麻醉科质控目标.docx

marketing strict internal cost control, business and innovation performance. -Increasing electricity access, price increase, electricity supply is guaranteed. In 2012, the company with coal inventory, get rewards of Jiangsu provincial government power to 266 million kWh. Through the small and bilateral trade, access to electricity 1.695 billion kWh, seeking removal compensation when the power 50 million-kilowatt, 116% market share in Jiangsu Province ranked first in the same capacity, the same type units. Company closely tracked coal linkage policies on July 1 and August 20 respectively increase prices 2.08 minutes and 2.5 points, profitability increased significantly. 公 . Job grading, remuneration of labour agreements into long-term contract workers compensation system, stimulating the enthusiasm of the staff. -Further strengthening of human resources management. Full implementation of the performance appraisal regulations, incentive effect. Complete the reserve cadre evaluation and selection, produced 10 primary reserve cadres and 11 secondary reserve cadres. Implementation of operation staff induction gang system, 14 staff posts be promoted. Strengthening the cultivation of professional technical leaders, selected coverage 9 13 factory-level professional and technical leaders. To enhance staff skills training, 8 staff technicians. Labor contract law compliance, contracts of up to 100%. -Star team-building to advance further. Establish a holding system implementation, and promoting the whole team-building goals, strengthen group management. Team building into a performance review, promoting the construction of the star team depth. This year, respectively, 1 track, 4 team four star rated five-star by Datang and the team. Four, insists on six cultural construction of harmonious development, really good job of party construction and the independent Commission against corruption, strengthening the humanistic care and psychological counseling, the enterprise culture construction to a new level. -Building of enterprise culture is fruitful. Companies adhere to the Shenhua lead of corporate culture, culture of responsibility at the core, to safety culture, a culture of learning, ethical culture, cost culture culture system-assisted, through various cultural integration, has boosted business centre, this year has won the Chinese cultural management advanced unit, National Advanced Unit in the building of enterprise culture of reform and opening up 30 and other honorary titles. The liability of the company culture: solving management problems of corporate culture project was awarded the CEC national electric power enterprise culture achievement award of excellence. The accident early warning and prevention system was rated as Chinas power of innovation management, innovation management of electric power enterprise in Jiangsu Province. -Party and the independent Commission against corruption continues to strengthen. Was carried out to maintain麻醉科质控目标麻醉医疗质量基本指标1、各种神经阻滞成功率90；2、硬膜外阻滞成功率95；3、与麻醉相关的、级医疗事故发身率0.08%；4、非危重病人麻醉死亡率0.02；5、术前访视、术后随访率100%；6、腰麻后头痛发生率10%；7、“三基”考核合格率100%；8、麻醉记录单书写合格率98；9、麻醉技术操作（实施麻醉操作和术中监护）合格率100；10、硬膜穿破发生率80%；14、医院感染率8；15、成分输血率70%；16、年医疗事故发生率0； 17、甲级病案率90%（无丙级病案)。 麻醉科质控措施 为了更好的加强医疗质量管理，不断提高医疗质量，从而达到规范化、科学化、标准化管理,结合我科实际情况，制定以下质量管理方案。(一)质量管理小组：组长： 科主任组员： 上岗主治医师、护士长、医师、护士（二)管理目标:1、基础质量：（1）全科医务人员认真贯彻执行中华人民共和国执业医师法及相关的法律法规。（2）加强“三基”培训，培养“三严”,努力做到严格要求、严密组织、严谨态度的作风.做到“三基”考核合格率100。（3）重视对中青年医师的培训。通过对病历检查、查房、病例讨论及参加学术活动等不断提高业务水平；做到医护人员人人掌握徒手心肺复苏。（4）住院医师先进行基础轮转及相关科室轮转,为进入临床打下基础.主治医师要深入学习麻醉专业知识，了解国内外麻醉专业新进展。副主任医师要掌握国内外麻醉专业新知识、新技术、新进展，总结临床经验并积极做科研工作，提高麻醉科的专业水平.2、环节质量：（1）加强危重症病人麻醉处理。麻醉医师依据手术通知单及会诊单及时会诊，仔细查看病人。有问题及时与上级医师及有关科室协商，做到术中密切观察病情变化，积极处理并发症。麻醉中死亡率0.02%。（2)重大抢救时，10分钟内到位。（3)急症手术做到及时进入手术应急状态，接到通知后10分钟内做好麻醉前准备工作。(4）加强麻醉科病历书写及处方质量管理,处方合格率95%。每一份麻醉病历均有麻醉前对病人的检查和麻醉后随访。要求麻醉单填写字迹工整,内容真实齐全.(5）加强院内感染的防治，对各种麻醉用具认真消毒或销毁，科主任负责定时抽查。3、终末质量：（1）处方合格率95%(2）急诊危重病人抢救成功率达到80.(3)院内感染率8%。(4)麻醉中死亡率0。02%。（三）管理计划：医疗质量的上述各项指标年内全部达标,以后逐年提高。（四）管理措施：1、努力完成医院下达的各项工作任务,并积极开展新项目，坚持岗位责任制。2、每月考评一次，发现问题及时纠正.3、授课老师认真备课,保证教学质量。4、支持大家搞科研、写论文，年底考评优秀以此为依据。5、加强对进修医生、研究生及实习医生的管理，主管教师认真负责，每月认真审阅麻醉记录单，在工作中严格把关，每周定期进行学术讲座和知识更新。6、根据考评结果，实施奖惩，并与奖金挂钩。2014年麻醉科质控计划1.加强麻醉诊疗常规和操作规范，能熟练运用诊疗常规和操作规范指导临床工作。2.合理规范的使用麻醉药品，质量与安全小组督察及记录。3。加强员工对麻醉设备操作规程的掌握,能熟练操作麻醉设备,有使用记录，麻醉与术中生命监护系统、空气调节系统定期保养，有记录，手术药品和器材有适度储备。4。对医疗活动中发生的异常医疗信息要及时请示报告，增加工作的危机感和机敏性。5.深刻领会“危重患者管理制度” 科室应加强对危重患者的管理及观察，处理急危重症患者的应急反应能力。加强对“科室处理急危重症患者的应急预案”的培训,对预案内容进行模拟训练，要求熟练掌握、反应迅速，有“人员紧急替代制度并保证联系通讯工具畅通以便出现各种突发事件时,相关人员能确保按时到位.6。履行各项告知程序，充分尊重患者权益。知情同意书由麻醉者或上级医师负责谈话及签发,用易于理解的语言解释麻醉、处置、操作的必要性和目的及利害得失等告知内容，并记录在同意书中，术中意外处理或改变麻醉方式时由具备资格的医师负责向患者家属告知；对新开展的麻醉方法及其他特定范围的手术麻醉方法及其他特定范围的手术麻醉由具备资质的上级医师或科主任负责告知谈话.7.术前麻醉访视：接到手术通知单后，麻醉医师应按要求进行术前访视，通过充分的术前检查对病情进行评估,决定适宜的麻醉方案，并记录于病历，由主治医师以上人员签字确认，确定麻醉方案时要考虑患者年龄、全身状态，对麻醉、处置的适宜性应进行讨论,选择最适宜的时机与麻醉方法，与患者或家属谈话，同意后签订手术麻醉同意书，开出手术前用药，并准备麻醉器械,落实查对制度，每个患者外科手术时必须有麻醉方案(计划），重点是全麻、危重患者、新开展手术及特殊患者.8.术中管理：术中应监测患者生理状态,进行麻醉效果评定，发生意外状况及改变麻醉方式要按规定流程进行，要由具备资格的医师负责谈话，落实查对制度。9.术后随访：麻醉师对患者术后麻醉复苏阶段的生理状态进行监测，对苏醒的判断有具体判断基本标准(意识状态、血压、呼吸状态等），应按规定时限去病区查看手术患者，并向责任护士交待注意事项，防止发生麻醉并发症,并做记录。10。加强对麻醉、精神性药品按国家有关规定进行管理与储存，做到“三专管理(专人、 专柜 、专册、 专用处方管理）有严格的使用管理规范与程序。11。对员工进行心肺复苏、“五机”“八包”等急救操作培训，做到知识不断更新，做到知晓掌握。落实“住院医师规范化培训方案”，有计划，有记录.12。医护人员熟悉医疗事故处理条例的内容要求，落实“科室防范医疗纠纷及事故发生的重点措施。13。医务人员每月学习执业医师法等相关法律法规。14。医师业务素质的提高是医疗水平提高的基础，通过每周岗位培训与学习,加强、弥补专业业务技术的不足从根本上提高医疗人员的专业技术的水平. 15。加强法制观念和法制意识，把好医疗护理关。增强责任感，树立牢固的防范意识,切实贯彻有关医疗事故处理的法律、法规，积极主动地运用法律手段维护、医患双方的合法权益和依靠法律维护医院的正当权利，杜绝医疗差错或事故的发生。16。严格医疗相关证据的管理，各种文字性的资料在书写时要字迹清晰，不得涂改.记录要全面,准确无误，规范合理，并保留完整的各种监测记录。 17。改善服务态度、规范医护行为:医护人员应严格规范自身的医疗行为与自身形象,行为应符合医疗护理规范要求，在手术中不谈论与手术无关的事情，不对患者的病情窃窃私语,尊重患者的人格，做到文明礼貌、稳重端庄、态度诚恳。18。每月召开质量与安全形式分析会，查找工作中不安全隐患，薄弱环节，针对存在的问题制定实施办法。2014年度麻醉质控每月质控重点一、 麻醉医师分级授权管理及医师知晓度调查，麻醉病例书写。二、 麻醉前，麻醉后访视三、 知情同意制度的落实,麻醉计划的制定四、 术中管理机麻醉意外处理流程五、 麻醉药品管理，及麻醉处方书写六、 术后镇痛七、 全身麻醉技术操作规范及流程八、 椎管内麻醉技术操作规范及流程九、 手术风险评估及安全核查十、 输血管理十一、 术前讨论及疑难病例讨论十二、 麻醉效果及质量评价以区域为单位进行有效组织，通过全国统一商品营销和区域活动促销的方式相结合，紧抓春节黄金时段，及节中、节后的消费需求，以中国古今结合“穿越式”的龙年春节文化为主题，security, profit, maintain stability and promote harmonious development as the main content of the three guarantees theme practice activities and stressing party spirit, to conduct, for example campaign, party and further improvement of the level of work. Staff participating in the honest and clean culture construction seminars, staffs sense of probity and enhanced. Founded by honest inspectors team composed of 12 employees to broaden the channels of supervision. Adhere to establish four good leadership activities, staff satisfaction rate of 98% to the team. -Group work dynamic. Promoting the openness of factory Affairs, proposal for a love letter box, to the vital interests of the staff Trade Union delegation leader meeting of the 26 system to discuss and safeguard their democratic rights. Improve the organizational structure of the mission, the work of strengthening. Organize maintenance labor emulation and health Cup competition, enhance the skills of staff. Organized a variety of cultural activities, physical and mental health care staff, to create a harmonious atmosphere. During the Wenchuan earthquake, donated all the company employees, to love, to support the disaster areas. This year, the company has won the Su . Cutting costs can be controlled, money should not be wasted management philosophy, management analysis, to improve management quality, improve cost control capacity and market competitiveness. Innovation of science and technology-science and technology innovation is to play the role of science and technology as the primary productive force, active use of new technologies, new materials, new processes, new equipment, increase investment in science and technology, strengthening scientific and technological training, speeding up transforming scientific and technological achievements, forming a number of proprietary technology, enhancing core competitiveness. Resource-saving-the-resources saving enterprise was to reduce coal consumption, water consumption, electricity at the core, enhance the operation of lean management to realize low consumption, high efficiency, reduce production costs. Second is to strengthen the business, financial, material, information and the optimization of organization and management, saving the internal transaction costs. Harmonious development of harmonious development-is to construct a foreign environment for development. XING refers to the internal security firm and internal management of the internal management measures are effective, harmonious. Foreign currency means Enterprise coordinating development of homeopathy, well, get along with the neighbors better. (B) XX 2013 five enterprises building intrinsic safety power company goals are: unplanned outage 0 times. Class of disorders 0, 0 is equivalent forced outage rate. No personal injury accident, material and equipment accidents do not occur, no fire, no environmental pollution accident. Enterprise integrated to achieve zero cases of violation, zero accidents, zero. Quality goal is: when generating capacity 7.5