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 có 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, htro•ng 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 có 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 dam bao cong bang cho benh nhan khi den dang ky kham berth.(KKB d'e nghi

Khoa Kham benh tham khdo dua ra cauhinh may dukten mua-,, Lap de nghi benh vien cung cap.

[*] 1-,,u11 Sr: - Thong nhat de nghi mua them 02 may * so tie dong cela phong kham, ba tri 01 tai khyvyr kham thu6ng va 01 tai khu vyy to nguyen; giao Phdng CIVT7' tham muu cho GDBV ye cauhinh, gia Ca clia may lay so ttr dOng tren (shin c6 bao ccio phan hoi cho GDBV)

Page 4

Stt Tieu chi .x

Tieu muc chua dat/han cite anh htroug mirc yeu can cua BV

Giii phap Chiu trach nhim thuc hiO Thoi gian attic hi0 Ghi chit

- Khoa KB & Phong CNTT cung phari hop len phuong an ket not die lieu (theo de nghi dia

khoa KB) va som bao cao ket qua vOi GDBK QLCL; ‘ - Thgc hien clang theo quy dinh ye thari gian dd yeu cau tai ke hoach.

2. JEksu kin ca sa vat chat phut vv nguoi benh

5

A2.2. [3] Ngtrai benh dtroc sir dung bu6ng ve sinh sach se va day &I cac phuong tien.

[1] Khoa can 1pm sang b6 tri bu8ng ve sinh de ngtrai benh lay nu& tieu xet nghiem VA trong buong ve sinh c6 gia de benh pham va san c6 ntrev, xa-phong rira tay; [2] Buong ve sinh sash se, khong c6 nuoc dlong„ khong c6 con trimg.

[1] Cai tao nha ve sinh danh cho ngtrai benh:

- Thtet ke gia de xet nghiem tai nha ve sinh; - Nha ve sinh sach, c6 check list theo dOi, danh gia chat luting ve sinh. - M6c treo quart' ao d6i voi NVS khep kin;

[11 Phong QTTTB lam &au moi ra soat, de xuat phucmg an cai tao len GD3V phe duyet - Cai too b6n, nen, ..... NVS

- B6 tri m6c treo quern do, dung cu, gia dung xet nghiem,...

- Khoa KSNK kiem soat chat luting lam ve sinh-co checklist.

[1] Hoan thien tnrk ngay 30/9/2018; Giam sat chat luting, phtrang tien KSNK, cac KR

[2] Dat Xa phong/dung dich rira tay tai nha ve sinh (Ap dung cho phong yeu cau)

[2] Cac khoa c6 phong yeu cau.KSNK, cac KP giam sat chat lugng, phuong den.

Truk ngay 30/8/2018

[*] Ltru Si: - Giao phong QTTTB thuc hien stea chaa,thay moi tinet bi tai lySV phyc vu rigufri benh. - Khoa KSNK giam sat ye lap moi cac thiet bi nhu mac treo quern ao, gia de "Ong xet nghiem. - Thvc hien clang theo quy dinh ye then gian der yeu .1-..clu tai ke hoach.

6

A2.3.[2] Ngtrai benh, duoc cung cap vat dung ca. nhan day du, sach se, chat Luang tot.

[1] Nguai benh khi nhap vien &roc cung cap mot b8 quern ao der dtrac giat sach, khong rach. [2] Nguai benh khi nhap vien ., . dtrac cung cap day dit cac vat dung ca nhan nhu vo than, v6 g8i, vai trai giuong (hoac shieu neu ngtrai benh co yeu cau tai cac khu vuc nong thOn). [3] Cac khoa CC, PHCN, TH, DD, HH, QLCL,3CK...de xuat By c6 ca so va trien khai cung cap cho benh nhan dich vu.

[1] Khoa KSNK, PDD phi hop len danh muc nhung khoa nao cung cap quern do cho n&troi benh, trien khai cung cap. [2] Ph6ng DD xay dung danh muc vat dung ca nhan nao benh vien se cung cap cho no/6i benh; va trien khai that hien. [3] Trien khai, danh gia hieu quern hoat dOng cung cap cho nguai benh.

[1] Phi:mg OD lam dau moi len danh sach cac Ichoa, cung cap va danh muc cung cap vat dung ca. nhan cho timg KP. [2] De xuat GDBV trang bi va phucmg an trien khai toi cac KR [3] Trien khai va bao cao ket qua dinh k3i.

[1] Trien khai ke hoach fru& ngay 20/8/2018.

[*] Ltru Si: Phong Dieu duffing lam d'au moi: [1] Lap danh muc cung cap vat dung, do ding ca nhan cho

Page 5

Stt : Tieu chi : • • ::: - • • • hiring mire yeu cau cua BV

Tieu muc chtra.dat/han the anh - Giii•phap Chiu track nhiem thu'c hien. Thoi gian thtrc. hien

Ghi ,•

chit

benh nhan nhap vien dieu tri tor benh vien; [2] Lam de nghi chuyen Phong QIT1B mua sap, nhan hang sau mua sap [3] PDD phoi hop yen cac khoa lien quan trien khai cho benh nhan di& tri not tra mum; [4] Trien khai hoot d'Ong cho benh nhan =con truerc 30/8/2018.[5] Thvc hien clang theo quy clinh ye thai gian cid yeu cau tai ke hooch.

7

A2.5. [4] Ngugi Ichuy& tat dugc tiep can day du vai cac KP va dich vu KCB trong benh vien

[1] Ntia v" sinh khu kham benh c6 buong ve sinh danh qng cho ngugi tan tat, (lugc, thiet ke I-a

di de xe Lau. tieD rOng va c6 den can dugc den cac be xi, nggi, c6

tay yin tai NI. tri be xi ngoi...).

[1] Lap them tay yin cho ngugi tan tat tai nha ve sinh.

[1] Phong QTTTB du tit kinh phi mua va lap ngay tai cac nha ve sinh.

Tnro'c ngay 15/8/2018 hoan thanh lap tay yin tai cac phOng ve sinh (it nhAt 1 phong/ 1 tang).

[*] Lau y:

Phong QTTTB: [1] Mua va cung cap' xe lan danh cho nguffi tang tat (duyet cau hinh xe) yeti so luvng Olxe/01 tang; then gian sore nhjt; [2] nix hien lap cow tay vin tai nha ve sinh cho nguai tang tat; so hrcmg Olxe/01 tang. [3] Thvc hien dung theo quy clinh ye thai gian cid yeu cau tai ke hooch.

3,. Dieu kien cham sec ngtrgi benh

8

A3.2. [4] benh

dugc kham va dieu tri trong khoa, pheng gon gang, ngan nap.

[1] CO tit gift 6 cho ngugi ,benh va nguari nha ngugi benh neu có nhu cau tai khu kham benh (b. phan don trep huang dan vies tong gift do hoac gift chia khOa to gift do). [2] Moi gitrOng berth, c6 mot tit dau giugng sir dung tot, khong bi hoen gi. [3] Trong nom co to chirc giefi thieu va tap huan phuang phap 5S cho nhan vien. [4] Ap dung phuang phap 5S tai khoa KB, XN, 2 khoa LS.

El [1] 'ilh vien co tit gift d6 cho nguai nha ngoai hanh lang, c6 du tit ;15.0 giugng cho nguoi benh dieu tri not tit;

[1] Cung cap ,. dauNgugi

[1] Phong DD-QTTTB lam a to u mai ra soat, de xua't GDBV trang bi mua tit gift do; mua tit dau giugng;

gitrang, to gift do cho benh vien tilt& ngay 20/9/2018.

[2] Benh vien to chirc tap huan 5 S tai BV. , [3] Thuc hanh 5S tai mot so khoa phong (khoa KB, 01 khoa CLS; 02 khoa LS).

[2] PhOng QLci, lam au m6i to chirc tap huan va trien khai ap dung 5S tat cac khoa trong benh vien;

[2] Tap huan" 5S tai BV truac ngay 05/8/2018. Trien khai thuc hanh 5S tai it nhat 5 KP trong BV; Bao coo danh gia trugc ngay 20/9/2018.

[*] Ltru Si: - Phong QTTTB:‘ [1] ra soat loi so hcong tit day givang trei? toan benh vien, mua moi ba xung chi so lulong titdau gialong tren toan benh vien; [2] ra soat so luvng titde do cho ngu:ai benh ke tai hanh lang, mua bo sung chi so luvng to de do cho benh nhan cho cac khoa,, co so it nhat 01 ta/01 khoa; [3] Thav hien clang theo quy clink ve thai gian d'd yeu cat' tai ke hooch.

4. Quy'en va lcri ich ctia nguiri b?nh

8

A4.1. [4] Nguoi bent , dirge cung cap thong tin va tham gia vao qua trinh dieu

dugc cung cap [1] NgtrOd ye thOng tin ye cba'n, clown, nguy ca,

tien luang, du ici:en phuang phap va tiled gian dieu tri khi nhap vien. [2] Nguei benh dugc thong bao

[1] Co ban huang an, quy dinh cho cac bac sy, dieu duang...cupg cap th6ng tin cho NB, t6i thieu bao gem th6ng tin ye chan down, nguy ca, tien luang, du kien

[11 Phong 10-1TH lam dau mai huang dan quy trinh, quy dinh cung cap thong tin ve chan down, dieu tri; va ban hanh trong benh vien. vi du "Phieu tarn tat thong tin

Truac ngay 05/8/2018, ban hanh va trien khai tai benh vien

Page 6

Stt: . . Tieu chi A

Tien muc chtra dat/k#n che anh :: • hirong mirc u yeu cau cua BV

Giii phap Chiu trach nhiem thirc hi'n . Thbi gian thtrc hien Gh

,i

chu

tri cong khai so luting -..-huoc va vat to tieu hao sir, dung hang ngay. [3] Co it nhat 50% tong so cac khoa Jam sang xay dung "Phieu torn tat thong tin dieu tri"* cho mot benh thuang gap tai khoa, sir dung tir d'6 hieu cho nguai benh.

phucmg phap va thai gian dieu tri khi nhap vien.

dial"' tri".

[2] Benh vien co ban quy dinh, twang dan yeu cau cong khai thuOc va vat to tieu hao sir dung hang ngay cho NB.

[2] Phong Dieu throng quy dinh huang dan yeu cau cong khai thuoc, vat to tieu hao sir dtmg hang ngay.

Tnrac ngay 05/8/2018, ban hanh va trien khai tai benh vien

[3] Danh gia ket qua tri6n khai

[3] Bao cao cac hoat &Ong tri'L khai tai berth vien dm KHTH & DD.

Tnrekc ngay 20/9/2018

9

A4.2. [4] Nguai benh duoc ton tr9ng quyen rieng tir

[1] Co quy dinh ve pan 1S7 va luu frit benh an chat che tai khoa lam sang va cac phong chtic nang. [2] Ngtrai henh có quyen km gia thong tin ye ket qua can lam sang mang tinh "nhay cam", co the gay bat 19i ve mat tam 1Sr, uy tin, cong viec dia nguai benh. BV chi dugc cung cap thong tin cho nguai nha nguai benh (hcac nguai khac co yeu cau) dugc chink nguai benh cho phep (trir tr.x.ang hop theo yeu eau cu co quan c6 tham quyen bang van ban)., [3] Nhan vien, y to co trach nhiem bao ve quyen rieng ti nguai benh ngan khong cho nguai ngoai vao chup anh to do ngtrer'_ benh va bao mat hinh anh nguai benh. [4] San co vach ngan hoac rem che di dOng tai cac khoa lam sang de phuc vu nguai benh trong cac mrong hop tham kham 41 chii, lam thit thuat hoac thay doi quan do, v'' sinh tai givang. (De nghi dm Khoa KB, TH, CDHA, QLCL,...)

[1] Co van ban huang ean viec quan 1ST va luu MI benh an tai tai khoa lam sang va phong chirc hang. [2] - CO van ban, guy& dinh, quy dinh dm BV huong dan khong cong khai cac thong tin dia nguai benh lien quan den mot so benh tat. Khong co truang hop 1)1 10 thong tin "nhay cam".

[11 Phan KHTH la dill mOi ban hanh: - "Quy dinh quan & 1S, luu frit HSBA tai khoa Lam sang va cac phong chic nang",_ - "Quy dinh huang dan khong cong khai thong tin cila nguai benh lien quan mot so benh(vi du HIV/AIDS, lau, giang mai, ung thu...)"

Trtgfc ngay 10/8/2018

[3] CO bien hien ,khong chup anh nguai benh neu chtra nhan dugc &Ong ST du nguai benh tai cac sanh, vi du "Vui long khong chup hinh quay phim, ton tong quyen rieng to nguai benh". [4] San c6 vach ngan hoac rem che di dOng. Vach ngan hoac rem che di dOng van hanh thuan tien khi dOng, ma.

[2] Phong QTTTB la dau mill lam:

- Poster "Cdm quy phim chip anh".

- Lam rem che, binh phong phuc vu kham benh, lam thit thuat tai cac khoa lam sang, can lam sang.

Hoan thanh trtnk ngay 20/9/2018.

[*] Ltru 57:

- Phong QTTTB la Tau moi: [1] phai hop vai cac khoa tong hop so luting, kieu clang; [2] phe duyet mua va [4] cung cap cho cac khoa phong dam bao yeu cau thue3c tieu chi [4] Thifc hien

Page 7

Stt Tieu chi Ti'C'u muc chua dat/han the anh

• • • : x • hirong mire yeu cau cua BV

Giii phap Chiu trach nhi?nr dug hi0 TWA gian thtrc hi0 Ghi chn

thing theo quy dinh -14 that gian cua yeu cau tai Ice hoach.

to

A4.3. Ngu6i benh dugc n6p vien phi thuan tien, cong Ichai, minh bach, chinh xac

[1] Nv6i benh nOp vien phi tai cac dia diem thu nOp do benh vien quy dinh, có Ma don theo dimg quy dinh cua tai chinh hoac quy dinh cua benh vien. [2] Npr6i benh dugc thong bao va to van tru6c khi bac, sy chi dinh cac ky thua‘t cao, thuoc dac tri, xet nghiem, chan down hinh anh, thaw do chirc nang dat tien hoac co chi phi lan. [3] Bang ke dugc in va cap cho ngu6i benh khi n6p vien phi ra vien hoac Icham benh ngoai tit. [4] Khoa de nghi: Khoa CC;

[1] - Nguei benh deu dugc . nhan hoa don. Quy cach va cac ' thong tin tren hoa don theo

dung quy dinh tai chinh hoac quy dinh cua benh vien (trtr6ng hop nay can lciem tra quy dinh cua benh vien va doi chieu yoi him don thirc te). [2] Toan b6 NB c6 sir (king cac dich vg, ky thuat c6 chi phi lOn dugc thong bao va to van day du truot khi bac sy th4c,hien. [3] Toan b6 NB dugc cap bang ke khi n6p vien phi ra vien hoac kham benh ngoai trit

[1] PhOng TCKT, KHTH la dau mai "Thiet ke bang ke chung cho cac knoa, phong trong benh vien".

Truk ngay 01/8/2018

11

A4.5. [4] Ngtr oi benh coy kien phan nan, thac mac hoac khen nggi dugc benh vien ti6p nNn, phan hoi, giai quyet kip thin

[1] Co hinh thirc ghi lai cac Y Id& phan hoi cuar,igtroi benh va phuong Inr,ong, ket qua xir lY (ghi lai bang so, may tinh, hoac phan mem quan lY theo doi...). [2] Cdc y kien cua nguai benh dugc chuyen den cac ca nhan, b6 phan c6 lien quan va dugc phan hoi hoac giai quyet kip th6i. [3] Co bao cao phan tich "nguyen

• A than goc re" cac van de ngu6ri benh thuong phan nan, thac mac xay ra do loi dia ca. nIfdn (bac sy, dieu duong...) hoac do loi chung oh town benh vien, 16i chung cua nganh (16i he thong)

[1] CO so sach hoac phan mem [1] ghi nhan cac Y kien phan hoi cua ngtr6i benh. S6 sach, phan mem c6 ghi va km cac Y kien NB. [2] CO quy dinh hoac quy trinh huong dan xir VT thong tin, y kien cua NB.

Phong TCHC li dau m6i - Ban hanh Quy trinh ti6p nhan va xir 1.3% thong tin chung cho toan benh vien; Cac khoa, phong cu the h6a tir quy trinh BV theo chirc nang nhiem vu dm don vi.

Truirc ngay 05/8/2018

[3] Trong bao cao co 'nue phan tich "nguyen than goc". Phucmg phap phan tich "nguyen nhan goc" can dugc hoc va cloc tir cac tai lieuquan ly chat ltron. Co de xuat cac giai phap Ichac phuc 16i ca nhan va loi chung cua benh vien.

* Phong TCHC la dill, mOi - Tiep than thting y kien phan nan, thac mac qua he thong theo doi dm benh vien, cung cap cho phong QLCL. * Phong CTXH la dAu mOi thu than nhimg thong tin tir float d6ng nhitn tin, phan h6i sau khi ra vien dm ngua,i benh, mang xd hOi cung cap cho ph6ng QLCL. * Phong QLCL thu than

Bit Tau thu th4p thong tin tir ngay 01/8/2018

Page 8

Stt Tiewchi .• A

Tieu muc iehtra d4t/h#n che anh

htrang mint veu du dm BV Giai phap - 'Chill trach nhiem thtyc hien Thai gian thtrc hien

, Ghi

chu,

thong tin va xir 1Sr, phan tich, lam bao cao.

[1 Lieu 57:

- Phong TCHC: [1] Phai hop voi Phong QLCL Thong nhcit bieu mart ghi nhan Y kien, phan,

that mac, thin khen ... cita ngtfai benh, ngtreri ima ngtroi benh thong, qua: so dien thoai‘dirong

day nong; horn thu- gop Y; tiep dan, ... [2] Thong ke' danh sach j kin va gwi girt* lieu ye phong

QLCL (Ent& 16h00 ngay 20 hang thong - de phong QLCL tong hop bao cao tai HD QLCL vao

ngay 25).

- Phong CTXH: [1] Phai hop vii Phong QLCL Thong nhat bieu ma-u ghi nhan 3', kien, phan,

thac mac, khen, ... cita ngtroi benh, ngtreri nhel nguoi benh thong qua: so dien thogi cham soc

khach hang; qua wing xa hOi (trang facebook,fanpage lien quan Glen phan anh ve benh vien,

trang website clia benh vien,...) ... [2] Thong ke danh sach Y kien va git giu lieu ve phong

QLCL (trtrov 16h ngay 20 hang awing - de phong QLCL tong hop bao cac tai HD QLCL vao ngay 25). - Khuyen khich cac don ca nhan, khoa phong trong benh vien: [1] Cnii cac 3'; kien, phi:1F,,

thac mac, khen, ... clia ngtrol nha ngithi berth, theo rnau (trong email cila cac khoa, phong) ye phong QLCL qua Oa chi email: phongoanlychatluongbvn@gmail.corn (heu co the xin giii

truck ngay 20 hang thong - de phong QLCL tong hop bao cao tai HD QLCL vao ngay 25).

12

A4.6. [5] Beth vien thgc hien lchao sat, danh gia six hai long n -trai benh va tien hinh cac bin phap can thiep.

[1] Xay dung ke hoach cai tien chat krong clga tren ban danh sach xac dirt cac van de uu tien can giai guyet [2] Tien hanh cai tien 9hAt Luang theo ke hoach va có bang chimg cho sir thay doi.

[1] Thgc hien khao sat theo quy dinh;, [2] CO ban ke hoach cai tien; Co bang chimg minh hoa cho sir thay doi tilt& va sau tai nhfing khoa co t$, le hai long trubt can thiep thap.

Phong QLCL lam dawmoi - Khdo sat, thong bao ket qua , - Hop vii don vi có diem thap n1 t; - Xay dtmg KH cai lien - Danh gia va neu sir thay cfOi sau cai tien.

- Khao sat su• hai lOrig dung Thai gian quy dinh bat Nu tin QuS, 1.2018 - Thw.-_, hien cai tien khi c6 vAn_ des chAt luting;

cao danh gia thay - doi doi tnrac sau can thiep truot ngay 30/9/2018

PHAN B. PHAT TRIEN NGUON NHAN LlcrC

1. So luvng va co. eau nhan lire

13

B1.1. [4] Xay dung ke hoach phat trien nhan lut berth vien • • •

[1] CO quy Binh cu the tuyen dun, uu dai nguon nhan tat y to co chat Luang. [2] Tien hinh danh Oa viec thut hien ke hoach phat trien nhan Luc y to hang nom .

[1] CO van ban, quy dinh ve viec tuyen dung nhan Luc y te. Trong van ban do có chi ra cac hinh thirc tru, tien, uu dai cho nguiyi co chat hrong tot hon. Ca9 hinh thirc uu tien co the Ja the TO dai ngO, hrong, php cap hoc phi tai chinh.

Phong TCHC la au mili thgc nhart, hre: hien cac hoat

ve - quy dinh v,e viec tuyen dung nhan hit y to (chi ra cac hinh

thirc uu tren, ,uu dai cho ngtrai ca chat luting tot hon; tru tien co tke is ch-A c/0 dai ngO, luting, phy cap hoac phi tai chinh)

134 sung vao quy 3/2018

Page 9

Stt Tien chi Tieu muc chua d4t/h4n the anh

huirng mtiv yeu can cfia BV Giai phi')

[2] CO bao cao danh gia viec thgc hien ke hoach phat trien nhan lire y te hang nam. Trong bao cao co neu ve tien de thuc hien, nhimg viec dal lam dugc va chua lam dugc; nhimg viec dung tien de va cham so vai tien

Chiu trach nhiem thtrc hi0

Phong TCHC lam bao cao danh gia viec thgc hien ke hoach phat trien nhan krc y te nam 2018

Thai gian thtyc hien

Truck ngay 30/9/2018

Ghi chit

14

B1,2. [3] Ban dam va duy tri on dinh so luting nhan benh vien

[1] NVYT khong trkrc 24/24 gi6 tai khoa HSCC; HSTC, GMPT, Sa sinh [2] Khoa de nghi: KSS, QLCL,

15

B1.3. [2] 3.do dam co cau chirc danh nghe nghiep va xap dinh vi tri vie lam ciia nhan hrc benh vien

[1] Ban mo ta..cong viec c ca chirc danh nghe nghiep duos cap nhat dinh kST it r,hat 2 nam 1 lan va khi can.

[*] Lum - Phong TCHC: Tren co- so quy dinh tuyen dung chung caa Sa Y ; Benh vien the the lai ban

cita benh vien b'ang them cac tieu chi d4c thin pith hop -)ai benh vien Nhi nhu- có dieu kien xet ho

so tzo)en dyngve chieng chi nhi khoa, dinh Throng nhi Ithoa,

[1] Theo bang phan cong trcrc c6 day du ngtr6i trgc trong Wan, nhung khong c6 ai true ca ngay 24/24 gi6 hoac 3 ngdy

[1 Luu 57: - Phong TCHC, Phong DD & Khoa HSTC: 11 Len phyang an trien khai lam ca, kip thi diem tai khoa Hai six; [2] (Neu du-oc) Trien khai lam tru-6-c ngay 20/9/2018.

[1] Phi:mg TCHC IA 'Ian mitt xay dung, phe duyet bang mo to cac chtic danh trong benh vien

true met lan.

Phong TCHC clan moi, phei hgp phOng DD filth toan trien khai lam ca, tai nhang khoa có tinh chat dac biet nhu HSTC; SS; CC

[I] CO bang chung da cap nhat khi can, vi du khi phat hien ra trong ban mo to cong viec thieu 1 so nhiem vu quan trong hoac khi trien khai thay chua phu hop thi bo sung, chinh sira ngay ma khong can d9i den chu kST 2 nam.

Trtr&c ngay 20/8/2018 phe duyet de an vi tri viec lam va bang mo to cong viec then chirc danh.

2. C hat luting nguan nhan hrc

16

B2.1. [3] Nh&In vien y te dugc ciao tao lien toc va phat trien ky

nang nghe nghiep

[1] CO to chirc hem tra tay nghe, chuyen mon cho nhan vien y te, dac biet la bac sy, y sy, dieu &rang, hi) sinh, ky thuat vien, dirge sy dugi 5 nam cong tac bang cac hinh thine (nhu thi sat hach, to chine h'ei thi...)

[1] CO ban ke hoach hem tra tay nghe, chuyen mon cho than vien y te, dac biet la bac

y sy, dieu du-Ong, he sinh, ky thuat vien, dugc sy clued 5 nam cong bien ban, hei dong cham, hinh thine hem tra,

[11 Phong KHTH lam (Ian mot, to chirc thi/hem tra tay nghe cho chirc danh bac sy tre có tham nien cong tap dugi 5 nam.

Bao cao ket qua truirc ngay 30/9/2018

Page 10

Stt Tieu chi Tieu my chua dkn/h4n the anh

htrong mtic yeu ca dim BV Giai phap Chill trach nhiem thtyc hien Thin gian thuc hien •

Gh ,i

chu

[2] Dan vi de xuat: PDD, QLCL danh gia

17

. B2.2 [4] Nhan" vien y to dirge nang cao kY

, nang giao tiep, irng xir, y dire

[1] Co lien hanh khao sat hoac danh gia sa be thai de img xir cila nhan vien y te va sir dung ket qua khao sat, danh gia de be tri nguoi phi]. hop 6 car vi tri viec lam thuong tiep xitc vai ngued benh va ngu6i nha ngtrai benh. [2] Co tien hanh danh gia viec hien khai nang cao thai de img xir, giao tiep, y due theo dinh Icy va có bao cao ve hinh thk/phuong phap va ket qua danh gia. [3] Y kien die khoa 3CK: tang cuOng tap hun cho NVYT ve the phong ung xir.

[1] Co bao cao khao sat hoac danh gia sa be thai de Img xir cita nhan vien y te. Khao sat c6 the dieu tra rieng ye phong each, thai de t'rng xir hoac long ghep trong khao sat six hai long oh NVYT .

[1-; PhOng TCHC dAu intqL thuc hien khao satidanh gia ve thai de irng xir dm NVYT cat ngang;

Bao cao so lieu trtrot ngay 20/9/2018

[2] CO bao cao khao sat hoac danh gia ve thai do img xir cila nhan vien y te tnrac va sau khi trien khai tap hudn. Trong W.° cao co so sanh ket qua khao sat ve thai do Ung xircita NVYT tnrac va sau tap huan.

(tnthc va sau khi tap huein ve

[2] Phong TCHC d'Au miii khao sat phong each frng xir ctia nhan vien c6 can thi'ep

tac phong thai d:o img xfr clia nhan vien y te)

Bio can trtrat ngay 20/9/2018.

[*] Ltru Si: - Phong TCHC:

+ Lap Ice. hoach 01 lop rap hucinv" tac phong thai clO Ling zie caa NVYT, lop do three hien clanh gia truOr va sau tap hucin; + Thyv hien khao sat thai do ang xii• caa nhan vien benh vien qua 02 kenh: [1] kenh tir clanh

gia dux ngweri benh va nguai nha nguffi benh; [2] kenh 2 la kenh danh gia tie Nhan vien(lanh ciao clanh gia nhan vien hay nhein vien cAinh gici nhan vien). + Viet bao cao thing theo quy clink ye thai gian cla yeu cau tai ice hogch

18

B3.1. [4] Bao dam chink sack tien lucmg, che

A do

,.

dill , n vie

nge ,, cda n y to

A a

[1] Ap dung thi ,diem hinh thuc "chi tra Oa ten ket qua ding viec" thi diem chi tra nguon thu nhap tan- g them dtra teen ket qua cong viec deli voi it nhdt met chirc danh nghe nghiep (bac sy, chrac sy, dieu &rang, ky thuat vien y, quan 1D- hoac thi diem tai it nhat met khoa lam sang va met khoa can lam sang.

[2] Berth vien c6 be cong op danh Oa ket qua cong viec cua it nhat met chirc danh nghe nghiep trong so cac eh& danh sau: bac sy, duct sy, dieu duerng, ky thuat vien y, guan1)',.

Co tai lieu htron dart danh gia va phan loai ket qua ding viec &rot chia thanh cac mire hoan thanh, vi du kern trung binh, kha, xuat sac... Co cac chi

[1] Phong TCHC la cfau miii tham mtru trien khai ap dung tai 1 ichoa /phong hoac tren 1 chirc danh trong 6 thang cuoi nam. VD: Quy thu nhap tang them thi diem chi tra cho ngtroi lao &Ong theo the mix dtra ten ket qua danh gia cho it nhat 01 chirc danh hoac thi diem tai it nhdt met khoa lam sang va met khoa can lam sang cho tat ca cac chirc

[1] Bao cao trtrOr ngay 30/9/2018.

Page 11

:St-1 ::Tieu- chi .x x

Tieu muc chug dat/han che anh • E • • .: :•E -: ' • ).- •

huong mire yeti cau cua BV Giai: phap :

, : Chili trach uhient:ttqc hien Thoi gian thtrc hien

• chu

Ghi ,

so, tieu chi do luting cu the ket qua, hieu suat thuc hi'en, ding viec. Sau khi clank gia ket qua cong viec co the xep thir to tir nguiyi lam tot nhat den kern nhat chia theo tirng nhom doi tugng hoac theo timg khoa/phong hoac phan theo cac mac A, B, C hoac 1, 2, 3, 4, 5..

danh. Vi du thi diem tai khoa kharn benh theo y'eu eau, khoa X-Quang.

[*] Lull : - Phong TCHC: + tham khao b0 cong cu clanh gia can b0 nhein vien theo vi tri va hoan thanh

cong viec tie lop Quem tri &din stc;

+ Viet brio cao clung theo guy clinh ye thol gian clei yeu eau tai hoach .ke'

19

B3.2. [4] Bao dam dieu kien lam viec va ve sinh lao dOng cho nhan vien y to

[1] Benh vien lap ho so ve sinh lao dOng, do kiem tra moi trueng lao d'Ong dinh ky (theo quy dinh du benh vien). [2] CO tien hark khao sat sir hai long caa nhan vien y to voi dieu kien lam viec, v sinh lao dOng.... BO cau hoi khi-o sat su hai long than vien y to dua,tren ho cau hOi do BO Y te, Si Y to ban hanh hoac benh vien to xay dung.

[1] CO ho so, tai lieu theo dOi cac dieu kien ve sinh moi trikmg lao Ong. Co cac chi so theo clOi moi twang lao dOng cu the va dugc ghi chep theo that gian, vi du so liking vi khuan trong 1 m3 lchOng khi tai khoa lam sang.

[1] Ph6ng TCHC daa moi xay dung hop citing, xin cap kinh phi thtrc hien danh gia moi trueng lao dOng tai benh vien dung theo quy dinh.

Bao cao ket qua truirc ngay 30/8/2018

[2] Ithao sat hai long qua ho cau hoi phu hop voi dac thu rieng dm benh vien.

[2] Phong TCHC, xay dung KH khdo sat va co ket qua khao sat cita than vien y to ye moi trix8ng, dieu kien lao dOng.

Bao cao sau khao sat ve moi trueng lam viec cita nhan vien benh vien trir&c ngay 20/9/2018

C2.1. [4] H8 so benh an, dugc lap day du, chinh xac, khoa hoc

_

[1] Co tinh tang ho so benh an chtra dugc lap kip thati sau khi nguoi benh nhap vien (24 gi8 voi ngued benh cap eau va 36 gio• voi benh thong thu5ng). Benh an co not dung khong d9c dugc ,chri vi'et. NhUng thong tin can dieu chinh dugc gach 136, ky ten nsuoi sira va thad gian qra (thong fay xoa hoac boi den de khong doe dugc nOi , dung di). [2] CO phan cong nhan vien chiu

20

[1] Chat luting HSBA tai cac khoa LS dam brio; - Tai phong KHTH co can ,b9^ dugc phan dog phu trach kiem tra, danh gia HSBA truck khi luu trir (CO van ban phe duyet/phan cong). Nguei dugc phan cOng liet ke dugc cac cong viec can thgc hien.

[1] Phong KHTH la dAtt moi - Cap nhat cac quy dinh, huong clan ye lam HSBA trong benh, gai chi dao ve cac khoa lam sang. - Phan cong can bO chuyen trach doc HSBA truck khi hru trit (CO van ban phan cong hoac ban mo to cong viec dm phong KHTH)

Van ban chirng mink co six phan cong can bO phu trach danh gia chat luting HSBA tai Phong KHTH (Qt471.2018)

[2] Co bang kiem danh gia chat luting b'nh an; CO than vien _

[2] Phong KHTH thyc ,hien kiem tra, danh gia the dO

CO brio cao danh gia chat luting HSBA caa cac don

Page 12

Stt Tieu chi Tien muc chug datthan the inh

• • - ' htrang muc yeu cau cua BV

Giai phap - Chiu trach nhietn thkrc hien -Thai gian tlnic hien' , !

: Ghi -:::':, ..

chu

trach nhiem kiem tra h6 so benh an thuang quy, danh gia viec ghi chep, chat luting thong tin... [3] CO tien hanh dach gia (hoac nghien cfru) ve chat luting ho so benh an va xac dinh ty'• le nhap sai ma ICD 10.

c6 tien, hanh danh giainghien dm chat luting ho so benh an dip ten bang kiem.

HSBA (theo bang kiem dit" Ay dying) 6i voi cac ,khoa lam sang, dua ra cac the tai kiem soat tuan thit flute hien dm nhan vien y te.

vi tir phong KHTH, th6i gian bao cao truac ngay 20/9/2018

[*] Ltru SI: - Phong KHTH: + Ban hanh van ban nang cao chat luting HSBA: [1] Cu the hoa quy chi ho sa benh On bang cac quy dinh, hwang dan - pha hap voi benh vien; [2] Van ban phan cling can bO thuac b6 phan kiem tra, danh gia HSBA tai phong KWH (cluacgiam clot Benh vien phe duyet). + Danh gia chat luting HSBA: [1] xay dung bang kiem clanh gia chat luting HSBA — benh an da tra ye phOng KHTH; [2] cicinh gia chat luting HSBA cua cac khoa, phong va tqan benh vien (so luang ca mciu dU Wm); [3] Bao cao pl-On tich ye chat luting HSBA sau khi My du ca. mau; dua ra cac 13) le so sanh giaa cac khoa lam sang; kkuyen ngh; sau co kit qua clanh gia; [4] Viet

, .

bao cao dUng theo quy clinh yi th6i gian da yeu cau tai ke hoach;

21

C4.3. [5] Trien khai chtrong trinh ve sinh tay

[1] Nu& rda tay tai bu6ng co thgc hien cac ky thu4t, Ilia thuat bao dam vo khuan dugc xir ly qua he thong may 19c mac holac bau 19c nuac (thay dinh IcST)., [2] Tien hanh nuoi cay vi kh"tkin' trong nu& tai mot so vi ,tri 1r9ng diem nhu voi nuac6 bu6ng thgc hien phan thuat, thu thuat, can lam sang; voi nuac uong true tiep tir cac may lac ritrOc (va cac vi tri khk neu c6 dieu kit thuc hien).

[1] Co he,thong may 19c mac host co bau 19c ntroci Co nhat 14 kiem tra loi 19c, bau loc va thay, rira16119c, baul9c nuac.

[13 Khoa KSNK la dau mai don doc cac khoa co buong thu thy* de xuat BV mua va lap he thong 19c nuac tai vi tri lam thil thuat

KSNK bao cao truc?c ngay 10/9/2018

[2] PhOng QTTTB la dau moi dinh IcY thay qua lac nuac. Nhat kY theo dOi qua host d'Ong may 19c mac va qua 19c.

Bao cao ket qua &irk ngay 10/9/2018

[2] Co cac bang chirng km till ghi than k'et qua cay giam sat vi, khuan tai cac vi tri tr9ng diem nhu voi mac a buong thgc hien phau thuat, thu thuat, can lam sang; nu& dung cho chay than nhan tan, voi mac uong truc tiep tir cac may 19c nuac. Ket qua cay giam sat vi khuan deu dat yeu cau.

:3] Khoa KSNK dau moi lam ke ':.•ioach mOi don vi danh gia VI SINH chat luting mac tai cac lavabol phau ,thuat, thu thuat va uong truc tiep cua nhan vien, ngtroi nha.

Bao cao ke qua danh gia mall mac tai benh vien. Bao cao hoan tat &Irk ngay 10/9/2018.

22

C4.4. [4] Giant sat, danh gia

, viec trien khai kiem soar

[1] CO thgc hien phong ngira chit' &Ong cho nhan vien y to (nhir tiem

• phong cho nhan vien co nguy co cao, phong chOng m".-5t so benh dich

[1] CO danh sach NVYT dugc tiem phong benh tit)/ theo mo hinh brih tat cua benh vien tai cac khu vuc nguy co cao.

[1] Phong TCHC lam dau moi moi don vi chirc nang tiem ph6ng chit dOng cho nhan vien lam viec tai khu vuc nguy co

Pining TCHC bao cao tiem phong chit dOng cho NVYT lam viec tai khu vuc c6 nguy co cao

Page 13

Stt Tienchi

A Tien muc chtra dat/han che anh.

hirong mire yeu ca‘ u cua BV • Giai phap Chiu trach nhiem th. trc hien Thai giantlitrc hien

Ghi

chit"

nhiem khuan trong benh vien

theo maa hoac theo mo hinh bent

[2] Theo dOi tinh hinh khang khang sinh tai benh vien

tat cua benh vien....). cao. tnrov ngay 05/9/2018

[2] Danh gia tinh hinh khang khang sinh tai benh vien

[2] Khoa KSNK phot hop khoa XN theo doi tS, le khang khang sinh tai benh vien.

Khoa KSNK lam bao cao trwCrc ngay 30/9/2018

23

C4.6. [2] Chat thai long quan 13', chat the theo dung quy dinh

[1] CO he th6ng xir 15, chat thL long

[1] He, th6ng dam bao hog Ong tot, xa thai an town voi moi twang.

[1] Benh vien de xuAt voi co quan chirc nang sarin dm he thong vao van hanh.

Khoa KSNK bio cao ye hoat d'Ong he thong ntrac thai cua Benh vien trtrov ngay 30/9/2018.

23

C5.3. [4] Ap dung huang clan quy trinh ky thuat KCB va trien khai cac bien ph#1 giam sat chat luting

[1] Hoan thanh be tai lieu "HuOng dan quy trinh ky thuat khan,' benh, chfra benh" phi. 'hop voi dial. kien benh vien va dac thu hoat deng chuyen mon, Oa tren huang dan cua B6 Y te. [2] Xay dtmg bang kiem giam sat viec titan thit cac quy trinh ky thuat cho met so quy trinh quan trong (theo danh gia ena benh vien, can cir tren pham vi tac deng, anh hiking tai hoat deng chuyen mon...) tai met so khoa lam sang. [3] Co ban bao cao giam sat viec

Man thu cac quy trinh ky thuat dua tren cac bang kiem, trong do có tj.• le tan thu cua cac Ichoalam sang.

[4] COng be bao cao ye viec tan thu cac quy trinh ky thuat cho nhan vien (trong do c6 fy le tuan thil quy

trinh ky thug cua tirng khoa lam sang) bang cac hinh thirc nhtr ban tin not b6, giri bao cao, tint diem tfr....

[1] Co be Huang dan quy trinh ky thug Icham benh, china benh" phu hop vai diet' kien benh vien va dac thu hoat dong chuyen mon, dua ten hugng dan cua Be Y te.

[1] Phong KHTH la din miii thtrc hien va chi dapcac khoa, phong trong viec cap nhat, xay dung huang dan quy trinh cua Benh vien Nhi Thai Binh

[1] Hoan thien cu6n "HuOng dan quy trinh ky thug benh vien" va ban hanh truck ngay 30/8/2018.

[2] Xay dung bang kiem giam sat tuan thit quy trinh Icy thuat: c6 cac bang chin-1g da hop, thao Klan, tham Ichao tai lieu, cap nhat, chinh sira... de khang dinh chinh benh vien da )(ay dung bang kiem.

[2] Phong KHTH la din mill thuc hien va chi dap cac khoa, phong trong viec cap nhg, xay dung bang kiem giam sat tuan thu quy trinh cua mot so quy trinh tai Benh vien Nhi TB.

[2] Hoan thien bang kiem "Giant sat met so quy trinh tai benh vien" va ban hanh trout ngay 05/9/2018.

[3] Co ban bao cao giam sat viec tuan thu cac quy trinh ky thuat dua teen cac bang kiem (co tST le than thu cua cac khoa lam sang); & cong khai bao cao teen website, hei nghl tai benh vien;

[3] Phong KHTH-DD tien hanh giam sat, danh gia tuan thu quy trinh cfra NVYT.

[3] Bao cao tY le tuan thu thtrc hien 10 quy trinh ky thug tai benh vien trok ngay 30/9/2018.

[*] Liru y: - Phong KHTH xac dinh titan thil quy trinh chuyen mon, ky thu4t dm Bic sy: [1] xay dung bang kiem clanh gici Man thft quy trinh ky thu at ('clai arcing la bac s5); [2] dcinh gici tf) le tuan thti cua tang loci quy trinh (than it nhat 5 quy trinh 47 thuat thwang bi xuat roan BHYT); [3] Bao cao phan tich ye ij'i le tuan thu quy trinh k.7 thuat cua bac sjYsau khi lay chi ca mau; dug ra cac tf) le, so sanh giag cac quy trinh; cac khoa lam sang; khuyen ng1;zi sau có ket qua clanh gia; [4] Viet bao cow thing theo quy ctinh ye theft gian cla yeu cau tai ke hogch;

Page 14

Stt Tieu chi Tieu mile chum d#t/h3n the anh

huong muc yen cau cua BV Giai phap Chiu trach nhiem thip hien Thai gian thtrc hien

Ghi chit

.

- Phong OD xac dinh tuan thii quy trinh chuyen mon., ky thuat dm Dieu throng: [1] xay

thing bang kiem danh gia tuan thil quy trinh ky thuat dieu &fang; [2] danh gia tf/ le tuan thu caa tirng loci quy trinh (than it nhat 5 quy trinh Icy thuat thlean& sec dung );_[3] Belo cao phan tich ye if, le tuan thii quy trinh ky thuat clia dieu duan&- sau khi lay du ca mail; dug ra cac tf, If so seinh girea cac quy trinh; cac khoa lam sang; kly.yen nghi sau có ket qua danh gici; [4] Viet bao cao dimg theo quy Binh ye thai gian &a' yeu cau icti ke hogch;

24

C5.4. [4] Xay dung cac Inrsmg dan than doan va dieu trit

[1] B6 tai lieu "Huang dan chart doan va dieu tri" do benh vien xay dung ducrc huOng dan va ap dpng thong nhat tren pham vi wan benh vien. [2] Cac lchoa, xay dung dugc "Huang dan chan doan va dieu tri" 10 benh thuang gap.

[1] BV cap nhat "Huang dan than doan va dieu tit"

[1] Phong KHTH, HD thu6c va dieu tri thuc hien xay dung Huang dan. . than doan va dieu tri

Co qui& dinh, ban hankHuang dan bo sung ve quy trinh Icy thuat tai benh vien trinfrc ngay 30/8/2018

[2] Xay dung du "Huang "Huang clan chan doan va dieu tri" 10 benh thtrang gap tai cac khoa LS

[2] Khoa Lam sang xay dung va ban hanh tai lieu Huang dan 10 benh thuoi gap tai khoa.

Cap rinat huong dan b6 sung quy trinh ky thuat 10 benh thuOng gap tai cac khoa lam sang trtrot ngay 30/8/2018

25

C5.5. [4] Ap dpng cac hiking dan than doan va dieu tri da ban hanh va giamsat viec thuc hien

[1] Co quy dinh v.,6 viec ap dung cac huang dan than Joan va dieu tri va theo cloi viec tuan thin. [2] Co ban hanh quy dinh cac khoa lam sang (hoac :oan benh vien, do benh vien to quy dinh) thuc hien binh (hoac kiem tra) benh an, tai thi6u 1 lan trong 1 thang., [3] Lap danh sach mot so benh thuang gap (theo ma hinh benh tat cac khoa lam sang va, chung benh vien), benh dieu tri bang Icy thuat cao, benh c6 chi phi lon can tin tien giam sat viec Man pit cac huong dan than doan va diet: tri. [4] Co ban bao cao giam sat viec tuan thin cac huong dan than doan va dieu tri, trong do co t-S, le tuan thit oh cac khoa lam sang.

[1] CO van ban quy dinh ve viec ap dung cac huong dan chan doan va dieu tri oh benh vien to xay di.mg: CO quy dinh thee dOi viec than thit cac huong dan than doan va dieu tri bang cac hinh thgc nhu quy dinh ty le cac ho soy benh an can duot kiem tra ngau nhien, theo dOi tuan thit tr'en phan mem benh an then tg hoac bang cach hinh thgc khac. [2] quy dinh thuc hien binh (hoac kiem tra) benh an, tai thieu 1 lan trong 1 thang. Hinh thgc binh benh an tai cac khoa lam sang.

Phong KHTH Oa mill tham matt ra quy dinh ve viec: [1] Ap dung cac htr6mg dan chin doan va dieu :ri dm benh vien; theo doi viec tuan thucac hung dan than doan va dieu tri cua benh vien; [2] Quy dinh thuc hien binh (hoac kiem tra) benh an, tai thieu 1 Ian trong 1 thang va hinh tittle binh benh an tai cac khoa lam sang.

Cap nhat va b6 sung nhang quy dinh, hitting dan ve ap dung huong dan, Man thil htrOng an, phac dO dieu tri do benh vien xay dung va phe duyet trtrov ngay 30/8/2018.

[3] CO bao cap ve giam sat Wan thit huong dan than doan, dieu tri. Trong dO chi ra , cac 16i thuang gap, cac van de bat

PhOng KHTH xay clung bang kiem giam sat, tien hanh danh gia tuan thil huong dan, phac do clieu tri do cac khoa lam

Phong KHTH bao cap ket qua danh gia, giam sat Sc Marl diu huong an, phac do dieu tri cilia

Page 15

Stt • Tieu chi Tien muc chug d3t/han the anh

: • : - •, • hating mire yeu can cua BV

Giii phip Chiu trach nhiem thirc hin :

Thai gian thirc hien' - Ghi: chit

linreyng da phat hien dugc; sang. cac benh thugng gap trunk ngay 25/9/2018.

[*] Ltru Sr: - Phong KHTH xac dinh tuan thii throng dan chin' doan va dieu tri: [1] xay dung bang I./".jm danh gia tuan this huong &in chan doan dieu tri caa benh vien; [2] dcinh gia tf) le tuantha hungdan chcrn clown dieu tri caa benh vien (chon it 'chat 5 huong dan chein doan va dieu tri thuang gap tai benh vien); [3] Bao cao phein tich ye tfi le tuan thii huong dein cl:din doan dieu tri caabenh vien sau khi lay da ca mau; [4] Viet bcio ccro clung theo quy dinh ye theri gian da

Jeu cau tai ke hoach;

26

C6.1. [4] H' thong quan 1-jf dieu du'ang boat d'Ong hieu quA

[1] Tien hanh theo doi sir thay den cac (10 chi so chat luting dieu duCmg ) theo thad gian, có bieu do theo doi, phan tich xu huong Bien . d'emg the chi so.

[1] CO ve bieu do theo doi xu hixon ket qua thus hien cac chi so bang diem, bang duamg noi...CO phan tich xu huong bien dOng cac chi so tot len hay kern di theo tiled gian; Mu do dirge ve bang phan mem to &Ong theo doi bien d'Ong cac chi so.

[1] Phong DD la d'Au miii chi dao cac khoa thkrc hien chi so chat lugng.

[1] PhOng Dieu &fans tong hop, danh gia ket qua thge hien chi so chat lugng cham, dua ra cac khuyen nghi trtrirc ngay 20/9/2018

27

C6.2. [4] Ngirgi benh dugc tir

gido dijc arc khoe khi dieu tri va truov khi ra vien

[1] TY l' wad benh n8i, MI duck dieu &fang, hO sinh tu van, tryyen thong, gide di,ic sue khoe chiem tir 50% traden. , [2] Nguali benh co dirge cac kien thirc, thgc hanh thiet yeu de tu theo dOi, cham soc, dieu tri va phong cac bien chimg cho ban than [3] Y kien dm khoa 3CK: xa-y dgng tai lieu TT GDSK.

[1] CO thuc hien tu van cho nguai benh trong thad gian narn vien va cO cac bang chimg mirth hoa, vi du co so kST nhan tham gia cac buoi sinh hoat h8i dong ngiroi benh, co, cac hinh anh tu van, hop hi:3i &Ong nguai benh. 12] Ph6ng DD da tien hanh kith° sat kien thirc, thgc hanh cua ngugi benh ye cac n8i dung theo d'Oi, cham dieu,soc, dia rzi va phong cac bien chfrng cho ban than de theo dOi dugc icet qua hoat d8ng tu van theo -DO cong cu, phieu khao sat,

hanh danh gia kien till:re, ve cila ngued benh ve cac not

dung theo doi, cham soc, diet'

van,

[1] PhOng DD la dau miii thgc hien va chi dao, cac khoa trong hoat dOng tir van, truyen thong gido due sire khOe doi vai nguad benh.

Phong DD có bao, cao ket qua khao sat kien thirc, thirc hanh, trong do có ten 52% nguoi benh narn dugc cac kien thirc, thuc hanh thiet yeu ve cham soc, dieu tri va phong cac bien chimg cila benh. Bao cao trtgre ngay 30/9/2018

Page 16

Stt Tieu chi: Tieu muc chtra dat/han cite anh

mire yeu ca. u dm BV Giai phap Thad gian thtyc hien

htrong Chiu trach nhim thuc hien

Ghi

chit

tri va phOng cac Bien chimg cho ban than.

28

C7.3. [3] Ngueri dugc danh

gia, theo doi gia, tinh tang Binh throng trong then gian nam vien

[1] Mau phieu danh gia sang loc tinh trang dinh duong [2] Ho stir benh an co ghi cac thong tin lien quan den dinTi. dual-1g nhu ket qua danh gia drib yang dinh duong, che dO an (net: can tkiet) va cac thong tin can km ST ye dinh duong.

[1] Cap nhat va xay dung mau phieu danh' gia tinh trang dinh duong phit hop vai benh vien; , [2] Chuan hoa lai each danh gia tinh tang dinh duong tren HSBA

Khoa Tieu hoa la dau mill chiu trach nhiem ye trien khai

lien quan dinh cac hoat tiet duong, tiet clye.

.-- Mau phieu danh gia tinh trang dinh duong

— Cac thong tinh dinh duong ghi chep day dn't tren HSBA

[1] Khoa fieu hoa cap mau nhat va ban hanh mau

phieu phis hop voi benh vien trir&c ngay

10/8/2018. [2] Danh gia chat luting ghi chep teen HSBA va dua ra khuyen nghi; thoi gian trink ngay

25/9/2018

29

C7.5. [3] NgtrOi berth dugc cung.

1, • cap the dO dinh duong phi]. hop vai benh 15/ trong thiyi gian nam vien

[1] Khoa dinh, duong -tiet the quan lY dugc chat luigng ve sinh an town thgc pham ctia ca soy cung cap suat an cho benh vien (bao gam ca nha an/cang-tin trong benh vien): c6 mau thgc pham luu, kiem tra thuOngxuyen, giant sat ve sinh nha bep (ke ca the bep an do to chirc hoac ca nhan dieu hanh cung cap suat an cho benh vien).

[1] Thvc hien theo dm, co so lieu ye an toan thgc pham cilia nha an benh vien

[1] Khoa Tieu hoa/b phAn dinh duong tiet the danh gia Man thu thirc hien cac quy dinh ye VSATTPdm don vi cang tin-nha an

Bao cao tuan UM' VSATTP cila don vi dugc dank gian , gia; thoi bao cao tong hop fru& ngay 15/9/2018

30

C9.2.[5] Bao dam co. sa vat chat va cac quy trinh k'y thalit cho hoat dOng Dtrgc

Co phan mem tra ciru thong tin thuoc

Benh vien trang bi phan ,mem quan tra d m thong tin thuoc.

Khoa dugc & CNTT chiu trach nhiem tim phan mem

De xuat benh vien mem; Chay frng dung va tric.h xuat bao cao; Th?ri han

truirc 10/9/2018

[*] Ltru ST:

- Khoa Dime: [1] Tim mua phdn mem phis" hop voi benh vien; [2] Phang CN77' thdm Binh va

danh gici tien ich caa phein mem; [3] Berth vien mua va sir dung tai benh vien

31

C9.3. [4] Cung

1mg thuoc, hOa chat va vat t-Lr y

dit, kip thai, bao dam chat luting

[1] Bp dam cung frng thuOc, vat to y to tieu hao lien mc, khong gian doan (khong .:-...6 tinh franc thieu thuOc van cuoi thang, cuoi nam hoac dau nam). [2] Cac khoa de xuat: Khoa TH de nghi tit lanh bao quart thuOc. Khoa

t o tieu ha day

[1] Cung tang thuoc kip then dam bao thuOc, h6a chat cho hoat 4ng dieu tri.

[1] Khoa Dugc chit: trach nhiem tham muu cho HD ihuOc va dieu tri xay dgng ke hoach cu the, kip Thai dam bao thuoc, hoa chat cho hoat dOng dieu tri.

Dam bao cung img lien tac,, dam bao chat ltrang thuc.

Page 17

Stt :: Tieu chi Tieu muc chwa dat/han the finh:

hurting muc yeu au cua BV : Giai phap - Chiu frith nhiem thtfc'hien Thbi gian thirc Wen

Ghi chu

dugs de xuat may hut am.

32

C10.24,5] Ap dung ket qua nghien ciru vao cai tien chat luting KCB va nang cao hoat d'Ong benh vien.

[1] Co ke hoach va,10 trinh trien khai ap dung cac, ket qua nghien cfru/sang kien de cai tien chatkqt luting kham, chtla benh va nang cao hoat dOng benh vien.

[2] Co bao cao danh gia hieu qua vies ap clung cac sari kien ho'ac giai phap mai rya IchAc phtic cac nhugc diem (neu co); lien tac scai tien chat luting dtra ten cac bang chfrng khoa hoc.

[1] Xay dung ban ke hoach va 1'0, trmh trien khai ap dung cac

qua nghien ciru/sang hen de cai tien chat luting kham, chi-fa benh va nang cao hoat d'Ong benh vien.(co xac dinh cac moe thei gian se, hien khai ap dung cac sang kien, ket qua nghien dm, tiled gian hoan thanh, co phap cow ngtroi va khoa phong dau mei thus hien, c6 du. kien kinh phi va nguon kinh phi de trien khai). [2] Co bao cao danh gia hieu qua vies Op dung cac sang kien hoac giai phap mai va khac phoc cac nh!.roc diem (bao cao co cac chi so dinh luting cu the do luting hieu qua ap clung cac sang kien, co so sanh try& - sau khi ap dung; c6 chi so hien qua can thiep cu the)

Phong KHTH, lam dAu mill xay dung ke hoach, 10 trinh *rig dung, nghien ciru tai benh vien va gam say cac don vi thtrc hien ke ke hoach.

Co du cac sang kien bao cao thus hien tai benh vien (CO danh mix bao cao, sang kien d'a nghiem thu va dirgc danh gia tar& sau) thiri gian tong hop tram's ngay 20/9/2018

[*] Ltru y: - Phong KHTH: [1] Ra soat cac not dung, cd tai', sang kien cai tien va hoan thanh Id hoach, PO Dinh trien khai, zing dung tai b?nh vien [3] Viet bao cao kit qua trien khai Y-rzg dungy de tai, sang kien vao thus tien. ;[4] Viet bao cao clang theo quy clinh ye thai gian da- yeu cau tai ke

roach;

33

D1.2.[4] Xay dung, trier' khai ke hoach va de an cai tien chat luting

[1] Ty le cac khoa/phong xay dung de an cai tien chat luting rieng ciia timg khoa/phong chiem tir 50% tong so khoa/phong tra len.

[1] PhOng/tO quan 1Y chat hr,gng co, km tilt cac de an cai tien chat luting cila cac khoa/phong. - Ty le cac khoa/phOng da xay citing xong de an cai tien chat luong rieng cOa tong khoa/phong chiem tir 50% tong

PhOng QLCL lam dOu miii trien khai cac hoat dOng lien quan; giam sat tien dO ciia cac khoa phong c6 de an cai tien.

Co du cac de an CTCL cap BV & KP thus hien tai benh vien (co danh muc bao cao, DACTCL da nghi"em thu) thoi gian tong hop trierc ngay 20/9/2018

Page 18

Stt Tieu chi Giai Tieu muc chtta dat/han the anh

huirng mite veu can cua BV phap Chiu trach nhiem thuc hien Thin gian thuc hien

Ghi chit

se Ichoa/phong tra len. - Cac de an do khoa/phong to xay dtrng, có the phoi hop voi cac khoa phong khde nhung can cai tien cho van de chat luting dac thin cua Ichoa/phong.

43

D1.3. [4] Xay dung van him chat Luang benh . • •

vien

[1] Xay dtmg be nhan dien thuong hieu va quy dien sir dung be nhan dien thuang hieu

[1] CO be nhan dien thuang hieu va quy dinh sir dung be 'than dien thuong hieu. - BO nhan „dien thtrang hieu, bao gom bieu tnmg, khan hieu da chrac dang lcSr ban quyen

[1: PhOng QTTTB la dau mei lam thit tuc clang 14, xin cap chimg nhan "be nhan dien thtrang - Benh vien Nhi Thai Binh"

CO chins nhkciia don vi co team quyen tnrerc ngay 30/9/2018

35

D2.1. [3] Phong ngira cac nguy co., dien bien bat thuang xay ra voi nguai

be.nh

[1] G,itrong chuyen dimg cho hei sire cap elm CO he thong bao goi [2] CO, he thong chuong hoac den bao dau gitremg tai toan be cac giuong benh cap ciru va cac gigong c6 ngtbi berth eharn sec cap I. [3] Khoa de nghi: Khoa CC, HSTC,HI-11DD,IN,3CK,.., Khoa CDHA: de nghi lam bien bao Inning dan nguai benh each goi NVYT trong tru?mg hop khan cap.

Van hanh he then& den bao, chvong goi tai dau gigOng buong cap ciru.

[1] Phong QTTTB, & Cac khoa prong ra soat, de nghi benh vien ditty hien cung img he thong.

Bao cao y6 Hot dOng cua he thong chuong/den bao dau gitrang trtrac ngay 20/9/2018.

36

D2.3. [3] Thgc hien cac bien phap phong ngira de giam, thieu cac sir CO y khoa

[1] Co xay dung bang kiem danh gia viec tuan thit cho It nhat 5 quy trinh ky thuat (uu tien cac quy trinh &rot, thgc hien thuang xuyen bi xuat toan tai benh vien). [2] CO kiem tra (dinh kY thuang xuyen hoac dot xuat) viec tuan thu quy trinh ky thua't theo cac bang kiem da xay dung, co bien ban kiem tra luu tilt [3] Co ghi 14i va có bao cao cac

Thgc hien danh gia tuan thit "Quy trnhky thuat"eita nhan vien y te ye

Phong KHTH, l!hong DD chiu trach nhiem teen kiem tra, danh gia viec tuan alit thtrc hanh.

Bap cao theo ket qua kiem t-_-a, danh gia trong nam trusfre ngay 20/10/2018

[3] CO ghi lai va co bao cao cap hanh vi da xay ra tren thuc te, c6 the gay ra hau qua nhung &roc phat hien va ngan chan kjp thai (la cac str co "gan nhu sap xay ra".

Phong QLCL diu co

Oi thu ti0p, phan tich sir O y khoa trong toan benh vien

Bao can tinh hinh sir CO y khoa, an toan nguai berth hang thang ve Sa Y te

[*] Lau S,: - PhOng KHTH icic dinh Was thil quy trinh chuyOn mon, lcy thOt dm BAc sy: [1] xay

Page 19

Stt' Tieu chi Tien muc chua dat/han the finh

: • ' - • Inking link yeu cau cua BV

Giai phap Chili trach nhiem time hi0 :

Thbi gian thirc hiin Ghi chu

hanh vi da xay ra ten thuc te, c6 the gay ra hau qua nhung dugc phat hien va ngdp chan kip thO-i (la cac su di "gan nhu sap xay ra".

thing bang kiem danh gia twin thu quy trinh ky thudt (ddi twang la bac sy); [2J danh gia tY le man thuclia tong loai quy trinh (chon it nhat 5 quy trinh Icy thudt thwang bi ),cucit toan BHY7); [3] Bao cao phan tich ye t)) le tuan thu quy trinh ky thudt clia bac sy:sau khi lay du ca. mau; duo ra cac If) k so sanh giaa cac quy trinh; cac khoa lam sang; khuyen ngig sau có kit qua danh gia; [4] Viet bolo cao dfing theo quy dinh ye thai gian da yeu cat' tat ke hoach; - Phong DD xac dinh tuan thii quy trinh chuyen mein, kjr" thu4t dm Dieu durryng: [1] xay dung bang kiem danh gia twin thii quy trinh ky thudt dieu &fang; [2J danh gia ty le tuan thit cita tong loai quy trinh (chan it nhat 5 quy trinh ky thuat thteon& Air dyng), [3] Ado cao phan tich ye tY le tuan thu quy trinh ky thuat ctia dieu &tang sau khi lay chi ca mdu; dua ra cac tY If so sanh giiia cac quy trinh; cac: khoa lam sang; khuyen nghi sau có kit qua danh gici; [4] Viet boo cao dung theo quy dinh ye thai gian cid yeu cau teal ke hoach;

37

D2.4. [3] Bao dam xac dinh chinh xac nguoi benh khi cung cap dich vu

[1] Co, xay dung quy dinh/quy trinh ve xac nhan va khang dinh dung nguoi benh, dung loai dich vu se cung cap cho nguoi benh truGc khi tien hanh cac dich vu char' down, dieu tri, phAu thuat, thd thuat. , [2] Co xay dung quy dinh ve viec xac nhan ban giao dung nguoi benh Oita cac nhan vien y te. [3] Co xay dung cac bang kiem de thuc hien kiem tra, doi chieu nguoi benh va dich vu cung cap. [4] Ap clung cac hinh thirc thil cong (hoac cong nglye th6ng tin) nhu ghi ten, ghi so, phat so... cho nguoi benh. va cac maU benh pham, dung cu,, thuoc, vat tu..; c6 lien quanden nguoi benh de tranh nham lan khi cung cap dich vu. [5] Y kien cUa khoa 3CK: xay ch,mg bang kiem xac dinh chinh xac nguoi benh.

[1] PhOng chirc nang tham muu xay dung quy dinh/quy trinh va bang kiem ve xac nhan va khang dinh dung ngu6i benh, dung loai dich vu se cung cap cho ngtrgi benh truck khi tien hanh cac dich vu. - Chan doan; - Dieu tri, - Phau thuat - Ban giao dung nguoi benh

[11 Phong QLCL lam d'Au mill chi dap cac ichoa phi:mg lien quan thuc hien xay dung quy trinh, bang kiem ,nhu khoa CDHA - phan chan loan; Phong KHTH - Dieu tri, phau thuat; Phong DD — ban giao &mg ngubi benh.

Tham muu ban harsh tai lieu va giam sat lc& qua trien khai tai benh vien. Bao cao trulfrc ngay 30/9/2018

[2] Ap dung cac hinh thirc thu cong (hoac cong nghe thong tin) nhu ghi ten, ghi sO, phat so... cho nguai benh va cac ‘mau benh pham, dung cu, thu6c, vat tu... di lien quan den nguoi benh de tranh nham lan khi cung cap dich vu.

[2] Ap dung trien khai cac hoot dOng tranh nham lan benh nhan

TOn hop va Bao cao dp dung trien khai tai benh vien truck ngay 20/10/2018.

Page 20

Stt Tieu chi htron . mire yeu cau cua BV

Tien mac chiral dat/han che anh Ghi Giai phap Chiu trach nhiem thtyc hien Thin gian thtyc hien

chn

38

D2.5. [3] Phong ngira nguy co trugt nga

[1] Co tien hanh ra soat tong the it nhat 1 lan trong 1 nam va lap danh sach cac vi tri co nguy co. tnrgt nga do thie't k6, do co so, ha tang khong (long b0 hoac xuong cap hoac do I do bat kS, khac dan tai nguy co tract nga. [2] Gitrimg Nnh cho nguoi be.nh c6 nguy Co trust nga cao (tre em, nguoi bi ton, thuthan cmg kinh...) co thanh chan phong nguin bt-th truot nga. [3] CO ban danh sach thOng ke nhang nguari bi tnrgt nga (ke Ca to tir) tai bent= vin trong nam, phan theo cac mire di) hau qua nhu tir vong; gay c"han, tay; Chan thtrcmg so nao; char_ thucmg phi' tang; shay matt... , [4] Khoa PHCN de xuat cai tien gitrOng b4th.

[1] Ti6n harsh ra soat, lap danh sach cac vi tri CO nguy co trugt nga tai bnh vin. [2] Cai tien thanh chart" giuimg be.nh tai cac vi tri yeu can.

[1j Phimg QTTTB &au m6i - Ra soat va thong ke cac vi tri troll, tnrcrt nga tai b'nh vie.n va co thgc hi'n khac phgc cac vi tri tren. , - Cai tien thanh char giutmg bnh tai mot so khoa yeu cau.

Bao cao truirc ngay 30/9/2018

[3] Phong QLCL thong ke nhang nguOi b'e'nh bi trucrt nga.

[2] Phong QLCL theo dOi, tong hgp va ding cac don vi xir 1:>, sir co xay ra.

Theo dOi va lap bao cao hang thang, My ke tnrerc ngay 30/10/2018

39

D3.2. [3] Do luting va giarn sat cai tien chat lugng benh vin

[1] Co tren 50% khodphong xay citing dugc it nhat 1 chi so chat lugng cu the nham danh gia va theo dOi chat luting hoat dOng cila khoa/phong do. [2] CO ban tong hcp danh sach cac chi so chat lugng (chung dm Nnh vin va cac khodphong) dugc theo dOi, giam sat.

Lqp danh mac cac de an cai tien chat lugng; Theo dOi tien dO theo bang kiem Theo dOi danhs gia chi so chat lugng tir cac de an CTCL

PhOng QLCL lam dau m6i trien khai thud hin.

Bao cao tien do, ket qua cila 15 de an CTCL tai cac lchoa,,phong; Bao cao cac chi so town b"nh vin trtrot ngay 30/9/2018

III. TO chirc thtrc hien

- Giao cho PhOng QLCL lam clan m6i theo tong hop, don d6c cac don vi thud hien nhiem vu trong ke hoach;

Bao cao HOi &Ong Quan ly chat lugng hang thang ve tien do thud hien, mUc do va kha nang hoan thanh cua tang chi tieu,

timg nhi'em vu va tang khoa, phong, hung ten thud hien dat mac tieu de ra.

Page 21

TM HOI BONG QUAN IS( CHAT LUVNG Chti - T 130h vien

NH1. THAI Birvii

Noi nhein: - LDBV (Bac) cap);

- Thanh vien HD-QLCL

- Cac khoa, phong trong benh vien;

- Ltru: VT, QLCL. Iv/

- Cac ca nhan, khoa phong dugc phan ding nhiem vu chu dOng cac phuang an trien khai va bao cao lien d9, kho

khan vuong mac trong khi thgc hien chi lieu, nhiem vu hang thang ve Phong QLCL. PHong QLCL se tong hgp bao cao

Chu tich H9i gong Quan VT chat lugng benki vien qua HQp Fled d9ng hang thang de có nhimg thao go, chi ciao kip tiled.

Teen day la ke hoach cai tien chat luting benh vien 6 thang cuOi nam va mot so cac giai phap thvc hien cai tiecn hugng d6n hoan thanh muc tieu chat luong de ra cua benh vien nam 2018. Chit tich Hifi dOng Quan 1ST chdt luting benh vien yeu cdu cac khoa, phong trong benh vien thgc hien nghiem tuc nhiem vu dugc

Ng Minh Chinh

Page 22