2022年平安医院创建工作总结.pdf

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1、1 XXXX 医院创建“平安医院”活动总结今年，我院在市委、市政府和市卫计委的统一领导下，在有关部门的协调配合下，结合医院等级评审、“三好一满意”活动和安全生产工作，全面开展平安医院创建活动，使医疗服务环境明显改善，医疗质量明显提高，安全隐患明显减少，治安防控能力显著增强，医患关系更加和谐，医院各项工作又好又快发展，确保了广大人民群众身体健康，现将创建工作总结如下。一、加强组织领导，开展宣传活动（一）制定活动方案，成立领导机构我院领导高度重视平安医院创建工作,把创建“平安医院”纳入工作计划，制定XXXX医院创建“平安医院”活动方案下发各科室，并成立以 XXX院长为组长，有关职能科室负责人及临床

2、科室主任为成员的创建“平安医院”活动工作领导小组，下设创建办公室，由分管领导担主任，形成一把手主管，分管领导亲自抓，分工协作、任务明确的组织管理机构。定期召开会议研究创建工作，办公室负责抓层层落实，确保我院综治工作和创建工作取得实效。（二）强化宣传培训，营造良好氛围结合我院实际，认真制定宣传计划，通过板报宣传、医院网站发布“创建平安医院”信息，定期举办“三基”知识技能考试、临床医疗护理知识培训等形式，不断提高医院员工安全意识，在院内形成了人人知晓平安医院创建、人人参与平安医院创建的浓厚氛围。2015 年共制作宣传板报6 期，发布宣传稿件12 篇。组2 织开展各类知识培训5 次，参加 2000

3、余人次。二、加强安全管理，确保安全生产（一）不断强化医院内部治安管理1、建立完善的内部治安保卫保障机制和工作机制，设立治安保卫机构。我院通过加强保安人员配备，提高保安人员待遇等措施加强治安队伍建设。与宜州市保安公司签订协议，设立了一个保安中队，配备专职保卫人员和保安队伍,现有保安人员26人，占在岗医务人员的3.7%，符合保安数量不低于在岗医务人员总数 3%的标准。2、实行动态治安管理，加强重点部位、重点时段，特别是夜间巡查。我院实行保安24 小时值班和巡查制度，值班人员定时对各科室楼层及重点区域进行巡查，并做好记录。2、完善防盗、防火、防破坏等各种安全防范设施。在经费紧张的情况下，拨出专款安装

4、了电子监控系统，分别在东院安装监控摄像头32 个、南院安装监控摄像头178 个，并与我市110开通监控平台，设置了安全监控室，由具有专业技能的保安人员24 小时值班，并配备了对讲机、电话等通讯设施。3、医院全面执行自治区卫生厅制定的医院安全保卫工作规范，制订了安全管理制度，开展经常性的安全检查和排查，及时消除内部安全隐患。定期组织重点岗位工作人员学习培训，加强保卫、保安人员培训，落实各项内部安全保卫措施。每年邀请市治安大队、市保安大队教官给我院保安人员进行专业化培训。2015 年开展安全培训3 次，参加人员60 人次4、主动与所在辖区的城东派出所、城南派出所和周边社区联系，开展联防共建。分别在

5、东院、南院区设立了警务室，严防违法犯罪行为发生。文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 H

6、M10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6

7、HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6

8、 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C

9、6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1

10、C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U

11、1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y93（二）安全生产责任有效

12、落实，岗位职责和技术操作规程完善，消防及安全设施齐全1、医院有效落实安全生产责任制，实行定岗、定人、定责制度。各科室严格遵照安全生产责任书内容，开展经常性安全检查，及时消除内部安全隐患。2015 年 5 月开展了全院性的安全生产大排查活动，排查出问题5 个，并及时整改，将安全隐患消除在萌芽中。2、岗位职责及技术操作规程完善。医院制定有各岗位的技术操作规定，定期对相关岗位人员进行培训，要求严格按照操作规程执行操作，特别是重要部位和重点科室、部门的操作规程。3、消防疏散出口、通道畅通，消防设施、灭火器材、报警系统、安全标识和应急照明齐全，灵敏有效，符合规范要求，通过了消防队的消防验收。水电设备管理

13、到位，无火灾隐患，易燃易爆物品存放符合安全防范标准。（三）制订防恐怖，防破坏，防灾害事故应急处置预案，定期组织演练医院制定了防恐怖、防破坏、防灾害（火灾）事故、防重大盗窃事故（放射源、毒麻药品、财务部门）、防群体性事件（大型医疗纠纷）应急预案、消防安全应急预案等应急处置预案，每年均组织医院职工开展演练。2015 年 5 月 28 日，我院在院内举办了消防安全知识培训和防控防暴应急演练，医院干部职工约400 人参加了培训及应急演练。2015 年 11 月 1 日，组织全院开展了消防、应急供电演练，参加演练100 余人。（四）加强患者安全管理，防止意外事故和伤害。一是制订医院重点科室、部门的安全管

14、理制度和措施。供水、文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6

15、ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6

16、 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K

17、6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1

18、K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V

19、1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10

20、V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y94 供电、供热、供氧、“毒、麻、精、放”药（物）品、

21、菌种、易燃易爆物品存放库房等重点要害部位、夜班值班科室实行24 小时值班守护制度，安排专人值班，毒麻药及一类精神药专人专柜加锁管理，做好物品登记，严防发生流失事件。二是所有仪器设备符合国家环保、卫监、计量等相关法律法规的规定，做到合法、合理与安全使用。三是按照食品卫生的要求，院内食堂各项管理制度完善，措施到位，保证群众和医务人员的食品卫生安全。（五）建立突发公共事件应急机构，应急处置工作预案完善，信息报告与反馈程序执行严格医院建立了突发公共事件应急领导小组，由院长任组长，分管副院长任副组长，各相关部门及科室负责人任成员。完善了应急处置工作预案，配置有应急处置快速反应力量；定期组织应急演练，并有

22、总体评价、改进措施。建立突发公共事件信息报告与反馈程序，医院应急办公室配备有电话、传真机、连接互联网的电脑，设有24 小时保持通畅总值班电话，保证了信息上报和反馈迅速、畅通。（六）医疗废物管理制度完善，措施到位医院成立了医疗废物及医源性污水处理工作领导小组，设置有医院感染管理与环境保护科，配有 3 名专职人员，设有生活垃圾集中存放点、医疗垃圾暂存点和污水处理系统。医院各科室产生的医疗废物，严格按医疗废物的相关制度和规定，用专用的包装袋或容器进行分类、收集、科室交接、运送至暂存地点交接登记，由来宾市鑫宾医疗废物处置有限公司负责清运和处置。医院的废水处理系统为NLC系列紫外 C水消毒系统，是采用目

23、前国际文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4

24、V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B

25、4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6

26、B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J

27、6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8

28、J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB

29、8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y95 上最先进的污水消毒系统（NLC系列紫外C 水消毒系统），克服了

30、使用消毒剂对环境造成的二次污染，这是其它消毒方法无法比拟的优点，保证了医院污水排放达到有关标准，不产生环境污染。三、加强医德建设，提高医疗质量，严格依法执业（一）加强医德医风和行风建设，定期开展医德教育和法律法规培训1、继续加大行风教育力度。一是继续加大医德医风、行风教育力度，2015 年开展各类医德医风教育培训会议6 次，参加培训 1500 人次。二是贯彻医务人员医德规范及实施办法，建立健全廉洁行医规章制度，健全完善医德制度规范，将医德医风考核与年度评优、绩效工资挂钩。2、加强法律法规和医疗机构从业人员行为规范学习，覆盖面达到100%，开展各类法律知识培训会议3 次，参加培训900 人次。3

31、、进一步加大治理商业贿赂工作力度。严禁医务人员“收红包、吃回扣、开大处方”等不良现象发生；严格执行药品网上集中招标采购，开展药品动态监控，杜绝药品购销环节的不正之风。2014 年至 2015 年共警示约谈药品配送商3 人次；暂停采购销售量异常波动的药品10 种。通过一系列措施，有效控制了医疗费用的增长，减轻了群众负担。（二）医疗安全措施完善，安全用药措施有效落实维护患者合法权益，制定了各种知情同意书，以充分尊重患者知情同意权和选择权。制定本单位的安全目标制度及规范。严格执行处方管理办法，制定了基本用药目录、处方集，制定了处方点评等制度。临床药师参与临床用药，配有临床药师3 人，文档编码:CV8

32、Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV

33、8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:C

34、V8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:

35、CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码

36、:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编

37、码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档

38、编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y96 对药物使用有动态监控，定期公布药物监控情况，对发生的药物不良反应能及时上报。严格执行

39、技术准入制度，科室开展新的诊疗技术，需提出申请，按制度规定审批后才能执行，严格按照制度进行新技术管理。制定了医院的核心制度，严格执行医师外出会诊管理制度。医疗机构临床上所用的设备、药物、试剂等均具备“三证”齐全，无过期或劣质物品。（三）依法执业，严格执行诊疗规范，严格院感管理和临床用血管理。我院严格依法执业，独立排班人员均为取得相应资格证件者，专业技术人员有相应的任职资格，从事产前诊断人员有母婴保健技术考核合格证。严格医院感染管理工作，设置有医院感染管理与环境保护科，配有 3 名专职人员，制定并落实院感的各项规章制度，按规定做好院内感染的监测及传染病报告工作，医疗废物的管理及处理合理及时。临床

40、用血管理制度完善，设置有血库，用血来源正规，血液保存符合要求，有关记录规范完善，交叉配血无差错，临床用血指征合理，输血前五项检验齐全，成血输血比例85%。（四）设有医疗质量管理机构，考核机制健全我院建立有质控办、考核办、客服部等医疗质量管理部门，成立有医疗质量管理委员会，制定有相应的医疗质量考核办法及细则。质控办定期对病历质量进行质控，考核办、客服部对医疗质量和服务水平进行考核，每月召开考核会，发放考核简报，将医疗服务质量与年终考核、评优、个人晋升及经济奖罚挂钩，制定有明确的奖罚办法。严格执行医师定期考核暂行办法，对文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4

41、V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B

42、4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6

43、B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J

44、6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8

45、J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB

46、8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 Z

47、B8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y97 医务人员制定了本单位的考核机制。四、加强院务公开和医患沟通，依法妥善处置医患纠纷（一）继续加强院务公开，强化医疗价格管理，杜绝不合理收费现象1、加

48、强领导，健全制度。成立院务公开领导小组，制定院务公开制度、职代会制度等制度，做到年初有计划，年底有总结，使院务公开工作有组织、有计划的开展。2、向患者公开医疗信息。将医药信息、医疗质量、单病种质量、处方质量、处方点评、门诊医师用药排名等信息向医院职工和群众公开。在门诊使用电子显示屏不间断的动态公示医疗收费价格、药品价格、一次性卫生材料价格等，便于群众就诊和监督，同时在住院部和门诊配置了2 台费用自动查询机，方便群众查询医药费用和住院费用。实行住院费用一日清单制度。每日将住院费用清单打印给患者，增加医疗服务和医疗收费透明度，让群众明明白白看病。3、向院内职工公开信息。设立院务公开栏。把医院职工普

49、遍关注的财务管理、重大决策、基建预结算、医疗设备和药品采购、人事任免等内容定期向医院职工和群众公开。2015 年 1-9月共进行院务公开9 期，财务收支公开9 期，公开医院重大问题决策 12 项。每年召开职工代表大会，接受医院职工监督。医院的重大决策、设备购买、劳务费发放、人事任命等均要通过职工代表大会讨论审议表决才能生效。充分发挥职工代表民主管理、参政议政和监督的作用。4、严格执行物价政策和物价部门核定的收费项目、收费标准，规范收费，不在规定的收费项目和标准之外自定收费项目、文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6

50、 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C6 HM10F10X10V1K6 ZB8J6B4V8Y9文档编码:CV8Q2P8U1C