cnOrganization and Functions组织结构与功能文档格式.docx
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cnOrganization and Functions组织结构与功能文档格式.docx
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Remarks/备注
目录TABLEOFCONTENT
1目标OBJECTIVE
2适用范围APPLICABILITY
3术语与释义TERMSANDDEFINITIONS
4角色与职责ROLESANDRESPONSIBILITY
5内容CONTENT
6参考REFERENCES
7相关文件RELEVANTDOCUMENTS
1OBJECTIVE
1目标
Tolistthevarioushospitalcommitteesandtheirareasofresponsibilityandfunctions.
列出一份医院委员会名单,并列明其各自的职责与功能。
2.APPLICABILITY
2适用范围
Thispolicyisappliedforwholehospitalwide.
本方针在全院范围内适用。
3.TERMSANDDEFINITIONS
3术语与定义
None
无
4ROLESANDRESPONSIBILITY
4.角色与职责
None
无
5内容
5.CONTENT
SECTION1ORGANIZATIONANDFUNCTIONSOFTHESTAFF
第1节员工组织与职能
5.1OrganizationoftheMedicalStaff:
ThemedicalstaffshallbeorganizedasaDepartmentalizedmedicalstaffincludingthefollowingdepartments:
5.1医务人员组织:
全体医务人员应按照科室进行编制,具体科室包括:
5.1.1Anesthesiology
5.1.1麻醉科
5.1.2ObstetricsandGynecology
5.1.2妇产科
5.1.3Neonatology
5.1.4新生小儿科
5.1.4Radiology
5.1.4放射科
5.2Anappointeddepartmentchairshallheadeachdepartmentwithoverallresponsibilityfor
thesupervisionandsatisfactorydischargeofassignedfunctionsundertheMEC.
5.2被任命的科室主任,须在医疗执行委员会(MEC)的领导下,牵头全面负责对其科室的
应有职能予以监督并圆满履行。
5.3ResponsibilitiesforMedicalStaffFunctions:
5.3医务人员的职能责任:
5.3.1Themedicalstaffofficers,departmentchairs,clinicalservicefunctions,chiefs,hospital
andmedicalstaffcommitteechairs,areresponsibleforworkingcollaborativelytodevelopa
processforcommunicationofmedicalstaffactivitiestotheappropriatedepartment,serviceor
committeeandtoelevateissuesofconcerntotheMECasneededtoensure
regulatory/accreditationcomplianceandappropriatestandardsofmedicalcare.
5.3.1高级医务职员、科室主任、门诊服务部门、主管、医院与医务人员委员会主席应合作开发
出能够将医务人员的活动情况通报给相关科室、服务部门或委员会的流程,并在必要时将关切问题提交至医疗执行委员会以确保对相关规定/认证准则以及医疗护理标准的遵守。
5.3.2Additionally,theCMOofthemedicalstaffshallappoint,incollaborationwiththeCEO,designatedphysicianstoserveonhospitalcommitteestohelpfulfillmedicalstaff
5.3.2此外,医务人员的首席营销官(CMO)应与首席执行官(CEO)共同指定医师担任医院委员会的成员,以帮助全院员工充分履行自己的职责。
5.4DescriptionofMedicalStaffFunctions:
Theresponsiblepartyislistedinparenthesesfollowing
eachactivityoutlinedbelow:
5.4医务人员职能描述:
在下列各项活动内容后的括号中列明了相应责任人:
5.5Governance,direction,coordination,andaction:
5.5管治、指导、协调与行动:
5.5.1Receive,coordinateandactupon,asnecessary,thereportsandrecommendationsfromdepartments,committees,othergroups,andofficersconcerningthefunctionsassignedtothemandthedischargeoftheirdelegatedadministrativeresponsibilities(MEC);
5.5.1从各科室、委员会、其他群体和高级职员收到与其指定职责、指定管理责任的履行相关的报告和建议,并在必要时进行协调和采取行动(医疗执行委员会);
5.5.2AccounttotheBoardandtothestaffwithwrittenrecommendationsfortheoverallqualityandefficiencyofpatientcareprovidedbymembersofthemedicalstaffatthehospital(CEO,CMOandMEC);
5.5.2采用书面建议的形式向董事会和全体员工说明由全院医务人员所提供的患者护理服务的整体质量与效率(首席执行官、首席营销官、医疗执行委员会);
5.5.3Takereasonablestepstoensureprofessionalandethicalconductandinitiateinvestigations,andpursuecorrectiveactionofmedicalstaffmemberswhenwarranted(CMOandMECwithinputfromtheappropriatedepartmentorclinicalservicechief);
5.5.3采取合理措施,确保职业行为的专业化及合乎道德,以及展开调查活动,并确保医务人员能够在万无一失的情况下采取相应的纠正措施(首席市场官与医疗执行委员会则须在听取相关科室或临床服务主管建议的基础上采取相应纠正措施);
5.5.4Makerecommendationsonmedical,administrative,andhospitalclinicalandoperationalmattersthatimpactpatientcare(CEO,COO,CMO,MEC);
5.5.4就医疗、管理以及与患者护理相关的医院临床和运营事宜提出建议(CEO、COO、CMO、MEC);
5.5.5Informthemedicalstaffoftheaccreditationandlicensurestatusofthehospital(CMO,MEC);
5.5.5向医务人员通报医院的资格认证与证照获取情况(CMO、MEC);
5.5.6Actonallmattersofmedicalstaffbusiness,andfulfillanynationalorlocalreportingrequirements(MEC);
5.5.6为全体医务人员的一切事务相关事宜行事,并遵守国家或地方所发布的任何汇报规定(MEC);
5.5.7Oversee,develop,andplancontinuingmedicaleducation(CME)programsandactivitiesthataredesignedtokeepthestaffinformedofsignificantnewdevelopmentsthatarerelatedtothefindingsofperformanceimprovementactivities(CMO,MEC);
5.5.7监督、开发及计划医学进修教育(CME)课程方案与活动,而这些方案与活动旨在向员工通报与其绩效改进活动相关的调研发现的重大最新进展(CMO、MEC);
5.5.8Provideeducationoncurrentethicalissues,recommendethicspoliciesandprocedures,developcriteriaandguidelinesfortheconsiderationofcaseshavingethicalimplications,andarrangeforconsultationwithconcernedphysicianswhenethicalconflictsoccurinordertofacilitateandprovideaprocessforconflictresolution(MEC,hospitalethicscommitteeorsubjectmatterexpert);
5.5.8就目前发生的道德问题开展教育活动,就道德方针与程序提出建议,针对牵涉到道德问题的案例开发相关标准与纲领;
在发生道德方面的冲突时,安排与相关医师进行会诊以便于及提供冲突解决流程(MEC、医院道德委员会或主题专家);
5.5.9Provideoversightconcerningthequalityofcareprovidedbyresidents,interns,students,andensurethattheyactwithinapprovedguidelinesestablishedbythemedicalstaffandgoverningbody(CMO,MEC);
5.5.9对住院医师、实习医师或学员的医护质量进行监督,并确保上述人员遵照医务人员和管理机构制定并经批准的纲领行事(CMO、MEC);
5.5.10Ensureeffective,timely,andadequatecomprehensivecommunicationbetweenthemembersofthemedicalstaffandmedicalstaffleadersaswellasbetweenmedicalstaffleadersandhospitaladministrationandtheboard(CEO,CMO,MedicalStaffOfficers,andMEC)
5.5.10确保医务人员与其领导之间、医务人员领导与医院行政部门及董事会之间实现有效、及时且足够全面的沟通(CEO、CMO、医务人员领导与MEC);
5.5.11MedicalCareEvaluation/PerformanceImprovement/PatientSafetyActivities(QualityImprovement–RiskManagementCommittee,PerformanceImprovementCommittee,CredentialsCommittee,HospitalSafetyCommittee;
seePeerReviewManual)
5.5.11医疗护理评估/绩效改进/患者安全活动(质量改进---风险管理委员会,绩效改进委员会、资格审查委员会、医院安全委员会;
详见《同行评审手册》);
5.5.12Communicatefindings,conclusions,recommendations,andactionstoimprovetheperformanceofphysicianstomedicalstaffleadersandtheBoard,anddefineinwritingtheresponsibilityforactingonrecommendationsforpractitionerimprovement.(SeePeerReviewPolicy)
5.5.12向医务人员领导与董事会传达有助于改进医师绩效的相关调研发现、结论、建议及行动,并采用书面形式对按照从业者绩效改进建议开展工作的责任进行界定(详见《同行评审手册》);
5.5.13Themedicalstaffshallalsoparticipateinhospitalperformanceimprovementandpatientsafetyprograms.(seePeerReviewPolicy)
5.5.13医务人员还须参与医院绩效改进与患者安全方案(详见《同行评审手册》);
5.5.14Credentialsreview(seePartIIICredentialsProcedures)
5.5.14资质审查(见《第三部分资质审查程序》);
5.5.15HealthInformationManagement(MEC,HospitalMedicalRecordCommittee)Reviewandevaluatemedicalrecordstodeterminethatthey:
5.5.15健康信息管理(MEC、医院病历委员会)审核并评估医疗记录以确保其:
5.5.15.1Properlydescribetheconditionandprogressofthepatient,thequalityofmedicalhistoriesandphysicalexaminations,thetherapy,andthetestsprovidedalongwiththeresultsthereof,andtheidentificationofresponsibilityforallactionstaken;
5.5.15.1对患者的状况与康复情况、过往医疗与体检的质量、疗法及其结果的相应检测、所有已采取措施的责任界定均予以恰当描述;
5.5.15.2Aresufficientlycompleteatalltimestopermitcontinuityofcareandcommunicationbetweenallthoseprovidingpatientcareservicesinthehospital.
5.5.15.2始终均保持充分完整,以确保提供的护理能够连续,并让医院所有护理人员间能实现有效沟通。
5.5.15.3Develop,review,enforce,andmaintainsurveillanceofmedicalstaffandhospitalpoliciesandrulesrelatingtomedicalrecordsincludingcompletion,preparation,forms,format,filing,indexing,storage,destruction,andavailability;
andrecommendmethodsofenforcementthereofandchangestherein.
5.5.15.3在医疗记录方面,对医务人员、医院方针与规定的相关监督予以开发、审核、实施并维持,包括医疗记录的完成、制定、形成、格式、存档、索引、储存、销毁和可得性;
并就相关实施办法及其变更提出建议。
5.5.16EmergencyPreparedness(MEC,CEO,CMO,COO,HospitalSafetyCommittee):
Assistthehospitaladministrationindeveloping,periodicallyreviewing,andimplementinganemergencypreparednessprogramthataddressesdisastersbothexternalandinternaltothehospital.
5.5.16应急准备(MEC、CEO、CMO、COO、医院安全委员会):
协助医院行政部门制定、定期审核并实施旨在解决医院内部和外部重大灾祸的应急准备方案。
5.5.17OrganizationalPlanning(Board,MEC,CEO,CMO,COOanddepartmentchairs)
5.5.17组织计划(董事会、MEC、CEO、CMO、COO与各科室主任)
5.5.17.1Participateinevaluatingexistingprograms,services,andfacilitiesofthehospitalandmedicalstaff;
andrecommendcontinuation,expansion,abridgment,orterminationofeach;
5.5.17.1参与对医院的现行方案、服务、设施以及医务人员进行评估;
并就上述各项内容的延续、扩展、删减或终止提出建议;
5.5.17.2Participateinevaluatingthefinancial,personnel,andotherresourceneedsforbeginninganewprogramorservice,forconstructingnewfacilities,orforacquiringneworreplacementcapitalequipment;
and
5.5.17.2参与评估实施新方案或服务、建设新设施或购置新(或替代)资本设备相关的财务、人事、及其他方面的资源需求、;
及
5.5.17.3assesstherelativeprioritiesforservicesandneedsandallocationofpresentandfutureresources;
5.5.17.3对当前和今后的资源配置的服务与需求的优先顺序进行评估;
5.5.17.4Communicatestrategic,operational,capital,humanresources,informationmanagement,andcorporatecomplianceplanstomedicalstaffmembers.
5.5.17.4向医务人员传达关于战略、运营、资本、人力资源、信息管理以及公司合规方面的计划。
5.5.18Bylawsreview(MEC,CEO,BylawsCommittee)
5.5.18细则审核(MEC、CEO、细则委员会)
5.5.18.1Conductperiodicreviewofthemedicalstaffbylaw,rules,regulationsandpolicies;
5.5.18.1对员工细则、规则、规章与方针进行定期审核;
5.5.18.2SubmitwrittenrecommendationstotheMEC,tothegeneralmedicalstaffandtotheBoardforamendmentstothemedicalstaffbylaws,rules,regulationsandpolicies.
5.5.18.2就医务人员细则、规则、规章和方针向MEC、全体医务人员和董事会提交书面建议。
5.5.19InfectionControlOversight(MEC,SeeHospitalInfectionControlCommitteeCharter)
5.5.19感染控制监督(MEC,详见《医院感染控制委员会宣言》)
5.5.20PharmacyandTherapeuticsfunctions(MEC,seePharmacyandTherapeuticsCommitteeCharter)
5.5.20药学与治疗学职能(MEC,见《药学与治疗学委员会宣言》)
5.5.21Responsibilitiesofdepartmentchairs:
5.5.21科室主任职责:
5.5.21.1Tooverseeallclinically-relatedactivitiesofthedepartment;
5.5.21.1对科室的所有临床相关活动进行监督;
5.5.21.2Tooverseealladministratively-
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