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1、三级综合医院评审标准实施细则(2011年版)为全面推进深化医药卫生体制改革,积极稳妥推进公立医院改革,逐步建立我国医院评审评价体系,促进医疗机构加强自身建设和管理,不断提高医疗质量,保证医疗安全,改善医疗服务,更好地履行社会职责和义务,提高医疗行业整体服务水平与服务能力,满足人民群众多层次的医疗服务需求,在总结我国第一周期医院评审和医院管理年活动等工作经验的基础上,我部印发了《三级综合医院评审标准(2011年版)》(卫医管发〔2011〕33号)。为增强评审标准的操作性,指导医院加强日常管理与持续质量改进,为各级卫生行政部门加强行业监管与评审工作提供依据,制定本细则。一、本细则适用范围《三
2、级综合医院评审标准实施细则(2011年版)》适用于三级综合性公立医院,其余各级各类医院可参照使用。本细则共设置7章73节378条标准与监测指标。第一章至第六章共67节342条636款标准,用于对三级综合医院实地评审,并作为医院自我评价与改进之用;在本说明的各章节中带“★”为“核心条款”,共48项。第七章共6节36条监测指标,用于对三级综合医院的医院运行、医疗质量与安全指标的监测与追踪评价。transformationofgovernmentfunctions,increasingethnic,religiousandotherUnitedFrontwork.Partyarmed,nati
3、onaldefensereserveforcesworkwasstrengthened.Whileaffirmingtheachievementsatthesametime,wealsoclearlyseethatmytowntherearestillsomeproblemstosolveeconomicandsocialdevelopmentofthedifficultiesandproblems,mainlyin:oneisthedominantindustryisstrong,butnotexcellent,featuredindustrylaggingbehind,stilldo
4、esnotfullymeettherequirementsofindustrialdevelopment,agriculturalindustrializationmanagementresponsibilities;Second,weakinfrastructure,especiallytransportationconstructionisstilllaggingbehind;Thirdcountryseriousshortageoffinancialresources,heavydebtburdenofhistory,stillplentyofpressureofworkandde
5、bt;Fouristhecadresandmassesofenvironmentalawarenessisnotstrong,moreandmorejunk,harmlesstreatmentmoredifficult,"environment-friendlyandresource-saving"societystillneedslong-termefforts;Fiveistheincreaseinsocialinstability,bindtheinterviewvisit,skippingappeal,refluxpetitionunabated,socialstabilitya
6、ndstress;Sixisoneofthefewcadresandthepioneeringandinnovativespiritisnotstrong,andworkstyletofalse,theservicelevelisnothigh,notadaptedtothecurrentlyoptimizedtospeedupthedevelopmentofthesituation.Weattachgreatimportancetotheseproblemsandadoptpracticalandeffectivemeasures,andeffortstosolvethem.Secon
7、d,thisyear'sobjectivesandmainideasthisisthekeytoruraldevelopmentyear,facingmanyrareopportunitiesfordevelopment,wemustfirmlyestablishasenseofopportunity,riskMachineconsciousnessandthesenseofresponsibilityandsenseofinnov