河南省消毒供應(yīng)中心驗收標(biāo)準(zhǔn)

1、wl cntinue to mprove he cmpa nys ine nal cntrol sy s, and seady mproveme nt i a biiy tomaage a nd cont ol, optmize busiessprocesses, toensure - resons bi s i n place to urt he sengt hen intenal cntr os, playa cntrol post independet ov esgh roe of evauatin cm p"g Wi llid pay esponsibi , tacvey m

2、 use of itenal a udl tools . c potetai management, .、一d eae. tansacions.eghe nig opeal ons in ar.a . Depening the kfrmaton maagement toesure ful commucai on "zeror as n.e.ocnstaty perfec ERP , ad BS+ , and P'a nd M S,ad SCM, i nfomainsy sem base d cnSuCin, ul integaion iformat on sys,a ceve

3、 d "main resouces shae d to-a. Portal sysema h ad .e pl, ply i nfomainsy sem on e nteprie of Asssant role； to peec y runmaite nance opeainof ricoris,promoe probem easns a nalySs a nd sysem ha.ove； t ostengteing BFS,a nd ERP, and S CM, teCnology a "l -.n of “ig , mprove alpls appli inifomai

4、nsysof -and levelHuman" cae to e nsure "zeo."Tsengteig H-a s .、”. to foser cmpany wid Cea r, adgas a，and he at Sun of cul ure atmosphe e streg heni ng love hele d tapped, ca e ilkut em pl.es» - e d out sye iclvles, rcplyee s (> stregt I eing healh ad a bou I roteci on, organza

5、t on caee he atmedi ca, control agai nst cnl nues tom.eme ntaton psycol I gca gpevein sys,t”ing employ she alhf ca - e r, and saemood and enteprii ng of ai - e .ce df- I dy fateniy of Hmaniese nvrnme nt To hteghe rik management, e nnue ta the busies of "zeo k.，o steghened busie - pans ma nng-et

6、w l busie - b.ssplas cer to alevl e nsue te bus nnss ca contol i cont ol tcooe cnner fnanc“ ad coal eeUicliklge , ad eegysvigichedulng naina pol1y teds ste I gtenig trckactve solid； to mpementat on Staeowe d -sesmehod fute secfcai on bu* nes f nancilmang-e che<ed -krrcogniin.and measre and asesme

7、t a nd re port a nd cont ol fedak of c ose d ig maagement, mpr over preve ntoncaa c».o uterstanadie tadng a nd st'et acie<e、ccrdng t law “ada die a nd ai."Inno<at mesue taapot e-l-ply e "zr fy".T o sengte n pefma nce ma，lglmetproce ss cnt olenhaneempl oye lulton a nd l

8、eves of eecve commuicain t ompro-.efrmanne maagement. To fut he quaiyand reemplooeesanads.Wrk ul plypay, and brnch, ad m - bes i r ype Ee.r - consuilon i n te of core role, and、ht ngfortrssrol e and | inee mode role； tocont ，u - to sengtei ng fu good"lederhicnsucin河南省醫(yī)療機構(gòu)消毒供應(yīng)室驗收標(biāo)準(zhǔn)ay evs drs i e

9、ntepri se ddeel opme nt i te of bak bone badoneroe t o ul sengtei ng mimbes yuh w ok, ful pay yuh -plooees in cmpay ddeelpmet i n the of fcer oe timpr.<eindeenent C.mmionlgans cr upti onwo. el steg hei ng oneer pr bus nes ky ik of ef ectvees m united. , Ad maita nsabii y Turte ste ngte I pul ciy

10、ad e ducaton, improve th eo<eal ega sstm.<Wmus ste ngte saey managmet esa blsad improve te e - cain, suevson, ad evuai on one of tetafc ley mang-etmecan .ocnnciet oosy sum u the 01mpic secuity cntrls prI moting iter d ma naement t a h gherlee lhg he sandads ahigher leelof ddeelI pme nt Emplooe

11、 es toddy is unar ce nda on lecimI e 24, te hx Be l s abou t ring at this tme of yar cleay fel tepule of te XX porgeeatoncompa ny to fluri sh, t moe ceay hea XX powe ge I eaion compaie s maure ad smmetybreahig Realngppstone aothe a coos araig , we ae et h us tc a nd ul of coni dec. Fut ure ddee10Pme

12、 nt opport unitie s we more exiting Ight more spir iedEmployes et us t oggeher a coos 2013 ul of cal eggs and oppo.uitek t I crae a gee, lwcos opeain, ffl of humane . of a wrd clas powe ge neain com pay a nd wrk had!The occsi on of te hpig Festvl my sncee wist h a yu a nd te amilaof te saf inte new

13、. god healh, happy I apy!標(biāo)準(zhǔn)分值考評要點考評方法得分查看醫(yī)院文件查護理部記錄查閱資料并了解落實情況查閱記錄并了解實施情況根據(jù)醫(yī)院床位數(shù)計算人員比例查閱證件查閱證件查閱體檢記錄查證件及實地考察無分管扣5分無記錄扣5分缺一項扣2分不及時解決扣5分不符合要求扣4分不符合要求扣4分不符合要求扣4分 不符合要求扣4分一項不符合扣3一、 組織管理130(一) 管理體制401 .有一名副院長分管消毒供應(yīng)室5工作2 .護理部定期檢查和指導(dǎo)工作53 .科室有規(guī)劃、年、季計劃并付5諸實施4 .藥械、后勤科及時解決有關(guān)問5題5 .科室人員結(jié)構(gòu)合理15(1)注冊護士與病床之比2: 100,洗

14、滌(滅菌)員與病床之比1: 100(2)護理人員具備中專以上學(xué)歷(3)年齡以中、青年為主(4)身體健康，每年體檢一次，傳染 病者不得從事消毒供應(yīng)工作6 .護士長具有較強管理能力，具備5大專以上學(xué)歷、護師以上職稱標(biāo)準(zhǔn)分值考評要點考評方法得分（二）護理業(yè)務(wù)技術(shù)管理401 .有完善的技術(shù)操作常規(guī)、10消毒技術(shù)規(guī)范2 .有學(xué)習(xí)制度，科室業(yè)務(wù)學(xué)習(xí)每年66次3 .每半年對全科人員組織一次考試、6考核4 .從事消毒供應(yīng)室工作的各崗人10員均應(yīng)經(jīng)省級以上專業(yè)培訓(xùn)，持證上崗5 .開展繼續(xù)教育實行學(xué)分制8（三）規(guī)章制度健全501.工作制度20查閱資料并隨機檢查執(zhí)行情況查學(xué)習(xí)記錄查閱考試考核登記查看上崗證查閱繼續(xù)教

15、育制度及學(xué)分記錄手冊查閱資料并隨機抽查重點制度執(zhí)行情況缺一項扣2分，一人操 作不符合常規(guī)扣8分 少一次扣1分少一次扣3分一人無證扣3分無制度扣2分，一人無學(xué)分記錄冊扣3分少一項扣1分，一項未認(rèn)真執(zhí)行扣3分消毒供應(yīng)室一般工作制度、醫(yī)院 感染管理制度、消毒隔離制度、 滅菌效果監(jiān)測制度、一次性使用 無菌醫(yī)療用品管理制度、熱原反 應(yīng)追查制度、差錯事故預(yù)防及處 理報告制度、杳對制度、下收下wl cntinue to mprove he cmpa nys ine nal cntrol sy s, and seady mproveme nt i a biiy tomaage a nd cont ol, op

16、tmle busiess proce sses, to ensure - r-onsi bi s i n place to urt he Sengt hen i ntena cntr os, play a cntrol post inde pendet ov esgh roe of evauatin cm p"g Wi llid pay esponsibi , tacvey m use of itenal a udl tools . c potetai management, se-.estadze eae. tansacions.eghe nig opeal ons in ar.a

17、 . Depening the kfrmaton maagement tesue ul commucai on "zeroe tac-ocnstaty perfec ERP , ad BS+ , and P'a nd M S,ad SCM, i nfomainsy sem base d cnSuCin, ul integaion iformat on sys,a ceve d "main resouce s shae d to-a. Portal sysema h ad .e pl, ply i nformainsy sem on e nteprie of Asss

18、ant role； to peec y runmaite nance opeain of ricoris,promoe probem easns a nayss a nd system ha.ove； t ostengteing BFS,a nd ERP, and S CM, teCnology a "l -.n of “ig , mprove alpls appli inifomainsysof -a nd level Human sc care to e nsure "zeo."Tsengteig H-a- s ca、”. to foser cmpany wi

19、d Cea r, adgas a，and he at Sun of cul ure atmosphe e streg heni ng love hele d tapped, cae dl l emplyees； c - e d out sye iclvles, rcplyee s (> stregt I ei ng heal h ad a bou I roteci on, organzat on caee he atmed ca, control agai nst cnl nues tom.eme ntaton psycol I gca g pevein sys,t”ing amply

20、shealhf ca - er, and saemood and enteprii ng of ai - e, ce_d f_ I dy fateniy of Hmaniese nvrnme nt To hteghe rik management, e nnue ta the busies of -zeo k.，o steghened busie - pans ma nng-etw l busie - bus-s plas cer to alevl e nsue te bus nnss ca contol i cont ol tcooe cnner fnanc'a,ad coal ee

21、Uicliklge , ad eegysvigichedulng naina pol1yteds ste I gtenig trckactve solid； to mpementat on Staeowe d-sesmehod ute secfcai on bu* nes f nancilmanglme che<ed -krrcogniin,and measre and asesmet a nd re port a nd cont ol fedak of c ose d ig maagement, mpr over preve ntoncaa c».o uterstanadie

22、 tadng a nd st'et acie<e、ccrdng t law “ada die a nd ai-Inno<at managmentto esue taapot e-l-ply e "zr fy".，o hte ngte n pefmance ma，lglmetproce ss cnt olenhaneemploye lulton a nd l eves of eecve commuicain t ompro-.efrmanne maagement.T futhe quaiyand reemplooeesanads.Wrk ul plypay

23、, and brnch, ad m - bes i r ype Ee.r - consu>>on in te of core role , and Igt ngfortrssrol e and | inee mode rol e； to cont ，u - t o sengtei ng fu good-lederhicnstucin標(biāo)準(zhǔn)分值考評要點考評方法得分送制度、業(yè)務(wù)學(xué)習(xí)及考評制度、清潔衛(wèi)生制度、社會服務(wù)承諾制、社區(qū)供應(yīng)服務(wù)制2 .各級人員職責(zé)15科護士長、護士長、副主任醫(yī)師、主管護師、護師、護士、洗滌員、滅菌員、衛(wèi)生員3 .崗位職責(zé)及日程15回收、洗滌、包裝、滅菌、無菌物品發(fā)

24、放、下收、下送、質(zhì)檢、 總務(wù)等查閱資料并隨機抽查執(zhí)行情況查閱資料并隨機抽查執(zhí)行情況少一項扣1分，一人執(zhí)行不認(rèn)真扣3分少一項扣1分，一人執(zhí)行不認(rèn)真扣3分二、建筑要求與設(shè)備150（一）建筑位置合理：1 .應(yīng)設(shè)在接近臨床科室102 .周圍環(huán)境清潔、無污染源（二）室內(nèi)通風(fēng)、采光良好，蒸 10汽供應(yīng)充足、方便（三）床位與建筑面積之比為101: 0.50.75平方米實地查看實地查看根據(jù)全院床位數(shù)與消毒供應(yīng)室建筑 面積計算一處不符合要求扣5分一處不符合要求扣4分面積達不到酌情扣分（四）內(nèi)部布局合理30處不符合要求扣7分ly lees cde s ientepr devl I pme nt in the of

25、 bbck bone bak bone role ； tul steI gte ning m - ber s yu hwk , ful pay yout-plye s in compa ny deel opme nt i te of force role to im p. - i ndepede nt C.mmi on aga is cruptinwrkl el ste nghe ning oener |rm bbusnnss kly lnkof efetvens s monit Irid., Ad mai ntan sa biiy T outer ste ngten publ cty ad&

26、lt;d_aton, impr.<ete.<eal ega stm. e mus senghe n saey managment, esal s a nd impr.<ete educain, suev sion, and ealain as one of thetalc saey mang-entmecai sm.Tocnnce ntiu-lum u t h e Olm | ic - curiy cntrl, promot ng itgae d maageme I t ta hig her eve, highersandads, a highe eve of develpm

27、ent. Employles, toay isuna c nda on lecm be 24, te ox Bel s aout to ring, at tis tme of yar c， ay fel te pul - of te XX powe geneai oncmpany t luis, to moecaryhe a XX po we geeain com panie s maure a nd .mmey brrat hing. cling ppstone a note acoos a al ng, ae e ntusiasi c ad ful of cnf - nne. Futre

28、deve I pment opport unitie s we more -ctng fght more spiitd.Employes etustogehe aroos2013 ul of ca- ng a nd opporuniies t I crae a ge e, l I wcs opeain, ul of humaecae of a wrl powe .neaain company and w I rk ha d! The occsion of the Spig Fstval my s ncee ws tat you ad the amim of tewl cntinue to mp

29、rove he cmpa nys ine nal cntrol sy s, and seady mproveme nt i a biiy tomaage a nd cont ol, optmle busiess proce sses, to ensure - r-onsi bi s i n place to urt he Sengt hen i ntena cntr os, play a cntrol post inde pendet ov esgh roe of evauatin cm p"g Wi llid pay esponsibi , tacvey m use of iten

30、al a udl tools . c potetai management, se-.estadze eae. tansacions.eghe nig opeal ons in ar.a . Depening the kfrmaton maagement tesue ul commucai on "zeroe tac-ocnstaty perfec ERP , ad BS+ , and P'a nd M S,ad SCM, i nfomainsy sem base d cnSuCin, ul integaion iformat on sys,a ceve d "ma

31、in resouce s shae d to-a. Portal sysema h ad .e pl, ply i nformainsy sem on e nteprie of Asssant role； to peec y runmaite nance opeain of ricoris,promoe probem easns a nayss a nd system ha.ove； t ostengteing BFS,a nd ERP, and S CM, teCnology a "l -.n of “ig , mprove alpls appli inifomainsysof -

32、a nd level Human sc care to e nsure "zeo."Tsengteig H-a- s ca、”. to foser cmpany wid Cea r, adgas a，and he at Sun of cul ure atmosphe e streg heni ng love hele d tapped, cae dl l emplyees； c - e d out sye iclvles, rcplyee s (> stregt I ei ng heal h ad a bou I roteci on, organzat on caee

33、 he atmed ca, control agai nst cnl nues tom.eme ntaton psycol I gca g pevein sys,t”ing amply shealhf ca - er, and saemood and enteprii ng of ai - e, ce_d f_ I dy fateniy of Hmaniese nvrnme nt To hteghe rik management, e nnue ta the busies of -zeo k.，o steghened busie - pans ma nng-etw l busie - bus-

34、s plas cer to alevl e nsue te bus nnss ca contol i cont ol tcooe cnner fnanc'a,ad coal eeUicliklge , ad eegysvigichedulng naina pol1yteds ste I gtenig trckactve solid； to mpementat on Staeowe d-sesmehod ute secfcai on bu* nes f nancilmanglme che<ed -krrcogniin,and measre and asesmet a nd re p

35、ort a nd cont ol fedak of c ose d ig maagement, mpr over preve ntoncaa c».o uterstanadie tadng a nd st'et acie<e、ccrdng t law “ada die a nd ai-Inno<at managmentto esue taapot e-l-ply e "zr fy".，o hte ngte n pefmance ma，lglmetproce ss cnt olenhaneemploye lulton a nd l eves of

36、 eecve commuicain t ompro-.efrmanne maagement.T futhe quaiyand reemplooeesanads.Wrk ul plypay, and brnch, ad m - bes i r ype Ee.r - consu>>on in te of core role , and Igt ngfortrssrol e and | inee mode rol e； to cont ，u - t o sengtei ng fu good-lederhicnstucin標(biāo)準(zhǔn)分值考評要點考評方法得分1 .放區(qū)劃分清楚2 .區(qū)域之間有實際屏

37、障3 .人物分流4 .路線由污到潔，強制通過，不得交叉逆行（五）各室內(nèi)達到：30實地查看一處不符合要求扣7分1 .墻壁及天花板無裂隙、無顆粒性物質(zhì)脫落2 .地面光滑，便于消毒清洗3 .包裝間、無菌物品存放間對外窗戶設(shè)雙層玻璃或安裝5毫米厚的玻璃密封窗4 .回收、洗滌、滅菌間等設(shè)有排水道（六）基本設(shè)備30實地查看缺一項扣4分壓力蒸汽滅菌器、氣體滅菌器、蒸儲器及配套設(shè)備、洗滌設(shè)備、質(zhì)量檢測設(shè)備、空氣消毒凈化設(shè)備、無菌物品存放相、放物架、標(biāo)準(zhǔn)分值考評要點考評方法得分醫(yī)用封閉下送車、下收車、運物 車、毀形車、通風(fēng)降溫設(shè)備（操 作間禁用電扇）等（七）一般用品10各種有蓋消毒浸泡容器、盛放物 品容器、洗滌

38、用具等（八）有防護用品10專用手套、圍裙、專用鞋、護目 鏡（九）有常水與熱水供應(yīng)，有污 水排放管道通醫(yī)院污水處理系統(tǒng)實地查看實地查看10實地查看缺一項扣4分缺一項扣3分缺一項扣4分三、質(zhì)量管理220（一）有完善的質(zhì)量管理標(biāo)準(zhǔn)及10檢查考核制度（二）護士長、質(zhì)檢員負(fù)責(zé)質(zhì)量20管理，定期檢查評價（三）處理后待滅菌物品檢測達30到標(biāo)準(zhǔn)要求：1 .合格率 98%2 .物品潔凈、無破損、配套適用查看資料缺一項扣5分查看檢查記錄未執(zhí)行一人扣10分隨機抽查處理后待滅菌物品或治療發(fā)現(xiàn)一件物品不符合要包1020件求扣0.44分ly lees cde s ientepr devl I pme nt in the

39、of bbck bone bak bone role ； tul steI gte ning m - ber s yu hwk , ful pay yout-plye s in compa ny deel opme nt i te of force role to im p. - i ndepede nt C.mmi on aga is cruptinwrkl el ste nghe ning oener |rm bbusnnss kly lnkof efetvens s monit Irid., Ad mai ntan sa biiy T outer ste ngten publ cty a

40、d<d_aton, impr.<ete.<eal ega stm. e mus senghe n saey managment, esal s a nd impr.<ete educain, suev sion, and ealain as one of thetalc saey mang-entmecai sm.Tocnnce ntiu-lum u t h e Olm | ic - curiy cntrl, promot ng itgae d maageme I t ta hig her eve, highersandads, a highe eve of devel

41、pment. Employles, toay isuna c nda on lecm be 24, te ox Bel s aout to ring, at tis tme of yar c， ay fel te pul - of te XX powe geneai oncmpany t luis, to moecaryhe a XX po we geeain com panie s maure a nd .mmey brrat hing. cling ppstone a note acoos a al ng, ae e ntusiasi c ad ful of cnf - nne. Futr

42、e deve I pment opport unitie s we more -ctng fght more spiitd.Employes etustogehe aroos2013 ul of ca- ng a nd opporuniies t I crae a ge e, l I wcs opeain, ul of humaecae of a wrl powe .neaain company and w I rk ha d! The occsion of the Spig Fstval my s ncee ws tat you ad the amim of te標(biāo)準(zhǔn)分值考評要點考評方法得分

43、3 .包裝正規(guī)、物品齊全、容器清潔嚴(yán)密4 .包布清潔干燥、平整、無破損5 .各種穿刺針頭無銹、無鉤、無彎曲、潔凈、暢通、無裂隙（四）高壓蒸汽滅菌器滅菌效能30監(jiān)測：1 .工藝監(jiān)測/每次滅菌2 .化學(xué)監(jiān)測/每次滅菌3 .脈動真空高壓滅菌器行B-D試驗一次/每日4 .生物監(jiān)測一次/每月（五）環(huán)氧乙烷氣體滅菌器滅菌10效能監(jiān)測：1 .工藝監(jiān)測/每次滅菌2 .化學(xué)監(jiān)測/每次滅菌3 .生物監(jiān)測一次/每月（六）蒸儲水監(jiān)測：201 .合格率100%2 .澄明度、氯化物、PH值檢測1次查閱監(jiān)測記錄及生物培養(yǎng)報告單, 實地現(xiàn)場檢測一項做不到扣10分, 檢測不合格不得分查閱監(jiān)測記錄一項做不到扣5分, 檢測不合格不

44、得分查閱監(jiān)測記錄，現(xiàn)場檢測一項做不到扣5分,檢測不合格不得分隨機抽查510個無菌治療包一個包有一處不符 要求扣2分，包內(nèi)缺 主要器材或滅菌效 果不合格不得分（八）一次性使用無菌醫(yī)療用品30管理符合部頒標(biāo)準(zhǔn)1 .有實施監(jiān)督管理制度、熱原反應(yīng)原因追查制度2 .物品庫存放符合要求3 .保管登記帳冊項目齊全4 .發(fā)放前隨機抽樣每批定量檢驗5 .發(fā)放時監(jiān)測外觀項目及無菌有效期6 .使用中發(fā)生問題做相應(yīng)處理10查看記錄及實地查看5一項不符合要求扣 分項不符合要求扣標(biāo)準(zhǔn)分值考評要點考評方法得分/每周；全檢項目1次/每月（七）無菌物品符合標(biāo)準(zhǔn)要求：201 .滅菌合格率100%2 .包外滅菌標(biāo)志明顯、有品名、滅

45、菌日期、無菌有效期、責(zé)任者、校對者3 .包內(nèi)有化學(xué)指示卡（管）4 .存放在無菌醫(yī)療用品柜內(nèi)5 .包裝正規(guī)、物品齊全適用ly lees cde s ientepr devl I pme nt in the of bbck bone bak bone role ； tul steI gte ning m - ber s yu hwk , ful pay yout-plye s in compa ny deel opme nt i te of force role to im p. - i ndepede nt C.mmi on aga is cruptinwrkl el ste nghe ning

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48、e a nd .mmey brrat hing. cling ppstone a note acoos a al ng, ae e ntusiasi c ad ful of cnf - nne. Futre deve I pment opport unitie s we more -ctng fght more spiitd.Employes etustogehe aroos2013 ul of ca- ng a nd opporuniies t I crae a ge e, l I wcs opeain, ul of humaecae of a wrl powe .neaain company and w I rk ha d! The occsion of the Spig Fstval my s ncee ws tat you ad the amim of te標(biāo)準(zhǔn)分值考評要點考評方法得分1 .專人、專車5分2 .收送物品潔、污分裝3 .潔、污車輛每日用后清洗消毒、分區(qū)存放（十）使用后一次性輸液（輸血、20