医院感染管理质量控制持续改进方案及措施.docxVIP

医院感染管理质量控制持续改进方案及措施

目录

一、医院感染管理质量控制持续改进方案概述....................3

1.1目的与意义...........................................3

1.2适用范围.............................................4

1.3管理原则.............................................5

1.4工作流程.............................................6

二、组织架构与职责..........................................7

2.1组织架构.............................................7

2.2职责分配.............................................8

2.3沟通协调机制.........................................8

三、风险评估与控制.........................................10

3.1风险识别............................................11

3.2风险评估............................................11

3.3风险控制措施........................................12

四、感染监测与报告.........................................13

4.1监测体系建立........................................14

4.2感染病例报告........................................15

4.3感染暴发调查与处理..................................16

五、手卫生与无菌操作.......................................17

5.1手卫生规范..........................................18

5.2无菌操作标准........................................19

5.3手卫生与无菌操作培训................................20

六、消毒与灭菌.............................................20

6.1消毒灭菌制度........................................21

6.2消毒灭菌质量监控....................................22

6.3消毒灭菌效果评价....................................23

七、环境与设备管理.........................................24

7.1环境卫生要求........................................25

7.2设备维护与消毒......................................26

7.3环境与设备监测......................................28

八、教育与培训.............................................30

8.1培训计划............................................30

8.2培训内容与方法......................................31

8.3培训效果评估........................................32

九、持续改进与质量评估.....................................32

9.1改进措施制定........................................34

9.2改进措施实施........................................35

9.3质量评估与反馈........