民营医院——医院医疗管理考评实施细则内容36.doc

医院医疗管理考核评价实施细则 目 录 一、医疗管理·································································································································（1） （一）依法执业，规范管理······················································································································（1） （二）组织机构和管理·························································································································（1） 二、医疗核心制度管理及执行情况···············································································································（4） 三、医疗质量管理与持续改进···················································································································（7） （一）临床科室质量管理与持续改进(产科除外)····································································································（7） （二）产科质量管理与持续改进················································································································（10） （三）重症抢救病房与急救室管理与持续改进····································································································（13） （四）门诊工作质量管理与持续改进············································································································（14） (五)临床检验质量管理与持续改进·············································································································（15） （六）输血质量管理与安全····················································································································（16） （七）医学影像质量管理与持续改进············································································································（17） （八）病理质量管理与持续改进················································································································（18） （九）药剂科质量管理与持续改进··············································································································（19） 四、.医院感染管理····························································································································（21） 五、护理管理··