3/9/2618

BIEN BAN KIEM TRA, DANH GIA CHAT LU'Q'NG B~NH V[~N NAM 2017

CApDlJNG CHO cAc DoAN KIEM TRA CUA co QUAN QUAN LY)

S~nh vien: SI;:NH VII;:N MAT DA NANGDia chi: 68 Phan Dang Luu, phuong Hoa Cuong sic, quan Hai ChaLl,Da NangGiam d6c: NGUYEN QUOC DATDi dong: 0913430152. Email:

THONG TIN DoAN KIEM TRA

- S6 va trich y~u cua quyet dinh doan kiSm tra: Quyet dinh s6 1383/QD-SYT ngay 30111/2017 v~ viec thanh I~p DeankiSm tra, danh gia chit IUQ11gbenh vien d6i voi cac Benh vien Hang 2 tro xuong true thuoc Sa Y t~- Noi ban hanh: Sa Y t~ TP Da N~ng - S6 IUQ11gthanh vien doan: 16- H9 va ten Truong dean kiern tra: Nguyen Tien Hong- Vi tri cong tac: Ph6 Giam d6c- H9 va ten TIm ky dean: Nguyen Hfiu Xuan Truong - Di~fl thoai lien h~: 0905.442.330- Dia chi Email tlmkYdoan:truongnhx@danang.gov.vn

\TOM TAT KET QuA DANH GIA CHAT LUQNG B~NH VI~N

I. TONG SO cAc TIEU CHi DVOC Ap DlJNG DANH GIA: 78/83 TIEU CHI

2. rf L€ TIEU CHI Ar D(jNG SO V6I 83 TIEU CHI: 94%

3. TONG SO DIEM CUA cAc TIEU CHi Ar Dl)NG: 227

4. DIEM TRUNG SINH CHUNG CVA cAc HEU CHI: 2.89

ttu« chi C3 wi C5 co h¢ sa 2)

KET QuA CHUNG CHIA THEO MUC Muc I Muc 2 Muc 3 MLl"C4 MLn:5 T6ng s6 ti·5. SO LU'ONG TIEU CHI DAT: 2 18 44 13 I n6. % TIEU CHI DAT: 2.56 23.08 56.41 16.67 1.28 78

Ngay. ..I~..thang ...(2 ...ndm..)o.(.r

THVKYDOAN(kY ten)

1/9

--------- --.----

3/9/2018

BAo cAo DO.AN KIEM TRA, DANH GIA CHAT LUQNG B~NHVI~N NAM 2017

I. KET QuA DOA.N KIEM TRA, DANH GIA cAc TIEU em CHAT LUQNG

MiiB~nh vi~n tl}' Doan KT danh Chi

so Chi tieu danh giaNAMgia NAM 2017 ti~t2017

A pHAN A. HU'ONG DEN NGU'Cn BENH (19)AI AI. Chi dan, don tiep, huang dan, ceip ciru nguoi benh (6)

ALl Ngiroi benh diroc chi dan r6 rang, don tiEp va huang dan cu th~ 3 3

A 1.2 Ngiroi benh dircc cho doi trong phong d~y du tien nghi va ducc3 3

v~n chuyen phu hop voi tinh trang benh t?t

AJ.3 Benh vien ti~n hanh cai li~n quy trinh kham benh, dap irng su3 3

hai long ngiroi benhAI.4 Benh vien bao dam cac di6u kien ceip ciru nguoi benh kip thai 3 2

AI.5 Ngiroi benh diroc lam cac thu t\l~, kham benh, thanh toan ... theo4 4

dung thir tv bao dam tinh cong bang va mire iru lien

AI.6 Ngiroi benh duoc huang dan va b6 tri lam xet nghiem, chAn3 3

do an hinh anh, tharn do chirc nang theo trinh tu thuan ti(:n

A2 A2. Di6u kien co s6 V?t ch§t phuc vu nguoi benh (5)

A2.1 Nguoi benh di6u tri n9i tru duoc n~m mot nguoi mot giuong 4 4

A2.2Ngiroi benh duoc sir dung bucng v~ sinh sach sf: va d~y du cac

3 3phuong tien

A2.3Ngiroi bcnh duoc cung ceip v~t dung ca nhan d~y du, sach se,

5 4chat hrong t6t

A2.4 Nguoi benh duoc huong cac tien nghi bao dam sire khoe, nang3 3

cao th~ trang va tam ly

A2.5Nguoi khuyet t~t duoc ti~p c?n voi cac khoa/phong, phuong

3 3tien va djch vu kharn, chira berth trong benh vien

A3 A3. Moi tnrong cham sac nguoi benh (2)

A3.1Ngiroi bcnh duoc di6u tri trong mci truong, canh quan xanh,

4 4sach, dcp

A3.2Ngiroi bcnh duoc kham va di6u trj trong khoa/phong gon gang,

3 3ngan nap

A4 A4. Quyen va lei ich cua nguoi benh (6)

A4.1N~uai benh duoc cung ceip thong tin va tham gia vao qua trinh

3 3dieu triA4.2 Nguoi bcnh duoc ton trong quyen rieng nr ca nhan 1\ 3

A4.3[Ngtroi bcnh ducc n9P vien phi thuan tien, cong khai, minh

4 4bach, chinh xacA4.4 Ngiroi benh diroc huang 19'i nr chu rnrong xa hoi hoa y t~ 0 0

A4.5Ngiroi benhco y ki~n ph an nan, thac m~c hoac khen ngoi diroc

4 2benh vien tlep nhan, ph an hoi, giai quyet kip thai

A4.6B~~ vien thuc hien khao sat, danh gia sir hai long ngiroi benh

3 2va tien hanh cac bien phap can thiep

BPHAN B. PHAT TRIEN NGUON NHAN Ll/C BI;:NH VJI;:N( 14)

BI B I. S6 IUQ'ng va CO' ceiu nhan luc benh vien (3)B 1.1 Xay dung k~ hoach phat tri~n nhan luc benh vien 3 3BI.2 Bao dam va duy tri 6n djnh s6 IU9'ng nhan luc bcnh vicn 3 3BJ.3 Bao dam co cau chirc danh nghe nghiep cua nhan lire benh vien 3 3

B2 B2. Ch§l hrong nguon nhan hrc (3)

B2.1 Nhan vien y t~ ducc dao (<;10 va phat trien ky nang ngh6 nghiep 3 2

B2.2 Nhan vien y t~ ducc nang cao ky nang ung xu, giao tiep, y due 4 4

B2.3Berth vien duy tri va phat tri6n b6n virng ch§t IU9'ng nguon nhan

4 4Il!c

B3 B3. Ch~ 09 dai ng9 va di6u kien, moi truong lam viec (4)

S'i

219

3/9/2018

MilBenh vien tu Doan KT danh Chi

~ Chi tieu da~h gia 'NAM gia NAM 2017 ti~tso 2017

B3.1 Bao dam chinh sach ti~n luong, ch~ d9 c1iiing9 cua nhan vien y 4 3t~

B3.2 Bao dam di~u kien lam viec, v~ sinh lao d9ng va nang cao trinh 3 4d9 chuyen man cho nhan vien y t~

B3.3 Sire khoe, oai song tinh th~n cua nhan vien y t~ oUQ'Cquan tam 4 4va cai thien

B3.4 T<;lOdung moi tnrong lam viec tich C\!Ccho nhan vien y t~ 4 4B4 B4. Lanh 0<;l0benh vien (4)

B4.1 Xay dung k~ hoach, quy hoach, chi~n IUQ'cphat tri~n benh vien 3 3va ccng b6 cong khai

B4.2 Tri~n khai van ban cua cac dp quan Iy 3 2B4.3 Bao dam ch~t IUQ'ng nguon nhan luc quan Iy benh vien 3 3B4.4 B6i duong, phat tri~n 09i ngii lanh dao va quan Iy k~ c~n 5 5

C PHAN C. HOAT DONG CHUYEN MON (35)CI C l. An ninh, tr~t tv va an toan chay n6 (2)CI.I Bao darn an ninh, trat tv benh vien 3 3CI.2 Bao dam an toan dien va phong chong chay n6 3 2C2 C2. Quart Iy h6 SO" benh an (2)C2.1 H6 sa benh an duoc I~p dily OLI, chinh xac, khoa hoc 3 3C2.2 H6 so benh an ducc quan ly chat che, d~y du, khoa hoc 3 3C3 C3. Ung dung cong nghe thong tin (2) (diem x2)C3.1 Quan Iy t6t CO" So' du lieu va thong tin y t~ 3 3

C3.2 Thuc hien cac giai phap irng dung cong ngh~ thong tin trong 3 2quan Iy va hoat dong chuyen manC4 C4. Phong ngua va ki~m soat nhi~m khuan (6)C4.1 Thi~t I~p vahoan thien h~ thong ki~m soar nhiem khu~n 3 3

C4.2 Xay dung va huang Dan nhiin vien y t~ thuc hien cac quy trinh] 3kiem scat nhiern khu~n trong benh vien

C4.3 Tri~n khai chuong trinh va giam sat tuan thu nra tay 3 3

C4.4 Danh gia, giam sat Vel trien khai ki2m soat nhiern khu~n trong 3 3benh vien

C4.5 Ch~t thai r~n benh vien duoc quan ly chjit che, xu Iy an roan va 3 3twin thu theo dung quy dinh

C4.6 Ch~t thai long benh vien duoc quan Iy chat che, xu ly an toan va 3 3twin thu theo dung quy dinhC5 C5. Nang luc thuc hien ky thuat chuyen man (5) (diem x2)C5.1 Thuc hicn danh m\IC ky thuat theo phan tuyen ky thuat 5 3

C5.2 Nghien cuu va tri2n khai ap dung cac ky thuat moi, phuong 3 3phap moi

C5.3 Ap dung cac huang Dan quy trinh ky thuat kham benh, chira 3 3benh va trien khai cac bien phap giarn sat chat IUQ"ngC5.4 Xay dung cac huang Dan chan doan va oi~u trj 3 3

C5.5 Ap dung cac huang Dan ch~n dean va di~u tri dil ban hanh va 2 2giarn sat viec thuc hienC6 C6. HO<;l(dong oi~u duorig va cham sac nguoi benh (3)

C6.1 H~ th6ng di~u duong truong duoc thi~t I(\p va hoat d9ng hieu 3 3quaNguoi benh ducc oi~u duong huang dan, tu v~n di~u tri va

C6.2 cham sac, giao due sire khoe phu hop voi benh dang duoc oi6u 4 4tri

C6.3 Nguoi benh duoc cham sac ve sinh ca nhan trong qua trinh di~u 3 3tri tai benh vienC7 C7. Nang lire thuc hien cham sac dinh during va ti~t ch~ (5)

C7.1 Benh vien t1~i~tI~p h~ thong t6 ChlTCo~ thuc hien cong tac dinh 2 2dirong va tiet che trong benh vien

C7.2 Benh vien bao darn CO" 50 vat chat 06 thuc hien cong tac dinh 3 3duong va ti~t ch~ trong benh vien

1

I)j

T1

fI

3/9

3/9/2618

MilB~nh vi~n h.l' Doan KT danh Chi

sa Chi tieu danh gia NAMgia NAM 2017 ti~t

2017

C7.3NgU<Ji berth duoc danh gia, theo doi tinh trang dinh dirong trong 3 2thai gian nim vien

C7.4 Ngiroi benh duoc huang dan, nr v~n ch~ dQ an phu hop voi 4 2b~nh ly

C7.5Nguoi benh diroc cung c~p ch~ dQ dinh dufmg phu hop voi

2 2benh ly trong thai gian nam vien

C8 C8. Ch~t luong xet nghiem (2)

C8.1B<'IOdam nang lire thuc hien cac xet nghicm huyet hoc, hoa 3 3sinh, vi sinh va giai ph au benh

C8.2 Bao dam ch~t hrong cac xct nghicm 2 2

C9 C9. Quan ly cung irng va suodung thu6c (6)

C9.l Benh vien thiet lap h~ thong t6 chirc hoar dQl1g ducc 3 3

C9.2 Bao dam co sa vat ch~t khoa Duoc 3 3

C9.3Cupg irng thu6c va v~t tu y t~ tieu hao d~y dLI, kip thai, bao dam 4 4chat luong

C9.4 SU dung thu6c an toan, hop Iy 3 3

C9.5Thong tin thuoc, t~eo doi bao ca? phan irng co hai cua thu6c 3 3(ADR) kip thoi, day du va co chat luong

C9.6 HQi d6ng thuoc va di~u tr] duoc thi~t l~p va hoar dong hieu qua 3 3

cia Cl O. Nghien ciru khoa hoc (2)

cro.i Tich cue tri~n khai hoar dong nghien cuu khoa hoc 2 2

cro.z Ap dung k~t qua nghien ciru khoa hoc trong heat dong berth4 I

vien va cac giai phap niing cao ch~t hrong kham, chira benh

D PHAN D. HOAT DONG cAr TIEN cHAT LUONG (II)

DI D I. Thi~l lap h~ thong va cai ti~n ch~t hrong (3)Dl.I Thi6t l~p h~ thong quan Iy ch~t hrong benh vien 2 2

DL2Xay dung va tri~n khai k~ hoach, d~ an cai ti6n ch~t hrong benh

2 2vienDI.3 Xay dung van hoa ch~t hrong 3 3

D2 D2. Phong ngira cac sir c6 kh~c phuc (5)

D2.lPh6ng ngira nguy ca, di~n bi6n b<1ttlurong xay ra voi nguai

2 2b~nh

02.2Xay dung h¢ thong bao cao, phan rich sir c6 y khoa va ti6n hanh

3 3cac giai phap khac phuc

D2.3Thuc hien cac bien phap phong ngira d~ giam thi~u cac sir c6 y

3 3khoa

02.4 Bao dam xac dinh chinh xac ngiroi benh khi cung dp dich vu 4 ~.JD2.5 Phong ngua nguy co nguoi benh bj truot nga 4 4

D3 03. Danh gia, do luong, hop tac va cai ti6n ch<1tIUQ'ng (3)f------Danh gia chinh xac thuc trang va cong b6 cong khai ch<1tIUQ'ng

D3.l 2 Ibenh vien03.2 Do hrong va giam sat cai ti6n chat luong benh vien 2 2

D3.3 Hop tac voi ca quan quan ly trong viec xay dung cong C\I, tri6n3 3

khai, bao cao hoat dong quan ly chat luong benh vien

E PHAN E. TIEU CHi DA,C THU CHUYEN KHOA

EIE I. Tiel! chi san khoa, nhi khoa Cap dung cho benh vien da khoaco khoa San, Nhi va benh vien chuyen khoa San, Nhi) (4)

El.I Benh vicn thict I~p h~ thong t6 chuc cham see san khoa va saa 0

sinh

EL2B~nh vien thuc hien t6t hoat dong truyen thong sire khoe sinh 0 asan truce sinh, trong khi sinh va sau sinh

E1.3 Benh vien tuyen truyen, t~p hu<1nva thuc hanh t6t nuoi cona a

bing siJ'a my theo huang dftn cua BQ Y t6 va UNICEF

E2.1 Benh vien thiet I~p h~ thong t6 clnrc cham sac nhi khoa a 0

I.-..

4/9

3/9/2018

II. BANG TONG HQP KET QuA CHUNG

S6

KET QuA CHUNG CHIA THEO MLrcMtrc Mtrc Mtrc Mtrc Mire Di~m TCJ 2 3 4 5 TB ap

dung

PHAN A. HU'6NG DEN NGU'Ol B$NH (J9) 0 '3 10 5 0 3.1 J J8

AI. Chi d~n, don tiep, huong d~n, dp CtJ'Unguoi benh (6) 0 I 4 J 0 3.00 6

A2. Di~u kien co sa v(it chat phuc vu nguoi benh (5) 0 0 3 2 0 3.40 5

A3. Moi tnrong cham sac nguci benh (2) 0 0 1 1 0 3.50 2

A4. Quyen va IO'i ich cua nguoi benh (6) 0 2 2 J 0 2.80 5

PHAN B. PHAT TRIEN NGUON NHAN U;C B$NH Vn;:,N (14) 0 2 6 5 1 3.36 14

B I. S6 luong va co du nhan Iuc benh vien (3) 0 0 3 0 0 3.00 3

B2. Chat luong nguon nhan lire (3) 0 1 0 2 0 3.33 3B3. Ch~ oQ oai ngQ va oi~u kien, moi tnrong lam viec (4) 0 0 1 3 0 3.75 4

B4. Lanh O\lO benh vien (4) 0 1 2 0 I 3.25 4

PHAN C. HOAT 80NG CHUYEN MON (35) I 9 23 2 0 2.74 35

C I. An ninh, tr(it tv va an toan chay n6 (2) 0 I I 0 0 2.50 2

C2. Quan Iy h6 sa berth an (2) 0 0 2 0 0 3.00 2

C3. Dng dung cong nghe thong tin (2) (diem x2) 0 I 1 0 0 2.50 2

C4. Phong ngua va ki~m soar nhiern khll~n (6) 0 0 6 0 0 3.00 6

C5. Nang lire thuc hien ky thuat chuyen man (5) (diem x2) 0 I 4 0 0 2.80 5

C6. Hoar dong di611 duong va cham sac nguoi benh (3) 0 0 2 J 0 3.33 3

C7. Nang luc thuc hien cham sac dinh duong va ti~t ch~ (5) 0 4 1 0 0 2.20 5

C8. Ch~t hrong xet nghiern (2) 0 I 1 0 0 2.50 2

C9. Quan Iy cung ung va suodung thuoc (6) 0 0 5 I 0 3.17 6

C IO. Nghien ciru khoa hoc (2) I 1 0 () 0 1.50 2

PHAN D. HOAT 80NG cAI TIl~N CHAT LU'ONG (II) I 4 5 I () 2.55 II

D I. Thi~t l(ip h~ thong va cai li~n ch~t hrong (3) () 2 1 () 0 2.33 3

D2. Phong ngua cac sir c6 kh~c phuc (5) 0 I 3 I 0 3.00 5D3. 8,'lI1h gia, do luong, hop tac va cai ti~n ch~t luong (3) I I I () 0 2.00 3

PHAN E. TIEU CHi 8Ac THU CHUYEN KHOA 0 0 0 () 0 0

E 1. Tieu chi san khoa, nhi khoa (ap dung cho benh vien da khoa co0 0 0 0 0 0khoa San, Nhi va benh vien chuyen khoa San, Nhi) (4)

5/9

, .

3/9/2018

III. TOM TAT CONG VIlJ:C KIEM TRA BlJ:NH VIlJ:N

3.1. T6 chirc dean, tien d<3thai gian, kh6i hrong cong viec thirc hien ... - Doan ki~m Ira, danh gia chat luong benh viend6i voi Benh vien M~t Da N~ng dircc thanh I~p theo Quyet djnh s6 1383/QD-SYT ngay 30/1112017 cua Giarn d6c Soy t~. Moi dai dien Bao hiern xii h<3ithanh ph6, Trung tam Truyen thong - Giao d\IC sue khoc tham gia la quan sat vien,- Doan ti~n hanh ki~l1l tra tai benh vien vao ngay 13/12/2017 - Doan phan lam 08 nhorn kicm Ira. Cac nhorn ti~n hanhki~m tra, daph gia chilt IU:Q11~benh vien theo sir phan cong cua TrlT6TI~doan. Sa~ khi ki~l1l tra giri k~t, qua (di~m vanhan xet) ve To thu ky de tien hanh tong hQ'P, hoan chinh Bien ban kiern tra. - To thir ky thong bao ket qua kiern tradanh gia. - Dai dien benh vien phat bi~u y ki~n - K~t luan cua Truong doan 3.2. S6 luong lieu chi ap dung, k~t quadanh gia chung, diem, s6 luong lieu chi theo cac mire, ty I~ cac mire ... - S6 hrong ticu chi ap dung: 78/83 neu chi - S6tieu chi khong ap dung: 05 A4.4: ngiroi benh diroc huong lei ill chu rnrong xii h<3ihoa y t6 E I, E2: cac tieu chi san -nhi - K~t qua danh gia chung: 2.89 - S6 hrong cac tieu chi dat: Mire I: 02 lieu chi, chi~m 2,56 ph5n tram -lirc 2: 18tieu chi, chi~m 23,08 ph5n tram Mire 3: 44 tieu chi, chi~m 56,41 phan tram Mire 4: 13 tieu chi, chi~m 16,67 ph§n tramMire 5: 01 tieu chi, chi~m US rh5n tram

IV. BIEU DO cAc KHIA C~NH CHAT LUQNG BlJ:NH V[lJ:

• a. Bi~u dB chung cho 5 phftn (tir phan A d~n phftn E)Hlf ONG£)~N Gu6 f BE !H Iig)

cAt TI~ c AT WONG (8

• b. Bi~u dB rieng cho phftn A (fir Al d~l1 A4)A 1 Chi dan-don tl~p-I1lf6I1gda i-r ap ClJU ngvo benn (E 1

A4. QUV~11 va hi ichcua nfjU"oi be;,h (6)

:"2 £)I~l,kit?n co so .at cnatphuc vu ng J')I !>~"ih 1=,) --...\ '"--

s('

A3 M6i lruaog cham see nguO' bellr, 2)

• c. Bi~u dB rieng cho phftn B (tir BI d~n B4)61 S61uO'I19 'Fa co du rhan IJC benh ,er '3)

82 Ch~1hrcnq rgu61' nh3 - JC (3)

B3, Ch~ d6 dai ngQ va di~u kien mOl hfong lam viec (4)

• d. Bi~u dB rleng cho phftn C (ill' CI d~n CIO)

6/9

3/9/2G18

C 1. ,A.n ninh. If?1 tv va an toan chay n6 i2)

ClO. Nghien cuu khoa hoc (2) C2 Ouan Iy h6 SO' benh an (21

C9 Qual1!v eung (mg va Slr dt,mg thuoc (6) C 3 Ung dung cong ngt's thcr.g tin (2)

C8 Ch~t IUQng xet ng!1i$m (2) C.+ Ph6ng n9lra va ki~'l1 scat nhiem khu~n (6)

•

CS Nang luc th\lc hienki tnuat chuyen 1110n(5)

C6. Hoat dong di~u duo-ng va cham see n9u01 benh (5,)

e. Bi~ua6 rieng cho ph~nD (tir Dl a~nD3)01, Thle! hsp he thong ,.a xa'¥ du n9 lrsn k!la,

k~ hoach cai ti4n ch~lllro'1g (3)

C7. Nang hrc t.rl\fC t'lencham see dirh dl.fong va tie! ehe (E,)

D3 Danh gia, 09 luor:g hop tacva cai lien chat IU9n9 (4)

D2 Phong r;glia c ac sai sot 5! c6:a each khac phuc (2)

";:::.Ii ~

-e-,)

.1,n

, .

7/9

3/9/2C18

IV. DOA.N KIEM TRA DANH GIA CHUNG VE CHAT LUQNG B~NH VJl}:N

- Cong tac chu~n bj h6 So', s6 sach, tai lieu minh chirng phuc vu ki~m tra chua oAy OUva kip thai, nhi~u tieu chidon vi nr cham chua sat voi thuc t~.- K~t qua ki~m tra danh gia cu~ Sa Y t~ So' voi k~t qua don vi tv ki~m tra co:Cac tieu chi tang oi~m: 00 tieu chiCac tieu chi giarn diem: 15 tieu chi, chiern 19,48 ph fin tram

V. DOA.N KIEM TRA DANH CIA VE UU DIEM CUA B~NHVl~N

5.1. Cong tac huang d~n nguoi benh- Benh vien co khuon vien thoang mat, b6 tri nhi~u cay xanh va dt tla gon gang; B6 tri dAy du gh6 ngoi, tudung v~t dung cha ngiroi b~n~ va ngua,i nha benh ~han;- Thuc hien tot cong tac chi dan, don tiep, huang dan nguoi benh- Nguoi benh duoc n(>p vien phi thuan tien; Bang gia vien phi duoc dan cong khai, d~ thay, c~p nhat gia dich vuKCB moi theo Thong tu 3~, Thong tir 02 kip thai; co danl? tai tren trang thong tin dien tu , _- Benh vien co cong khai so oi~n tboai duong day nong, so dien thoai ducc in ro rang, dan co dinh tai vi tri denhin thay; co phan cong can b(> true duong day nong 24/24h;- Benh vien co t6 chirc khao sat hai long nguoi benh l1(>itru, ngoai tru hang quy;5.2. Cong tac phat tri~n nguon nhan hrc- Hien tai BY co 39 bac sl, dam baa dll theo d~ an vi tri viec lam.- Dan vi co xay dung chinh sach thu hut, uu oiii 06i voi bac si.- Xay dung quy hoach va b6 nhiem theo quy dinh.- Dam baa ch~ 0(>chinh sach cha CBYCLD.5.3. Cong tac chuyen mana) Cong tac b6 so benh an, chat IU'Q'nglam sang- Thuc hien hAu h6t cac danh muc ky tbuat theo phan tuyen chuyen mon quy djnh tai Thong ttr s6 43/2013- H6 So' benh an sach se, dAy au thong tin.b) Cong tac ki~m scat nhiern khu5n va hoar o(>ng oi~u duongDuy tri t6t cong tac ki~m scat nhiem khu~n va hoat dong oi~u duong.c) Cong tac Ducc:- Khoa Duoc oa t6 chuc dAy all cac b(>phan thee quy dinh cua Thong nr 22; co thanh l~p don vi thong tin thuocva Hoi 06ng thuoc oi~u trio- Trang bi ofiy du cac phuong tien lam viec, trang thi~t bi theo doi, baa quan thu6c.

VI. DOA.N KIEM TRA DANH GIA VE NHUQC DIEM, VAN DE TON T~I

6.1. Cong tac huong o~n ngiroi benh- Co' ban darn baa cac oi~u kicn v~ CO' sa v~t ch~t phuc ViI nguoi benh, tuy nhien v~ sinh t<;limot s6 khu V\I'Chanh lang, khu v~ sinh phong benh chua dam baa; m(>t s6 noi con it' dong nurrc, khong co bang buong v~ sinhnarn/nir.- Con tinh trang benh nhan nam va nir trong cling I buong benh.- Tu thuoc cap ciru darn baa theo chuyen khoa mat, tuy nhien chira darn baa CO' s6 thu6c dp ciru thco quy dinhcua BYT.- Chua co k~ hoach, phirong an va t6 ChlTChu~n luyen phong chay chira chay trang nam 20 I7; Chua thanh I~poQi an ninh phan irng nhanh, chua trang bi may bQ darn lien lac.- H6 so, s6 sach v~ khao sat su hai long nguoi benh va y ki~n v~ benh vien eon han che; Khoug thuc hien ghichep cac y ki~n v~ benh vien trong nam 2017; Chua phan tich, baa cao k~t qua khao sat SiThili long nguoi benhva cong b6 k~t qua cho NYYT.6.2. Cong tac phat triEn nguon nhan lucChua xac djnh tieu chi cu th~, 1(>trinh thuc bien cu th~ trong k~ hoach phat trien nhan [\IC t611g th6 giai doan2016 - 2020; K~ hoach phat tri~n nhan lire hang nam chua ofiy ou va o~ nghj b6 sung trong thai han I tufin. K~hoach dao tao nhan luc narn 2017 chua duoc giarn 06c phe duyet.6.3. Cong tac chuyen mona) Cong tac h6 So' benh an, ch:lI lirong lam sangQuy trinh ky thuat KCB chira c~p nhat (nr niim 20 12 d~n nay). Chua I~p danh sach cac quy uinh ky thu~lthuong quy t0i benh vienc) Cong tac dinh dirong - ti~t che: con nhieu han ch~d) Cong tac xet nghicrnChua thuc hien chuong trinh ngoai kiern; chua cong b6 au di~u ki~n ATSH. Chua co can bQ xct nghi~m trinhoQ sau o~i hQce) Cong tac Duqc:Clma co can bQ chuyen trach lam cong tac duqc lam sang; clma ti~n hanh pha ticb, aanh gia slr dilng thuGe; theoABCNEN; CAn co IQ tdnh o~ xay dil1lg kho thu6c d0t tieu chuftn GSP.d) Cong tac nghien clru khoa hoc: h6 So' s6 sach v~ cong tac NCKH h0n ch~, chua t6 chlrc sinh ho~t khaa hQcoinh ky I lfin/thang; Chua xay d\lng kS ho~ch va IQtrlnh ling d\lng cac kSt qua NCKH vaa di ti~n ch~t luqngKCB va nang cao ch~t luqng b~nh vi~n.6.4. Ha~t oQng cai tiEn ch~t IUQ'ngB~nh vi~n tbllC hi~n chua dAy all cac ha~t o(>ng celi ti§n ch~t luqng.

. I

, .

VII. DOA.N KIEM TRA DE XUA..T cAc VA..NDE l1u TIEN CAN CAI TlltN

8/9

3/9/2018

- f)~nghi BV giai quyet ngay tinh trang mroc lr dong, diet loang quang, bo g~y.- f)~nghtdan vi cho chuyen vien chuy~n trach ki~m soar nhiem ~huan tham ~ia t~p hu~n KS. II( (t6i thieu 3 ,thang): ho tro kinh.phi de bo sung in bieu nrong cho tung loai chat thai. C6 kc hoach cho dao tao, c~p nh~t kienthirc ve cong tac dieu ducng,- £)~ nghi BV thuc hien cong tac nr v5n dinh during cho nguoi benh (vi nguoi benh Ian tu6i. co bcnh kern);thuc hien bang truyen thong va co tai lieu truyen thong cho ngiroi bcnh; xac dinh va phan loai cac nguoi benhco nguy co \ ~ dinh dufmg; co k~ hoach dao tao hoac tuyen dung bac si dinh duong.- f)~nghi BV ra soat, chu~n hoa cac tai lieu, h6 sa, s6 sach v~ cong tac NCKH; Tang cuong sinh hoar khoa h9CI thang/lan va xay dung KH, IQ trinh irng ,d~ng k~t qua NCKH. . . .- BV can thanh I~p rnang luoi Quan Iy chat luong benh vien; BV can xay dung de an thanh Iftp To QLCL coquy dinh ro cac vi tri viec lam, b6 sung bao cao ch5t luong tren website; k~ hoach cai ti6n chAt lirong nam 2018dn c6 k~t qua d~u ra cu th6, d6 c~p d6n nQi dung do luong va giam sat ch5t lirong; T6 QLCL cAn luu h6 sa,van ban lien quan.

VIII. Y KIEN PHAN HOI CUA B:¢ H VI:¢N VE KET QUA KIEM TRA

Ti6p thu cac g6p y cua Dean kiern tra d~ co giai phap khac phuc cac mat con han che, dan dAn cai ti6n ch~tluqng b~nh vi~n d?t ITIUCcao han.

IX. KET LU~N CUA TRUONG DOA.N KIEM TRA

- Ghi nhan va danh gia cao nhirng n6 luc cua toan th~ CBVC benh vicn trang thuc hien cong tric chuycn mono- £)~ nghi Benh vien co k~ hoach sua chira ngay co sa v~t ch5t da xuong cap: Ra soat, chufin hon cac heat clQngcai ti6n ch~t hrong benh vien.- guon nhiin luc cua benh vien tuong o6i ITI?nh, cong lac chuyen man t61 tuy nhien cac dich \\1 kern thco chiraoap ung ovqc yeu du.

TRVONG £)oA KIEM TRA(kY tell)

THVKY £)OAN(ky ten)

Ngay.J.J ..tluuig ..i%..nam.2t.!..r

15 BS Nguyen Qu6C Df'

\.

~

.:_.:&/ro.~.

-,

9/9