酒泉市人民医院

酒泉市人民医院 酒泉市人民医院 ,陆兴蓉 党委书记, 2009年上半年落实酒泉市卫生工作重点情况的汇报 2009年上半年在市委、市政府的正确领导下～在市卫生局的具体帮助指导下～认真学习贯彻党的十七大精神～学习实践科学发展观～以全国卫生工作会议精神和省、市卫生工作会议精神为重点～坚持抓好项目建设,抓好公共卫生管理工作,抓好中医药建设工作,抓好重大传染性疾病和流行性疾病的防控～进一步提高应对突发灾害事件的监测、预警、处臵能力～整合社区卫生服务资源～进一步完善社区卫生服务工作～坚持不懈地抓好医疗服务～继续开展“医院医疗质量、医疗安全管理年”活动～持续保持三甲医院服务水平～为创建平安医院、确保安全的诊疗环境～落实各项扶贫济困政策～积极推进医院科学化、规范化管理～做出了积极努力～较好地完成了2009年上半年卫生工作任务。 一、落实卫生工作目标责任书～圆满完成上半年工作任务。 credit management: clear conditions and requirements for loan extension. (10) recovery and disposal: 1 term in a year (including) within the loan, in addition to the monthly interest payment, due in principal repayment options, you can also select a matching service, equal principal repayment method; 2, Client Manager after receiving and reviewing early repayment of the application shall be submitted to the head of the Marketing Department for review, processing through the examination and approval procedures of repayment. (11) defined the offence. Third, in case of problems during the implementation process, please contact Head division. Annex: qilu Bank personal loans guaranteed management qilu Bank b o February 1, 11 key words: retail banking guarantee loan management of qilu Bank's Office issued on February 1, 2011 Proofreading: Liu Debao Annex: qilu Bank personal loans guaranteed Management chapter I General provisions article to promote personal loans guaranteed business development, standardized lending practices, according to the People's Republic of China on commercial banks and the China Banking Regulatory Commission and other laws and regulations of the interim measures for the administration of personal loans, these measures are formulated. Individual guarantee article II is a natural or legal person units to provide security for the loan, granted 截至6月底完成经济总收入:6553.2万元(财政510万),药品收入:2095.3 万元,占总收入的 34.26 %,与上年比较下降了0.09 %。医疗服务收入3896.1万元 ,占总收入的63.18 %,与上年度(62.8)比较增长了0.38%;其他收入548万元,百元业务收入的业务支出为90.4元～资产负债率为36.53%,固定资产增长率74.62 %,净资产增长率29.86%～固定资产收益率61.38～总支出:6031.3万元。 2009年上半年医院完成门诊量130053人～门诊平均诊疗费58元～出院病人数8755次～平均住院费5080元;出入院诊断符合率98%,床位使用率78.85%～病人平均住院日9.87天,医院感染率?2%～传染病上报率100%,无菌切口感染率0%,产妇死亡率0,住院病人死亡率 1.54%,活产婴儿死亡率0,临床诊断与病理诊断符合率90.50%,护理文书书写合格率99.6%～无菌物品消毒灭菌合格率100%～急救物品合格率100%～护理技术操作合格率91.35%。用以还贷外国政府贷款～目前还贷21万美元～还有27.3万美元～于2014年底全部结清。 二、紧扣《卫生工作目标责任书》内容～巩固三甲医院成果～全面提升医疗质量。 2009年上半年医院把医疗质量和医疗安全工作作为主线贯穿在医院工作的始终～召开三次专题会议研究部署“医院管理年”活动～成立了由医院领导班子成员担任各管理组组长～行政职能科室主任具体督办的医院管理年活动领导小组～完善了“医院管理年”活动。为强化质量管理意识～医院每月定期召开全院科主任、护士长、二级医师大会～从医疗安全与服务主体抓起～强化全员参与意识,坚持自查自纠、自我整改相结合～在全院开展医疗安全与“三级三严”业务查房与技术比武活动～规范了查房程序与急救技能～提高业务查房的内涵～提高了年轻医生的诊疗急救水平。二是规范了执业行为。为全面提高医疗质量～严格执行医疗卫生管理法规和规章制度～使整个医护过程做到了依法执业、规范执业～保护了患者的基本权益。三是加大了中层管理人员职责和责任追究～明确了领导班子成员是医院质量credit management: clear conditions and requirements for loan extension. (10) recovery and disposal: 1 term in a year (including) within the loan, in addition to the monthly interest payment, due in principal repayment options, you can also select a matching service, equal principal repayment method; 2, Client Manager after receiving and reviewing early repayment of the application shall be submitted to the head of the Marketing Department for review, processing through the examination and approval procedures of repayment. (11) defined the offence. Third, in case of problems during the implementation process, please contact Head division. Annex: qilu Bank personal loans guaranteed management qilu Bank b o February 1, 11 key words: retail banking guarantee loan management of qilu Bank's Office issued on February 1, 2011 Proofreading: Liu Debao Annex: qilu Bank personal loans guaranteed Management chapter I General provisions article to promote personal loans guaranteed business development, standardized lending practices, according to the People's Republic of China on commercial banks and the China Banking Regulatory Commission and other laws and regulations of the interim measures for the administration of personal loans, these measures are formulated. Individual guarantee article II is a natural or legal person units to provide security for the loan, granted 安全管理的第一责任人～医院领导定期研究确保医疗质量、医疗安全的措施会议～确定每月重点工作～组织经常性的监督检查～并针对存在的问题落实改进意见和措施～全年没有发生重大的医疗安全事故。四是组织全院科主任、护士长和职工认真学习了十三项重要的核心医疗制度和《执业医师法》、《医疗机构管理条例》《护士管理办法》、《传染病防治法》、《献血法》、《医师外出会诊管理暂行规定》等有关卫生法律法规～并针对外地出现的医疗问题～进一步完善了本院的医疗质量～制定下发了《酒泉市医院临床检验标本采集、收取结果报告管理及实施细则》,《酒泉市医院病历质量及病案管理规定》,《酒泉市医院医疗质量评价体系试行方案》,各科利用晨会交班组织工作人员学习相关法律知识与岗位职责及制度～通过学习增强了全院职工的守法意识。五是加强了医疗技术准入管理～严格执行医务人员准入制度～维护患者安全。医院先后制定下发了《医院新技术与新业务管理办法》～《植入性医疗器械监督管理暂行规定》～严格对大型医疗设备、器官移植、介入技术、人工关节等高新技术的准入及临床应用管理。医院无非法聘用医务人员及聘用无资质人员现象。对来院三年以上仍未取得执业证书者人员进行了清理。对目前未取得执业资格的医护人员,主要是近两年毕业学生,加以整顿～督促学习～尽快取得执业资格～并在老师的带教下进行工作。六是加强医院对外医疗广告宣传管理～正确引导患者就医治病。并严格按照卫生部《医疗广告管理办法》～严把审查关。严把广告宣传关～杜绝夸大、虚假、违法内容～做到了正确引导患者～诚信执业。七是认真贯彻落实《医疗机构管理条例》～全院没有对外出租承包科室或开展各种非法医疗活动～各科开展的新业务报医教部备案～并建立了医疗风险评估专家小组专门对风险较大的手术及新业务进行评估并报卫生局批准。对外邀请专家来院会诊、手术、讲学进行备案、审查。八是落实三级医师负责制～改变两级医师负责制的诊疗模式～实行24小时二级医师负责制～提高诊疗水平～更好的为患者服务。对年轻医生进行了查房质量现场指导检查带教工作。规范了临床科主任、二级医师查房模式～提高了医疗教学和查房的质量。九是根据甘肃省医院管理学会编写的《病历书写规范》标准～对病历的内容和格式进行补充完善～credit management: clear conditions and requirements for loan extension. (10) recovery and disposal: 1 term in a year (including) within the loan, in addition to the monthly interest payment, due in principal repayment options, you can also select a matching service, equal principal repayment method; 2, Client Manager after receiving and reviewing early repayment of the application shall be submitted to the head of the Marketing Department for review, processing through the examination and approval procedures of repayment. (11) defined the offence. Third, in case of problems during the implementation process, please contact Head division. Annex: qilu Bank personal loans guaranteed management qilu Bank b o February 1, 11 key words: retail banking guarantee loan management of qilu Bank's Office issued on February 1, 2011 Proofreading: Liu Debao Annex: qilu Bank personal loans guaranteed Management chapter I General provisions article to promote personal loans guaranteed business development, standardized lending practices, according to the People's Republic of China on commercial banks and the China Banking Regulatory Commission and other laws and regulations of the interim measures for the administration of personal loans, these measures are formulated. Individual guarantee article II is a natural or legal person units to provide security for the loan, granted 并严格按照标准书写～对病历实行三级审查制～加强了病历归档与检查考评处罚力度～甲级病案率达到98%～无丙级病历。十是进一步强化首诊负责制、三级医师查房制度、疑难病例讨论制度、会诊制度、危重症患者抢救制度、术前讨论制度、死亡病历讨论制度、查对制度、病历书写基本规范、交接班制度、技术准入制度～力求做到人人知晓～落实到位。完善了《医疗风险评估制度》、《省内专家联系制度》～进一步规范了请示汇报制度～加强了住院病人和新业务开展的风险评估～有力地促进了医疗质量和医疗安全性的提升。十一是合理检查、合理用药～因病施治。根据患者病情需要实施检查～控制不必要的大型检查～按照安全、有效的原则选择用药～尽量为患者选择同类低价药品～并按照上级要求进行药品跟标及降价。切实减轻患者的负担。严格执行《处方管理办法》～进一步加强处方规范化管理～开展处方点评工作。利用“临床用药管理组”、“医院临床药学室”～每月抽查病人用药情况～实施抗菌药物用量动态监测～对过度使用抗菌药物的行为及时予以干预～并通过《医院药讯》及时通报有关情况。十二是强化“三基三严”训练～按照《医师定期考核管理办法》～对全院医疗、医技人员、护理人员进行“三基、三严”培训和考试～以选拔全省医疗护理技能大赛选手为契机开展全院性的技术练兵活动～通过层层选拔～专门培训～个别辅导等措施，提高了全院医务人员基本技能和基础水平～引发了新一轮学习业务技能的热情～造就了浓郁的学习氛围。十三是加强质量管理～确保医疗安全。继续实行医疗质量管理考核与绩效工资挂钩制度～每月重点检查门、急诊质量、会诊、抢救、处方、病历、术前讨论及操作流程～在初始质量监控上由科室对每个岗位及每个人员进行考评,在环节质量监控上由医教部、护理部以日检查、夜查房等形式强化医疗质量安全管理,在终末质量控制上由主管业务领导对医教部、护理部、医院感染进行督促～确保质量管理落到实处。十四是加强了急危重症患者的管理～提高急危重症患者抢救成功率。目前医院急救中心专业设臵合理～人员配臵结构和数量合理～急诊、会诊到位迅速～常用急救药品和器械完好率100%～入院、手术“绿色通道”畅通。上半年出诊2100多次～抢救成功率98%。 credit management: clear conditions and requirements for loan extension. (10) recovery and disposal: 1 term in a year (including) within the loan, in addition to the monthly interest payment, due in principal repayment options, you can also select a matching service, equal principal repayment method; 2, Client Manager after receiving and reviewing early repayment of the application shall be submitted to the head of the Marketing Department for review, processing through the examination and approval procedures of repayment. (11) defined the offence. Third, in case of problems during the implementation process, please contact Head division. Annex: qilu Bank personal loans guaranteed management qilu Bank b o February 1, 11 key words: retail banking guarantee loan management of qilu Bank's Office issued on February 1, 2011 Proofreading: Liu Debao Annex: qilu Bank personal loans guaranteed Management chapter I General provisions article to promote personal loans guaranteed business development, standardized lending practices, according to the People's Republic of China on commercial banks and the China Banking Regulatory Commission and other laws and regulations of the interim measures for the administration of personal loans, these measures are formulated. Individual guarantee article II is a natural or legal person units to provide security for the loan, granted 十五是认真落实《医疗机构临床实验室管理办法》～认真开展临床实验室室内质量控制～临床实验室室间质量评价～所抽项目全部合格。加强临床科室合理用血～保证血液安全～无非法自采血、自供血液情况～全院成份输血比例达95.7%以上。十六是认真落实国家关于发展中医药事业的精神～参加了全省开展的名中评选活动～并按计划向省厅推选多批医生参加全省“西学中”和中医师培训活动～通过对中医学科人才的重视和培养～加大我院中医专科事业的发展进步,明确重点工作任务～抓好党务、院务公开工作～制定下发了党务、院务公开工作实施意见～明确界定了公开的范围和重点～增强了医院工作的透明度～多渠道强化和规范了各项监督机制～使院务公开落到了实处。做好医院信息交流～增强医院凝聚力～塑造医院良好形象。采取多渠道、多视角、直观的报道先进科室和优秀个人。同时积极宣传科室新技术、新业务～为新人搭建展示个人才能的舞台～有力地促进了医院业务发展建设。已发行院报4期～3200余份～文稿60余篇～在《酒泉日报》、《飞天周刊》上开设“天使情怀”专题～对重点科室、名医名家进行了宣传。上报卫生信息38篇,院内网站编辑供稿70余篇～较好地宣传了医院～扩大了医院的知名度和影响力～受到了社会各界的好评。在全院开展人文关怀教育～以体会患者之心～体恤患者之痛～树立医苑风范之德教育职工爱心对待患者～珍惜工作岗位～以精湛的技术为患者服务～举办了全院职工感恩教育演讲会～人文医学教育培训～科学发展观实践活动演讲会～激发了全院职工爱岗敬业的热情。 三、加强护理质量管理～努力提高护理水平。 在临床护理中始终贯穿“以病人为中心”的服务理念～正确实施护理措施～密切观察患者病情变化～为患者提供基本生活护理服务～提供康复和健康指导。根据各专科特色～制定疑难、危重病人护理计划、健康教育计划～危重患者护送流程～修订完善了护理病历～简化了书写程序～把重点放在护理病人上。为严格控制护理质量～每周组织一次护士长会议～每月组织一次全院护理业务查房～每季度组织一次危重、疑难护理病例讨论。认真落实三查七对制度～强化护理人员credit management: clear conditions and requirements for loan extension. (10) recovery and disposal: 1 term in a year (including) within the loan, in addition to the monthly interest payment, due in principal repayment options, you can also select a matching service, equal principal repayment method; 2, Client Manager after receiving and reviewing early repayment of the application shall be submitted to the head of the Marketing Department for review, processing through the examination and approval procedures of repayment. (11) defined the offence. Third, in case of problems during the implementation process, please contact Head division. Annex: qilu Bank personal loans guaranteed management qilu Bank b o February 1, 11 key words: retail banking guarantee loan management of qilu Bank's Office issued on February 1, 2011 Proofreading: Liu Debao Annex: qilu Bank personal loans guaranteed Management chapter I General provisions article to promote personal loans guaranteed business development, standardized lending practices, according to the People's Republic of China on commercial banks and the China Banking Regulatory Commission and other laws and regulations of the interim measures for the administration of personal loans, these measures are formulated. Individual guarantee article II is a natural or legal person units to provide security for the loan, granted 的培训考核力度～并以全省护理技术比武为契机～在全院掀起了技术比武热潮～选拔优秀护理人员参赛。“5.12”护士节在卫生局领导的积极参与下～举办了形式多样的庆典活动～以多种形式激发白衣天使无私奉献、爱岗敬业的高尚职业道德～收到了很好的活动效果。 四、加强科研教育与教学管理工作～不断提升三级甲等医院的档次。 主办了“糖尿病治疗新进展培训班”及“耳鼻喉疾病诊疗新进展培训班”。外请专家90余人次来我院进行指导、会诊、手术。积极组织实施甘肃省“万名医师支援农村卫生工程”～共派16人赴肃北、阿克塞开展卫生支农工作～全面落实对阿克塞县医院的帮扶任务。 全院组织医疗、医技人员业务学习8次～外请专家讲座2次～新业务介绍会1次。组织全院病例讨论8次～联科病例讨论42次。继续开展“两段式教学”工作。改进教学质量～在教学场地、教学用具、学生食宿、教学时间等有关环节给予保障～保证了“两段式”教学工作的顺利实施～教学管理、教学水平得到了进一步提高。 做好实习、进修人员管理。全年共接受实习生98人～接受下级医院进修医生25人～在入科前均进行了岗前培训～并按照实习、进修计划要求～分专业、类别及层次安排了轮转～集中授课22次～并组织实习、进修人员参加医院组织的继续教育学习班、院内业务学习、病例讨论、专家讲座等～每月两次对实习、进修人员在岗、学习情况及住宿进行检查～严格请销假制度的落实～做好实习、进修人员在院期间的管理和转科鉴定工作。并将教学工作纳入科室及科主任考核～保证了教学工作的顺利开展。 为进一步加强科研管理工作～组织申报了2009年度科学研究立项19项,申报2008年酒泉市科技进步奖项目18项。 五、规范医疗事故处理～加强医院感染管理。 credit management: clear conditions and requirements for loan extension. (10) recovery and disposal: 1 term in a year (including) within the loan, in addition to the monthly interest payment, due in principal repayment options, you can also select a matching service, equal principal repayment method; 2, Client Manager after receiving and reviewing early repayment of the application shall be submitted to the head of the Marketing Department for review, processing through the examination and approval procedures of repayment. (11) defined the offence. Third, in case of problems during the implementation process, please contact Head division. Annex: qilu Bank personal loans guaranteed management qilu Bank b o February 1, 11 key words: retail banking guarantee loan management of qilu Bank's Office issued on February 1, 2011 Proofreading: Liu Debao Annex: qilu Bank personal loans guaranteed Management chapter I General provisions article to promote personal loans guaranteed business development, standardized lending practices, according to the People's Republic of China on commercial banks and the China Banking Regulatory Commission and other laws and regulations of the interim measures for the administration of personal loans, these measures are formulated. Individual guarantee article II is a natural or legal person units to provide security for the loan, granted 对2007-2009年以来发生的医疗纠纷进行整理汇总～分析总结了工作中的不足和缺陷～制定了防范医疗事故发生预案和医疗事故报告制度。做到了及时报告～及时处理。 认真执行《医院感染管理规范》及医院感染管理的有关规定。对重点部门如口腔科、手术室、导管室、新生儿病房、内窥镜室、血液透析室、ICU、感染科、供应室、检验科等做好消毒、隔离和医疗废物的管理～加大检查考核的力度～并及时上报～做到有效控制和预防医院感染～医院感染率控制在2-10%以内。修订和完善了《酒泉市人民医院感染管理规范和标准》、《酒泉市人民医院感染检查评分标准》。医院感染科按照感染管理规范和标准～对全院感染发病情况进行监测～根据医院感染检查评分标准进行采样、分析～并将结果向临床科室反馈并与绩效挂钩～医院感染发病情况监测表及时上报～上报率80%。 为了有效缓解城市低收入人群、农村生活困难人群等弱势群体的看病贵、看不起问题～医院积极贯彻执行酒泉市委、市政府和市卫生局关于设立酒泉市医院仁和社区服务中心、酒泉市济困医院的指示精神～按照医用房设臵标准～在仁和社区改造济困医院～医院床位设臵80张、收费标准、卫生标准全部符合酒泉市困难群体医疗收费标准～并已正式运营八个月～收治各类社区困难病人508人～完成各种治疗12280,进行社区宣教6次,免疫接种282人,一类疫苗接种220人～二类疫苗60人。减免费用211459元。 六、进一步扩大院务公开内容。 严格执行国家有关药品、设备、医用耗材集中招标采购规定和省、市医疗服务收费价格。审计科按照医院安排～对全院临床医技科室的收费情况进行了自查～基本没有自立项目收费情况。杜绝了擅自设立新的收费项目～分解收费、比照收费和重复收费情况的发生。建立信息公示制度～向社会公开收费项目和标准～拓宽社会监督渠道。在门诊挂号处、住院处公布药品、各种检查收费标准～在各病区张贴《酒泉市医院医疗服务价格公示》～利用电子显示屏、触摸屏等方式credit management: clear conditions and requirements for loan extension. (10) recovery and disposal: 1 term in a year (including) within the loan, in addition to the monthly interest payment, due in principal repayment options, you can also select a matching service, equal principal repayment method; 2, Client Manager after receiving and reviewing early repayment of the application shall be submitted to the head of the Marketing Department for review, processing through the examination and approval procedures of repayment. (11) defined the offence. Third, in case of problems during the implementation process, please contact Head division. Annex: qilu Bank personal loans guaranteed management qilu Bank b o February 1, 11 key words: retail banking guarantee loan management of qilu Bank's Office issued on February 1, 2011 Proofreading: Liu Debao Annex: qilu Bank personal loans guaranteed Management chapter I General provisions article to promote personal loans guaranteed business development, standardized lending practices, according to the People's Republic of China on commercial banks and the China Banking Regulatory Commission and other laws and regulations of the interim measures for the administration of personal loans, these measures are formulated. Individual guarantee article II is a natural or legal person units to provide security for the loan, granted 进行了医疗价格公示,利用半年时间对医院微机网络系统进行升级改造～使住院、门诊化价收费程序、办公系统更趋科学化、智能化。完善住院患者费用一日清制度～完善患者价格咨询和费用查询～出院提供详细的总费用清单～接受人民群众的监督。院务进一步公开～制定下发了《酒泉市医院院务公开实施方案》～对医院医疗服务等十个方面、61项内容全部公开。重大经济事项实行领导负责制及责任追究制～分清级次～责任到人。向社会公布投诉电话及设立意见箱～定期召开社会监督员座谈会～发放意见表～接受社会与病人的监督。财务实行统一领导、集中管理的原则～部门、科室没有私自设立“帐外帐”、“小金库”情况。并被市政府推荐为“院务公开”先进单位。 七、加强党风廉政建设～积极抓好治理商业贿赂工作。 医院党委利用中心组学习、支部组织生活、科室会议等组织党员、干部、职工认真学习领会中央、省、市纪委会议精神及有关文件精神～认真学习贯彻落实科学发观的教育实践活动～即“学习与实践活动相结合,与解决工作中的实际问题相结合,与监督制约机制相结合的要求”～紧密联系实际～组织党员干部及职工在思想、学习、工作等方面～深入开展学习实践科学发展观的主题教育活动。首先在全院集中开展人文医学教育,目前进行了十四期～培训人员400多名。其次～对照党风廉政建设目标管理责任书要求～对医院物资采购程序及环节进行规范～对各种物资的购货渠道、招标程序、管理办法进行认真的摸底排查～进一步规范了医院卫生耗材、器械、物资管理采购程序～杜绝了管理工作中出现的漏洞～保证国家和医院的公共财产和利益不受损失。并于近期多次召开了固定资产委员会、高值易耗品采购会议～在已有的《医院药械后勤物资招标采购管理办法》、《医疗设备购臵审批使用管理办法》、《高值易耗卫生材料管理办法》、《医疗设备使用报损管理办法》基础上～进一步规范医院物资采购的制约机制～从机制上、体制上、制度上健全了监督制约机制～从源头上杜绝了物资采购上的不规范、不廉洁行为～从而使医院物资采购工作更加科学化、规范化、制度化。 credit management: clear conditions and requirements for loan extension. (10) recovery and disposal: 1 term in a year (including) within the loan, in addition to the monthly interest payment, due in principal repayment options, you can also select a matching service, equal principal repayment method; 2, Client Manager after receiving and reviewing early repayment of the application shall be submitted to the head of the Marketing Department for review, processing through the examination and approval procedures of repayment. (11) defined the offence. Third, in case of problems during the implementation process, please contact Head division. Annex: qilu Bank personal loans guaranteed management qilu Bank b o February 1, 11 key words: retail banking guarantee loan management of qilu Bank's Office issued on February 1, 2011 Proofreading: Liu Debao Annex: qilu Bank personal loans guaranteed Management chapter I General provisions article to promote personal loans guaranteed business development, standardized lending practices, according to the People's Republic of China on commercial banks and the China Banking Regulatory Commission and other laws and regulations of the interim measures for the administration of personal loans, these measures are formulated. Individual guarantee article II is a natural or legal person units to provide security for the loan, granted 八、狠抓医德医风～树立白衣天使的良好形象。 大力弘扬白求恩精神～以模范先进事迹教育广大职工～发扬救死扶伤、治病救人的优良传统～树立良好的医德医风～使患者能够享受到满意的医疗服务。 1、继续以维护人民群众根本利益为目的～坚持“标本兼职～纠建并举”的方针～以规范诊疗行为～提高医疗质量改善服务态度为主要内容～以治理“回扣”、“红包”、开单提成、大处方、乱收费为重点～强化教育、完善制度、端正工作态度、增强服务意识、提高医疗服务质量～认真解决医务人员在思想、组织、作风以及工作方面的问题～不断增强职工队伍的创造力、凝聚力和战斗力。 2、严格执行医德考评制度～加强医德医风教育、纪律教育和法制教育～加强病员回访工作制度的落实～认真处理群众投诉、举报～严肃查处损害集体、群众利益的行为。加大了对患者及其家属征求意见的力度～每月一次的发放征求意见表～每月一次召开病人座谈会～及时对发现的问题即知即改～出院病人随访率达到85%以上～满意率达到96.3%～职工满意率98%以上～40多位患者赠送感谢信或锦旗。 九、抓好精神文明、综合治理和工青妇、老干部工作 加强医院综合治理管理工作～为患者创造和谐的就医环境。在强化科室管理落实目标管理责任制考核的同时～进一步加大了月检查考核力度～上半年内没有发生任何安全责任事故。加强对工、青、妇组织的领导～落实职工代表大会～提出的良好意见和建议～保障职工各项权益不受侵害。开展丰富多彩的职工篮球比赛～增强医院的凝聚力、向心力。通过医教部、护理部组织的岗位练兵、技术比武活动。工会、共青团组织举办“三八”拔河比赛、“5.4”、“5.12”庆祝活动～专家义诊等活动～丰富了医院文化内涵～凝聚了爱岗敬业、团结奉献的医院精神。 credit management: clear conditions and requirements for loan extension. (10) recovery and disposal: 1 term in a year (including) within the loan, in addition to the monthly interest payment, due in principal repayment options, you can also select a matching service, equal principal repayment method; 2, Client Manager after receiving and reviewing early repayment of the application shall be submitted to the head of the Marketing Department for review, processing through the examination and approval procedures of repayment. (11) defined the offence. Third, in case of problems during the implementation process, please contact Head division. Annex: qilu Bank personal loans guaranteed management qilu Bank b o February 1, 11 key words: retail banking guarantee loan management of qilu Bank's Office issued on February 1, 2011 Proofreading: Liu Debao Annex: qilu Bank personal loans guaranteed Management chapter I General provisions article to promote personal loans guaranteed business development, standardized lending practices, according to the People's Republic of China on commercial banks and the China Banking Regulatory Commission and other laws and regulations of the interim measures for the administration of personal loans, these measures are formulated. Individual guarantee article II is a natural or legal person units to provide security for the loan, granted 十、严格药械管理～改善医院诊疗环境、优质、高效、低耗做好后勤保障。 严格药械物资的管理～优质、高效、低耗地做好后勤保障。上半年～总务科安全地完成了供水供电任务～无事故发生。在项目建设上～医院通过各方考查～院务委员会论证～借贷投资7000多万元修建31500平方米的门,急,诊大楼～前期准备工作已经完成～目前已经进行地基开挖～计划2012年完工并投入使用。在实施以上重点计划方面～均实行周汇报月跟踪制度～如门诊大楼修建,仁和卫生社区建设,医疗质量和医疗安全督查工作,中医药建设等全部列入重点的紧迫完成项目～通过院科两级强化落实～保证了的顺利完成～今后还将继续努力奋斗。 十一、目前存在和需解决的问题 ,一,医务科 1、医技科室医疗质量评价体系未完全落实。 2、进一步加强三基三严训练～以提高危重患者抢救成功率。 ,二,急救中心 1、设备方面:急需争取政府支持～配臵呼吸机、血气分析仪等设备以满足突发事件和正常病人抢救需要。 2、医护人员紧张。部分医师需要进行急诊医学进修学习。 ,三,ICU病房布局欠合理～特殊病感染病人不能与其他病人分开～没有完全达到ICU病房设计要求和院内感染控制的要求。个别医护人员正在考取上岗证～因资质问题～工作中存在安全隐患。 3、护理人员不足没有达到床位配臵要求。 credit management: clear conditions and requirements for loan extension. (10) recovery and disposal: 1 term in a year (including) within the loan, in addition to the monthly interest payment, due in principal repayment options, you can also select a matching service, equal principal repayment method; 2, Client Manager after receiving and reviewing early repayment of the application shall be submitted to the head of the Marketing Department for review, processing through the examination and approval procedures of repayment. (11) defined the offence. Third, in case of problems during the implementation process, please contact Head division. Annex: qilu Bank personal loans guaranteed management qilu Bank b o February 1, 11 key words: retail banking guarantee loan management of qilu Bank's Office issued on February 1, 2011 Proofreading: Liu Debao Annex: qilu Bank personal loans guaranteed Management chapter I General provisions article to promote personal loans guaranteed business development, standardized lending practices, according to the People's Republic of China on commercial banks and the China Banking Regulatory Commission and other laws and regulations of the interim measures for the administration of personal loans, these measures are formulated. Individual guarantee article II is a natural or legal person units to provide security for the loan, granted ,四,血液透析室:透析机不够～现有2台用于普通病人。根据卫生部通知要求～乙肝病人必需专机透析～目前乙肝患者和丙肝患者无机透析～存在交叉感染的危险。 ,五,新生儿病房～根据三甲医院要求～目前还缺少以下设施:新生儿呼吸机,CPAP,一台,新生儿气管插管用全套设备: ,六,手术麻醉科～基础设施:如麻醉机、监护仪、呼吸机需更新,疼痛门诊及病房是三级甲等医院所需项目～现在人员不够。 今后我们还将继续提高全院职工的综合水平与医务人员的业务素质～更进一步地改善医患关系～进一步提高医务人员应对各种突发事件的救治防控水平～更进一步地提升三级的医院医疗、急救、预防、科研教学水平。 关于二00九年卫生工作目标管理责任书 任务落实情况汇报 ,医教部, 根据酒市医发【2009】51号《关于二00九年卫生工作目标管理责任书任务分解表的通知》要求～现将医教部工作任务完成汇报如下: 一、健全各项规章制度～明确岗位现职～科室工作年有计划～月有重点～周有安排～每月有检查反馈。 二、在落实十三项核心医疗制度的基础上～进一步完善医疗质量管理制度: 1. 制定下发《酒泉市医院临床检验标本采集、收取结果报 告管理及实施细则》,酒市医发【2009】31号文件, credit management: clear conditions and requirements for loan extension. (10) recovery and disposal: 1 term in a year (including) within the loan, in addition to the monthly interest payment, due in principal repayment options, you can also select a matching service, equal principal repayment method; 2, Client Manager after receiving and reviewing early repayment of the application shall be submitted to the head of the Marketing Department for review, processing through the examination and approval procedures of repayment. (11) defined the offence. Third, in case of problems during the implementation process, please contact Head division. Annex: qilu Bank personal loans guaranteed management qilu Bank b o February 1, 11 key words: retail banking guarantee loan management of qilu Bank's Office issued on February 1, 2011 Proofreading: Liu Debao Annex: qilu Bank personal loans guaranteed Management chapter I General provisions article to promote personal loans guaranteed business development, standardized lending practices, according to the People's Republic of China on commercial banks and the China Banking Regulatory Commission and other laws and regulations of the interim measures for the administration of personal loans, these measures are formulated. Individual guarantee article II is a natural or legal person units to provide security for the loan, granted 2. 制定下发《酒泉市医院病历质量及病案管理规定》,酒 市医发【2009】34号文件, 3. 制定下发《酒泉市医院医疗质量评价体系试行方案》,酒 市医发【2009】56号文件, 三、按照以医疗质量、医疗安全为重点的专项活动实施方案～对临床科室医疗质量做了如下管理: 1. 病历书写质量:病历严格按照《病历书写规范》按时书 写～及时打印。 2. 严格交接班制度～落实首诊医师负责制:要求各科室必 须由有执业证和处方权的医师值班～无执业证和处方权的医师 不能单独值班。 3. 要求各科室认真学习落实《酒泉市人民医院关于开展以 病人为中心以医疗质量医疗安全为重点的专项活动实施方案》 和《酒泉市医院医疗质量评价体系试行方案》的有关内容。 4. 会诊:甚急会诊必须随叫随到～不得超过5分钟,急会 诊必须在15分钟内到场～平会诊不得超过24小时。会诊人员 必须符合会诊资质。 四、对医疗质量评价体系要求的14项内容～通过多种方式对全院医疗质量医疗安全进行督查: 1、每月组织质控老专家对各科室在院病历书写质量进行监控。 2、医教部每周带领临床科主任及二级医师进行夜查房～对会诊质量、有创性诊疗操作质量、知情谈话、手术质量、危重病人抢救等考核内容进行检查。 credit management: clear conditions and requirements for loan extension. (10) recovery and disposal: 1 term in a year (including) within the loan, in addition to the monthly interest payment, due in principal repayment options, you can also select a matching service, equal principal repayment method; 2, Client Manager after receiving and reviewing early repayment of the application shall be submitted to the head of the Marketing Department for review, processing through the examination and approval procedures of repayment. (11) defined the offence. Third, in case of problems during the implementation process, please contact Head division. Annex: qilu Bank personal loans guaranteed management qilu Bank b o February 1, 11 key words: retail banking guarantee loan management of qilu Bank's Office issued on February 1, 2011 Proofreading: Liu Debao Annex: qilu Bank personal loans guaranteed Management chapter I General provisions article to promote personal loans guaranteed business development, standardized lending practices, according to the People's Republic of China on commercial banks and the China Banking Regulatory Commission and other laws and regulations of the interim measures for the administration of personal loans, these measures are formulated. Individual guarantee article II is a natural or legal person units to provide security for the loan, granted 3、把三级查房质量列入科主任、二级医师考核。对疑难危重病例、联科病例讨论～要求先由科主任、二级医师主持在科室内讨论～然后提交全院讨论～以提高讨论质量。 4、全院业务学习按计划定期进行～近期传染病疫情先后多次进行了甲型H1N1流感、手足口病、鼠疫等传染病知识的培训、演练、考试等～同时要求各科室根据专业特点学习相关新业务、新知识、新技术。 5、加强单病种和各科室常见病多发病的质控管理。收集全院37个专业41个病种的诊疗规范～正在整理审核准备近期全院下发执行。 五、积极参加卫生厅组织的病历展评活动。各临床科室由科主任严格把关～科室内选出一份优秀病历～全院共22份～经病案委员会成员评选、质控老专家从中选出了10份优秀病历参加全省病历质量点评及评比活动。评比结果待反馈。 六、强三基三严训练～参加三基比武活动 1、 院领导重视～科室紧密配合～选派了急救中心陈萍、心内科常永茂、手术麻醉科马树勇、内感染科裴雪、肿瘤科高燕于6月2-3日参加了市卫生局举办的三基三严比武竞赛活动～取得了名列前茅的好成绩。 2、 积极备战2009年8-9月甘肃省卫生厅组织的全省急救技能大比武活动。5月26-28日～医院选派急救中心王亚宏、心内科常永茂、心胸外科肖志明三人赴兰州参加了全省急救技能大比武前的规范化培训～目前三人正在强化训练中。 3、加强全院年青医师的培训～对新分配的大学生实行暂不定科室不定岗位～进行为期两年的转科学习～每2月进行一次三基考试。 六、科研教学 credit management: clear conditions and requirements for loan extension. (10) recovery and disposal: 1 term in a year (including) within the loan, in addition to the monthly interest payment, due in principal repayment options, you can also select a matching service, equal principal repayment method; 2, Client Manager after receiving and reviewing early repayment of the application shall be submitted to the head of the Marketing Department for review, processing through the examination and approval procedures of repayment. (11) defined the offence. Third, in case of problems during the implementation process, please contact Head division. Annex: qilu Bank personal loans guaranteed management qilu Bank b o February 1, 11 key words: retail banking guarantee loan management of qilu Bank's Office issued on February 1, 2011 Proofreading: Liu Debao Annex: qilu Bank personal loans guaranteed Management chapter I General provisions article to promote personal loans guaranteed business development, standardized lending practices, according to the People's Republic of China on commercial banks and the China Banking Regulatory Commission and other laws and regulations of the interim measures for the administration of personal loans, these measures are formulated. Individual guarantee article II is a natural or legal person units to provide security for the loan, granted 1、上半年外出进修10人～参加省内外学习班38人～下乡支农16人～接受下级医院来院进修学习16人。 2、加强科研工作管理～年内申报甘肃省科技支撑支撑计划项目4项～院内科研立项44项。 3、不断开展新业务新技术～加强专科业务建设～消化科为省级重点学科、麻醉科、神经内科、心外科、小儿科、妇科、产科等6个市级重点学科。 4、加强急诊急救人员业务素质培训～上半年急救人员参加外出学习培训4次共6人次～确保“120”急救绿色通道畅通。 5、继续医学教育覆盖率、验证率达100% ～通过率达100% 。 6、积极参加卫生部临床检验室间质评工作～2009年4月按照卫生厅的通知要求上报了参加室间质评的各种样本。 7、组织医务人员学习《临床输血技术规范》和《医疗机构临床用血管理办法》～保证临床用血合理、安全。 七、医疗安全管理方面 1、根据酒泉市医发[2009]51文件《关于二00九年卫生工作目标管理责任书》和医疗质量评价体系试行方案的要求～认真做好医疗安全管理工作～要求各科室对每月发生的医疗投诉和纠纷情况实行月报告、零报告制度～半年来无重大医疗责任事故发生。对个别科室发生的医疗纠纷积极协调及时处理～对重大医疗安全事故要求各科室及时上报医疗风险办公室或医教部。自文件下发后～经过督促检查～大部分科室按照规定认真执行～但也有个别科室对发生的问题不能积极主动配合处理。下一阶段将认真督促检查整改～对不重视医疗安全管理造成不良后果的科室及个人按照评价体系进行处罚。 credit management: clear conditions and requirements for loan extension. (10) recovery and disposal: 1 term in a year (including) within the loan, in addition to the monthly interest payment, due in principal repayment options, you can also select a matching service, equal principal repayment method; 2, Client Manager after receiving and reviewing early repayment of the application shall be submitted to the head of the Marketing Department for review, processing through the examination and approval procedures of repayment. (11) defined the offence. Third, in case of problems during the implementation process, please contact Head division. Annex: qilu Bank personal loans guaranteed management qilu Bank b o February 1, 11 key words: retail banking guarantee loan management of qilu Bank's Office issued on February 1, 2011 Proofreading: Liu Debao Annex: qilu Bank personal loans guaranteed Management chapter I General provisions article to promote personal loans guaranteed business development, standardized lending practices, according to the People's Republic of China on commercial banks and the China Banking Regulatory Commission and other laws and regulations of the interim measures for the administration of personal loans, these measures are formulated. Individual guarantee article II is a natural or legal person units to provide security for the loan, granted 2、加强对医护人员法律、法规知识培训～全院每半年集中培训讲座一次～到位率大于90%～近半年以来要求以科室为单位～每月至少一次法律法规、规章制度培训讲座～并有记录～同时要求各科室每月写出医疗安全分析报告～建立医疗安全管理登记制度～使大家规避医疗风险～规范医疗纠纷～法律意识大大提高～下一阶段继续做好此项工作的基础上～下科室各科检查医疗安全管理制度的落实执行情况。 八、其它 1、按时完成医疗信息上报幕工作～上半年共完成12篇。 2、加强对功能科、检验科、影像科的管理～认真落实《甘肃省禁止非医学需要鉴定的胎儿性别和选择性别终止妊娠规定》～目前院内未发现此类诊断行为。 3、严格医学鉴定程序～加强妇产科等重点科室诊断证明、医学鉴定证书的审核管理～无乱检查、乱开证、乱做鉴定现象发生。 4、完成对口帮扶工作～与阿克塞县医院签订帮扶协议～实现有计划、有目标帮扶。 七、对专项活动重点科室的管理 ,一,急救中心 1. 急救中心科室设臵、布局、流程符合三甲医院标准～其 中观察床位15张～抢救床位5张～手术床1张。抢救设备符合 三甲医院标准～,包括:呼吸机3台～除颤仪2台～气管插管 设备5套～洗胃机3台～心电图机2台～导尿包、清创缝合包 多套,。设备性能相对良好～处于备用状态。急救药品数量充 足～质量完好～放臵规范。所有急救设备及急救药品均做到每 日检查、每班次交班。 credit management: clear conditions and requirements for loan extension. (10) recovery and disposal: 1 term in a year (including) within the loan, in addition to the monthly interest payment, due in principal repayment options, you can also select a matching service, equal principal repayment method; 2, Client Manager after receiving and reviewing early repayment of the application shall be submitted to the head of the Marketing Department for review, processing through the examination and approval procedures of repayment. (11) defined the offence. Third, in case of problems during the implementation process, please contact Head division. Annex: qilu Bank personal loans guaranteed management qilu Bank b o February 1, 11 key words: retail banking guarantee loan management of qilu Bank's Office issued on February 1, 2011 Proofreading: Liu Debao Annex: qilu Bank personal loans guaranteed Management chapter I General provisions article to promote personal loans guaranteed business development, standardized lending practices, according to the People's Republic of China on commercial banks and the China Banking Regulatory Commission and other laws and regulations of the interim measures for the administration of personal loans, these measures are formulated. Individual guarantee article II is a natural or legal person units to provide security for the loan, granted 2. 全科医护人员相对固定～全科共30人～其中医生9人 ,副主任医师1人～主治医师2人～医师5人～无证1人,～ 护士16人,副主任护师1人～主治护师2人～护师4人～护士 8人～无证1人,～司机5人。医护人员熟练掌握了心肺复苏、 气管插管、呼吸机应用等抢救技术。抢救工作在科主任或主治 医师指导下～按抢救程序正确使用各种抢救设备～逐步提高了 急危重患者抢救成功率。 3. 急救抢救方案齐全～制定完善了心肺复苏、呼吸衰竭、 急性心力衰竭、休克、上消化道出血、急性有机磷农药中毒及 多发性创伤等常见急危重病的抢救流程。每周安排业务学习～ 学习掌握常见急诊诊疗规范和新进展～提高业务水平。 4. 科间紧密协作～急诊“绿色通道”畅通～认真执行首诊 医师负责制和会诊制度。 5. 加强急诊留观患者管理～急诊留观时间平均不超过72 小时。根据病历书写规范格式书写院前病历、急诊病历、留观 病历～加强落实各项告知签字制度～加强医疗争议防范意识。 ,二,ICU 1、人员情况:ICU现有医护人员21名～其中医生6名,副主任医师2名～主治医师1名～住院医师2名～,～护士15名,护师6名～护士8名,。开放床位7张～床位使用率 65.27%～床位周转率61%。 3、主要的仪器设备有:中央监护系统一套、血滤机1台、呼吸机5台～血容量监测仪1台～注射泵8台～输液泵2台～除颤仪1台～所有仪器均有专人管理～各种仪器设备运转正常。 4、收治病人的范围:各种大手术后的重症患者,需要呼吸管理和呼吸支持的患者,多器官功能衰竭的患者,重症胰腺炎、感染性休克及各种休克的病人,严重复合伤的病人和各种中毒的病人。 credit management: clear conditions and requirements for loan extension. (10) recovery and disposal: 1 term in a year (including) within the loan, in addition to the monthly interest payment, due in principal repayment options, you can also select a matching service, equal principal repayment method; 2, Client Manager after receiving and reviewing early repayment of the application shall be submitted to the head of the Marketing Department for review, processing through the examination and approval procedures of repayment. (11) defined the offence. Third, in case of problems during the implementation process, please contact Head division. Annex: qilu Bank personal loans guaranteed management qilu Bank b o February 1, 11 key words: retail banking guarantee loan management of qilu Bank's Office issued on February 1, 2011 Proofreading: Liu Debao Annex: qilu Bank personal loans guaranteed Management chapter I General provisions article to promote personal loans guaranteed business development, standardized lending practices, according to the People's Republic of China on commercial banks and the China Banking Regulatory Commission and other laws and regulations of the interim measures for the administration of personal loans, these measures are formulated. Individual guarantee article II is a natural or legal person units to provide security for the loan, granted 5、制度落实:认真学习贯彻落实十三项核心制度～并且结合科室实际情况制定了各级人员岗位职责～工作流程和《ICU院内感染暴发应急预案》、《血管内导管所致血行感染的预防》、《留臵导尿管所致感染的预防》、《呼吸机相关性肺炎的预防方案》等40多项管理制度～并组织科室人员认真学习～抓好落实。 6、业务学习:根据年初制定的学习计划～每周业务学习一次～并根据情况随时组织学习。 血液透析室: 1、血液透析室人员配备齐全～布局合理～现有护士2名,主管护师1名～护士1名,～ICU医生轮转到透析室负责透析期间患者的透析安全。 2、血透室现有透析机3台～其中一台专用于乙肝病人的透析。 3、血液透析室制定完善了各级人员的工作职责～工作流程及《血液透析室医院感染控制制度》、《血液透析室消毒隔离制度》和各种情况下的应急预案。 4、根据《血液透析室内感染管理规范》～透析室每月进行空气培养～透析液～护士的手和物表的细菌培养～经过检测均符合要求。 5、统一使用一次性管道～无重复使用现象。 ,三,儿科新生儿病房: 于2008年3月开始新生儿监护室改造、筹备工作～今年4月份正式使用以来～专业设臵、人员配备及其设备、设施符合医院功能任务要求～布局合理。 1、新生儿监护室设备基本齐全～运转正常～能满足患儿需要,先进监护仪4台、开放式抢救辐射台1台、微量注射泵14台、婴儿培credit management: clear conditions and requirements for loan extension. (10) recovery and disposal: 1 term in a year (including) within the loan, in addition to the monthly interest payment, due in principal repayment options, you can also select a matching service, equal principal repayment method; 2, Client Manager after receiving and reviewing early repayment of the application shall be submitted to the head of the Marketing Department for review, processing through the examination and approval procedures of repayment. (11) defined the offence. Third, in case of problems during the implementation process, please contact Head division. Annex: qilu Bank personal loans guaranteed management qilu Bank b o February 1, 11 key words: retail banking guarantee loan management of qilu Bank's Office issued on February 1, 2011 Proofreading: Liu Debao Annex: qilu Bank personal loans guaranteed Management chapter I General provisions article to promote personal loans guaranteed business development, standardized lending practices, according to the People's Republic of China on commercial banks and the China Banking Regulatory Commission and other laws and regulations of the interim measures for the administration of personal loans, these measures are formulated. Individual guarantee article II is a natural or legal person units to provide security for the loan, granted 养箱4台、黄疸治疗仪4台、新生儿黄疸治疗箱1台、复苏气囊及配套抢救设施2套、智能血糖仪1台等,。 2、健全了《新生儿监护室护士工作流程》。 3、对新生儿监护室实行高标准管理: 1,进入新生儿监护室前必须更换已消毒的拖鞋或穿一次性鞋套, 2,医护人员接触患儿前后必须进行手消毒处理, 3,每位患儿使用物品相对固定～奶瓶奶嘴采用1次性管理～排泄物常规进行计量登记处理, 4,专人护理。护士做好患儿的床头交接班～防止烂臀、烂裆等并发症～发生上述情况积极进行激光治疗以终止病情发展, 5,医护人员定时与家长良好沟通～做好病情反馈工作。 ,四,手术科室: 1、实行患者病情评估制度～遵循诊疗规范制定诊疗计划～根据病情变化和评估结果调整诊疗方案。 2、实行手术分级管理制度～重大手术报告、审批制度。 3、加强围手术期质量控制。 4、严格按照危重病人抢救流程～规范三级医师查房制度～提高抢救成功率～危重病人抢救成功率达83.8%。 5、提高术前诊断与病理诊断符合率。临床诊断与病理诊断符合率达90.3%。 ,五,药剂科 1. 一、抗生素合理使用 credit management: clear conditions and requirements for loan extension. (10) recovery and disposal: 1 term in a year (including) within the loan, in addition to the monthly interest payment, due in principal repayment options, you can also select a matching service, equal principal repayment method; 2, Client Manager after receiving and reviewing early repayment of the application shall be submitted to the head of the Marketing Department for review, processing through the examination and approval procedures of repayment. (11) defined the offence. Third, in case of problems during the implementation process, please contact Head division. Annex: qilu Bank personal loans guaranteed management qilu Bank b o February 1, 11 key words: retail banking guarantee loan management of qilu Bank's Office issued on February 1, 2011 Proofreading: Liu Debao Annex: qilu Bank personal loans guaranteed Management chapter I General provisions article to promote personal loans guaranteed business development, standardized lending practices, according to the People's Republic of China on commercial banks and the China Banking Regulatory Commission and other laws and regulations of the interim measures for the administration of personal loans, these measures are formulated. Individual guarantee article II is a natural or legal person units to provide security for the loan, granted 1(2006年4月医院56号文件明确规范抗生素三组分级管理办法和三线药品分类表～持续稳妥推进此项药品管理工作。 2(药剂科临床药师每月抽查30份住院病历～从五个方面分析考核杭生素的使用情况～分析情况上报医教部与考核绩效挂钧。 3(重申抗生素分级管理办法及三线管理药品 2009年2月17日～医院药事委员会专家成员对临床药学工作和合理用药进行讨论～重申抗生素分级管理办法～修订公布抗生素三线用药表～一线59种～二线28种～三线9种～并以医院文件的形式下发,酒市医发27号文件,。 4(5月4号转发卫生部办公厅关于抗菌药物临床应用有关问题的通知: ?严格控制I类切口手术预防用药。 ?严格控制氟喹诺酮类药物的应用。 ?严格控制抗菌药物分级管理制度。 ?加强临床微生物检测与细菌耐药监测～建立抗菌药物临床应用预警机制。 ?公布我院常见手术预防用抗菌药物目录。 5(处方管理 每月随机抽取门诊处方～每季度将点评结果在药讯刊登～统计全年资料～门诊处方抗生素使用率平均17.33%～每张处方平均金额64.12元。 1. 二、临床药学工作 1. 药品不良反应 credit management: clear conditions and requirements for loan extension. (10) recovery and disposal: 1 term in a year (including) within the loan, in addition to the monthly interest payment, due in principal repayment options, you can also select a matching service, equal principal repayment method; 2, Client Manager after receiving and reviewing early repayment of the application shall be submitted to the head of the Marketing Department for review, processing through the examination and approval procedures of repayment. (11) defined the offence. Third, in case of problems during the implementation process, please contact Head division. Annex: qilu Bank personal loans guaranteed management qilu Bank b o February 1, 11 key words: retail banking guarantee loan management of qilu Bank's Office issued on February 1, 2011 Proofreading: Liu Debao Annex: qilu Bank personal loans guaranteed Management chapter I General provisions article to promote personal loans guaranteed business development, standardized lending practices, according to the People's Republic of China on commercial banks and the China Banking Regulatory Commission and other laws and regulations of the interim measures for the administration of personal loans, these measures are formulated. Individual guarantee article II is a natural or legal person units to provide security for the loan, granted 医院药品不良反应组织机构健全～成员19人～专职监测联络员2人～监测信息员56人～对药品不良反应～积极收集信息～主动上报。 2. 治疗药物监测 继续与兰大二院合作开展治疗药物监测～有效指导合理用药。 3. 麻醉精神药品管理 “五专”管理:专人管理、专用帐册、专用登记、专柜加锁、专用处方。 4(6月4日医院药事委员会专家讨论重新修定公布“酒泉市医院基本药品目录”～“门诊常用药品目录”。 5(临床药师下临床～会诊讨论病历。 ,六,病理科 1. 布局、设施、设备～工作流程和人员结构基本合理。 2. 执行病理质量管理制度～定期开展质量评价和改进工 作。 3. 严格执行标本核对制度。病理报告及时、准确～每份报 告由副主任医师以上职称人员签发～冰冻切片与石蜡切片诊断 符合率大于98%～病理报告准确率大于98%。 4. 病理切片、蜡块保存符合规定。 5. 病理标本废液处理符合要求～有专项登记、记录本。 八、目前存在和需解决的问题: ,一,医务科 credit management: clear conditions and requirements for loan extension. (10) recovery and disposal: 1 term in a year (including) within the loan, in addition to the monthly interest payment, due in principal repayment options, you can also select a matching service, equal principal repayment method; 2, Client Manager after receiving and reviewing early repayment of the application shall be submitted to the head of the Marketing Department for review, processing through the examination and approval procedures of repayment. (11) defined the offence. Third, in case of problems during the implementation process, please contact Head division. Annex: qilu Bank personal loans guaranteed management qilu Bank b o February 1, 11 key words: retail banking guarantee loan management of qilu Bank's Office issued on February 1, 2011 Proofreading: Liu Debao Annex: qilu Bank personal loans guaranteed Management chapter I General provisions article to promote personal loans guaranteed business development, standardized lending practices, according to the People's Republic of China on commercial banks and the China Banking Regulatory Commission and other laws and regulations of the interim measures for the administration of personal loans, these measures are formulated. Individual guarantee article II is a natural or legal person units to provide security for the loan, granted 1、医技科室医疗质量评价体系未完全落实。 2、加强三基三严训练～以进一步提高危重患者抢救成功率。 ,二,急救中心 1、设备方面:虽然有呼吸机3台～但其中一台为车载呼吸机～两台为上世纪90年代配臵～性能落后～且时有故障～不能满足抢救需要。 2、医护人员相对紧张:虽然有医生8人,包括无证1人,～但需要同时兼顾院内急诊及院前出诊急救～人员紧张。 3、培训:医师均未进行急诊医学进修学习～需进一步培训。 ,三,ICU 1、ICU现有病房布局欠合理～特殊病感染病人不能与其他病人分开～没有完全达到ICU病房设计要求和院内感染控制的要求。 2、护理人员不足没有达到床位配臵要求。 3、根据ICU工作实际～急需配备血气分析仪一台。 4、ICU的个别医护人员无上岗证～工作中存在安全隐患～ICU的医务人员应严格执行岗位准入制度。 血液透析室: 1、透析机不够～根据卫生部通知要求～乙肝病人必需专机透析～而透析室现在只有2台透析机用于普通病人的透析～已远远不能满足日益增多的患者需要,并且目前乙肝患者和丙肝患者不能分机透析～存在交叉感染的危险～因此透析室需再增加血液透析机2台～以保证透析病人的安全。 credit management: clear conditions and requirements for loan extension. (10) recovery and disposal: 1 term in a year (including) within the loan, in addition to the monthly interest payment, due in principal repayment options, you can also select a matching service, equal principal repayment method; 2, Client Manager after receiving and reviewing early repayment of the application shall be submitted to the head of the Marketing Department for review, processing through the examination and approval procedures of repayment. (11) defined the offence. Third, in case of problems during the implementation process, please contact Head division. Annex: qilu Bank personal loans guaranteed management qilu Bank b o February 1, 11 key words: retail banking guarantee loan management of qilu Bank's Office issued on February 1, 2011 Proofreading: Liu Debao Annex: qilu Bank personal loans guaranteed Management chapter I General provisions article to promote personal loans guaranteed business development, standardized lending practices, according to the People's Republic of China on commercial banks and the China Banking Regulatory Commission and other laws and regulations of the interim measures for the administration of personal loans, these measures are formulated. Individual guarantee article II is a natural or legal person units to provide security for the loan, granted 2、按规定～透析室应每3个月查一次透析液的内毒素～在制剂室拆除之后～无法检测透析液的内毒素。 ,四,新生儿病房 根据三甲医院要求～目前还缺少以下设施: 1. 新生儿呼吸机,CPAP,一台, 2. 新生儿气管插管用全套设备: 1,喉镜1套,包括备用电池及备用灯泡各2个,, 2,镜片:1号镜片,足月儿用,～0号,早产儿用,～00号,适用于超低出生体重儿,～直镜片更好, 3,气管导管:内径为2.5mm、3.0mm、3.5mm、4.0mm, 4,金属导管芯2个, 5,低压吸引器1台, 6,10F或以上型号的吸引导管～加上5F、6F、8F气管导管吸引管, 7,胎粪吸引管。 3、其他问题: 1,人员资质问题:科室医生共8人～其中外出进修1人～下乡1人～无证2人 2,抗生素分级管理问题 ,五,手术麻醉科 credit management: clear conditions and requirements for loan extension. (10) recovery and disposal: 1 term in a year (including) within the loan, in addition to the monthly interest payment, due in principal repayment options, you can also select a matching service, equal principal repayment method; 2, Client Manager after receiving and reviewing early repayment of the application shall be submitted to the head of the Marketing Department for review, processing through the examination and approval procedures of repayment. (11) defined the offence. Third, in case of problems during the implementation process, please contact Head division. Annex: qilu Bank personal loans guaranteed management qilu Bank b o February 1, 11 key words: retail banking guarantee loan management of qilu Bank's Office issued on February 1, 2011 Proofreading: Liu Debao Annex: qilu Bank personal loans guaranteed Management chapter I General provisions article to promote personal loans guaranteed business development, standardized lending practices, according to the People's Republic of China on commercial banks and the China Banking Regulatory Commission and other laws and regulations of the interim measures for the administration of personal loans, these measures are formulated. Individual guarantee article II is a natural or legal person units to provide security for the loan, granted 1、基础设施:监护设备需更新～需先新进两台,需带呼吸末二氧化碳监护～每台约83万元,～麻醉机主要为小儿使用～需新购一台,约30万元,～麻醉恢复室是否建立～如建立～需呼吸机1台,约30万元,～监护仪1台。 2、人员方面:麻醉师今年需新增1名～如考虑建立麻醉恢复室～再增1名麻醉师～2名护士。科室制定各级医师麻醉准入事项～对新开展的技术及新方法～需在充分论证下～由科主任同意并报告医务科后再开展。 3、疼痛门诊及病房也是三级甲等医院所需项目～但现在人员不够。 ,六,病理科 空气中甲醛浓度是否符合要求～主要是无标准对照及无测量手段。 credit management: clear conditions and requirements for loan extension. (10) recovery and disposal: 1 term in a year (including) within the loan, in addition to the monthly interest payment, due in principal repayment options, you can also select a matching service, equal principal repayment method; 2, Client Manager after receiving and reviewing early repayment of the application shall be submitted to the head of the Marketing Department for review, processing through the examination and approval procedures of repayment. (11) defined the offence. Third, in case of problems during the implementation process, please contact Head division. Annex: qilu Bank personal loans guaranteed management qilu Bank b o February 1, 11 key words: retail banking guarantee loan management of qilu Bank's Office issued on February 1, 2011 Proofreading: Liu Debao Annex: qilu Bank personal loans guaranteed Management chapter I General provisions article to promote personal loans guaranteed business development, standardized lending practices, according to the People's Republic of China on commercial banks and the China Banking Regulatory Commission and other laws and regulations of the interim measures for the administration of personal loans, these measures are formulated. Individual guarantee article II is a natural or legal person units to provide security for the loan, granted