In order to further improve the hierarchical diagnosis and treatment system, standardize the referral behavior of medical institutions in Chongqing, and ensure medical safety, recently, the Chongqing Municipal Health Commission, the Chongqing Municipal Administration of Traditional Chinese Medicine, and the Chongqing Municipal Bureau of Disease Control and Prevention jointly issued the "Chongqing Medical Institutions Referral Management Measures (Trial)" (hereinafter referred to as the "Measures").
The Measures propose that medical institutions at all levels in Chongqing should follow the principles of informed choice, hierarchical management, comprehensive trade-off, resource sharing, and continuous treatment in hierarchical diagnosis and treatment.
Among them, the principle of hierarchical management is as follows: minor diseases in the community, major diseases in the hospital; Patients with common diseases, frequent diseases, well-diagnosed chronic diseases, and convalescent patients are diagnosed and treated in primary medical institutions; Intractable diseases, critical and serious diseases are diagnosed and treated in general hospitals or specialized hospitals at or above the second level.
The Measures also provide clear explanations on key issues such as which situations require referral, where referred patients can be transferred, and which circumstances medical institutions can refuse referral.
When do medical institutions need to arrange a referral?
The Measures point out that if a medical institution has one of the six types of circumstances in the process of diagnosing and treating a patient, the patient shall be transferred to a medical institution with the ability to diagnose and treat patients:
Category 1: Diagnosis and treatment of diseases beyond the practice registration of medical institutions;
Category 2: do not have the corresponding medical technology clinical application qualification or surgical qualification;
Category 3: The condition is difficult and complex and cannot be clearly diagnosed, and further diagnosis and treatment are required;
Category 4: Limited to the level of diagnosis and treatment, technical capacity, or equipment conditions of medical institutions, and does not have the ability to diagnose and treat;
Category 5: Infectious diseases that need to be transferred to designated medical institutions for treatment in accordance with relevant regulations;
Category 6: Other circumstances stipulated by the administrative department of health.
Where do referred patients go?
The "Measures" proposes that the referred patients will be given priority and transferred to the nearest higher-level medical institution in the district or county where the patient resides.
If the higher-level medical institution does not have the ability to diagnose and treat, it can be transferred to the relevant medical institution according to the service area of the regional medical center or the service scope of the medical alliance.
Critically ill patients with special conditions, and patients with difficult and complex cases, should be transferred to medical institutions with the capacity for diagnosis and treatment according to the needs of their conditions. Persons with infectious diseases and mental illness shall be transferred to the corresponding medical institutions designated by the administrative department of health.
Where a referral agreement has been signed between medical establishments, the referral shall be made in accordance with the agreement on the premise of following the referral principles provided for in these Measures.
For patients such as pregnant women and critically ill newborns, where the administrative departments of health have clear referral requirements, they shall follow the relevant referral requirements.
In the event of a public health emergency and major casualty, all types of medical institutions at all levels in the city shall be treated in accordance with the requirements of the administrative department of health, consultation and referral.
According to the "Measures", in the process of diagnosing and treating patients, secondary and tertiary hospitals can also transfer patients to primary medical institutions within the medical alliance that meet the corresponding conditions.
How do I get a referral?
The Measures propose that medical institutions should establish a green channel for referral and strengthen communication and contact with the referred patients' conditions and follow-up treatment.
The hospital to which the patient is transferred should contact the hospital to be transferred in a timely manner to communicate the patient's relevant information. After receiving the information, the hospital to be transferred will take the initiative to contact the patient as soon as possible, clarify the patient's intention, explain the precautions for transfer, track the referral process, and improve the referral efficiency.
During the hospitalization of patients referred to hospitals, the referring physician from the transferring medical institution may be invited to participate in the case discussion.
After the patient is transferred to a medical institution for hospitalization, the physician in charge shall promptly check "Transfer from other medical institutions" on the Home of the medical record "Admission Route" and fill in the "Patient Source".
After the inpatient is transferred out of the medical institution, the physician in charge shall promptly check the "medical order transfer" or "medical order transfer to community health service organization/township health center" on the "discharge method" on the Home of the medical record and fill in the "name of the medical institution" to which it is transferred.
Under what circumstances can a referral be denied by a medical provider?
According to the Measures, when a patient requests a referral, the referral may be refused to be made by the following medical institutions:
Category 1: Medical institutions designated by the health administrative department or the government in response to emergencies; Category 2: It is necessary to carry out isolation and treatment of patients in accordance with the law; Category 3: Other circumstances stipulated by the administrative department of health.
Hierarchical diagnosis and treatment is one of the key medical reform policies frequently mentioned by the National Health Commission in recent years.
The Beijing Municipal Government pointed out in the interpretation document of relevant policies and measures that the connotation of hierarchical diagnosis and treatment can be summarized in 16 words: primary diagnosis, two-way referral, acute and slow treatment, and upper and lower linkage.
The first diagnosis at the grassroots level is to adhere to the principle of the masses' voluntariness, and encourage patients with common and frequent diseases to go to the primary medical and health institutions for treatment first through policy guidance.
By improving the referral procedure, the two-way referral focuses on smoothing the downward referral of patients in the chronic and convalescent phases, and gradually realizes the orderly referral between different levels and categories of medical institutions.
The acute and chronic disease diagnosis and treatment service system is to improve the subacute and chronic disease service system, transfer patients who have passed the acute stage from tertiary hospitals, and implement the acute and chronic disease diagnosis and treatment service functions of various medical institutions at all levels.
The linkage between the upper and lower levels is to establish a division of labor and cooperation mechanism between medical institutions to promote the vertical flow of high-quality medical resources.
In order to promote the establishment of a hierarchical diagnosis and treatment system, the state has made positive efforts to realize the first diagnosis and referral of chronic diseases, common diseases, and frequent diseases at the grassroots level, and to promote the sinking of high-quality medical resources.
The "Measures" issued by Chongqing Municipality this time are a specific refinement of the implementation of Chongqing's hierarchical diagnosis and treatment system, and have positive significance for building an urban and rural medical and health service system with reasonable layout, hierarchical optimization, perfect functions and coordinated linkage.
Chongqing Municipal Measures for the Administration of Referral of Medical Institutions (Provisional)
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Article 1 In order to further improve the hierarchical diagnosis and treatment system, standardize the referral behavior of medical institutions in Chongqing, ensure medical safety, and safeguard the health rights and interests of patients, in accordance with the "Regulations on the Administration of Medical Institutions", the General Office of the State Council's "Guiding Opinions on Promoting the Construction of a Hierarchical Diagnosis and Treatment System" (Guo Ban Fa [2015] No. 70), the National Health Commission, the National Development and Reform Commission, the Ministry of Finance, the Ministry of Human Resources and Social Security, the State Administration of Traditional Chinese Medicine, and the National Bureau of Disease Control and Prevention "Notice on Carrying out the Pilot Work on the Construction of Compact Urban Medical Groups" (Guo Wei Yi Zheng Han [2023] No. 27), the National Health Commission, the Central Preparation Office, the National Development and Reform Commission, the Ministry of Finance, the Ministry of Human Resources and Social Security, the Ministry of Agriculture and Rural Affairs, the National Health Insurance Administration, the State Administration of Traditional Chinese Medicine, the National Bureau of Disease Control and Prevention, the State Food and Drug Administration, the Guiding Opinions on Comprehensively Promoting the Construction of a Close-knit County Medical and Health Community (Guo Wei Ji Ji Fa [2023] No. 41) and other relevant laws, regulations and documents, combined with the actual situation, these measures are formulated.
Article 2 These measures apply to referrals between all types of medical institutions at all levels in the city.
Article 3 The Chongqing Municipal Health Commission, the Chongqing Municipal Administration of Traditional Chinese Medicine, and the Chongqing Municipal Bureau of Disease Control and Prevention are responsible for the supervision and guidance of the referral work of medical institutions in the city, and the health administrative departments of each district and county (autonomous county) are responsible for the supervision and guidance of the referral work of medical institutions within their respective administrative areas.
Article 4: Referrals by medical establishments shall follow the following principles:
(1) The principle of informed consent. Starting from safeguarding the interests of patients, we fully respect patients' right to know and choose, so that patients can truly enjoy the convenience, speed, and efficiency of referral.
(2) The principle of hierarchical diagnosis and treatment. In accordance with the principle of minor illnesses in the community and major illnesses in hospitals, patients with common diseases, frequent diseases, chronic diseases with clear diagnoses, and convalescent patients are to be diagnosed and treated in primary medical institutions, and difficult and critical diseases are to be diagnosed and treated in general hospitals or specialized hospitals at or above the second level.
(3) The principle of comprehensive trade-offs. In order to improve the pertinence and effectiveness of the diagnosis and treatment of patients' diseases, the patient's condition and the characteristics of the hospital's specialty and disease should be considered when transferring patients from primary medical institutions to general hospitals or specialized hospitals at or above the second level. In the event of a public health emergency, all types of medical institutions at all levels in the city must accept the designated referral of the health administrative department.
(4) The principle of resource sharing. In accordance with the requirements, implement a system of mutual recognition of medical examination and medical imaging examination results between lower levels and higher levels and medical institutions at the same level, and must not carry out unnecessary examinations or treatment for patients. Strengthen technical cooperation and personnel exchanges, and promote the rational use of health resources.
(5) The principle of continuous treatment. Establish an effective, rigorous, practical and smooth referral channel to provide patients with holistic and continuous medical services.
Article 5: Medical establishments bear primary responsibility for referrals that occur in that institution, and their primary responsibilities include:
(1) Formulate the institution's referral system, process, and emergency response plan on the basis of relevant provisions on referrals, and organize their implementation;
(2) Responsible for the statistics and analysis of patients referred by the institution;
(3) Regularly assess and supervise the implementation of the institution's referral management systems, and put forward improvement measures and requirements;
(4) Other duties as prescribed by the administrative department of health.
Article 6: The principal responsible person for a medical establishment is the first person responsible for the institution's referral work. Where medical establishments have beds, they shall clarify or establish a referral management department to be responsible for the day-to-day management of referrals. Where medical establishments do not have beds, they shall designate full-time (part-time) personnel to be responsible for the day-to-day management of referrals.
Article 7: In any of the following circumstances in the course of diagnosing and treating patients, medical establishments shall transfer the patients to medical establishments that have the capacity to diagnose and treat patients:
(1) Diagnosis and treatment of diseases beyond the practice registration of medical establishments;
(2) Lack of corresponding medical technology clinical application qualifications or surgical qualifications;
(3) The condition is difficult and complex and cannot be clearly diagnosed, and further diagnosis and treatment is required;
(4) Limited to the level of diagnosis and treatment, technical capacity, or equipment of the medical establishment, and does not have the ability to diagnose and treat;
(5) The infectious disease needs to be transferred to a designated medical institution for treatment in accordance with relevant provisions;
(6) Other circumstances provided for by the administrative department of health.
Where the provisions of the preceding paragraph are met, but the medical establishment's assessment finds that the patient's condition is unstable and temporarily unsuitable for referral, a medical institution with the capacity for diagnosis and treatment shall be invited to arrange for a physician consultation, and after the patient's condition is stabilized, a referral is to be made in accordance with the provisions of these Measures.
Article 8: In accordance with the provisions of Article 7 of these Measures, medical establishments that truly need to be referred after assessment shall be transferred to a medical institution with more capacity for treatment based on the needs of the condition and the following principles:
(1) Priority and nearby transfer to a higher-level medical institution in the district or county where the patient resides;
(2) When medical establishments in the first paragraph of this article do not have the capacity for diagnosis and treatment, they shall be given priority transfer to relevant medical establishments in accordance with the service area of the regional medical center or the scope of services of the medical alliance;
(3) Critically ill patients with special conditions, or patients with difficult and complex cases, are transferred to medical establishments with the capacity for diagnosis and treatment as needed by their conditions;
(4) Persons with infectious diseases or mental illness are transferred to corresponding medical establishments designated by the administrative departments for health;
(5) Where a referral agreement has been signed between medical establishments, the referral shall be made in accordance with the agreement on the premise of following the referral principles provided for in these Measures.
Article 9: Where the administrative departments of health have clear referral requirements for patients such as pregnant women and critically ill newborns, they shall follow the relevant referral requirements.
Article 10: In the event of a public health emergency or major casualty, all types of medical institutions at all levels in the city shall carry out treatment, consultation and referral in accordance with the requirements of the administrative department of health, so as to protect the health rights and interests of patients to the greatest extent.
Article 11: In any of the following circumstances in the course of diagnosing and treating patients, second- and third-level hospitals shall follow the principle of voluntariness and transfer the patient to a basic level medical institution within the medical alliance with appropriate diagnosis and treatment capacity:
(1) Common and frequent diseases, acute and chronic diseases, and remission periods;
(2) Patients with chronic non-communicable diseases have a clear diagnosis, stable condition, and a definite treatment plan, and need to maintain treatment;
(3) The condition is stable after surgery and it is necessary to continue rehabilitation;
(4) Late stages of the disease that only require conservative, supportive, palliative or palliative care;
(5) The infectious disease has passed the infectious period, the condition is stable, and it needs to be followed up and managed;
(6) Those who are old, infirm, disabled, or demented and need care for chronic diseases;
(7) The patient or family member requests a referral and is deemed to be feasible after assessment by the attending physician;
(8) Other circumstances provided for by the administrative department of health.
Article 12: Before medical establishments refer patients, they shall inform them of the reasons for the referral, the medical establishments to which they are transferred, precautions, and unexpected circumstances that may occur during the referral, and sign an informed consent form; If it is inappropriate or impossible to inform the patient, the close relatives shall be informed and the informed consent form shall be signed.
Where patients are incapacitated and unable to contact their close relatives, they may be referred in accordance with the provisions of these Measures with the approval of the person in charge of the medical establishment or the authorized person in charge. For "three noes" and vagrant patients, medical establishments shall also inform the relevant rescue departments.
Article 13: Where patients or their close relatives do not agree to the referral arrangements or take the initiative to request a referral and contact them to be transferred to another medical institution for treatment on their own, the medical institution from which they are transferred shall cooperate, inform the patient or their close relatives of the possible risks, and require them to sign for confirmation. In any of the following circumstances, the transfer medical institution may refuse the referral:
(1) Medical institutions designated by the administrative department of health or the government to respond to emergencies;
(2) It is necessary to carry out isolation and treatment of patients in accordance with law;
(3) Other circumstances provided for by the administrative departments of health.
Where, after being assessed by a medical establishment, it is found that the patient's condition is not suitable for referral, but the patient or their close relatives strongly request a referral, the medical establishment shall fully inform the patient or their close relatives of the possible risks and require them to sign for confirmation.
Article 14: Where medical establishments make referrals in accordance with article 7 of these Measures, the transferring medical establishments shall fully communicate with the transferring medical establishments on the patient's condition, vital signs, transport situation, and so forth, and reach a consensus to ensure the safety and orderliness of the transfer work.
Where medical establishments make referrals in accordance with the provisions of Article 11 of these Measures, the transferring medical establishments shall communicate with the transferring medical establishments on the patient's follow-up treatment plan and give guidance.
Article 15: Medical establishments shall establish green channels for referrals, and strengthen communication and contact with referred patients for their illness and follow-up treatment. The transfer out hospital should contact the hospital to be transferred in a timely manner, communicate the relevant information of the patient, and take the initiative to contact the patient as soon as the hospital to be transferred after receiving the information, clarify the patient's intention, explain the precautions for transfer, track the referral process, and improve the efficiency of the transfer. For inpatients who are referred to hospitals, during the patient's hospitalization, the referring physician from the transferring medical institution may be invited to participate in the case discussion.
Article 16 After a patient is transferred to a medical institution for hospitalization, the physician in charge shall promptly check "Transfer from other medical institutions" on the Home of the medical record in the "Admission Route" and fill in the "Patient Source"; After the inpatient is transferred out of the medical institution, the physician in charge shall promptly check the "medical order transfer" or "medical order transfer to community health service organization/township health center" on the "discharge method" on the Home of the medical record and fill in the "name of the medical institution" to which it is transferred.
Article 17: Medical establishments shall, in accordance with the requirements of the administrative departments for health, promote the interconnection and interoperability of residents' electronic health records and patients' electronic medical records, promote mutual recognition of medical examination results, ensure the continuity of diagnosis and treatment of patients, and reduce duplication of examinations.
Article 18: The administrative departments of health in all districts and counties (autonomous counties) should earnestly perform their regulatory responsibilities, strengthen the supervision and management of the referral work of medical establishments, urge medical establishments to complete and improve the management system related to referrals, standardize referral behavior, strengthen the punishment of violations of laws and regulations, and ensure the quality and safety of medical care.
Article 19: Where medical establishments do not make referrals in accordance with relevant provisions, they are to be dealt with in accordance with the "Regulations on the Administration of Medical Institutions", the "Chongqing Municipal Measures for the Management of Negative Practice Conduct in Medical Institutions" and other relevant provisions.
Article 20: Where medical personnel do not carry out referral work in accordance with relevant provisions or refer patients in violation of regulations, they are to be dealt with in accordance with the "Chongqing Municipal Implementation Rules for the Nine Standards for the Honest Practice of Medical Institution Staff (Provisional)", "Chongqing Municipal Measures for the Management of Negative Practice Conduct of Medical Personnel (Provisional)", and other relevant provisions.
Article 21 These Measures shall be interpreted by the Chongqing Municipal Health Commission, the Chongqing Municipal Administration of Traditional Chinese Medicine, and the Chongqing Municipal Bureau of Disease Control and Prevention.
Article 22: These Measures shall come into force on the date of issuance.
Source: Chongqing Municipal Health Commission, Good Doctor (reprinted for sharing only, the copyright belongs to the original author.) If there is an error or infringement of the source, please contact us, we will correct and delete it in time, thank you! ）
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