【正文】 ........................................................................................................................13一、預(yù)約診療服務(wù)（可選，縣醫(yī)院為必選）...................................................................................................13二、門診流程管理.........................................................................................................................................14三、急診綠色通道管理. ...............................................................................................................................15四、住院、轉(zhuǎn)診、轉(zhuǎn)科服務(wù)流程管理....................................................................................................19五、基本醫(yī)療保障服務(wù)管理.............................................................................................................21六、保障患者合法權(quán)益.................................................................................................................................22七、投訴管理.................................................................................................................................................24八、就診環(huán)境管理.........................................................................................................................................25第三章　患者安全 ....................................................................................................................................27一、確立查對制度，識別患者身份...............................................................................................................27二、確立在特殊情況下醫(yī)務(wù)人員之間有效溝通的程序、步驟...................................................................29三、確立手術(shù)安全核查制度，防止手術(shù)患者、手術(shù)部位及術(shù)式發(fā)生錯誤.................................................30四、執(zhí)行手衛(wèi)生規(guī)范，落實(shí)醫(yī)院感染控制的基本要求.................................... ..........................................31五、加強(qiáng)特殊藥物的管理，提高用藥安全...................................................................................................32六、臨床“危急值”報(bào)告制度....................................................................................................................33七、防范與減少患者跌倒、墜床等意外事件發(fā)生... .................................................................................34八、防范與減少患者壓瘡發(fā)生....................................................................................................35九、妥善處理醫(yī)療安全（不良）事件...............................................................................................36十、患者參與醫(yī)療安全............................................................................................................................37第四章　醫(yī)療質(zhì)量安全管理與持續(xù)改進(jìn) ................................................................................................38一、醫(yī)療質(zhì)量管理組織.................................................................................................................................38二、醫(yī)療質(zhì)量管理與持續(xù)改進(jìn).....................................................................................................................40三、醫(yī)療技術(shù)管理........................................................................................................................................43四、臨床路徑與單病種質(zhì)量管理與持續(xù)改進(jìn)（可選，縣醫(yī)院為必選）...............................................46五、住院診療管理與持續(xù)改進(jìn).....................................................................................................................48六、手術(shù)治療管理與持續(xù)改進(jìn).....................................................................................................................54七、麻醉管理與持續(xù)改進(jìn)............................................................................................................................58八、重癥醫(yī)學(xué)管理與持續(xù)改進(jìn)（可選，縣醫(yī)院為必選）........................................................................63九、感染性疾病管理與持續(xù)改進(jìn)................................................................................................................66十、中醫(yī)管理與持續(xù)改進(jìn)............................................................................................................................69十一、康復(fù)治療管理與持續(xù)改進(jìn)................................................................................................................71十二、疼痛治療管理與持續(xù)改進(jìn)（可選）....................................................................................................73十三、精神科疾病的管理與持續(xù)改進(jìn)（可選）.........................................................................................75十四、藥事和藥物使用管理與持續(xù)改進(jìn)....................................................................................................78十五、臨床檢驗(yàn)管理與持續(xù)改進(jìn)................................................................................................................88十六、病理管理與持續(xù)改進(jìn).........................................................................................................................96十七、醫(yī)學(xué)影像管理與持續(xù)改進(jìn)...............................................................................................................103十八、輸血管理與持續(xù)改進(jìn)......................................................................................................................106十九、醫(yī)院感染管理與持續(xù)改進(jìn)..............................................................................................................112二十、血液凈化管理與持續(xù)改進(jìn)（可選，縣醫(yī)院為必選）..................................................................118二十一、醫(yī)用氧艙管理與持續(xù)改進(jìn)（可選）...........................................................................................124二十二、其他特殊診療管理與持續(xù)改進(jìn)（可選）..................................................................................127二十三、病歷（案）管理與持續(xù)改進(jìn)......................................................................................................131第五章　護(hù)理管理與質(zhì)量持續(xù)改進(jìn)........................................................................................................136一、確立護(hù)理管理組織體系.......................................................................................................................136二、護(hù)理人力資源管理...............................................................................................................................138三、臨床護(hù)理質(zhì)量管理與改進(jìn)..................................................................