阿克苏地区第二人民医院等级评审目录_医院等级评审材料目录

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医院等级评审制度

汇 编

阿克苏地区第二人民医院二〇一二年八月

阿克苏地区第二人民医院等级评审

制度汇编目录

一、科学规范的内部管理机制···························（1）

1.住院医师接收规范化培训的制度···················（1）2.临床路径管理指导原则（试行）·····················（1）3.公立医院特需服务措施内容·······················（1）

二、承担政府指令性任务·····························（1）

1.支援基层具体实施方案··························（1）2.传染病控制措施································（1）3.特定人群实行医疗救助制度及保障措施··············（1）4.新生儿卡介疫苗与乙肝预防接种制度···············（1）

（1）疫苗管理制度····························（1）（2）卡介苗首诊制度··························（1）（3）乙脑疫苗首诊制度·························（1）（4）卡介苗接种操作规程························（1）（5）乙肝疫苗接种操作规程······················（1）5.向卫生部门报送信息制度与流程···················（1）6.阿克苏地区卫生监督信息报送办法·················（1）三．应急管理（大平）··································（1）四．临床医学教育及科研·······························（1）

1.医学继续教育管理制度···························（1）

2.关于继续医学教育的实施方案··················（1）3.继续医学教育规划····························（1）

五、住院、转院、转科服务流程管理·······················（1）

六、保障患者合法权益·································（1）

关于尊重和维护患者合法权益的管理制度············（1）

七、患者安全·········································（1）

1.患者身份标识制度······························（1）2.关键流程患者身份识别措施·······················（1）3.转科交接登记制度、交接程序和身份识别措施·········（1）4.腕带身份识别标识制度··························（1）

八、确立在特殊情况下医务人员之间有效沟通的程序、步骤·····（1）

1.阿克苏地区第二人民医院医嘱管理制度与流程········（1）2.紧急情况下口头医嘱制度与执行流程···············（1）3.口头医嘱制度··································（1）4.口头医嘱执行流程······························（1）5.危急值报告及临床应答制度及流程·················（1）6.危急值报告及临床应答流程·······················（1）

九、确立手术安全核查制度，防止手术患者、手术部位及术式发生错误··················································（1）

手术前准备管理制度······························（1）

十、医药质量管理组织······························（1）

1.医疗质量与医疗安全管理和持续改进方案········（1）2.医疗质量与安全管理目标与责任················（1）3.医疗安全管理工作计划与考核方案·············（1）

十一、医疗质量管理与持续改进·················（1）1.危急重患者管理标准与措施··················（1）

2.围手术期管理标准与措施····················（1）3.输血与药物管理标准与措施··················（1）4.有创诊疗操作管理标准与措施················（1）

5.“三基”培训及考核制度····················（1）6.患者安全目标······························（1）

十二、医疗技术管理··························（1）1.医疗技术管理·····························（1）

2.医疗分类管理·····························（1）3.医疗分级管理·····························（1）

十三、临床路径与单病种质量管理与持续改进（可选，县医院为必选）··································（1）1.单病种质量指标信息台账··················（1）

十四、住院诊疗管理与持续改进···············（1）1.肠道外营养疗法的规范或指南···············（1）

2.激素类药物的制度·························（1）3.血液制剂类制度···························（1）4.出院指导与随访工作管理相关制度和要求·····（1）5.市县级医院常见肿瘤规范化诊疗指南（试行）··（1）

十五、手术治疗管理与持续改进···············（1）1.手术医师资格分级授权管理制度与程序······································（1）

2.手术医师能力评价与再授权的制度与程序······································（1）