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目的:通过对11所二级医院等级医院评审结果进行分析,找出11所医院存在的共性及个性问题,为兵团医院感染质量控制中心工作的开展提供依据。方法:依据卫计委下发二级医院等级医院评审细则医院感染管理相关条款,做为评审专家参与兵团系统11所二级医院应用系统及个案追踪方法进行现场评审工作。结果:医院感染管理与持续改进条款:A条款达标率54.55%,B条款达标率72.73%,C条款达标率90.91%。结论:兵团二级医院医院感染管理仅停留在制度落实及日常监测,有45.45%医院未能体现管理质量及监测质量持续改进,专职人员的自身能力建设有待提高。
OBJECTIVE: To analyze the results of the review of 11 Hospitals at different levels to find out the commonalities and individualities in 11 Hospitals, and provide the basis for the work of Corps Hospital Infection Quality Control Center. Methods: According to the terms of hospital infection management of the Second Hospital Hierarchy Evaluation Committee issued by the State Health and Welfare Commission, the evaluation committee participated in the on-site assessment of the application system and case-tracking method of 11 Hospitals in the Corps. Results: The hospital infection management and continuous improvement provisions: A clause compliance rate of 54.55%, B clause compliance rate of 72.73%, C clause compliance rate of 90.91%. Conclusion: The management of Nosocomial Second Hospital infection only stays in the system implementation and routine monitoring. 45.45% of the hospitals failed to demonstrate the continuous improvement of the quality of management and the quality of monitoring, and the capacity building of full-time staff needs to be improved.