医院全程医疗质量管理和持续改进方案.doc

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1、医院全程医疗质量管理和持续改进方案全程医疗质量管理和持续改进方案全程医疗质量管理和持续改进方案为了加强全程医疗质量管理并做到持续改进，促进医疗质量管理工作、提高医疗质量、防范医疗纠纷、加强医疗安全性，特制定本方案。1、在分管领导和医疗质量管理委员会领导下，医务科加强与科室质量管理小组联系，不定期到临床科室了解医疗质量问题，检查督促其规章制度执行情况。2、抓好六个重点，确保医疗质量。重点制度落实：如首诊负责制、查对制度、死亡讨论制度。重点科室：急诊科、手术室及麻醉科、外科。重点人群：新分配、主诊医师及进修人员。重点时间：节假日、工作繁忙或闲时、夜间。重点患者：疑难、危重、急诊患者。重点问题事件：

2、医疗纠纷、差错、事故处理等。3、质控办每季度向各科主任、护士长和有关部门通报医疗质量检查结果，并提出整改措施。4、每月审阅分析统计室的有关质量信息统计资料。5、定期接受各职能部门的专项质量检查。6、各科结合工作实际加强对医务人员“三基”教育、培训和考核。7、各科结合实际每年对规章制度、诊疗常规、操作规程进行检查改进。8、建立质量奖惩制度，每季度查出的医疗质量问题与绩效工资挂钩，责任到人。9、年度的质量评价与考核结果，列入评先的条件。10、加强医疗质量的全员质量意识和安全性教育，每月各科室组织二次以上，医务科每月组织一次以上的业务人员安全教育活动。结束语！祝大家学到有用的知识，提升自己的能力，实

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