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医疗质量手册是阐明医院医疗质量方针、目标、规定医疗质量体系基本结构、并对医疗质量体系作出详细阐述的文件,是医疗质量体系文件中的纲领性文件。医疗质量手册是医院建立健全和实施医疗质量体系并保持其有效运行应长期遵循的行为规范、统一标准和共同准则。医疗质量手册的内容一般应包括医疗质量方针和目标,组织结构,影响医疗质量管理、执行、评价工作的人员职责、权限和相互关系,质量体系要素及其控制内容和方法,手册评审、修改和控制的规定。医疗质量手册的结构、形式和深度,医院可以根据实际情况确定,以满足需要为准。医疗质量手册的编制既要以系列标准为依据,又要以医院目前的质量管理水平、人员素质、管理意识、实践经验为基础,不能脱离现实。医疗质量手册由院长批准发布。
The medical quality manual is a document that clarifies the hospital’s medical quality policy, goals, and stipulates the basic structure of the medical quality system and elaborates on the medical quality system. It is a programmatic document in the medical quality system documentation. The medical quality handbook is a code of conduct, a unified standard, and a common rule that the hospital should follow for a long time to establish and improve the medical quality system and maintain its effective operation. The contents of the medical quality manual should generally include the medical quality policy and objectives, organizational structure, personnel responsibilities, authorities and interrelationships affecting the quality management, implementation and evaluation of the medical care, quality system elements and their control content and methods, manual review, modification and Control regulations. The structure, form, and depth of the medical quality manual can be determined by the hospital based on the actual situation to meet the needs. The preparation of medical quality manuals must be based on series standards, but also on the basis of the hospital’s current quality management level, personnel quality, management awareness, and practical experience, and cannot be separated from reality. The medical quality manual is approved by the president for release.