, and a supervision column is set up in the hall to make it public.
(3) Improve service quality: strengthen medical quality management and implement medical quality assurance scheme according to relevant regulations and standards of health administrative departments; Regularly check and assess the implementation of various rules and regulations and post responsibility system for personnel at all levels, ensure medical safety and service quality, and continuously improve service level.
(IV) Cross-infection management in hospital: A leading group for cross-infection management in hospital has been set up, which is composed of relevant personnel and regularly educates and trains relevant personnel. Relevant rules and regulations, such as medical waste treatment management, hospital infection and disinfection management, are fully recorded by special personnel, and the disinfection effect is regularly monitored by key departments and parts. The label of the prepared disinfectant is clear, complete and standardized.
(V) Disposal of solid medical wastes: all medical wastes are collected by classification, the temporary storage time of wastes is marked with warning signs according to regulations, the waste containers are sealed to prevent stabbing, and the temporary storage places of wastes are "five precautions" xx, and the transportation and transfer of medical wastes are handled by special personnel with signature records.
(6) Disposal of disposable medical supplies: All disposable medical supplies are collected by the medical waste treatment station after soaking, disinfection and destruction, and are harmlessly disinfected and burned. There are detailed handover records of medical wastes, and there is no resale or gift. All operators are trained and have special protective facilities and equipment.
(VII) Report on epidemic situation management: Our hospital has established a strict epidemic situation management and reporting system, and designated a special person to be responsible for epidemic situation management. The contents of the epidemic situation register are complete, and the epidemic situation report card is standardized. The epidemic situation report is checked once a month, without omission or delay.
(8) Self-inspection of drug management: After investigation, our hospital has never used counterfeit drugs, expired, invalid or illegal drugs.
Third, there are shortcomings.
First, due to lack of funds, some medical equipment can not be maintained or updated in time, which has affected the in-depth development of related businesses to a certain extent, and the development potential is insufficient.
Second, limited by the establishment, the staff is tight, the workload is heavy, there are not many opportunities for further study in provincial medical institutions, and the knowledge updating cycle is long, which has affected the service level to a higher level to some extent.
Fourth, the direction of future efforts.
Our hospital must take this self-examination as an opportunity, under the leadership of the superior business department, conscientiously implement the spirit of the superior meeting, strictly abide by the Regulations on the Management of Medical Institutions, strengthen management measures, optimize the quality of personnel, be pragmatic, blaze new trails, and constantly improve the quality of medical services and technical services.
Article 2 Self-inspection report on professional market supervision
In order to further strengthen the supervision of the medical industry, rectify and standardize the practice of medical institutions, and safeguard people's health rights and interests, according to the requirements of the Notice of the Provincial Health and Family Planning Commission and the Provincial Bureau of Traditional Chinese Medicine on Carrying out Special Supervision and Inspection of Medical Institutions' Legal Practice (Su Weijian [20XX]13), the Municipal Health and Family Planning Commission is scheduled to carry out special supervision and inspection of medical institutions' legal practice in the whole city from September to July of 20xx. The relevant matters are hereby notified as follows: 1. Work objectives.
For the purpose of serving people's health, we should focus on social concerns, adhere to problem orientation, innovate supervision and law enforcement means, strengthen supervision and inspection of medical institutions' practice behavior, severely investigate and punish illegal acts according to law, focus on solving outstanding problems in the field of medical services at this stage, further rectify and standardize the market order of medical services, and earnestly safeguard people's health rights and interests.
Second, the task
(a) a comprehensive self-examination, earnestly implement the rectification measures (20XX September 10). Health and family planning administrative departments at all levels should quickly deploy medical institutions within their jurisdiction to carry out self-examination and self-correction of practicing lawyers in an all-round way, comprehensively and conscientiously implement rectification measures for the problems found in self-examination, and submit the self-examination and rectification and the Book of Practicing Lawyers (see Annex 1 for the template of the book) to the registered health and family planning administrative department.
(2) Supervise and inspect, and severely investigate and deal with illegal acts (20xx165438+1October 20xx). Health and family planning administrative departments at all levels and health supervision institutions shall, according to the self-examination and self-correction of medical institutions, conduct key supervision and spot checks or "double random" inspections for different types of medical institutions, and severely investigate and punish violations of laws and regulations according to law.
1, secondary and tertiary hospitals (including maternal and child health care institutions, the same below). Focus on checking whether there are contracted departments, medical activities beyond the scope, hiring non-health technicians, illegally carrying out medical technology that prohibits clinical application, carrying out medical technology that restricts clinical application without filing, and carrying out clinical application of medical technology that is clearly managed according to clinical research.
2. There are hospitals (including unclassified), outpatient departments and clinics. Focus on checking whether there are illegal acts such as issuing false medical documents, renting out and lending the practice license of medical institutions, not charging according to the publicity standards, carrying out medical activities beyond the scope, hiring non-health technicians, illegally carrying out medical beauty, maternal and child health care, family planning and other technologies, and urinary, skin and sexually transmitted diseases.
3. Clinical application of stem cells. First, for medical institutions that have filed stem cell clinical research according to regulations, it is important to check whether stem cell clinical research is carried out according to the scope of the filing project, and whether there are stem cell clinical research projects that are directly put into clinical application without authorization. Second, for unlicensed medical institutions, complaints and medical advertisements are used as clues to seriously investigate and deal with the behavior of conducting clinical research and clinical application of stem cells without authorization.
All localities should, on the basis of the basic standards of medical institutions in the city and the investigation of medical technology, focus on the medical institutions that have repeatedly illegally published medical advertisements, concentrated complaints and reports, and been punished.
Third, the job requirements
(1) Strengthen organizational leadership. Health and family planning administrative departments at all levels, health supervision institutions and medical institutions should proceed from the height of earnestly safeguarding the health rights and interests of the broad masses of the people, strengthen leadership, clarify responsibilities, and ensure that this special supervision and inspection work is implemented and achieved practical results. This supervision and inspection is carried out by means of comprehensive self-examination of medical institutions, comprehensive supervision and inspection by health and family planning administrative departments in the jurisdiction, and supervision by provincial and municipal health and family planning administrative departments. During the special inspection, the Municipal Health Supervision Institute strengthened the supervision of the work of health supervision institutions at all levels, and the Municipal Health and Family Planning Commission listed and supervised major typical illegal cases, and timely organized various localities to carry out inspections. If the self-examination and rectification are not serious, the regulatory responsibility is not implemented, and the case investigation is not in place, the relevant personnel will be seriously investigated for responsibility in accordance with the relevant provisions of party discipline and political discipline.
(two) the implementation of work responsibilities. All kinds of medical institutions at all levels should earnestly implement the responsibility of practicing according to law, carefully control laws and regulations, and comprehensively carry out self-examination and rectification of practicing according to law. Health and family planning administrative departments at all levels and health supervision institutions should conscientiously implement their supervision responsibilities, innovate supervision and inspection methods in light of the actual situation in their respective jurisdictions, actively explore "double random" and flight inspection methods, and strengthen supervision and inspection. Mass complaints, reports and media exposure. Case clues should be investigated and verified one by one, and real-name reports should be given timely feedback, so that everything can be checked and pieces can be echoed. When illegal acts of medical institutions and medical personnel are found, they should be severely punished according to law, and no cases should be investigated or condoned. For serious violations of laws and regulations, resolutely revoke the relevant medical subjects of medical institutions or the practice license of medical institutions or the practice license of maternal and child health care technical services, and revoke the practice certificates of relevant personnel.
(3) Strengthen coordination and cooperation. All localities should link the results of supervision and inspection with the verification and evaluation of medical institutions and the management of bad practice scores, explore the establishment of a "blacklist" system, bring medical institutions and related personnel with major illegal cases into the social credit system according to law, and increase the punishment for illegal acts. Strengthen communication and cooperation between departments, and timely notify or transfer illegal acts such as medical advertisements and medical service prices that are not under the jurisdiction of the health and family planning administrative department in accordance with relevant laws and regulations. Anyone suspected of committing a crime should be promptly transferred to judicial organs for criminal responsibility according to law, and it is strictly forbidden to "substitute punishment with punishment" or "refuse to transfer the case".
(4) Play the role of social supervision. All localities should unblock the channels for reporting complaints and take the initiative to publicly report complaints (Wuxi Health Supervision Office reported complaints at 82827 1 10) to encourage the masses to provide clues about illegal cases. Effectively strengthen communication with the media, actively publicize the progress of relevant work, increase the exposure of typical cases, invite the media to follow up when investigating major cases, and increase the deterrent effect on criminals. Pay close attention to recent changes in public opinion, carefully analyze and judge, respond to social concerns in a timely manner, and create a good social atmosphere for special supervision and inspection.
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Article 3 Self-inspection report on professional market supervision
According to the work requirements of the Implementation Plan for Centralized Renovation of Primary Medical Institutions in XX City (Wei [20xx]15) issued by the XX Municipal Health Bureau, and according to the rectification opinions of the XX County Health Bureau on the problems found in the special inspection of XX Hospital, XX Hospital attached great importance to it, and the top leaders personally grasped it and strictly rectified it. First, the leaders attached great importance to it and set up a self-inspection leading group.
On April 19, a meeting was held on the rectification of medical institutions to study and implement the implementation plan of centralized rectification of primary medical institutions in XX. Medical staff in the whole hospital learn medical and health laws and regulations, and incorporate the norms and learning such as the Law on Medical Practitioners, Regulations on Management of Medical Institutions, Regulations on Nurses, Prescription Management Measures, and Code for Writing Medical Records into performance appraisal. Set up a leading group with the president as the leader, the vice president as the deputy leader and the heads of various departments as members to carry out self-examination and self-correction on standardizing hospital practice according to law and improving hospital management level.
Two, adhere to the practice of law, standardize the scope of practice.
1, all departments of health centers engage in practice activities in strict accordance with the scope of practice license of medical institutions, and there is no phenomenon of exceeding the practice of diagnosis and treatment subjects.
2. There are 48 staff members in the hospital, including 13 medical practitioners and assistant medical practitioners, 6 pharmacists, 2 medical imaging technicians and 1 person. Strictly undocumented and non-health technicians engage in medical activities alone.
3, hospital consultation in strict accordance with the Interim Provisions on the management of medical consultation.
4. There is no illegal release of medical advertisements.
5. Prohibit dental clinics opened without permission.
6, standardize the writing and management of medical documents, medical documents timely, accurate, complete and standardized. Medical records, prescriptions and nursing records must be standardized in accordance with the Basic Norms for Medical Records Writing and Prescription Management Measures of China formulated by the Ministry of Health.
Three, conscientiously implement the basic drug system
All drugs in health centers are national essential drugs, and the drug supply of service stations and village clinics in the jurisdiction is purchased and distributed by the hospital online, with a sales rate of zero, and there are no counterfeit drugs, expired and ineffective drugs.
Four, the implementation of disinfection and isolation system, put an end to infection accidents.
Strictly implement the injection operation rules, so as to achieve "one person, one needle, one tube, one use and one disinfection" and put an end to the repeated use of medical consumables. Regularly carry out disinfection and sterilization effect testing and establish records. Strict implementation of hospital infection and infectious disease reporting system. Disposable medical supplies are all soaked, disinfected and destroyed, then harmlessly disinfected and incinerated, and detailed handover records of medical wastes are kept, and there is no resale or gift.
In short, the hospital attaches great importance to standardizing practice and pays close attention to the implementation of further standardizing practice behavior, laying a solid foundation for improving medical quality.