患者安全目标管理 质量考核内容及标准 评分方法（patient safety target management quality assessment content and standard scoring method）

患者安全目标管理质量考核内容及标准评分方法（PATIENTSAFETYTARGETMANAGEMENTQUALITYASSESSMENTCONTENTANDSTANDARDSCORINGMETHOD）THISPAPERISCONTRIBUTEDBYJKWPENGDOCDOCUMENTSMAYEXPERIENCEPOORBROWSINGONTHEWAPSIDEITISRECOMMENDEDTHATYOUSELECTTXTFIRSTORDOWNLOADTHESOURCEFILETOTHELOCALMACHINEMEDICALQUALITYMANAGEMENTANDCONTINUOUSIMPROVEMENTPROGRAM,MEDICALQUALITYMANAGEMENTANDCONTINUOUSIMPROVEMENTPROGRAMANDQUALITYASSESSMENTSTANDARDCLINICALLABORATORYFIRST,QUALITYMANAGEMENTRELATEDOBJECTIVESANDEVALUATIONINDICATORS1QUALITYMANAGEMENTRELATEDOBJECTIVES1TOIMPLEMENTTHEREGULATIONSONBIOLOGICALSAFETYMANAGEMENTOFPATHOGENICMICROORGANISMLABORATORY,THEMANAGEMENTMEASURESOFCLINICALLABORATORYOFMEDICALINSTITUTIONSANDSOONCENTRALIZEDSETTINGOFCLINICALLABORATORY,UNIFIEDMANAGEMENTANDRESOURCESHARINGUNIFIEDSTANDARDOFLABORATORYMANAGEMENT,UNIFIEDQUALITYCONTROLANDQUALITYASSURANCE2CLINICALLABORATORYLAYOUTANDPROCESSSAFETY,REASONABLE,INLINEWITHHOSPITALINFECTIONCONTROLANDBIOLOGICALSAFETYREQUIREMENTS3CARRYOUTTHEINSPECTIONITEMSINACCORDANCEWITHTHECATALOGUEISSUEDBYTHEHEALTHADMINISTRATIONDEPARTMENT,ANDDONOTCARRYOUTTHEITEMSTHATHAVEBEENELIMINATEDORNOTAPPROVEDSPECIALLABORATORIESGETAPPROVALPERMISSION4CLINICALEXAMINATIONITEMSMEETTHECLINICALNEEDS,ANDCANPROVIDE24HOURSEMERGENCYINSPECTIONSERVICE,THEIMPLEMENTATIONOF“CRITICALVALUEREPORTING“SYSTEM5IMPLEMENTTHETOTALQUALITYMANAGEMENTANDIMPROVEMENTSYSTEM,CARRYOUTINTERNALQUALITYCONTROLANDPARTICIPATEINTHEROOMQUALITYEVALUATIONACCORDINGTOTHEREGULATIONSSTRICTLYCOMPAREANDCONTROLTHEQUALITYOFBEDSIDEINSPECTIONITEMSACCORDINGTOTHEREGULATIONS6TESTREPORTTIMELY,ACCURATE,STANDARDIZED,STRICTAUDITSYSTEM7COMPLYWITHTHEINSPECTIONITEMSANDOPERATINGPROCEDURESOFTESTINGINSTRUMENTS,REGULARLYCALIBRATETHETESTINGSYSTEM,ANDELIMINATETHEUNQUALIFIEDEQUIPMENTANDREAGENTSINTIMENOUNAUTHORIZEDEQUIPMENTANDREAGENTSAREUSED8PATIENTS,PHYSICIANSANDNURSESARESATISFIEDWITHTHESERVICEOFTHEINSPECTIONDEPARTMENTTWOTHERELEVANTEVALUATIONINDEXES,EVALUATIONINDEX1BLOOD,URINARYANDSTOOLROUTINETEST,ECG,IMAGINGROUTINEINSPECTIONPROJECTBEGANTOISSUETHETIMELESSTHAN30MINUTESFROMTHEEXAMINATION,BIOCHEMISTRY,COAGULATIONANDIMMUNETESTPROJECTBEGANTOISSUEATIMELESSTHAN6HOURSFROMTHEINSPECTIONRESULTS,BACTERIOLOGYINSPECTIONITEMSFROMTHEBEGINNINGTOCHECKTHERESULTSISSUEDBYTHETIMELESSTHAN4DAYSONE2CLINICALCHEMISTRYEQAANNUALAVERAGEPASSVIS1203HAEMATOLOGYEQAANNUALAVERAGEPASSMODIFIEDDEVIATIONINDEXDI24LABORATORYOFIMMUNOLOGYQUALITYEVALUATION,THEAVERAGEANNUALAVERAGESCOREABOVETHENATIONALAVERAGE5BACTERIAEQAANNUALCORRECTIDENTIFICATIONRATEGREATERTHAN80IN6PATIENTS,PHYSICIANSANDNURSESFORLABORATORYSERVICESATISFACTIONISMORETHAN90THREEQUALITYASSESSMENTSTANDARDOFLABORATORYQUALITYASSESSMENTSTANDARDPROJECTQUALITYMANAGEMENTQUALITYASSESSMENTCONTENTANDSTANDARDSCORINGMETHOD,CLINICALLABORATORYCENTRALIZEDSETTING,UNIFIEDMANAGEMENTACCORDINGTOTHE“LABORATORYOFPATHOGENICMICROBIOLOGYLABORATORYWHETHERBIOLOGICALRISKIDENTIFICATION,NONONSTAFFINTOTHELOGO,NOLOGOBUCKLE5POINTSTHEBIOSAFETYMANAGEMENTREGULATIONS“MANAGEMENT,NOTTOCARRYOUTELIMINATIONANDWITHOUTTHEAPPROVALOFTHEPROJECTPCR,HIVDETECTIONPROJECTHASMADETHEPROVISIONSOFTHECERTIFICATEOFACCEPTANCEINSPECTIONREPORTPCR,HIV,11STAFFCERTIFICATEANDRELATEDPROJECTS,1PEOPLEWITHOUTALICENSESTAFFDEDUCTED10POINTSTYPEOFBIOCHEMICALANALYZER,PERIPHERALLYMPHOCYTEGENETICTESTINGSTAFFOBTAINTHERELEVANTPROJECTCERTIFICATETHEESTABLISHMENTOFSPECIMENRECEIVINGREGISTRATIONANDCHECKINGSYSTEMANDIMPLEMENTTHEIMPLEMENTATIONREPORTISSUED11SIGNBECAUSETHESYSTEMFAILSTOPERFORMDUETOLOSTSAMPLESORTESTRESULTSOFEACHERROR,DEDUCTED20POINTS,CAUSINGDISPUTESACCORDINGTOTHERELEVANTSETTONORMALCANPROVIDE24HOURSEMERGENCYSERVICEDETECTIONEMERGENCYINSPECTIONREPORTTIMELY,CANDOA2FROM2INTHEHOSPITALEMERGENCYMEDICALRECORDSANDCLINICALCRITICALPATIENTSINTHERESULTSOFRANDOMTESTINGREPORT,2HOURSTESTREPORTASLESSTHAN30MINUTES,THEOTHERPROJECTPROJECTISWHETHERINTIME,1EMERGENCYINSPECTIONREPORTOVERTIMEDEDUCTED10POINTS1OTHERPROJECTSOVERTIMEDEDUCTED5POINTS24BLOOD,URINEANDSTOOLROUTINETESTSINCETHEEXAMINATIONBEGANTOISSUETHETIMELESSTHAN30MINUTES,HOURSOFOFFSITEDEDUCTED20POINTSBIOCHEMISTRY,COAGULATIONANDIMMUNETESTPROJECTTOPRODUCERESULTSTIMELESSTHAN633DOCUMENTINSPECTIONDEPARTMENTSELFINSPECTION,TOSEEWHETHERTHEESTABLISHMENTOFTHEHOSPITALCRITICALVALUEREPORTSYSTEM,CHECKTHEREGISTRATIONOFTHECRITICALVALUECLINICALHOURS,BACTERIOLOGYINSPECTIONPROJECTSINCETHEEXAMINATIONBEGANTOISSUETHETIMELESSTHAN4DAYS1CASESREPORTISNOTSTANDARDORREGISTRATIONISNOTSTANDARDIZED,10POINTSTHEIMPLEMENTATIONOFCRITICALVALUEREPORTINGSYSTEMCLINICALDEPARTMENTSSETUPTHELABORATORYSHALLNOTBEISSUEDACLINICALTESTREPORT1SEETHESCENEANDCHECKSCLINICALMEDICALRECORDS,CLINICALDEPARTMENTSSETUPTHELABORATORYISISSUEDBYCLINICALEXAMINATIONAT1INSPECTIONDEPARTMENTTOESTABLISHQUALITYMANAGEMENTTEAM,THEDIRECTORISTHEFIRSTRESPONSIBLEPERSONTOFOUNDASETOFCLINICALDEPARTMENTCLINICALLABORATORYISSUEDINSPECTIONREPORTOFTHECLINICALDEPARTMENTSDEDUCTIONOF10POINTSTHEESTABLISHMENTOFINTERNALQUALITYCONTROLSTANDARDOPERATINGPROCEDURESANDINDOORANDROOMMANAGEMENTPROCEDURES22DOCUMENTDATA,TOSEEWHETHERTHEESTABLISHMENTOFINTERNALQUALITYCONTROLANDSTANDARDOPERATINGPROCEDURES,INDOORROOMMANAGEMENTPROCEDURESANALYSISANDIMPROVEMENTMEASURESTHENUMBERANDRESULTSOFINTERNALQUALITYCONTROLANDDETECTIONPRECISIONCONTROLINTHEFANSITEINSPECTIONINDOORQUALITYCONTROLCHARTANDQUALITYCONTROLOFTHEPROFESSIONALINDOOREQASCORESCERTIFICATEMAYBEISSUEDWITHINTHEINDOORQUALITYCONTROLINSPECTIONREPORT1DOESNOTMEETTHEREQUIREMENTSOFDEDUCTIONOF10POINTS,THENUMBEROFINTERNALQUALITYCONTROLPROBLEMS10POINTSAND1ITEMSOFQUALITYEVALUATIONTWOTECHNICALADMITTANCESERVICEQUALITYQATHEESTABLISHMENTOFQUALITYASSURANCESYSTEMOFWARDINSPECTION,INCLUDINGPATIENTPREPARATION,SPECIMENCOLLECTION,QUALIFIEDDEDUCTED10POINTSSTORAGE,TRANSPORT,SPECIMENSPECIMENSPECIMENRECEIVINGPROCEDURES3,ACCESSTOINDOORROOMTOSUMMARIZEANDANALYZETHERECORDS,THEREISNOSUMMARYANALYSISANDCORRECTIVEMEASURESDEDUCTED10POINTS3CORRECTIVEMEASURESOFCLINICALCHEMISTRYEQAANNUALAVERAGEPASSVIS120HEMATOLOGYROOMTOIMPLEMENTINEFFECTIVEDEDUCTIONOF10POINTSQUALITYASSESSMENTOFANNUALAVERAGEPASSMODIFIEDDEVIATIONINDEXDI2LABORATORYOFIMMUNOLOGYQUALITYASSESSMENT4WARD4VIEWSPECIMENS,INSPECTIONNOTES,ANDCHECKS3INEACHOF1NURSES,1NURSINGPEOPLEANNUALAVERAGETHERESULTSABOVETHENATIONALAVERAGEBACTERIALEQAANNUALAPPRAISALTOGRASPTHEINACCURATEDEDUCTIONOF5POINTSTHECORRECTRATEWASHIGHERTHAN80ALLTESTITEMSHAVESTANDARDOPERATINGPROCEDURES1CHECKDATA,OPERATINGPROCEDURESLACKADEDUCTIONOF5POINTS1POSITIVERATEOFBACTERIALCULTUREISMORETHAN30,EXAMINATIONRATEWAS100,2AND2FIELDCHECKURINESEDIMENTBACTERIA,URINEANDBLOODTESTRESULTSANALYSISOFTHEREGISTRATIONOFTHEDRYCHEMICALANALYSIS,ANDSTATISTICALANALYSIS,THEPOSITIVERATEANDTHEMIRRORSLAGANALYZERRECHECKRATEWAS60THEBLOODRATEANDMICROSCOPICANALYSISTOMEETTHEREQUIREMENTSDETECTIONRATE,SEEOILSPECIALMIRRORREALARMANDLEUKEMIAWHATISTHEPROPORTIONOFTHESPECIMENSHAVEBEENREIMPLEMENTED,1POSITIVERATEORBACTERIOSCOPYDOESNOTMEETTHEREQUIREMENTSOFDEDUCTIONOF10POINTSINSPECTIONREPORT,APPLYSINGLEWRITINGSTANDARDCHINESEFORM,CLEARWORDS,NOTE1NORMALRANGEFROMEACHTESTCHAMBEROFTHESAMPLE5INSPECTIONREPORTAND10SAMPLESOFBONEMARROWINSPECTIONREPORTEVALUATES1WAI,INSPECTIONREVIEWSIGNATURES1REPORT,THEREPORTINATIMELYMANNER,ADISCLAIMEROTHERSINGLESTANDARDDEDUCTIONOF5POINTSTHECONTENT2FROM210SAMPLESOFBONEMARROWINSPECTIONREPORT,FOUND1NONPRACTICINGPHYSICIANSREPORTISSUEDBYTHEDEDUCTIONOF10POINTSDIAGNOSTICREPORTOFCLINICALEXAMINATIONISSUEDBYAPRACTICINGPHYSICIANUSEOFREAGENTSANDCONSUMABLESQUALIFIED,REGISTRATIONCERTIFICATE,PRODUCTIONLICENSEANDTHEAPPROVALOF11SPOTCHECKS5KINDSOFREAGENTS,ANDTHEVERIFICATIONOFDOCUMENTS,FOUND1KINDSOFREAGENTSUPPLIESORLACKOF“THREECERTIFICATES“DEDUCTED10POINTSSENDFILESNOREAGENTWITHTHEAPPROVALOFTHEQUALITYDOCUMENTSQUALITATIVEORSEMIQUANTITATIVETESTISTHEUSEOFEXPIREDREAGENTSDEDUCTED10POINTSAGENTSHOULDBEMARKED“CRITICAL“THATISRELATEDTOQUALITYINSPECTIONPROCEDURESUSETHEBATCHREAGENTAPPROVED22CHECKSYET,FOUND1KINDSOFREAGENTQUALITYDOCUMENTSDEDUCTED10POINTS3ORIGINALRECORDSCHECKTHEDETECTION,FOUND1KINDSOFREAGENTSISNOTSTANDARDTHATISNOTMARKED“CRITICALVALUE“OR“QUALITYINSPECTIONPROCEDURESBUCKLE5BATCHINSPECTIONREAGENT34SPOTCHECKS5BATCHESOF“INSPECTION“REAGENT,1KINDSOFREAGENT“MISSINGBATCHINSPECTION“DEDUCTED5POINTS4OFALLINSTRUMENTATIONEQUIPMENTCALIBRATIONPLANTHELABORATORYCALIBRATION,THECALIBRATIONANDMEASUREMENT,1WHETHERTHEREQUIREDMAINTENANCE,THEREISNOCALIBRATIONRECORDS,NOCALIBRATIONRECORDSADEDUCTIONOF5POINTS1VERIFICATIONUNITCALIBRATIONANDMAINTENANCEPROCEDURESTHEPROVISIONSOFTHESTATE2OFTHE2INSTRUMENTCALIBRATIONOFTHEQIANGZHAMANDATORYVERIFICATIONCERTIFICATE,FOUNDASTRONGINSPECTIONINSTRUMENTISNOTDEDUCTED5POINTSTHEINSTRUMENTACCORDINGTOTHEPROVISIONSFORDIFFERENTINSTRUMENTSORAMETHODTOCARRYOUTTHESAMETESTSCOMPARINGTESTRESULTS1PHASE1VIEWTHANTHEORIGINALDATARECORDOFTHETEST,FIELDTESTOFDIFFERENTINSTRUMENTSANDMETHODSOFTHESAMESAMPLERESULTS,THEERRORISLESSTHAN1/2PTTHEACCEPTABLERANGEBEDSIDETESTITEMSARENOW1QUARTERLYCHECKSHOULDBECARRIEDOUTONTESTITEMSNOCOMPARISONTESTORNOORIGINALDATARECORDANDDEDUCTED5POINTSRESULTS1COMPARISONTESTSDONOTMEETTHEREQUIREMENTSOFDEDUCTED5POINTS2CHECKTHEORIGINALRECORDSANDBEDSIDETESTCOMPARISONOFDATA,NOBEDSIDEEXAMINATIONRECORDSANDDATAONDEDUCTIONOF5POINTSTHEDEVELOPMENTANDIMPLEMENTATIONOFBIOSAFETYWORKSYSTEMANDTESTPROCEDURESEXPERIMENTALSPECIMENSOF11VIEWDOCUMENTS,NOSYSTEMORPRACTICEFORDEDUCTIONOF5POINTSTECHNICALSPECIFICATIONSINSPECTIONREPORTREAGENTCONSUMABLESINSTRUMENTCALIBRATIONCOMPARISONTESTBIOSAFETYTHREE2CHECKTHEDOCUMENTS,REGULATIONSORASEPTICOPERATIONPROCESSISNOTSTANDARDIZEDTHEDEDUCTIONOF5POINTSONSITEINSPECTIONANDEXPERIMENTTOSEETHEPOISONOUSBACTERIAVIRUSOFTHEREGULATIONS2ISEQUIPPEDWITHPERSONALPROTECTIVEEQUIPMENTOVERALLS,GLOVES,MASKS,GOGGLES,EYEWASHWITHSTRAINSFORSTORAGEDOESNOTACCORDWITHSTANDARDDEDUCTIONOF5POINTS,NOSPECIALCUSTODYDEDUCTED5POINTS3SCENEWITHOUTTHEUSEOFPROTECTIVEEQUIPMENT,ACCORDINGTOTHEREQUIREMENTSOFEACHDEDUCTED5POINTSTHEOTHER34SCENESTERILIZERMONITORINGTHEEFFECTOFREGISTRATION,NOREGULARMONITORINGRECORDSDEDUCTED10POINTSEACHTHEALLOCATIONOFSTERILIZATIONANDAIRDISINFECTIONEQUIPMENTULTRAVIOLETLAMPORAIRDISINFECTIONEQUIPMENT,45SCENEEXPERIMENTFOUNDTHATWASTEDISPOSALPROCESSDOESNOTCOMPLYWITHTHESTANDARDDEDUCTIONOF10POINTSTHEPRESSURESTEAMSTERILIZER,SINGLELABORATORYDISINFECTIONEQUIPMENTANDUSEOFRECORDS5GASPRESSURESTEAMSTERILIZERREGULARSTERILIZATIONEFFECTMONITORING,RECORDTHEMANAGEMENTOFWASTEANDWASTESPECIMENSCONFORMSTOTHEREQUIREMENTSFORTHEMANAGEMENTOFMEDICALWASTESCLASSIFIED,PLACEDWITHSPECIALTOOLBOX,HANDCOLLECTIONPATHOGENSCONTAININGSPECIMENS,CULTUREMEDIA,STRAINS,SEEDSMUSTBEPRESSURESTEAMSTERILIZATIONORCHEMICALDISINFECTANTIMMERSIONDISINFECTION,ACCORDINGTOTHETREATMENTOFINFECTIOUSWASTE1ATLEASTONCEAQUARTERTOCARRYOUTTHEDEPARTMENTOFMEDICALSERVICESAFETYEDUCATION,IMPROVEMEDICALCLOTHINGLESSTOCARRYOUTADEDUCTIONSAFETYAWARENESSMEDICALSERVICESAFETY2TIMELYREPORTINGANDPROPERLYHANDLINGMEDICALNEGLIGENCEANDMEDICALDISPUTESNOTTIMELYREPORTINGANDPROCESSINGPOINTSAND3COMPLETEDTHEMANDATORYMANDATORYTASKSERIOUSLYANDHEALTHSUPPORTTASKS,ANDACTIVELYPARTICIPATEINTHEGOVERNMENTORGANIZATIONDIDNOTCOMPLETETHETASKOFSUPPORTINGAGRICULTUREANDTHEGOVERNMENTMANDATORYHEALTHPOINTSOFSOCIALPUBLICWELFAREACTIVITIES1DEPARTMENTSOFHOSPITALQUALITYMANAGEMENTPROFESSIONAL,COMPLEXTECHNOLOGY,ITSELFCONSTITUTESACOMPLEXTECHNICALSYSTEMTHETECHNICALLEVELANDMANAGEMENTABILITYOFTHEDEPARTMENTDIRECTORDETERMINETHEQUALITYLEVELOFTHEDEPARTMENTTOAGREATEXTENTINADDITIONTOPEERREVIEW,ASAGENERALBUSINESSADMINISTRATIVEFUNCTIONS,THEREISNOABILITYTODIRECTLYCONTROLTHEQUALITYOFTHEFORMATIONOFTHEWHOLEPROCESSLINKQUALITYCONTROL,FINALQUALITYCONTROLANDEVALUATIONISTHERESPONSIBILITYANDREGULARWORKOFQUALITYMANAGEMENTTEAMOFDEPARTMENTDIRECTORANDDEPARTMENTQUALITYCONTROLDEPARTMENTTHEQUALITYCONTROLPOINTSOFTHEDEPARTMENTWEREDEDUCTED,ANDTHEQUALITYCONTROLTEAMMEMBERSTOOK50TEAMRESPONSIBILITIES2DEPARTMENTQUALITYMANAGEMENTTEAMRESPONSIBLEFORTHEORGANIZATIONOFTHEDEPARTMENTSTAFFATALLLEVELSTOIMPLEMENTTHEQUALITYMANAGEMENTQUALITYCONTROLPOINTSATTHEENDOFFIVEATTHEENDOFTHEYEAR,AFTERDEDUCTINGTHEDIRECTORSDEANFUND35REGULATIONS,COMBINEDWITHTHEQUALITYOFUNDERGRADUATEEDUCATION,EXAMINATIONROOMANDOTHERRELEVANTREGULATIONSANDQUALITYMANAGEMENTSYSTEMIMPLEMENTATION,IDENTIFYPROBLEMS,TIMELYCORRECTIVE3DEPARTMENTQUALITYMANAGEMENTTEAMISRESPONSIBLEFORCOLLECTINGANDSUMMARIZINGTHERELEVANTINFORMATIONOFUNDERGRADUATEQUALITYMANAGEMENT,ANALYSISANDSUMMARY,ANDREGULARLYREPORTTOTHEMEDICALQUALITYMANAGEMENTCOMMITTEEANDQUALITYCONTROLDEPARTMENTQUALITYMANAGEMENTWORKNOSOCOMIALINFECTIONINDEPARTMENT1FORTHEPREVENTIONANDCONTROLOFHOSPITALINFECTIONMANAGEMENTRULESANDREGULATIONSOFTHEIMPLEMENTATIONOFTHEDEPARTMENTSOFTHEHOSPITALFEELPOINTSDEDUCTED,HOSPITALFEELGROUPMEMBERSBEAR50FOURTHEMANAGEMENTTEAMRESPONSIBILITIESOFINSPECTIONANDGUIDANCEATTHEENDOFTHEYEAROFFIVEPOINTS,THEENDOFTHEDEDUCTIONOFTHEDIRECTORSIN15TO2OFTHEFUNDANDTHERELATEDRISKFACTORSOFHOSPITALINFECTIONMONITORING,ANALYSISANDFEEDBACK,PUTFORWARDCONTROLMEASURESANDGUIDETHEIMPLEMENTATION3OFTHENOSOCOMIALINFECTIONSITUATIONINVESTIGATION,STATISTICALANALYSIS,ANDTOTHEHOSPITALINFECTIONTHEMANAGEMENTCOMMITTEEORTHEPERSONINCHARGEOFTHEMEDICALINSTITUTION4OFHOSPITALRELATEDINDICATORSOFCLEANINGANDDISINFECTIONSTERILIZATIONANDISOLATION,ASEPTICTECHNIQUE,MEDICALWASTEMANAGEMENTOFPATIENTS,PHYSICIANSANDNURSESONLABORATORYSERVICESATISFACTIONDEGREEISLARGERTHAN90EACHMONTHTOTHECLINICALDEPARTMENTSOFMEDICALSTAFFANDPATIENTSWEREINVESTIGATED,SATISFACTIONDECREASEDBY1POINTS,5POINTSDEDUCTEDTWOHOSPITALINFECTIONMANAGEMENTQUALITYEXAMINATIONCONTENTANDSTANDARDSCORINGMETHOD1ISACCORDINGTOTHERELEVANTLAWSANDREGULATIONSOFTHESTATE,INACCORDANCEWITHTHE“MANAGEMENTMEASURES“REQUIREMENTSOFTHEHOSPITALINFECTION,NOTACCORDINGTOTHEACTUALSITUATIONINTHEDEVELOPMENTOFRELEVANTSYSTEMSDEDUCTED5POINTSEACHSYSTEMDIDNOTCARRYOUTADEDUCTIONOF10POINTSFORMULATEANDIMPLEMENTTHERULESANDREGULATIONSOFTHEHOSPITALINFECTIONMANAGEMENT2ISBASEDON“FUNCTIONALREQUIREMENTS“MEASURESFORTHEADMINISTRATIONOFHOSPITALINFECTIONANDHOSPITALTHETASK,THEESTABLISHMENTANDPERFECTIONOFTHEMEDICALDEPARTMENTFAILSTOESTABLISHINFECTIONMANAGEMENTTEAM1DEDUCTED5POINTSMANAGEMENTSYSTEMOFHOSPITALINFECTION2HOSPITALINFECTIONGROUPDIDNOTPERFORMTHEIRDUTIESBYTHEDEPARTMENTOFHOSPITALINFECTIONISPENALIZED,HOSPITALTEAMMEMBERSBEAR50ATTHEENDOFTHEYEAROFFIVEPOINTS,ATTHEENDOFTHEDEDUCTIONOFTHEDIRECTORSINTHEDEANFUND153HOSPITALINFECTIONMANAGEMENTDEPARTMENTISIMPLEMENTINGTARGETMANAGEMENTRESPONSIBILITY,CLEARRESPONSIBILITIES4HOSPITALBUILDINGLAYOUT,FACILITIESAREREASONABLE5WORKPROCESSMEETSTHEREQUIREMENTSOFHOSPITALINFECTIONCONTROLTHETARGETMANAGEMENTRESPONSIBILITYSYSTEMHASNOTBEENDEDUCTED5POINTSTHERESPONSIBILITYHASNOTBEENIMPLEMENTEDFOR5POINTSTHEFACILITIESLAYOUTISUNREASONABLEANDDEDUCTED5POINTSTHEWORKPROCESSDOESNOTMEETTHEREQUIREMENTSEACHITEMDEDUCTED5POINTSWHETHERTHEESTABLISHMENTOF6CASESOFHOSPITALINFECTIONMONITORING,MONITORING,DISINFECTIONANDSTERILIZATIONOFTHENECESSARYENVIRONMENTALSANITATIONSYSTEMHASNOTBEENESTABLISHEDTHEDEDUCTIONOF5POINTSMEASURINGANDREPORTINGSYSTEMOFHOSPITALINFECTION7ISINACCORDANCEWITHTHEPROVISIONSOFTHEREPORTFAILINGTOREPORTEVERYTIMEWEREDEDUCTED5POINTS1CASESOFFALSENEGATIVE10POINTSDEDUCTED8SPECIFIESWHETHERTHERELATEDSYSTEMOFHOSPITALINFECTIONCONTROLOFKEYMANAGEMENT,INCLUDINGINFECTIOUSSYSTEMDIDNOTDEVELOPADEDUCTIONOF5POINTSDISEASEDEPARTMENT,DEPARTMENTOFSTOMATOLOGY,OPERATIONROOM,ICU,NEONATALWARD,DELIVERYROOM,ENDOSCOPEROOM,DEPARTMENTOFHEMODIALYSISCATHETERROOMANDCLINICALINSPECTIONDEPARTMENTANDDISINFECTIONSUPPLYROOMFIVE9ISTHEREAVIOLATIONOFTHENORM5MINUTESFOREACHVIOLATIONOFTHEREGULATION10ISTOSTRENGTHENTHECONTROLOFKEYPROJECTSINTHEMANAGEMENTOFHOSPITALINFECTION,INCLUDINGVENTILATORASSOCIATEDLUNGEACHOVER1MINUS2POINTS10POINTSINFLAMMATION,BLOODINFECTIONCAUSEDBYINTRAVASCULARCATHETER,INDWELLINGCATHETERINDUCEDURINARYTRACTINFECTION,SURGICALSITEINFECTION,DIALYSISRELATEDINFECTIONSETCTHEHOSPITALINFECTIONRATEOFLESSTHAN1011WHETHERTHEESTABLISHMENTOFMEDICALPERSONNELSTERILEOPERATION,DISINFECTIONANDISOLATIONSYSTEM,HANDHYGIENENORMS,NOSYSTEMDEDUCTED5POINTSOCCUPATIONEXPOSURESYSTEM1SYSTEMSDIDNOTIMPLEMENTTHEDEDUCTIONOF10POINTS12,THEREISAVIOLATIONOFHANDHYGIENENORMSVIOLATIONOFHANDHYGIENENORMS,DEDUCTED5POINTSEACH13ISTOEXAMINEDISINFECTANTANDDISPOSABLEMEDICALINSTRUMENTSANDAPPARATUSRELATEDPROOFPROOFWITHOUTAUDIT,EACHDEDUCTED20POINTS14MEDICALDEVICEACCORDINGTOTHEPROVISIONSCANBEUSEDREPEATEDLY,WHETHERTHEIMPLEMENTATIONOFSTRICTMEDICALINSTRUMENTCLEANINGANDDISINFECTIONANDREPEATEDUSEISNOTIMPLEMENTEDSTRICTCLEANING,DISINFECTIONORSTERILIZATION,EACHTIMESWEREDEDUCTED20POINTSANDMONITORINGTHEEFFECTOFSTERILIZATION15WHETHERTHEMONITORINGEFFECTISUPTOSTANDARD16WHETHERTOCARRYOUTMONITORINGOFDRUGRESISTANTSTRAINS,ANDGUIDERATIONALUSEOFANTIBIOTICS17WHETHERTOCHOOSEANTIBACTERIALDRUGSACCORDINGTOTHETESTRESULTS18WHETHERTOCARRYOUTTHEMONITORINGOFDRUGRESISTANTSTRAINSACCORDINGTOTHEREGULATIONS19WHETHERTOESTABLISHTHEOCCUPATIONALSAFETYSYSTEMFOREMPLOYEES20,WHETHEROCCUPATIONALEXPOSUREISTIMELYREPORTED21THEPREVALENCERATEOFLESSTHAN10OFHOSPITALINFECTIONRELATEDEVALUATIONINDEX,SPECIALDEPARTMENTSSUCHASICU,DEPARTMENTOFHEMATOLOGY,DEPARTMENTOFONCOLOGYISLESSTHANOREQUALTO15THENOSOCOMIALINFECTIONPREVALENCESURVEYWEREFOUNDMORETHAN96THEQUALIFIEDRATEOFDISINFECTIONANDSTERILIZATIONOFMEDICALINSTRUMENTSWAS100EACHOVER1DEDUCTED5POINTSEACHFELL1DEDUCTED2POINTSEACHFELL1DEDUCTED10POINTSMONITORINGTHEEFFECTOFNONCOMPLIANCE,DEDUCTED10POINTSEACHNOPATHOGENICEXAMINATIONANDDRUGSENSITIVITYTESTACCORDINGTOTHEREGULATIONS,EACHTIMEDEDUCTED5POINTSACCORDINGTOTHEEXAMINATIONRESULTSOFUSEOFANTIMICROBIALDRUGS,EACHWEREDEDUCTED10POINTSFORRESISTANCEMONITORINGINACCORDANCEWITHTHEREGULATIONS,EVERYTIMEDEDUCTED5POINTSFAILINGTOESTABLISHEMPLOYEEOCCUPATIONSAFETYSYSTEMDEDUCTED5POINTSDEDUCTED10POINTSTHESYSTEMISNOTIMPLEMENTEDNOTDEDUCTED10POINTSOCCUPATIONEXPOSUREREPORTTHREE,PATIENTSAFETYTARGETMANAGEMENTQUALITYASSESSMENTCONTENTANDSTANDARDSCORINGMETHODFIRST,STRICTIMPLEMENTATIONOFTHECHECKSYSTEM,THEFIRSTGOAL,STRICTIMPLEMENTATIONOFTHECHECKSYSTEM,IMPROVETHEACCURACYOFMEDICALSTAFFIDENTIFICATIONOFPATIENTSSIX1MULTIDEPARTMENTSWORKTOGETHERTODEVELOPACCURATEIDENTIFICATIONOFPATIENTIDENTITYSYSTEMANDPROCEDURESTOIMPROVEANDPERFECTEACHLINKOFEACHSECTION,THEIMPLEMENTATIONISNOTINPLACE,EACHTIMEDEDUCTED10POINTS,RESULTINGINTHEERRORBUCKLEEVERYTIMEDEDUCTED30POINTSROOMDEPARTMENTSPATIENTSIDENTIFICATIONSYSTEMINTHECOLLECTION,ADMINISTRATIONOROTHERTREATMENTBEFOREBLOODTRANSFUSIONBEFORETHEEVENT,MUSTBESTRICTLYENFORCEDTOTHESYSTEM,SHOULDATLEASTUSETWOPATIENTIDENTIFICATIONMET