cnOrganization and Functions组织结构与功能.docx

1、cnOrganization and Functions组织结构与功能组织结构与功能ORGANIZATION AND FUNCTIONSDocument Coding/文件编码APW-MD-MO-0004-PL-V1Primary Dept./主管部门Medical Department医疗部Distribution/适用范围Hospital Wide全院Prepared By/拟订Medical Department医药部Reviewed By/审核Approved By/批准Version/版本Version 1 版本1Effective Date/生效日期Remarks/ 备注目录TAB

2、LE OF CONTENT1 目标 OBJECTIVE2 适用范围 APPLICABILITY 3 术语与释义 TERMS AND DEFINITIONS4 角色与职责 ROLES AND RESPONSIBILITY5 内容 CONTENT6 参考 REFERENCES7 相关文件 RELEVANT DOCUMENTS 1 OBJECTIVE1 目标 To list the various hospital committees and their areas of responsibility and functions.列出一份医院委员会名单，并列明其各自的职责与功能。2. APPLIC

3、ABILITY2 适用范围 This policy is applied for whole hospital wide. 本方针在全院范围内适用。3. TERMS AND DEFINITIONS3 术语与定义None无4 ROLES AND RESPONSIBILITY4. 角色与职责 None 无5 内容 5. CONTENT SECTION 1 ORGANIZATION AND FUNCTIONS OF THE STAFF 第1节 员工组织与职能5.1 Organization of the Medical Staff: The medical staff shall be organi

4、zed as a Departmentalized medical staff including the following departments: 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：5.1.1 Anesthesiology 5.1.1 麻醉科5.1.2 Obstetrics and Gynecology5.1.2 妇产科5.1.3 Neonatology 5.1.4 新生小儿科5.1.4 Radiology 5.1.4 放射科5.2 An appointed department chair shall head each department with

5、 overall responsibility for the supervision and satisfactory discharge of assigned functions under the MEC. 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。5.3 Responsibilities for Medical Staff Functions: 5.3 医务人员的职能责任：5.3.1 The medical staff officers, department chairs, clinical service f

6、unctions, chiefs, hospitaland medical staff committee chairs, are responsible for working collaboratively to develop aprocess for communication of medical staff activities to the appropriate department, service orcommittee and to elevate issues of concern to the MEC as needed to ensureregulatory/acc

7、reditation compliance and appropriate standards of medical care.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。5.3.2 Additionally, the CMO of the medical staff shall appoint, in collaboration with theCEO,designated physician

8、s to serve on hospital committees to help fulfill medical staff5.3.2 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。5.4 Description of Medical Staff Functions: The responsible party is listed in parentheses following each activity outlined below: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：

9、5.5 Governance, direction, coordination, and action:5.5 管治、指导、协调与行动：5.5.1 Receive, coordinate and act upon, as necessary, the reports and recommendations from departments, committees, other groups, and officers concerning the functions assigned to them and the discharge of their delegated administra

10、tive responsibilities (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）；5.5.2 Account to the Board and to the staff with written recommendations for the overall quality and efficiency of patient care provided by members of the medical staff at the hospital (CEO, CMO a

11、nd MEC); 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）；5.5.3 Take reasonable steps to ensure professional and ethical conduct and initiate investigations, and pursue corrective action of medical staff members when warranted (CMO and MEC with input from the appropriate depa

12、rtment or clinical service chief); 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）；5.5.4 Make recommendations on medical, administrative, and hospital clinical and operational matters that impact patient care (CEO, COO, CMO, MEC); 5.5.4

13、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）；5.5.5 Inform the medical staff of the accreditation and licensure status of the hospital (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）；5.5.6 Act on all matters of medical staff business, and fulfill any national or local reporting requirements (MEC);

14、 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）；5.5.7 Oversee, develop, and plan continuing medical education (CME) programs and activities that are designed to keep the staff informed of significant new developments that are related to the findings of performance improvement activities (CMO, MEC)

15、; 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）；5.5.8 Provide education on current ethical issues, recommend ethics policies and procedures, develop criteria and guidelines for the consideration of cases having ethical implications, and arrange for consultation with

16、 concerned physicians when ethical conflicts occur in order to facilitate and provide a process for conflict resolution (MEC, hospital ethics committee or subject matter expert);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）；5.5.9 Prov

17、ide oversight concerning the quality of care provided by residents, interns, students, and ensure that they act within approved guidelines established by the medical staff and governing body (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）；5.5.10 Ensure effective, time

18、ly, and adequate comprehensive communication between the members of the medical staff and medical staff leaders as well as between medical staff leaders and hospital administration and the board (CEO, CMO, Medical Staff Officers, and MEC)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

19、、医务人员领导与MEC）；5.5.11 Medical Care Evaluation/Performance Improvement/Patient Safety Activities (Quality Improvement Risk Management Committee, Performance Improvement Committee, Credentials Committee, Hospital Safety Committee; see Peer Review Manual)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

20、查委员会、医院安全委员会；详见同行评审手册）；5.5.12 Communicate findings, conclusions, recommendations, and actions to improve the performance of physicians to medical staff leaders and the Board, and define in writing the responsibility for acting on recommendations for practitioner improvement. (See Peer Review Policy)

21、 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）；5.5.13 The medical staff shall also participate in hospital performance improvement and patient safety programs. (see Peer Review Policy) 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）；5.5.14 Credentials review (see Part

22、 III Credentials Procedures) 5.5.14 资质审查（见第三部分 资质审查程序）；5.5.15 Health Information Management (MEC, Hospital Medical Record Committee) Review and evaluate medical records to determine that they: 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：5.5.15.1 Properly describe the condition and progress of the patien

23、t, the quality of medical histories and physical examinations, the therapy, and the tests provided along with the results thereof, and the identification of responsibility for all actions taken;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；5.5.15.2 Are sufficiently complete at all

24、times to permit continuity of care and communication between all those providing patient care services in the hospital. 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。5.5.15.3 Develop, review, enforce, and maintain surveillance of medical staff and hospital policies and rules relating to medical

25、 records including completion, preparation, forms, format, filing, indexing, storage, destruction, and availability; and recommend methods of enforcement thereof and changes therein. 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。5.5.16 Emergency

26、 Preparedness (MEC,CEO,CMO, COO, Hospital Safety Committee): Assist the hospital administration in developing, periodically reviewing, and implementing an emergency preparedness program that addresses disasters both external and internal to the hospital. 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

27、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。5.5.17 Organizational Planning (Board, MEC,CEO, CMO, COO and department chairs) 5.5.17 组织计划（董事会、MEC、CEO、CMO、COO与各科室主任）5.5.17.1 Participate in evaluating existing programs, services, and facilities of the hospital and medical staff; and recommend continuation, expansi

28、on, abridgment, or termination of each; 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；5.5.17.2 Participate in evaluating the financial, personnel, and other resource needs for beginning a new program or service, for constructing new facilities, or for acquiring new or replacement capi

29、tal equipment; 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5.5.17.3 assess the relative priorities for services and needs and allocation of present and future resources; 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；5.5.17.4 Communicate strategic, operational, capital, human resources, i

30、nformation management, and corporate compliance plans to medical staff members. 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。5.5.18 Bylaws review (MEC, CEO, Bylaws Committee)5.5.18 细则审核（MEC、CEO、细则委员会）5.5.18.1 Conduct periodic review of the medical staff bylaw, rules, regulations and policies;5.5.

31、18.1 对员工细则、规则、规章与方针进行定期审核；5.5.18.2 Submit written recommendations to the MEC, to the general medical staff and to the Board for amendments to the medical staff bylaws, rules, regulations and policies.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。5.5.19 Infection Control Oversight (MEC, See Hospital

32、 Infection Control Committee Charter) 5.5.19 感染控制监督（MEC，详见医院感染控制委员会宣言）5.5.20 Pharmacy and Therapeutics functions (MEC, see Pharmacy and Therapeutics Committee Charter) 5.5.20 药学与治疗学职能（MEC，见药学与治疗学委员会宣言）5.5.21 Responsibilities of department chairs: 5.5.21科室主任职责：5.5.21.1 To oversee all clinically-related activities of the department; 5.5.21.1 对科室的所有临床相关活动进行监督；5.5.21.2 To oversee all administratively-