医师首次授权、考核及再次授权办法.docVIP

文件名称

Document

文件类别：程序

Documentcategory:Procedure

文件编号：

RS-AC-0008-001

Documentnumber:

RS-AC-0008-001

医师首次授权、考核及

再次授权办法

Physician’sinitialprivileges,evaluationandrenewalprivilegesregulation

责任部门：人事部

Responsibledepartment:

DepartmentofHumanResources

首发日期：2014-10-28

Dateestablished：2014-10-28

附件：0个共0页

Appendix：0(0page)

新订日期：2014-10-28

Daterevised：2014-10-28

版本：第1版，13页

VersionVer.1(13pages)

1.标准Standard:

医院应具备标准化、客观的循证程序，用于授权医务人员收治患者和/或提供符合其资质的其他临床服务。Thehospitalhasastandardized,objective,evidence-basedproceduretoauthorizemedicalstaffmemberstoadmitandtotreatpatientsand/ortoprovideotherclinicalservicesconsistentwiththeirqualifications.

2.目的Purpose:

为保护患者安全和推动临床服务质量，医院必须评估其医务人员之临床能力，以授权该医务人员执行临床服务的范畴或项目，并持续监测及评估医师医疗服务的质量及安全性，判定医师的资质和临床专业权限是否可以延续。Toensurethesafetyofthepatientsaswellasimprovingclinicalservicequality,thehospitalmustassesstheclinicalcompetenceofitsmedicalstaffinordertoauthorizeastaffforclinicalserviceorprojectprivilegedelineation.Thecontinualmonitoringandassessmentofthequalityandsafetyoftheclinicalservicesprovidedbythephysicianmustbeperformedinordertodeterminethequalityofthephysicianaswellasthecontinueauthorizationofhis/herprofessionalclinicalprivileges.

3.范围Scope:

适用于临床医生，包括外聘医生。Applicableforclinicians,includingexternalphysicians.

4.定义Definition:

授权：是指判断医生现有的工作能力并确定其可以从事临床服务的范围，称为“授权”。Privilege:“Privilege”referstothedeterminationofamedicalstaffmember’scurrentclinicalcompetenceandmakingadecisionaboutwhatclinicalservicesthemedicalstaffmemberwillbepermittedtoperform.

它是医院为保护患者安全、提高医疗服务质量所要做的最重要的决定。Itisthemostcriticaldeterminationahospitalwillmaketoprotectthesafetyofpatientsandtoadvancethequalityofitsclinicalservices.

5.权责Responsibilities:

5.1管理职责：医务人员授权管理委员会主要负责，医疗部、人事部主任协助ManagementResponsibilities:Medicalstaffprivilegemanagementcommitteeisresponsiblef