(完整word版)二甲评审目标责任书(科室版).pdf

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1、二甲评审目标责任书根据二级综合医院评审标准(2012 年版)实施细则要求及我院工作安排，医院二甲等级评审（以下简称评审）工作是我院近三年的中心工作，各科室必须将此项工作列为重点。为确保医院顺利通过评审验收，特制订本目标责任书，具体内容如下：一、目标任务2017 年底内完成并通过二甲评审工作。二、工作要求1、各科室成立评审工作小组，科室主任是第一责任人，应尽全力保证本科室顺利通过评审工作。2、医院各职能部门主任为本专业评审工作第一责任人，负责本专业的评审工作。3、各科室要认真组织学习陕西省二级综合医院基本指标（2015 版）及原卫生部二级综合医院评审标准实施细则（2012 版），逐条对比，凡涉及

2、本科室的条款，应按基本指标和评审标准相应类别要求做好自查整改及资料的收集，做好评审支撑材料准备工作。4、科室要认真执行、落实各级各类人员岗位职责及医院工作制度。5、针对医院管理涉及考核内容比重较大的问题，要做到全面梳理并完善各项规章制度、应急预案、工作流程。6、抓好单病种、临床路径、抗菌药物、围手术期、医疗投诉、不良事件、病案质量管理等重点工作。7、理顺好急诊绿色通道；急危重症患者管理；检验标本的采集以及临床危急值报告登记管理；影像检查中患者安全和隐私的防护管理；患者安全目标的管理；入、出院（转科）管理等重点环节。8、采取列清单、个案追踪法模拟检查，注重医疗质量持续改进工作。9、要针对医院管理

3、工作中存在的问题和薄弱环节，对照评审标准，提出具体明确的整改目标，坚持重在整改、重在落实的原则，花大力气、下大决心，坚决整改到位。10、各分管院领导、职能科室要对自己管理的科室进行检查、督查，提出反馈意见，限期整改，以达到持续改进的目的。11、全员迎检，全员参与。坚决服从评审办公室工作安排，及时如期、按质按量完成评审办公室布置的各项具体工作任务。三、问责1、每次督察出来的问题要限期整改，对多次出现同类问题没有整改到位的要对责任人实施相应处罚措施。2、对查找出来的问题医院已明令整改而科室拒不整改的，对科室负责人诫勉谈话。3、对查找出来的问题，医院明令个人整改而未在规定期限内整改的，除按相关规定处

4、理外，当年不能提职、调资、评优、评先。文档编码:CY10T10J4E4N8 HB8U5D9V9T2 ZC9U1A4P4L3文档编码:CY10T10J4E4N8 HB8U5D9V9T2 ZC9U1A4P4L3文档编码:CY10T10J4E4N8 HB8U5D9V9T2 ZC9U1A4P4L3文档编码:CY10T10J4E4N8 HB8U5D9V9T2 ZC9U1A4P4L3文档编码:CY10T10J4E4N8 HB8U5D9V9T2 ZC9U1A4P4L3文档编码:CY10T10J4E4N8 HB8U5D9V9T2 ZC9U1A4P4L3文档编码:CY10T10J4E4N8 HB8U5D9V9T

5、2 ZC9U1A4P4L3文档编码:CY10T10J4E4N8 HB8U5D9V9T2 ZC9U1A4P4L3文档编码:CY10T10J4E4N8 HB8U5D9V9T2 ZC9U1A4P4L3文档编码:CY10T10J4E4N8 HB8U5D9V9T2 ZC9U1A4P4L3文档编码:CY10T10J4E4N8 HB8U5D9V9T2 ZC9U1A4P4L3文档编码:CY10T10J4E4N8 HB8U5D9V9T2 ZC9U1A4P4L3文档编码:CY10T10J4E4N8 HB8U5D9V9T2 ZC9U1A4P4L3文档编码:CY10T10J4E4N8 HB8U5D9V9T2 ZC9U

6、1A4P4L3文档编码:CY10T10J4E4N8 HB8U5D9V9T2 ZC9U1A4P4L3文档编码:CY10T10J4E4N8 HB8U5D9V9T2 ZC9U1A4P4L3文档编码:CY10T10J4E4N8 HB8U5D9V9T2 ZC9U1A4P4L3文档编码:CY10T10J4E4N8 HB8U5D9V9T2 ZC9U1A4P4L3文档编码:CY10T10J4E4N8 HB8U5D9V9T2 ZC9U1A4P4L3文档编码:CY10T10J4E4N8 HB8U5D9V9T2 ZC9U1A4P4L3文档编码:CY10T10J4E4N8 HB8U5D9V9T2 ZC9U1A4P4L

7、3文档编码:CY10T10J4E4N8 HB8U5D9V9T2 ZC9U1A4P4L3文档编码:CY10T10J4E4N8 HB8U5D9V9T2 ZC9U1A4P4L3文档编码:CY10T10J4E4N8 HB8U5D9V9T2 ZC9U1A4P4L3文档编码:CY10T10J4E4N8 HB8U5D9V9T2 ZC9U1A4P4L3文档编码:CY10T10J4E4N8 HB8U5D9V9T2 ZC9U1A4P4L3文档编码:CY10T10J4E4N8 HB8U5D9V9T2 ZC9U1A4P4L3文档编码:CY10T10J4E4N8 HB8U5D9V9T2 ZC9U1A4P4L3文档编码:

8、CY10T10J4E4N8 HB8U5D9V9T2 ZC9U1A4P4L3文档编码:CY10T10J4E4N8 HB8U5D9V9T2 ZC9U1A4P4L3文档编码:CY10T10J4E4N8 HB8U5D9V9T2 ZC9U1A4P4L3文档编码:CY10T10J4E4N8 HB8U5D9V9T2 ZC9U1A4P4L3文档编码:CY10T10J4E4N8 HB8U5D9V9T2 ZC9U1A4P4L3文档编码:CY10T10J4E4N8 HB8U5D9V9T2 ZC9U1A4P4L3文档编码:CY10T10J4E4N8 HB8U5D9V9T2 ZC9U1A4P4L3文档编码:CY10T1

9、0J4E4N8 HB8U5D9V9T2 ZC9U1A4P4L3文档编码:CY10T10J4E4N8 HB8U5D9V9T2 ZC9U1A4P4L3文档编码:CY10T10J4E4N8 HB8U5D9V9T2 ZC9U1A4P4L3文档编码:CY10T10J4E4N8 HB8U5D9V9T2 ZC9U1A4P4L3文档编码:CY10T10J4E4N8 HB8U5D9V9T2 ZC9U1A4P4L3文档编码:CY10T10J4E4N8 HB8U5D9V9T2 ZC9U1A4P4L3文档编码:CY10T10J4E4N8 HB8U5D9V9T2 ZC9U1A4P4L3文档编码:CY10T10J4E4N

10、8 HB8U5D9V9T2 ZC9U1A4P4L3文档编码:CY10T10J4E4N8 HB8U5D9V9T2 ZC9U1A4P4L3文档编码:CY10T10J4E4N8 HB8U5D9V9T2 ZC9U1A4P4L3文档编码:CY10T10J4E4N8 HB8U5D9V9T2 ZC9U1A4P4L3文档编码:CY10T10J4E4N8 HB8U5D9V9T2 ZC9U1A4P4L3文档编码:CY10T10J4E4N8 HB8U5D9V9T2 ZC9U1A4P4L34、对评审工作态度不端正的科室或个人，工作不力，重视不够，时间观念不强造成影响全院此项工作进度及严重后果者，给予全院通报批评及处罚

11、。5、在评审工作中明显影响了医院评审工作的科室在年终综合目标考核中取消一切评优、评先资格。四、奖励对在此项工作中成绩突出的科室和个人，给予重奖。分管院领导：目标责任科室科主任：2015 年 4 月 15 日 2015年 4 月 15 日文档编码:CY10T10J4E4N8 HB8U5D9V9T2 ZC9U1A4P4L3文档编码:CY10T10J4E4N8 HB8U5D9V9T2 ZC9U1A4P4L3文档编码:CY10T10J4E4N8 HB8U5D9V9T2 ZC9U1A4P4L3文档编码:CY10T10J4E4N8 HB8U5D9V9T2 ZC9U1A4P4L3文档编码:CY10T10J4

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