盘县人民医院创建二甲医院工作实施方案

盘县人民医院创建二甲医院工作实施方案 盘县人民医院创建二甲医院工作实施方案 为了提升医院综合竞争力，迎接贵州省综合医院等级评审，根据各项考核指标，特制本工作实施方案。 医院等级是医院功能、任务、规模和管理水平、质量水平、技术水平的综合标志，是医院综合竞争力的体现。2011年，贵州省将重新启动医院分级管理评审;我院经过多年的发展，已具备创建二甲医院的条件，从即日起正式启动创建二甲医院工作，并将向上级卫生主管部门提出将我院列入二甲医院评审 计划 项目进度计划表范例计划下载计划下载计划下载课程教学计划下载 的申请。为此，医院要求全院职工积极行动起来，围绕创建二甲医院这个中心目标，统一思想，统一认识、统一行动，团结一心，把各项工作做细、做实、做严。现结合医院具体情况，制定如下实施方案。 一、指导思想 以邓小平理论和“三个代表”重要思想为指导，全面落实科学发展观，紧密围绕医院能力建设，加强细节管理，全体动员，提高各项工作质量，推进学科建设，构建和谐医院，全面达到二级甲等医院评审新 标准 excel标准偏差excel标准偏差函数exl标准差函数国标检验抽样标准表免费下载红头文件格式标准下载 。通过二甲医院的创建与达标，进一步完善医院科学管理的长效机制，提高医院整体实力，促进医院科学发展、又好又快发展。 二、目标任务 1、通过二甲医院的创建与达标，进一步完善医院科学管理的长效机制，全面规范医院管理，统筹协调推进学科建设，建立一支医德医风好、技术精湛、服务优良的职工队伍和合理的人才梯队，提高县级医院能力建设，促进医院全面、协调、可持续发展。 supplies and get to use, the registration of company assets, record maintenance, maintenance of effective management; 2.6 cost management: preparation of the annual administrative budget, control administrative costs, determine the scope of cost-sharing, sharing the office expenses by month; 2.7 information management: responsible for documents, materials, information and publicity, communication links, and ensure promptly, ranking officers reporting; responsible for the collation and analysis of information, provide the basis for corporate decisions; corporate culture construction, planning, editing, internal publications; 2.8 vehicle management: responsible for the management, repairs and maintenance of vehicles; 2.9 legal disputes: the company responsible for the handling of disputes; 2.10 other: maintaining normal working order, and security. General Manager General Manager job description 1, 1.1 develop strategies and plans: according to company strategic planning, establish the annual management plan, reported to the Board of Directors for approval; 1.2 decomposition measures: according to the Board of Directors issued the annual management plan, annual index of decomposition, through the Organization of coordination mandate in charge of the Department Organization and implementation, ensuring comprehensive implementation of annual indicators; 1.3 inspection: convenes the General Manager Office, through 2、力争2011年年底通过省等级医院评审委员会对我院二级甲等医院的评审。 三、组织保证 1、创建工作实行主要领导挂帅、分管领导主抓，职能部门及各科室各负其责的工作责任制。 2、医院成立创建领导小组及创建办公室，全面负责创建二甲医院工作的领导、组织及协调工作。 3、创建办公室在医院创建领导小组的领导下，负责创建二甲医院的具体工作，制订全院创建实施方案、各阶段工作安排和工作要求，督促指导、检查考核创建工作，收集整理、汇总分析各类资料信息，作好上下反馈，完成创建所需的各种相关资料。 4、创建领导小组按照《贵州省城乡医院对口支援工作绩效考核指标》(试行)，认真做好各专业组创建实施、自查整改、评审迎检等工作。 5、各职能部门、各科室要克服畏难情绪，加强组织领导，明确责任分工，根据医院创建实施方案、各阶段工作安排和要求，及时进行布置、落实，认真组织学习培训，深刻领会其精神实质，加大督促指导、检查考核力度，作好资料的收集整理、建册归档工作。 6、全院各科室在医院创建领导小组的统一部署下，成立创建工作小组，在科主任和护士长(或科室负责人)的具体负责下，责任到人，有计划、有步骤地完成本科室的创建计划、医院阶段性工作安排及相关资料准备工作。 supplies and get to use, the registration of company assets, record maintenance, maintenance of effective management; 2.6 cost management: preparation of the annual administrative budget, control administrative costs, determine the scope of cost-sharing, sharing the office expenses by month; 2.7 information management: responsible for documents, materials, information and publicity, communication links, and ensure promptly, ranking officers reporting; responsible for the collation and analysis of information, provide the basis for corporate decisions; corporate culture construction, planning, editing, internal publications; 2.8 vehicle management: responsible for the management, repairs and maintenance of vehicles; 2.9 legal disputes: the company responsible for the handling of disputes; 2.10 other: maintaining normal working order, and security. General Manager General Manager job description 1, 1.1 develop strategies and plans: according to company strategic planning, establish the annual management plan, reported to the Board of Directors for approval; 1.2 decomposition measures: according to the Board of Directors issued the annual management plan, annual index of decomposition, through the Organization of coordination mandate in charge of the Department Organization and implementation, ensuring comprehensive implementation of annual indicators; 1.3 inspection: convenes the General Manager Office, through 7、全院党员、共青团员要在创建工作中起好模范带头作用，团结全院职工，为创二甲医院作出贡献。 8、根据医院阶段性工作重点，利用网站、宣传栏、医院园地等多种形式广泛宣传，层层动员，营造“人人参与创建，事事关系评审” 的创二甲浓厚氛围。 9、创建领导小组、创建办公室及各职能部门结合医院阶段性工作及具体情况，适时召开各种会议，研究分析重大事项，制定工作策略。 10、创建领导小组要适时向卫生主管部门汇报创建二甲医院的进展情况，获得支持和帮助。 四、工作步骤与要求 (一)学习动员阶段(2010年10月至2010年12月) 1、医院召开全院动员大会，宣讲创建二级甲等医院对我院生存与发展的重要性，布置实施方案、各阶段工作安排和工作要求，调动全院每一个职工的积极性，步调一致，上下齐心，通力合作，扎扎实实地做好工作。 2、组织全院干部、职工认真学习，逐条领会《贵州省城乡医院对口支援工作绩效考核指标》(试行)的目的要求，结合本院工作实际，找出差距，以便于整改。 3、各临床科室应紧密联系工作实际，认真学习《贵州省城乡医院对口支援工作绩效考核指标》(试行)，按《贵州省城乡医院对口支援工作绩效考核指标》(试行)要求，逐条落实，做好医护质量、安全及科室管理工作。 supplies and get to use, the registration of company assets, record maintenance, maintenance of effective management; 2.6 cost 3 management: preparation of the annual administrative budget, control administrative costs, determine the scope of cost-sharing, sharing the office expenses by month; 2.7 information management: responsible for documents, materials, information and publicity, communication links, and ensure promptly, ranking officers reporting; responsible for the collation and analysis of information, provide the basis for corporate decisions; corporate culture construction, planning, editing, internal publications; 2.8 vehicle management: responsible for the management, repairs and maintenance of vehicles; 2.9 legal disputes: the company responsible for the handling of disputes; 2.10 other: maintaining normal working order, and security. General Manager General Manager job description 1, 1.1 develop strategies and plans: according to company strategic planning, establish the annual management plan, reported to the Board of Directors for approval; 1.2 decomposition measures: according to the Board of Directors issued the annual management plan, annual index of decomposition, through the Organization of coordination mandate in charge of the Department Organization and implementation, ensuring comprehensive implementation of annual indicators; 1.3 inspection: convenes the General Manager Office, through 4、组织部分管理干部到相邻友好医院参观，学习先进经验，提升管理水平和能力。 5、各职能部门、各科室按照医院实施方案、本阶段工作安排和要求，结合科室实际情况，制定创建 工作计划 幼儿园家访工作计划关于小学学校工作计划班级工作计划中职财务部门工作计划下载关于学校后勤工作计划 、落实工作措施、召开工作会议，作好宣传发动，组织全体职工进一步学习《贵州省城乡医院对口支援工作绩效考核指标》(试行)，及医院实施方案，提高认识，深刻领会创建二级甲等医院的重要性与必要性。 (二)组织实施阶段(2011年1月至2011年6月) 1、职能部门要加强检查考核。各职能科室按照《贵州省城乡医院对口支援工作绩效考核指标》(试行)的要求，结合医院的各项管理制度，加大管理力度，按照科室职能，抓好、落实好以下工作，每月有工作重点，每月检查考核。 (1)全面建设医院文化，依法依规办院。把“以病人为中心”作为医院建设与发展的核心理念，医院每位职工要立足本职，爱岗敬业，以实际行动践行医院的宗旨和精神，从我做起，构建医院特色文化。 (2)严格依法执业，实施规范管理。严格执行医疗卫生管理法律法规、诊疗护理规范与常规，认真落实医院各级各类人员岗位职责及工作制度，进一步完善考核约束机制，坚持实施医院—职能部门—科室三级考评，实现制度管理、规范管理。 (3)合理设置医院组织机构，认真落实院科两级管理责任制，坚持科学民主依法决策，认真推行院务公开，充分发挥各级管理干部和全院职工的积极性，加强协作和协调，充分发挥医院整体管理效能。 supplies and get to use, the registration of company assets, record maintenance, maintenance of effective management; 2.6 cost management: preparation of the annual administrative budget, control administrative costs, determine the scope of cost-sharing, sharing the office expenses by month; 2.7 information management: responsible for documents, materials, information and publicity, communication links, and ensure promptly, ranking officers reporting; responsible for the collation and analysis of information, provide the basis for corporate decisions; corporate culture construction, planning, editing, internal publications; 2.8 vehicle management: responsible for the management, repairs and maintenance of vehicles; 2.9 legal disputes: the company responsible for the handling of disputes; 2.10 other: maintaining normal working order, and security. General Manager General Manager job description 1, 1.1 develop strategies and plans: according to company strategic planning, establish the annual management plan, reported to the Board of Directors for approval; 1.2 decomposition measures: according to the Board of Directors issued the annual management plan, annual index of decomposition, through the Organization of coordination mandate in charge of the Department Organization and implementation, ensuring comprehensive implementation of annual indicators; 1.3 inspection: convenes the General Manager Office, through (4)发挥医院三级质量管理组织作用，实行综合目标长效管理。充分发挥医疗质量、病案、药事、感染、输血等管理委员会的职能和作用;医院及科室的质量管理组织要充分履行职责，按照“质量、安全、服务、管理、绩效”综合目标认真开展质量管理活动。 (5)加强细节管理，全面提高工作质量。加强基础医疗护理质量和安全管理，要把缺陷管理作为最基础的管理手段，以查找缺陷为手段，以整改缺陷为目标，强化零缺陷意识，对生命高度负责，全面提高医院各项工作质量。强化人人从我做起，从细节做起，做细、做实、做严各项工作。 (6)统筹协调，推进学科建设。加强重点学科和特色专科建设，围绕“人才、学科、团队”三位一体的管理模式，协同各学科团队管理，强力推进医院整体技术水平的提高，促进医院各学科的可持续发展。 (7)加强财务管理，改善基础保障设施。认真落实二甲医院财务管理和信息管理的要求;进一步加强住院环境、后勤配套实施的改造，强化后勤服务社会化管理，着力为病人及工作人员营造良好的就医和工作环境。 (8)强化培训，提高职工整体素质。认真落实“三基三严”培训、继续教育培训、住院医师规范化培训等工作，进一步强化法律法规知识的培训学习，切实抓好行风建设和民主评议工作，依法行医。 (9)开展优质服务和诚信服务，提高服务水平。全院职工要进一步转变思想观念，以病人为中心, 强化自律、慎独意识，规范医疗行为，改进服务作风，做细、做实、做严各项工作，持续改进医疗护理 supplies and get to use, the registration of company assets, record maintenance, maintenance of effective management; 2.6 cost 5 management: preparation of the annual administrative budget, control administrative costs, determine the scope of cost-sharing, sharing the office expenses by month; 2.7 information management: responsible for documents, materials, information and publicity, communication links, and ensure promptly, ranking officers reporting; responsible for the collation and analysis of information, provide the basis for corporate decisions; corporate culture construction, planning, editing, internal publications; 2.8 vehicle management: responsible for the management, repairs and maintenance of vehicles; 2.9 legal disputes: the company responsible for the handling of disputes; 2.10 other: maintaining normal working order, and security. General Manager General Manager job description 1, 1.1 develop strategies and plans: according to company strategic planning, establish the annual management plan, reported to the Board of Directors for approval; 1.2 decomposition measures: according to the Board of Directors issued the annual management plan, annual index of decomposition, through the Organization of coordination mandate in charge of the Department Organization and implementation, ensuring comprehensive implementation of annual indicators; 1.3 inspection: convenes the General Manager Office, through 服务质量，保证医疗安全，为患者提供人性化、优质和安全的医疗服务。 2、各科室要加强工作落实。各科室、各部门要对照《贵州省城乡医院对口支援工作绩效考核指标》(试行)，查找存在问 题 快递公司问题件快递公司问题件货款处理关于圆的周长面积重点题型关于解方程组的题及答案关于南海问题 ，认真落实实施计划与具体措施，确保达标。 (1)各科室的创建工作小组要认真组织实施创建工作计划，对照《贵州省城乡医院对口支援工作绩效考核指标》(试行)，把本科室、本专业要求的全部标准排项分析，逐条落实，责任到人。尤其对差距较大的项目，要有相应的达标措施。科室通过努力能完成的项目，要指派专人负责，限期完成。需要医院统一解决的问题或项目，要列出问题或项目的名称及解决的意见建议及时报分管职能部门。各科室、各专业无权放弃任何一个项目的分值。 (2)各科室、各部门要认真执行落实各级各类人员岗位职责及医院工作制度，按照分级管理要求，实施科学化、规范化、制度化管理。重点抓好法律法规、岗位职责、核心制度及操作规程的执行、医疗护理基础质量、环节质量及终末质量的管理、医院感染控制、成份输血及医疗安全管理等。各项管理工作要及时记录，提高内涵质量。质量、安全管理工作要长抓不懈，保证为病人提供优质安全的服务，行政后勤部门保证为临床提供优质的服务。 (3)各级质量管理组织要充分履行职责，认真开展质量管理活动，质量管理记录要反映出计划、实施、控制、评价、反馈、改进的全过程，尤其要反映出环节质量的控制过程、质量的持续改进过程。 supplies and get to use, the registration of company assets, record maintenance, maintenance of effective management; 2.6 cost management: preparation of the annual administrative budget, control administrative costs, determine the scope of cost-sharing, sharing the office expenses by month; 2.7 information management: responsible for documents, materials, information and publicity, communication links, and ensure promptly, ranking officers reporting; responsible for the collation and analysis of information, provide the basis for corporate decisions; corporate culture construction, planning, editing, internal publications; 2.8 vehicle management: responsible for the management, repairs and maintenance of vehicles; 2.9 legal disputes: the company responsible for the handling of disputes; 2.10 other: maintaining normal working order, and security. General Manager General Manager job description 1, 1.1 develop strategies and plans: according to company strategic planning, establish the annual management plan, reported to the Board of Directors for approval; 1.2 decomposition measures: according to the Board of Directors issued the annual management plan, annual index of decomposition, through the Organization of coordination mandate in charge of the Department Organization and implementation, ensuring comprehensive implementation of annual indicators; 1.3 inspection: convenes the General Manager Office, through (4)强化“三基三严”培训，加强继续教育培训，卫生技术人员三基考核人人达标。 (5)各科室除做好本科室的达标工作外，还要负责院内的统一协调工作。 3、各部门、各科室应按《贵州省城乡医院对口支援工作绩效考核指标》(试行)要求，进一步规范、完善各类资料，应有详实的原始材料作支撑，作好创建汇报材料的准备。 (三)自查自纠阶段(2011年7月至2011年9月) 1、各部门、各科室按达标工作的实施情况，要有计划的多次组织自查，不断地查漏补缺，通过努力能得到的分就坚决不丢。 2、医院统一组织，模拟评审检查方式，分专业组进行一次全院性达标自查，对医院达标工作进行全面考评验收。 3、根据自查考评验收的得分情况，进一步补漏补缺。 4、创建办收集、整理全套达标自查资料，报医院创建领导小组审阅，并向省评审委员会递交评审 申请书 入党申请书下载入党申请书 下载入党申请书范文下载下载入党申请书民事再审申请书免费下载 及相关材料，此项工作应于2011年10月1日前完成。 (四)冲刺迎检阶段(2011年10月至2011年12月) 1、根据自查评分情况，对被扣分项目进行梳理，对通过的项目予以总结。 2、对没有达标的项目采取扎实措施进行最后冲刺，迅速全面整改，落实整改责任人，明确整改时间。 3、全院职工以良好的精神面貌、优质的服务、过硬的基本功和精 supplies and get to use, the registration of company assets, record maintenance, maintenance of effective management; 2.6 cost 7 management: preparation of the annual administrative budget, control administrative costs, determine the scope of cost-sharing, sharing the office expenses by month; 2.7 information management: responsible for documents, materials, information and publicity, communication links, and ensure promptly, ranking officers reporting; responsible for the collation and analysis of information, provide the basis for corporate decisions; corporate culture construction, planning, editing, internal publications; 2.8 vehicle management: responsible for the management, repairs and maintenance of vehicles; 2.9 legal disputes: the company responsible for the handling of disputes; 2.10 other: maintaining normal working order, and security. General Manager General Manager job description 1, 1.1 develop strategies and plans: according to company strategic planning, establish the annual management plan, reported to the Board of Directors for approval; 1.2 decomposition measures: according to the Board of Directors issued the annual management plan, annual index of decomposition, through the Organization of coordination mandate in charge of the Department Organization and implementation, ensuring comprehensive implementation of annual indicators; 1.3 inspection: convenes the General Manager Office, through 湛的技术，迎接省评审委员会的领导和专家的考核评审。 五、重点注意的问题及重点要求 1、《贵州省城乡医院对口支援工作绩效考核指标》(试行)，旨在建立医院科学的长效管理机制，提高县级医院救治能力，从而缓解看病难的问题，同时也减轻病人看病负担。通过创建二甲医院，按照标准，理顺并规范各科室、各部门的管理，形成常态，促进医院各方面工作的可持续发展。 2、根据《贵州省城乡医院对口支援工作绩效考核指标》(试行)，评审前三年，医院有一级医疗事故、非法行医、超范围执业、医院私自组织血源用于临床、遗弃病人、发布虚假违法医疗广告、医疗纠纷造成严重社会群体性事件等12种一票否决的情况，取消申报等级。对设置帐外帐、“小金库”、开单提成、传染病漏报瞒报迟报、违规开展新药临床试验、麻醉精神药品管理不规范、使用过期变质失效药品、丢失病案、医生私自外出诊治病人等12种情况实行倒扣分。各部门、各科室要严格管理，杜绝发生以上情况。 3、医院将创建二甲医院工作纳入综合目标管理，各职能科室要根据创建工作计划，加大管理力度，及时进行布置、落实、指导，时时了解工作进展情况。全院工作人员在创建工作中的表现，各科室要按照《医院管理制度》，严格进行考核。 4、创建工作坚持“谁主管，谁负责”的工作责任制，科室主任是创建工作的第一责任人，各级干部要在创建工作中切实履行好职责，真抓实干，不走过场, 保证政令畅通和工作落实。中共党员、共青团员supplies and get to use, the registration of company assets, record maintenance, maintenance of effective management; 2.6 cost management: preparation of the annual administrative budget, control administrative costs, determine the scope of cost-sharing, sharing the office expenses by month; 2.7 information management: responsible for documents, materials, information and publicity, communication links, and ensure promptly, ranking officers reporting; responsible for the collation and analysis of information, provide the basis for corporate decisions; corporate culture construction, planning, editing, internal publications; 2.8 vehicle management: responsible for the management, repairs and maintenance of vehicles; 2.9 legal disputes: the company responsible for the handling of disputes; 2.10 other: maintaining normal working order, and security. General Manager General Manager job description 1, 1.1 develop strategies and plans: according to company strategic planning, establish the annual management plan, reported to the Board of Directors for approval; 1.2 decomposition measures: according to the Board of Directors issued the annual management plan, annual index of decomposition, through the Organization of coordination mandate in charge of the Department Organization and implementation, ensuring comprehensive implementation of annual indicators; 1.3 inspection: convenes the General Manager Office, through 在创建工作中要起好模范带头作用。 5、创建工作工作量大，涉及到医院的方方面面，需要全院各科室、全体职工的共同努力才能完成。医院各科室、各部门要围绕创建二甲医院这个中心工作，统一思想，统一认识，统一行动，严格按照评审标准及医院实施方案落实各项工作。全体职工要以饱满的热情、坚决的态度、扎实的工作，从我做起，从细节做起，认真学习标准，找出差距，用实际行动弥补差距，做细、做实、做好各项工作，团结一心，确保二甲医院评审顺利通过。 六、问责 1、每次督察出来的问题凡是在以前的规章制度中规定了的，均按规章制度处理; 2、对查找出来的问题医院已明令整改而科室拒不整改的，除对科室负责人提出书面警告批评外，降当月该科绩效工资10个百分点; 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，除按相关规定处理外，当年不能提职、调资、评优、评先; 4、对创建工作持相反态度的科室或个人，情节较为突出的，除本院处理外，再报请上级处理; 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视为不合格科室。 盘县人民医院 2010年10月13日 supplies and get to use, the registration of company assets, record maintenance, maintenance of effective management; 2.6 cost 9 management: preparation of the annual administrative budget, control administrative costs, determine the scope of cost-sharing, sharing the office expenses by month; 2.7 information management: responsible for documents, materials, information and publicity, communication links, and ensure promptly, ranking officers reporting; responsible for the collation and analysis of information, provide the basis for corporate decisions; corporate culture construction, planning, editing, internal publications; 2.8 vehicle management: responsible for the management, repairs and maintenance of vehicles; 2.9 legal disputes: the company responsible for the handling of disputes; 2.10 other: maintaining normal working order, and security. General Manager General Manager job description 1, 1.1 develop strategies and plans: according to company strategic planning, establish the annual management plan, reported to the Board of Directors for approval; 1.2 decomposition measures: according to the Board of Directors issued the annual management plan, annual index of decomposition, through the Organization of coordination mandate in charge of the Department Organization and implementation, ensuring comprehensive implementation of annual indicators; 1.3 inspection: convenes the General Manager Office, through