【正文】 山東大學(xué)齊魯醫(yī)院三 甲 復(fù) 審 全 員 應(yīng) 知 應(yīng) 會(huì) 手 冊(cè)二 O 一二年一月1目錄第一章 醫(yī)院評(píng)審基礎(chǔ)知識(shí) ....................................................................................................1 ....................................................................................................1 ....................................................................................................1 ............................................................................................1 ....................................................................................................1 ....................................................................................................1 ................................................................................................1 ................................................................................1 ....................................................................................................2 ..........................................................................................2 ..............................................................................................2 ..................................................................213.《三級(jí)綜合醫(yī)院評(píng)審標(biāo)準(zhǔn)實(shí)施細(xì)則》指標(biāo)體系構(gòu)成 ......................................214.《三級(jí)綜合醫(yī)院評(píng)審標(biāo)準(zhǔn)實(shí)施細(xì)則》項(xiàng)目分類(lèi) ..............................................2 ......................................................................................................2 ......................................................................................................2 ..........................................................................................2 ......................................................................................3 ..........................................................3 ..........................................................................3 ......................................................................................3第二章 醫(yī)療質(zhì)量與醫(yī)療安全管理 PDCA..........................................................................................................5 ....................................................................................科兩級(jí)質(zhì)量管理組織 ........................................................................5 ........................................................................................................5 年患者安全目標(biāo)及措施 ...............................................................................7 ........................................................................9 ..............................................................................................10 ......................................................................................11 ..................................................................................12 ........................................................................................12 ........................................................................................122 ................................................................................14 ................................................................................................14 ................................................................................................14 ....................................................................................................15 ........................................................................................16“三基三嚴(yán)” ........................................................................................17 ............................................................................................17 ....................................................................................17 ....................................................................................18 ............................................................................................18 ................................................................................................18 ....................................................................18 ............................................................................................19 ................................................................................................19 ....................................................................20 ....................................................................................20 ................................................................................20 ................................................20 ................................................................................21 ........................................................................21 ....................................................................................21 ........................................................................21 ........................................................................................23 ................................................................................................23 ........................................................................................23“優(yōu)質(zhì)護(hù)理服務(wù)示范工程”活動(dòng)是哪一年開(kāi)始的 ............................24“優(yōu)質(zhì)護(hù)理服務(wù)示范工程”活動(dòng)的主題和目標(biāo) ................................2439.“優(yōu)質(zhì)護(hù)理服務(wù)示范工程”要求的六項(xiàng)工作內(nèi)容 ........................................2病房排班模式 ............................................24 ................................................24 ........................................................................................24 ........................................................................................24 ................................................................24 ....................................................................25 ....................................................................................25 ..