Summary of hospital internal control

The goal of internal control is mandatory, and its measures are defensive, so hospital internal control is also extremely important. The following is a summary of hospital internal control that I collected for you. Welcome to read!

Summary of hospital internal control

With the correct leadership and strong support of the district party committee, the district government, the district health bureau and the relevant departments at higher levels in 2xx, our hospital fully implemented the spirit of the 18th National Congress of the Communist Party of China, took the opportunity of establishing a grade hospital, strengthened scientific management, highlighted connotation construction, improved various rules and regulations, improved medical conditions, created a specialty of traditional Chinese medicine, and actively carried out preventive services. Maintain the momentum of the rapid development of the hospital, and better complete all the work in that year. Make the management level, overall scale and total business of the hospital leap to a new level. The work in 2xx is summarized as follows:

First, the indicators of economic work completed in 2xx:

As of October 2th, the total income of the hospital was RMB 1,, including financial subsidies of RMB 1,, medical income of RMB 1,, and drug income of RMB 1,, accounting for%. The annual business volume of 2xx is expected to reach 1, yuan.

second, pay close attention to political and ideological work and implement the construction of party style and work style.

in 2xx, our hospital carried out a solid project? Year of improving work style and efficiency? Activity, create? People are satisfied with the activities of grass-roots units? ，? Three good and one satisfied? Activities, strictly implement the provincial, municipal and district "on the implementation of the eight central regulations" notice and the District Health Bureau on strengthening the construction of the health industry style of ten provisions. First of all, clarify the division of tasks and responsibilities of the members of the leading group in the construction of professional ethics, and form a leadership pattern and working mechanism that pays close attention to * * * management; Establish a system of accountability, and incorporate the work of professional ethics into the target management of leading cadres' assessment. Secondly, strengthen the education of medical ethics and professional ethics, fully mobilize and involve all staff, educate the medical and health personnel to firmly establish the idea of serving the people wholeheartedly, strengthen professional responsibility, professional ethics and professional discipline, and enhance service awareness. Assess the professional ethics of health technicians every year, and link it with various rewards and punishments. Third, resolutely correct unhealthy trends in the purchase and sale of medicines. Standardize the procurement behavior of drugs and health equipment; Strictly implement the provincial health department's "on stopping medical and health personnel from accepting? Red envelopes? Provisions on the Investigation of Responsibility < P > and other relevant regulations, resolutely investigate and deal with kickbacks such as clinical promotion fees, billing fees, prescription fees, prescription fees, and other issues such as prescribing, random inspections, and arbitrary charges, so as to achieve reasonable inspection, rational drug use, and reasonable charges; It is forbidden to accept patients? Red envelopes? . Fourth, the hospital office and nursing department organized and the dean attended, and invited the representatives of patients and patients' families in various subjects to hold a symposium on the construction of morals, solicit opinions and suggestions and solve them in time. In 2xx, the symposium was held four times, with more than 8 people attending; All the year round, leaders and workers from all walks of life were invited to be supervisors of morals, and a social questionnaire survey was conducted on the hospital's medical ethics, medical care quality, technical level and medical environment. The comprehensive satisfaction rate of the hospital was 96.6%, and the comprehensive satisfaction rate was 96.7%.

Third, strengthen the internal management of the hospital and speed up the development of the hospital

(1) Insist on developing medicine through science and technology and attach importance to personnel training and scientific research. First of all, according to the business development and work needs of our hospital, we have enriched the ranks of middle-level cadres and added reserve forces for the development of the hospital. Implementing the responsibility system of attending doctors, strengthening the teaching of young comrades, constructing a three-step talent team, accepting undergraduates, sending out advanced learners, and attending 9 graduate classes in western learning. Encourage young doctors to carry out upgrading study. Secondly, strengthen study and training to improve the professional quality of medical staff. Every Wednesday is designated as the training day of traditional Chinese medicine knowledge in the whole hospital, and every Tuesday, I participate in state administration of traditional chinese medicine video learning and carry out business training in the hospital for 23 times; Organize the whole hospital? Sanki? The knowledge was tested 6 times, and the qualified rate reached 98.5%. The three basic examinations in the whole region ranked second. Supervise the medical department, nursing department and other functional departments to organize in-hospital business lectures successively. On the other hand, yes? Go out, please come in? Ways to speed up personnel training. Third, adhere to science and technology to promote medicine and carry out new technologies and projects. Medical equipment such as stone crusher and all-active immunity analyzer have been purchased successively, which provides a guarantee for clinical diagnosis and treatment.

(2) pay close attention to the quality management of medical care to ensure medical safety. Seriously organize and

urge the medical department, nursing department and other functional departments to carry out regular medical quality inspection activities, carefully check and analyze the writing of medical records and prescriptions, the use of antibiotics and the implementation of disinfection and isolation, and reward and punish them in strict accordance with the hospital management system. At the same time, give full play to the coordination, guidance, supervision and other functions of administrative and logistics functional departments, and provide a strong logistics guarantee for the normal development of clinical frontline business. Due to the effective measures < P >, the quality of medical care has steadily increased, and there have been no major medical errors and accidents in the past year, effectively preventing medical risks and promoting the rapid growth of medical business. At the same time, patients' trust in hospitals is getting higher and higher.

(3) further strengthen the management of the new rural cooperative medical system. First, ensure the participation rate of 1% and ensure full coverage. It is necessary to truly put the participants in place. The second is to improve the compensation scheme to ensure that the actual compensation ratio of the people's hospitalization medical expenses is above%. The third is to improve service capabilities and ensure 1% network service coverage. Improve the village-level network reporting system, comprehensively improve the management and operation quality of the new rural cooperative medical system, and ensure that the participating people can take a card to see a doctor and settle accounts by card, which is fast, convenient, fair and transparent. Fourth, strengthen supervision and management, further standardize medical service behavior, and rationally use cooperative medical funds. Clear responsibility, strict assessment of rewards and punishments, strengthen the monitoring of fund use, implement average cost control, limit payment for single diseases, strictly investigate bed-hanging hospitalization, strictly control large prescriptions, and prevent imposters.

(4) further promote the equalization of public health services. Organize the implementation of public health services such as tuberculosis prevention and treatment, rural pregnant women's hospital delivery subsidy, rural pregnant women's free folic acid supplementation before and during pregnancy, free pre-marital medical examination, prevention of mother-to-child transmission of AIDS, syphilis and hepatitis B, free supplementary hepatitis B vaccine for children under 15, and free surgery for poor cataract patients.

(5) further improve the system of essential drugs. First, strictly regulate the purchase channels of essential drugs and implement zero-difference sales. For a few village clinics and a few health service points, it is strictly forbidden to sometimes purchase drugs by themselves or sell them at zero price difference. Resolutely put the big policy of medical reform in place. Second, seriously implement the performance appraisal system. Performance appraisal is the reform of medical and health system, and special treatment is an important content of implementing the basic drug system. The internal staff should be assessed and cashed, and the village clinics should also be assessed and cashed in time. It is strictly forbidden to muddle along and play cards. It is strictly forbidden to fail to check, only fail to check, and fail to check less. The third is to resolutely strengthen the management of medication. It is necessary to continue to strengthen the supervision of rational drug use by medical personnel, continue to monitor and analyze the abnormal situation of drug users, drug use structure and drug use quantity, and implement a system of regular reporting, regular analysis and regular rectification to ensure rational drug use in clinic.

Fourth, steadily promote the construction of grade hospitals

First, carefully compare the establishment standards and assessment rules, and thoroughly understand the spirit; The second is to make a plan, decompose it into relevant functional departments according to the assessment requirements and contents, clarify the responsible person, and pay close attention to the implementation of the work; The third is to carefully find the gap and formulate rectification measures. For the problems that are difficult to solve in the department, bring them to the meeting of the founding team, and the leaders of the hospital will make a decision on the spot; Fourth, closely follow the scoring points and improve relevant information; The fifth is to promote the development of all work with the standardized standards of second-class hospitals and strive to improve service satisfaction; Sixth, strengthen confidence, overcome difficulties, seek truth from facts and be pragmatic, and earnestly do a good job in the specific work of reviewing and reviewing secondary hospitals for inspection.

Highlights of work in 2xx: Establishing grade hospitals and realizing standardized management. Mainly manifested in the following aspects:

1. Improve the organizational system, standardize the setting and naming of departments.

2. Increase investment to improve the hospital environment. More than 5, yuan has been invested successively to modify the first floor of the newly-built ward building into a standard disinfection supply room, expand and relocate the pharmacy and traditional Chinese medicine decocting room, and build parking lots and green belts. More than 4, yuan has been invested to introduce all-active immunity analyzer, and Chinese medicine diagnosis and treatment equipment such as stone crusher and specific wave therapeutic instrument have been added.

3. Information construction is developing rapidly. Dozens of computers have been added to the ward clinic, and electronic medical records are used in both wards and clinics.

4. Strengthen business technology learning and strictly implement it? Three basics and three strictness? . More than 5, yuan has been invested to set up a network video learning platform for traditional Chinese medicine technology in state administration of traditional chinese medicine, and the staff of the whole hospital are organized to study every Tuesday afternoon. Every Wednesday afternoon, the hospital organizes appropriate Chinese medicine technology study, and scientifically improves the assessment rules. Effectively carry out pre-job training for new staff, on-the-job staff? Three basics and three strictness? And health laws and regulations knowledge training examination, requiring everyone to pass.

5. Give full play to the characteristic advantages of traditional Chinese medicine. College construction has achieved results. Carry out the performance appraisal of traditional Chinese medicine, improve the performance appraisal scheme of traditional Chinese medicine, and include the utilization rate of traditional Chinese medicine pieces, the treatment rate of traditional Chinese medicine and the treatment rate of superior diseases of traditional Chinese medicine into the comprehensive assessment objectives of the department. Integrate pain department, anorectal department and diabetes department with strong strength and obvious advantages of traditional Chinese medicine as municipal, district and key specialties. Staff in pain department, anorectal department and diabetes department have been added, and TCM diagnosis and treatment equipment such as fumigation warehouse and TCM specific wave therapeutic instrument have been added. Initially establish a ward comprehensive treatment area and an outpatient comprehensive treatment area. Treat the disease before it happens? Service platform, open physical identification clinic, carry out winter disease treatment service in summer, and promote the development of traditional Chinese medicine characteristics and advantages.

6. Hospital culture construction has been implemented. Further clarify the core value system composed of hospital purpose, hospital training and development strategy. The hospital has its own courtyard song "Angel's Choice", which fills the blank of hospital culture construction. Staff Manual and Culture Manual were compiled and trained. Through development? Three good and one satisfied? Activities, the creation of civilized demonstration window, medical ethics evaluation, etc., and vigorously advocate the industry atmosphere of self-discipline and introspection; Vigorously advocate inheriting and innovating the sense of responsibility and mission of Chinese medicine. Press? No disease hall? The design style, design and decoration? Baicaotang? Perfect combination of the unique traditional Chinese medicine with the reality of our hospital, giving people a double enjoyment of vision and knowledge.

Main working ideas, objectives, tasks and promotion measures in 2xx

I. Guiding ideology

In 2xx, the hospital will take the Party's? 18th National Congress? Guided by spirit, with? Second b? Hospital as a starting point, closely around the overall work arrangement of the district health bureau, combined with our hospital? Twelfth Five-Year Plan? , scientific management, speed up the training of talent echelon, and comprehensively improve the level of specialist medical technology and community medical service capabilities; Increase investment, introduce new technologies and projects, speed up the construction of key colleges and enhance core competitiveness; Actively explore new modes of cooperation, rely on superior hospitals to enrich medical, scientific and research resources, improve the overall business level, further realize the leap-forward development from township center hospitals to district-level hospitals of integrated traditional Chinese and western medicine, and provide safe and convenient medical services for the residents in the region.

Second, the work index

The number of people treated was% higher than that of 2xx; Number of people discharged from hospital, an increase over 2xx years; The business income is 1, yuan, an increase of% over 2xx, and the proportion of medicines is controlled below 35%.

III. Objectives, tasks and main measures

1. Strengthen the scientific management of hospitals and consolidate the achievements of the establishment of secondary hospitals

(1) Strengthen the construction of leading bodies, carefully study the report of the 18th National Congress of the Communist Party of China and the eight central regulations on improving work style and keeping close contact with the masses, and earnestly implement the responsibility system for building a clean and honest government. Strict requirements for the staff of the hospital, consciously accept supervision, and put an end to violations of discipline and discipline such as red envelopes and kickbacks. Work hard, tell the truth, do practical things, and refrain from putting on airs, making superficial articles and engaging in image projects.

(2) to improve the hospital's executive power, on the basis of perfecting various rules and regulations in 2xx, the key point in 2xx is to effectively combine the incentive mechanism with the executive power, define the objectives, and track the assessment.

(3) Strictly implement the performance appraisal scheme, combine the distribution with the workload more closely, and constantly improve the appraisal system for middle-level cadres.

(4) speed up the construction of talent team structure and improve the reserve talent pool. Encourage qualified comrades to participate in postgraduate study in western learning; Send business backbones to higher-level hospitals for training; Adopt? Three basics training? 、? Continuing education? Various forms, such as continuing education for technical personnel of the whole hospital; Strengthen the training and optimization of reserve talents in various forms to speed up the construction of hospital talent echelon. At the same time, we will recruit talents through multiple channels. In 2xx, we plan to introduce 3 undergraduate students of traditional Chinese medicine, 1 nursing staff, 2 laboratory technicians and 2 imagers.

(5), care about the workers' lives, ensure that the welfare benefits of the workers are improved, build a dormitory building for the workers, and effectively improve the workers' lives, thus enhancing the cohesion and centripetal force of the workers in the whole hospital.

2. Strengthen medical quality management and improve the level of medical services

(1) Further improve the quality management organizations and quality management committees at the hospital and department levels to promote the continuous improvement of medical quality.

(2) Strictly implement hospital rules and regulations and the post responsibilities of medical staff, and strengthen quality management, especially the medical core system.

(3) Strengthen the awareness of safe medical treatment and implement the patient safety objectives. Organize employees to learn relevant laws and regulations, strictly implement medical and health management laws and regulations, diagnosis and treatment nursing norms, and implement hospital medical defect management measures.

(4) Standardize electronic medical records, improve the connotation quality of medical records, and promote the whole medical work by grasping the quality of medical records. The medical department should intensify the spot check of medical records, announce the results of spot checks in time, and reward and punish them according to the standards.

(5) Continue to promote the quality control of clinical pathway and single disease, actively develop new pathways, control the variation rate, and improve the access rate. All departments in the hospital should carry out at least one clinical pathway, actively promote clinical rational drug use, and reduce the drug ratio. The medical department, the science and education department, the pharmacy department, and the hospital infection department should jointly conduct random spot checks from time to time, focusing on continuously rectifying the irregular use of antibiotics, earnestly implementing the prescription review system, and implementing dynamic monitoring and extraordinary early warning on prescriptions. Continue to promote clinical pharmacy. Control the rational use of blood and strictly implement the examination and approval system.

(6) Strive to improve the service quality, adhere to the people-oriented principle, and build a three-dimensional service system to ensure seamless medical services. The nursing department should strengthen the continuing education of nurses, improve the overall quality of the nursing team and continue to do a good job? Quality care? , the implementation of refined management, improve the cultivation of nursing team. Actively carry out traditional Chinese medicine nursing and promote the development of the characteristics and advantages of traditional Chinese medicine.

(7) Actively carry out preventive services, improve service processes and provide them to the public.