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  • Bt:NH VIEN NHI THAI BINH CONG HOA XA HOI CHU NGHIA VItT NAM

    HO QUAN LY CHAT LUVNG DOc 14p - Tu do - Hunh phtic

    SO: 4020 /BVN-QLCL Thai Binh, ngay 2 dicing 7 nam 2018

    KE HOACH

    CAI TIEN CHAT LticiNG BVNH VIEN 6 THANG CUOI NAM 2018

    Can cir ke't qua phiic tra cda doan danh gia chat luting benh vien 6 thing dau nam 2018; can cu vao muc tieu ke hoach

    cai tin chat luting nam 2018 cilia Benh vien;

    H6i clang Quan 15, chat luting xay dung ke hoach cai tien diem chit luting benh vien ved cac not dung nhu sau;

    I. Muc tieu

    - Khac phvc ton tai han the da chi ra sau danh gia chat luting 6 thing diu nam cua doan danh gia, trie'n khai cac cai

    tin nham dat muc tieu diem chat luting trong 1:16 tieu chi la khong c mdc 1; con 03 mdc 2 va 08 mix 5;

    - Hoar' thien cac quy trinh, huerng din chin doan va di&t tri, quy zrinh cham soc dieu &ang, quy trinh quail 13', he

    thong theo tieu chuin iso, xay dung bang kiem danh gia su tuan thu cua nhan vier' y to ve thtrc hien theo quy trinh,

    huOng din; Cac phong chdc nang to chdc giam sat, bao cao danh gia, phan tich sir tuan thd quy trinh, twang din dm nhan

    vien y te;

    - Tang cuerng sir phi hop, chi dao cua cac H6i dOng: QLCL; DD; Thuac& didu tri, Khoa hoc&197 thuat Nnh

    nghiem titc thuc hien dm cac ca nhan, khoa, phong trong benh vien de hoan thanh not dung, rnvc tieu kC hoach cai tien

    chat luting nam 2018 cda benh vien; Ranh gia chat luting benh vien cuOi nam "theo bo tieu chi chat luting benh vien" vao

    tuan thin nhat cda tiling 10 nam 2018.

    Page 1

  • II. 1N(0 dung ke'' hoach

    Stt Tieu chi Tieu muc china dat/han the anh

    ., ' ' A ' , hiro'ng mire yeu cau cua BV

    Giai phap Chiu tract nhiem thuc hien Thoi gian thtyc hien Ghi

    , chu

    PHAN A: HUNG DEN NGU'6I BENH

    1. Chi dan, don tiep, htrong an ngtr?ri benh

    1

    A1.1 [4]: Ngu:Oi benh dugc chi dan re rang, don tiep, huang din

    [1] Chua cap nhat soy do benh vien, khoa, phong theo tinh hinh thgc te, cc') nhimg bien, bang da" di, khong con pha hop nhimg van dugc treo lam bien chi dan; Nei dung va hinh thilc ten bans bien htrang dan chua thong nh'it theo be nhan dien thtrang hieu, co, met so khoa, ph6ng chua c bien phong, chua hien thi 2 thtr tieng Anh va Viet ten met bien; [2] De nghi tir KP: Thieu bien bien vay du not dung so phong va ten phong tai met so phong cap cfru, phong each ly, benh nhan n:ang, thieu ten ghi bang 2 thin tieng (khoa truyen nhiem, PHCN, HSTC, QLCL);

    [1] He thong bien bao deng be va Jam lai vach chi dtrang,, de xuat phixong an lam mai, bang chat lieu khac, tot, ben hon;

    [2] ife, dam bao dugc mire 5 nhu ke hoach de xuat trien khai the dien tir va may tinh tien trong gift xe dap, xe may, O to tai benh vien.

    [1] Phong QTTTB la flan m6i hoan thien he theing bien bao tai benh vien; , - Ithao sat 1-1- e thong -pang bieu tai benh vien. len du town, de xuat lank dao benh vien; - Thgc hien treo he thong bien (da duce phe duyet). - Thi cong dung line chi dung t4i,khoa kham benh, sanh tang 1 (neu dugc phe duyet).

    Truk ngay 20/8/2018

    Tnrerc ngay 10/9/2018

    Trtrerc ngay 30/9/2018

    cu the: QTTTB, Mau than, 3CK Dlige

    [2] Phong TCHC lam (ILI mOi de xuat Lanh dao Benh vien, don vi coi xe thgc hien hoat Ong quan ly nha xe: Then khai img dung CNTT vao thu tien giri xe qua the tir;

    [*] Liu ST: - Phong TCHC: + Chiu trach nhiem ye rkii dung hien he thong ceia benh Wen; - PhOng QTTTB: + Chiu trach nhiem ye r..oi dung hien phat sinh trongbenh vien;

    + Chiu trach nhiem lam cac bien theo not dung de nghi tie cac khoa, khi chive phe duyet cz,ia Gicim doe Ik'nh vien. _phong

    2

    A1.2 [4]: Nguoi benh dugc ch6

    trong phong day du tien nghi va dugc van chuyen phi" hop vai tinh tram benh tat. Truyen nhierm Ho hap

    [1] Quy trinh kham, sang 19c benh truyen nhiem dugc xay dung, thieu ngay ban hanh, chua cap nhat vai quy trinh kham mei; [2] Khuan vien phong khan_, khoa truyen nhiem chat chei nen be tri khu vise sang 19c, phan loci, van chuyen ngtroi benEt ngay tai khu virc tiep den con chua co.

    [1] Xay dung va ban hanh quy trinh, sang _19c, each ly benh truyen nhiem bien soan; ban hanh va phat ye cho cac KR

    [11 Phi:mg KHTH lam (fan mOi tren co' si5r quy trinh sang 1oc, each ly berth truyen nhiem: - Khoa KB, TN chiu trach nhiem ye chuyen mon cap nhat, xay dung, thong nhat quy trinh - Bien soan, ban hanh va phat ve cho cac KR

    Trtrik ngay 10/8/2018

    Trtrerc ngay 20/8/2018

    Page 2

  • Stt Tieu chi Tieu muc chua dat/han the anh

    Inning mirc,yeu can cua BY Giai phap Chit' trial nhiemtiny hien

    r Thesigian tiny hien

    Ghi chirr.

    Ngoai [3J Clara CO bang chirng xac dinh tien hanh khao sat dinh Icr tren pham vi toan benh vien, lap danh sach cac vi tri tinh toan nhu cau de ,cung cap mua mai, sita chira ghe cho phuc vu cho rived berth den kham benh.

    [2] BV bo: tri khong gian din phong trien khai khu sang 19c, cach ly khi co benh dich tai kham benh va tai benh vien.

    [2] Khoa KB, TN: - Co phucmg an trier! khai - Bo tri hien him ye guy, phong, khong gian cho khu kham, sang 19c, cach ly dam bao khi CO dich 'thy ra la trien khai dung nhu phtrang an de ra

    Trtrac ngay 10/8/2018 Trtrac ngay 20/8/2018

    [2] Khao sat dinh lcSr teen pham vi toan benh vien, lap danh sach cac vi tri filth toan nhu eau de cung cap mua mai, situ chfla ghe cha phuc vu cho ngueri benh den kham Nnh.

    [3] Phong QTTTB chin trach nWm: s - Khao sat ve nhu eau, sue chita ghe cho cho nguoi benh ngoai tit - Thut hien lap cac bang chirng &rc hien hoat ding sira chila, mLa sap phuc vu berth nhan den kham benh tai benh vien.

    Truirc inky 30/8/2018

    Ltru lei I% bing chting da cung cap ghe ch?r cho khu vire KB

    r] Lim ST: - Khoa KB, Truyen nhiem khao sat va len phtrong an khi do dich 14nh xay ra tai bOh vien; chuan bi son sang cac dieu kien nhu: [1] xac,dinh clueing di rieng; [2] bang bien huc'mg dan duang di rieng danh cho ngueri benh truyer! nhiem; [3] bo tri phong, khu vuc don tiep, kham sang 1pc, [4] van chuyen benh nhein den khu vuc each ly hen the tai da viec lay cheo sang cac benh nhcin khac, khu vuc khac trong khuan vien benh Wen

    - Phng QT-TTB: + Doi voi throng line chi dan tai khu vuc don tiap, kham benh va CDHA; Phong QTTTB phoi hop vai phong QLCL thong shat vi tri, mau sac, not dung czia cluing line truac khi lap phuang an thi cong, du toan kinh phi va tien dO cong viec trinh giam doe. Benh vier'

    phe guy-et; va giam sat don vi thi cong dam bao an toan, chat luting, thing thai gian. + Doi voi viec khao sat ghe chi" viz 66 tri ghe chit cfianguiri benh tai khu v(rc klubn b0h, can lam sang va not tra: Khoo sat toan bO he thong ghe cho tai benh vien; co Id hooch cu the thay the, mua bo sung, lam mai tai cac khu vuc can thiet,.. phe duyet Giam d'Oc B'enh vien va trien khai thi cong dam bao thai gian quy dinh.

    3

    A1.4 [3]. BV bao dam cac, truing hop cap dru nguai benh kip thoi: KHTH,

    [1] Con met so khoa, phong khong luu "van ban ve Mir to urn tien kham va xir tri cho doi tuong ngueri benh cap cfru (neu c6 along nguai benh cap cfru)". [2] Co quy dinh dm china ngay cho

    Berth vien ban hanh cac quy trinh, quy dinh, huang dan lien quan den hoat cling chuyen mon KCB

    [1] Phong KHTH IA dau mai can that, xay dung quy dinh, quy trinh dinh lien quan den haat ding chuyen mon nhu - "Thir to tru lien kham va xir tri cho dOi Wong nguiei berth cap

    Triro'c ngay 20/8/2018

    Page 3

  • Stt Tieu chi iT Ghieu muc chua (.14t/h4n the anh htOng mire yen cau Oa BY chit

    Giai phap.

    Chili trach ihiem thuc hi0 Theri gian thirc hilen

    CC,PHCN, NGOA1, DISQC

    nguoi benh cap ciru trong twang hop chua kip dong vien phi hoac khOng co nguoi nha nguoi benh di kern. , [3] MOt s6 khoa chua co "quy dinh ye hOi chan nguoi benh, trong do co h6i chan' nguoi benh 'tang da99 ban giam doc/truang phong Ke hoach tong hop phe duyet". [4] cac KP: CC, HSTC, DTTN, TH, PHCN, QLCL, de nghi Phong KHTH cap that va xay dung med. (KSS-Hop rift kinh nghiern KQ danh gia CC)

    ciru" - "Ciru chi-re. ngay cho nguoi benh cap cum tong trirong hop chua kip dong vien phi hoac IchOng co nguoi nha nguoi benh di kern" - "Quy dinh ve hOi chan nguoi benh, trong do c6 hOi chan nguoi benh nang lige ban giam d6c/truang phong Ke hoach tong hgp phe duyet". [2] Phong KHTH tham muu va chit tri to eh& HOi nghi Hop rut kinh nghiern &nit 2id cong tac cap ciru nguoi benh --...ai benh vien

    Truk nay 20/9/2018

    [*] Ltru Si: - Phong KHTH IA dill mili thong nhAt Bien sown not dung & phe duyet nhang quy dinh tren (sap khi coy E'en dm cac khoa lam sang, kham benh, HOi dong ehuyen mOn). - Thong nhat chung 1 the thicc (phe duyet ma-ket trw6t khi in) va cung cap cac bieu mau tren cho cac khoa, phong trong benh vien theo yeu cau & clang quy clinh sic dung tai lieu; (luu tai KHTH, QLCL). - Thyv hien citing theo quy clinh v' thoi gian cid yeu cau tai k' hoach.

    4

    A1.5 [4]. Ngtreri benh duoc lam cac this tuc dang ky, kham benh theo dung tha ti'r No dam

    tinh cong bang va mirc uu tien KHTH, K.B

    [1] CO quy dinh Ye 'dui tugng nguoi benh dugc uu tien duos ban giarn" d6c phe duyet.

    [2] Co bo phan phat so (bang

    may hoac this cong dat tai b9

    phan tie'', don khu kham berth) va

    , . , , huang clan nguai berth xep hang.

    xin 02 may lay so to clung)

    [1] Cap nhat, xay dung, xin phe duyet va ban hanh quy dinh ye dui Wong nguoi benh dugc uu tien kham benh

    Phong KHTH lam dAu m6i Gang khoa KB cap nhat xay dung quy dinh "Doi tugng Liu tien kham benh" va niem yet tai khoa KB, teen Website ctia BV

    Truk ngay 10/8/2018

    [2] Trang bi may lay s6 to -

    dOng de d