泰山医学院附属医院三甲评审应知应会.doc

目录 医院评审基础知识···················································1 医院管理部分······················································ 院务公开部分······················································ 人事部分·························································· 财务部分·························································· 医疗安全部分······················································ 信息网络部分······················································ 医学设备部分················································ 后勤保障部分······················································ 医疗安全保卫部分·················································· 门诊服务部分·················································· 护理部分······················································ 医疗保险部分·················································· 双向转诊部分·················································· 医院感染管理部分·············································· 公共卫生部分·················································· 输血管理部分·················································· 药事管理部分·················································· 附件1 15项医疗核心制度················································ 附件2 应急事件处理简易流程············································· 附件3 消防安全宣传常识··············································· 附件4 危急值管理制度 ··············································· 第一章 医院评审基础知识 一、什么是医院评审（全员知晓） 医院评审是指按照卫生部《医院评审办法》要求，根据医疗机构基本标准和医院评审标准，开展自我评价，持续改进医院工作，并接受卫生行政部门对其规划级别的功能任务完成情况进行评价，以确定医院等级的过程。 二、医院评审的原则（全员知晓） 坚持政府主导、分级负责、社会参与、公平公正的原则。 三、医院评审的方针、主题、核心、评审重点、重要指标包括：（全员知晓） 方针：以评促建、以评促改、评建并举、重在内涵 主题：质量、安全、服务、管理、绩效 核心：以病人为中心 评审重点：医疗品质和医务绩效 重要指标：医改任务完成情况 医院评审的中心内容（全员知晓） 围绕质量、安全、服务、管理、绩效，体现以病人为中心的理念、持续改进的理念、建立长效机制的理念。 五、医院评审的目标（全员知晓） 通过医院评审，促进构建目标明确、布局合理、规模适当、结构优化、层次分明、功能完善、富有效率的医疗服务体系，对医院实行科学化、规范化、标准化分级管理。 六、医院评审的周期、体检形式、结论分类、自评时间（全员知晓） 评审的周期为4年，形式分为周期性评审和不定期重点检查。结论分为甲等、乙等、不合格。自评时间不少于6个月 七、医院周期性评审方式（全员知晓） 包括对医院的书面评价、医疗信息统计评价（DRGs负性时间评价）、现场评价（包括追踪法）和社会评价（第三方满意度测评）等方面的综合评审。 八、二级综合医院评审依据及