护理重点环节质控检查制度护理质量管理持续改进措施

护理部重点环节质控检查制度护理质量管理持续改进措施,护理三级质量控制架构.,护理质量管理控制方法,护理部重点环节质控检查制度,护理质量管理持续改进措施,主要内容,护理质量管理与安全管理委员会,50%,护理三级质量控制架构,三级质控,二级质控,一级质控,科护士长,护士长,护理部重点环节质控,护理部护理质量小组,护理缺陷分析鉴定小组,安全（压疮、跌倒、坠床）管理小组,消毒隔离质量管理小组,护理文书管理小组,病区质量管理小组,危重病人护理质量，基础护理质量、健康教育质量管理小组,急救物品质量及药品管理小组,重点科室护理质量管理小组,护士长质量管理考核小组,临床路径护理小组,环节质控小组,科室护理质量活动小组（1级质控组） 科护士长质量控制（2级质控）这一层是护理质控的中心 护理部质量控制组（3级）质控组）是护理质量监控的核心,护理质量管理控制方法,科室护理质量活动小组（级质控组）,护士长每月质量全面自检一次，辅助本科室的护理质量监控、对护士工作的指导，存在问题的跟进。每周按检查项目随时检查：每月对护理人员技术操作考核一次；每月进行业务学习一次每2月业务查房一次护士长每周对设备、器械、急救物（药）品完好状态检查一次。1级质控组对本科护理质量实施现场控制，每月将质控结果进行分析、整改，填写护士长手册及护理质量相关报表上报护理部。,科护士长质量控制（级质控）,有科护士长对各科护理质量进行督导整改，做到每周检查每月反馈。每月有计划地根据科室护理质量薄弱环节进行检查，按护理部规定每月完成全部管辖科室的质量缺陷督导、整改，每月完成对重点部门的检查，填写科护士长手册及护理相关质量月报表。,护理部质量控制组（ 级）质控组,每月单项督检、每季度全面督检护理部安排定期、不定期午查；护理部安排护士长轮流不间断夜查；每日按护理部质控项目有计划有针对性的对护理工作进行专职随机检查；每月对重点科室，如手术室、麻醉复苏室、供应室、急救中心、ICU、产房、血液净化、内镜中心、导管室、介入室、新生儿等进行专项质量检查。及时分析存在问题，提出改进。护理部每年分层次对全员护理人员进行技能考核,护理部质量控制组（ 级）质控组,护理部每年对全院护理人员理论考试两次。按要求根据医院不同时期的工作重点、护理核心制度、专科护理、护理工作难点及薄弱环节确定质量检查重点护理部检查完毕将存在的问题向科室护士长反馈，提出整改意见及详细的改进要求并指导科室解决，每季度上报全院各科室所有质量检查的结果登载于医院医疗质量考核月报表上，随时向住院院长汇报护理质量检查情况，将全院护理质控结果报经管办与科室挂钩。年终进行护理质量达标情况总结，并与全院护士长考核兑现。,重点环节质控检查,4个重点环节管理 重点之人重点之时重要之事重要之物的管理,重点之人的管理,新调入的、有思想情绪的、工作严谨性较差的护士,病人环节监控,新入院、手术、急危重证、有发生医疗纠纷潜在危险的病人,重点之时的管理,工作繁忙、易疲劳时间、交接班时、护理操作集中时间,重要之事的管理,在进行导尿、静脉留置针、雾化、及管道护理等操作时，主动向病人或家属解释，应明确交待注意事项，取得理解和配合防止管道滑脱等输液、输血、注射、各种过敏试验等。虽然是日常工作但应强调严格查对制度并密切观察病人，如果一旦发生问题，都是人命关天的大事，作为护理管理中监控的重点之重点。,重要之事的管理,加强抢救工作，做好急危重证病人急救工作的快速反应时间，护士长和高年资护士必须在现场参与抢救和指导下级护士，科护士长加强管理指导、督促、检查工作，发现问题及时反馈科室进行整改。,重点之物的管理,加强急救药品与物品、高危药品管理，做到班班交接，认真记录，护士必须作到使用后及时补充、记录。护士长采取不定期、不定班检查督促，每月清查1次，确保药品、物品无过期，无失效、无霉变和无损坏。仪器设备作到1台1本记录，班班交接，定期维护、检修确保运行正常，所有仪器设备完好处于功能位，护士长每天检查。科护士长加强管理指导、督促、检查工作，发现问题及时进行书面反馈科室进行整改。,护理部重点环节质控检查制度,1为加强护理质量的控制，实施护理部双人查房制度2有护理部成员及护士长完成节假日，午间及晚间重点环节的质量控制3护理部每月有重点的安排检查2-3个质控项目，或提问考核相关核心制度及应急预案和流程4护士长在检查当日领取质控检查登记表并认真检查、记录。检查次日及时反馈给问题科室改进。5护理查房人员应按规定着装，遇有特殊情况需调班时。应到护理部备案。,护理质量持续改进概念,护理质量的核心保障病人安全护理质量不是一个固定的目标，而是持续改进的过程。,护理质量管理持续改进措施,海恩法则 每一起严重事故的背后，必然有29次轻微事故和300起未遂先兆以及1000起事故隐患。法则强调两点：一是事故的发生是量的积累的结果；二是再好的技术，再完美的规章，在实际操作层面，也无法取代人自身的素质和责任心。,海恩法则的启示,假如人们在安全事故发生之前，预先防范事故征兆、事故苗头，预先采取积极有效的防范措施，那么，事故苗头、事故征兆、事故本身就会被减少到最低限度，安全工作水平也就提高了。由此推断，要制服事故，重在防范，要保证安全，必须以预防为主。-前瞻性护理质量管理模式,将终末式的监控行为转变为为一线护士提供指导、指引、培训等的服务行为，规范护理行为，提高服务的同质性和有效性。,持续性护理质量改进,护理质量管理持续改进措施,1护理部质量管理与持续改进委员会根据当年护理质量管理的热点问题进行讨论，每年修订护理质量考核标准，制定全院护理质量控制计划，各科室根据当年科室护理质量控制计划，并组织实施。2根据质控标准由质量管理与持续改进委员会安排季度检查工作3日查：护士长每日检查危重抢救病人及新入病人等质量内容并与各班护士工作质量挂钩4周查：护士长每周抽查和每月查相结合5月查：护理管理质量委员会每月对各护理单元进行一次质量检查，重点查护理安全，治疗护理执行情况，急救物品，仪器，治疗室管理，基础护理技术操作和急救技术操作，消毒隔离，病历书写，健康教育，危重病人护理等,护理质量管理持续改进措施,6夜查：每周查房两次，有护理部成员及护士长组成，检查夜班护理工作情况，处理突发事件及进行人力调配，同时负责重点科室抽查7每年对全员护理人员进行急救CPR操作培训一次8随时进行皮肤压伤，跌倒，特殊管路滑脱，差错，护理会诊的上报登记9每月根据质控部检查情况进行分析讲评，寻找存在问题，分析原因，制定改进措施，并在全院护士长大会上反馈，达到持续质量改进10每月在护士长会上进行护理差错分析11护士长组织本科全体护理人员开会讨论，将存在问题进行分析，提出整改措施，科护士长负责整改,护理质量管理持续改进措施,12次月专职质控员再次督导整改效果，将结果记录在护理质量持续改进本上13奖励与处罚奖励与处罚：每月将质控结果与科室护理工作奖惩挂钩，如当月发生严重差错，事故，重大护理纠纷核实后上报院委员会处理,谢谢,Diagram,ContentsThemeGallery is a Design Digital 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