Municipal health committees, provincial hospitals, provincial medical service management evaluation centers:

In order to further strengthen the hospital supervision and management, promote the hospital to strengthen the connotation construction, promote the high-quality development of the hospital, and standardize and improve the hospital grade evaluation, our committee has formulated the Zhejiang Provincial Hospital Evaluation Method. It is hereby printed and distributed to you for compliance.

Zhejiang Provincial Health Commission

March 8, 2024

(Form of information disclosure: active disclosure)

Zhejiang Provincial Hospital Evaluation Measures

Chapter I General Provisions

Article 1 In order to further strengthen hospital management, constantly improve the hospital evaluation system, improve medical quality, ensure medical safety, improve the comprehensive level of the hospital, and promote the high-quality development of the hospital, these measures are formulated in accordance with the Regulations on the Administration of Medical Institutions, the Detailed Rules for the Implementation of the Regulations on the Administration of Medical Institutions, and the relevant provisions of the national health administrative department.

Article 2 Hospital evaluation refers to the process in which hospitals carry out self-evaluation, continuously improve hospital work, and accept the evaluation by the health administrative department on the completion of their planned functions and tasks according to the basic standards of medical institutions and hospital evaluation standards in accordance with the requirements of these Measures to determine the level of hospitals. The health administrative department conducts comprehensive evaluation on the hospital's party building talent work, functional orientation, practice behavior, medical quality, service ability, management level, and the construction of smart hospitals and clean hospitals through statistical evaluation, on-site evaluation, social evaluation and other methods and methods.

The hospital review referred to in the Measures includes the review of hospitals at all levels and all types (the same below). The validity period of hospital review conclusions is four years, and dynamic management is implemented.

Article 3 The main basis for hospital evaluation is laws, regulations, rules, and normative documents, standards, diagnosis and treatment norms formulated and promulgated by the national and provincial health administrative departments.

Article 4 All kinds of hospitals at all levels within the province that have legally obtained the Practicing License of Medical Institutions shall participate in the review in accordance with these Measures. After the reorganization of resources, the hospital area or branch of the same legal entity or the same legal representative will participate in the review as a part of the hospital (except for the medical community).

Hospital integrated management refers to the unified formulation and implementation of rules, regulations and standards, the unified management of functional departments and clinical departments, the interconnection of information systems, the unified deployment of medical resources, and the unified registration management of medical personnel.

Article 5 Hospital grade review shall adhere to the dynamic review mechanism of promoting construction, improvement and demotion through evaluation, pay attention to the combination of irregular key inspection, spot check, flight inspection, daily quality control assessment and other work carried out by the health administrative department and each quality control center on the hospital, and pay attention to the application of inspection results and daily assessment results in the review process.

Chapter II Review Rules and Grade Management

Article 6 Hospitals in Zhejiang Province are divided into three grades and four grades, namely, Grade III A, Grade III B, Grade II A, Grade II B, and Grade I hospitals, of which Grade I hospitals are not graded. Class I hospitals are directly evaluated and recognized by the practice registration authority according to the basic standards of medical institutions. If some hospitals have not issued evaluation standards, the provincial health administrative departments or the health administrative departments of cities divided into districts with corresponding evaluation management authority shall clearly refer to the management level according to the basic standards of medical institutions.

Article 7 A newly built hospital can apply for the first review in principle after obtaining the Practicing License of Medical Institution and practicing for three years. Before the first review, the hospital shall be managed according to the construction level, and no grade shall be determined. In case of any change in the level of hospital setting, the first review can be applied for according to the changed level and category in principle after three years of practice. The hospital shall complete the first review application within 3 months after obtaining the first review qualification. If a hospital fails to apply for review within the time limit, and still fails to apply after being reminded in writing by the health administrative department of the jurisdiction, the practice registration authority shall identify it as a non graded hospital.

Article 8 Hospitals participating in the grade reevaluation shall generally complete the application for review at least 3 months in advance on the expiration date of the validity period of the hospital's review grade; If a hospital fails to apply for review within the time limit, and still fails to apply after being reminded in writing by the health administrative department of the jurisdiction, the practice registration authority shall identify it as a non graded hospital.

Article 9 Hospital grade evaluation shall focus on the application of performance evaluation results of public hospitals, and take the evaluation results as the admittance conditions of hospital evaluation, which shall be determined in the evaluation standards of various types of hospitals.

Article 10 Social run hospitals shall establish and improve their own indicator evaluation system according to the performance evaluation indicators of national public hospitals, and the provincial health administrative department shall determine the ranking by reference to the performance evaluation standards of national public hospitals.

Article 11 In case of major medical accidents, major hospital infection events, major production safety accidents, major illegal acts, and major professional ethics events in the hospital, the health administrative department shall, according to the consequences of the events and the responsibilities identified by the relevant departments, circulate a notice of criticism, make rectification within a time limit, and revoke the hospital grade if the situation is serious or causes major social impact.

Chapter III Review Authority and Organization

Article 12 The hospital review work shall be subject to the hierarchical responsibility system.

The provincial health administrative department is responsible for the formulation and promulgation of hospital evaluation standards and methods, as well as the supervision and management of the evaluation work, organizing the evaluation work of the provincial application for Class III hospitals and the first application for Class II Class A hospitals, and confirming the hospital grade.

The health administrative departments of the cities divided into districts are responsible for organizing the review of Grade II Grade B hospitals and the reevaluation of Grade II Grade A hospitals within their jurisdiction, and confirming the grade of Grade II hospitals. The review results shall be reported to the provincial health administrative department for record.

The county (city, district) health administrative departments are responsible for the identification of the first-class hospitals within their jurisdiction. The determination results shall be reported to the health administrative department of the city divided into districts for the record.

Article 13 The provincial and municipal health administrative departments shall, within their limits of authority, set up a hospital evaluation expert committee (hereinafter referred to as the evaluation committee), which shall have an office. The evaluation committee shall work under the leadership of the health administrative department. The health administrative department shall strengthen the supervision and management of the evaluation committee.

Article 14 The main responsibility of the evaluation committee is to make suggestions on the hospital evaluation policies, measures, evaluation methods and procedures, and to provide the basis for the health administrative department to make decisions; According to the review arrangement and deployment of the health administrative department, organize and implement the hospital review specifically and propose review conclusions and suggestions; Participate in the establishment and management of reviewer base, and carry out reviewer training.

The Evaluation Committee Office is responsible for organizing, coordinating, implementing, summarizing and other daily work.

Article 15 The members of the evaluation committee are mainly composed of managers and experts who have some experience in hospital management, medical treatment, medical technology, nursing, medical education and scientific research, finance, personnel management, etc.

The members of the jury shall be selected and appointed by the health administrative department on the basis of recommendations from hospitals, medical management service guidance institutions, industry associations (associations), medical insurance agencies, social assessment institutions, etc., and in principle, they shall be appointed once every four years. The members of the jury should be adjusted in time if they are not suitable to serve as members due to work adjustment. No civil servant in the administrative department may hold a post or hold a part-time job in the appraisal committee.

The jury shall have one chairman, several vice chairmen and members. The chairman and vice chairmen shall be determined by the administrative department of public health.

Article 16 The appraisal committee shall establish and improve the system and work discipline, including the appraisal work process, the appraiser work system and the challenge system, to ensure that the appraisal work is standardized, orderly, fair and fair.

Article 17 The provincial and municipal health administrative departments shall establish a pool of reviewers, formulate a management system for reviewers, implement dynamic management, and strengthen supervision over reviewers. The reviewer database is composed of management personnel and experts with rich experience in hospital management, medical treatment, nursing, medical technology, hospital sense, pharmacy, finance, logistics, professional ethics construction, etc.

Article 18 The assessors are divided into provincial assessors and municipal assessors, which shall meet the following conditions.

（1） Served in hospitals above Grade II Grade A;

（2） More than 5 years of work experience in the corresponding field;

（3） Have the title of deputy high or above or corresponding level;

（4） Be healthy and able to undertake the review work;

（5） Be able to perform duties conscientiously, impartially, honestly and honestly.

Article 19 If an assessor has any of the following acts, the administrative department of health shall order him to make corrections, and if the circumstances are serious, he shall be removed from the pool of assessors and investigated for corresponding responsibility.

（1） Should avoid but not avoid;

（2） Absence without leave;

（3） The review work is not carried out according to the hospital review standards;

（4） Receive gifts and cash gifts from the reviewed hospital;

（5） Organize paid training on hospital evaluation;

（6） Other acts that are not objective and impartial in performing their duties.

If the reviewer fails to obey the task arrangement for two consecutive times, or is not competent for the review due to health and professional ability, the jury shall recommend the health administrative department to cancel the qualification of the reviewer.

Chapter IV Review Procedures and Conclusions

Article 20 According to the hospital evaluation standards formulated by the National Health Commission or the State Administration of Traditional Chinese Medicine, and in combination with the priorities of medical and health work in Zhejiang Province, the actual situation and characteristics of hospital management, the hospital grade evaluation standards of Zhejiang Province are formulated, which will be released after being reported to the National Health Commission or the State Administration of Traditional Chinese Medicine for the record.

Article 21 Each hospital shall conduct self-evaluation according to the evaluation standards, determine the corresponding level of application according to the self-evaluation results, and report to the health administrative department in charge of practice registration and the health administrative department of the city divided into districts after formal examination. For hospitals applying for Grade II A and Grade III A and Grade III B for the first time, the application materials shall be submitted through the hospital evaluation management system of Zhejiang Province, and the self inspection results shall be filled in and submitted to the provincial evaluation committee after being reviewed by the provincial health administrative department.

Other hospitals applying for Grade II Grade A and Grade II Grade B shall submit application materials to the health administrative department of the city divided into districts, fill in the self inspection results, and submit them to the appraisal committee of the city divided into districts after passing the formal review.

If the hospital applying for the re evaluation of the original grade fails to pass the self-evaluation, it can apply for postponement of the evaluation. The longest time limit for postponement of the evaluation shall not exceed 1 year.

Article 22 The evaluation committee shall, according to the plan and deployment of the health administrative department, analyze the big data of the hospitals applying for evaluation, conduct on-site verification when necessary, determine the evaluation plan based on the statistical analysis results and on-site verification, and organize the on-site evaluation work to form the on-site evaluation results.

Article 23 The review committee shall timely form a review report based on the on-site review results of the hospital and report it to the health administrative department.

The review work report shall include the overview of the review work, on-site review results and review conclusions and suggestions, main problems existing in the reviewed hospital, rectification opinions and other problems that need to be explained.

Article 24 The health administrative department shall make a review conclusion based on the review work report submitted by the evaluation committee, report it to the health administrative department at the next higher level for filing, and propose rectification opinions for the hospitals that fail to pass the review.

Article 25 The review conclusions of hospitals at all levels are divided into qualified and unqualified. For hospitals with "unqualified" review conclusions, a notice of rectification will be issued and a period of 3-6 months will be given.

The hospital shall apply to the health administrative department of practice registration for reexamination in time after the expiration of the rectification period. If the reexamination conclusion is unqualified, the health administrative department shall reduce or revoke the hospital grade according to its authority and the specific situation of the evaluation.

Article 26 Before approving the hospital grade, the health administrative department shall publicize the conclusion of the hospital evaluation through the network and other media for 7 days. If there is no objection or the objection does not affect the evaluation conclusion, the official document shall be issued for confirmation, and the grade certificate shall be issued. At the same time, it shall be submitted to the health administrative department at the next higher level for record and announced to the public.

Article 27 The administrative department of health shall take the initiative to publish the conclusions of hospital evaluation, and the hospital shall publicize the grades in a conspicuous position and accept social supervision.

Chapter V Supervision and Management

Article 28 The administrative department of health shall strengthen the organization, leadership, supervision and management of hospital review work, ensure the fairness and impartiality of hospital review work, and strengthen the examination and supervision of review organization, review plan, review personnel composition, avoidance system, review procedures, discipline implementation and other aspects, so as to maintain the credibility of hospital review work.

Article 29 The service fees for the assessors shall be paid by the health administrative department that organized the assessment. The evaluated hospital shall not give gifts, cash gifts and labor service fees to the members of the evaluation team in any name.

Article 30 If any member of the appraisal committee, staff member of the appraisal committee office or appraiser violates the regulations and interferes with the normal appraisal work, or takes advantage of his position or work to seek illegitimate interests, the health administrative department and the appraisal committee shall correct and deal with them in a timely manner, and disqualify them from participating in the appraisal work. The health administrative department and the appraisal committee shall terminate their employment relationship with them, Inform the affiliated units and deal with them as appropriate.

Chapter VI Supplementary Provisions

Article 31 The Health Commission of Zhejiang Province is responsible for the interpretation of these Measures.

Article 32 These Measures shall come into force as of May 1, 2024. The Measures for the Evaluation of Hospitals in Zhejiang Province (ZWF [2019] No. 54) shall be repealed at the same time.

Link: policy interpretation

Links: illustration

enclosure: Notice of Zhejiang Provincial Health Commission on Printing and Distributing Zhejiang Provincial Hospital Evaluation Methods.pdf