Accreditation standards for health facilities in Ukraine · KYIV 1998
Ministry of Health of Ukraine
Abt associates inc.
Accreditation standards for health care facilities
of Ukraine
Kyiv 1998
112
Ministry of Health of Ukraine
ZdravReform Project (Abt Associates Inc.)
Accreditation standards for health facilities in Ukraine · KYIV 1998
Accreditation standards of health care facilities of Ukraine // I.B.Demchenko, V.A.Pischikov, V.V.Omelchenko, A.P.Huk, V.M.Lekhan, K.D.Babov, I.N.Shmatkova, T.O.Olexiyuk. - Kyiv: Ministry of Health of Ukraine (MOH), 1998. - 113 p.
“Accreditation standards of health care facilities of Ukraine” are approved by MOH decrees #2 of 1.18.98.
“Accreditation standards of health care facilities of Ukraine” are meant for specialists who work in the health care orgnization and expertise sphere, specifically in the area of accreditation of health care facilities.
The authors extend their gratitude to ZdravReform Program and all health care professionals for additions and changes in the course of preparation of the material.
@ Copyright of the Ministry of Health of Ukraine. All rights regarding this edition are registered, including translation into foreign languages. Any copying (printing, photocopying, taping etc) of this edition or its parts is prohibited unless appropriate permission is granted by the Ministry of Health of Ukraine.
Order RN-20.05.98. UR-11. Print run amounts to 1500 copies.
TABLE OF CONTENTS
1. GENERAL STANDARDS / 16
1.1 FACILITY MANAGEMENT / 16
1.2 PERSONNEL / 21
1.3 ORGANIZATION / 26
1.4 SERVICE (STRUCTURAL DEPARTMENT) MANAGEMENT / 30
1.5 PATIENT RIGHTS AND RESPONSIBILITIES / 34
1.6 ECONOMICS AND FINANCE / 37
1.7 HEALTH INFORMATION AND ANALYTICAL SERVICE / 44
1.8 METROLOGICAL PROVISION / 47
1.9 EPIDEMIOLOGICAL SAFETY / 51
1.10 MEDICAL FACILITY BUILDING STANDARDS / 55
2. QUALITY OF HEALTH CARE / 59
3. MEDICAL CARE / 68
3.1 GENERAL RELULATIONS ON THE PHYSICIAN / 68
3.2 PRIMARY HEALTH CARE / 69
3.3 EMERGENCY AND URGENT CARE SERVICE / 78
3.4 OUT-PATIENT CARE / 81
3.5 IN-PATIENT CARE / 84
3.5.1 GENERAL REGULATIONS / 84
3.5.2 SURGERY, ANESTHESIOLOGY AND INTENSIVE CARE (RESUSCITATION) / 86
3.5.3 REHABILITATION / 92
3.5.5 MATERNITY AND CHILD CARE / 92
3.6 ANCILLARY SERVICES (PARACTINICS) / 98
3.7 MEDICINE UTILIZATION / 100
3.8 SPECIALIZED SERVICES / 102
3.8.1 BLOOD SERVICE / 102
3.8.2 PATHOANATOMICAL SERVICE / 103
3.9 SANATORIUM-RESORT CARE / 104
GENERAL INFORMATION
The development of new relations in health care system, especially at the background of emerging health insurance, requires thorough revision of quality issues, guarantees to provide health services free of charge as well as operational conditions in health facilities so as to comply with up-to-date requirement to render high quality care at the lowest cost. First of all, it assists to reason specific financing level and amount of user fees depending on medical personnel qualification and quality of services provided at the facility. Very often solving these challenges creates the conflict of interests between the state, companies, health insurance organizations, health providers and patients, i.e. consumers of health services and health care.
The process of decision-making in this sphere particularly in searching tools to implement approved recommendations becomes more aggressive and more dynamic as a result of introduction of new economic relations for the case of care, wider opportunities for insurance organizations and patients to choose polyclinics and hospitals which are able to provide care of higher quality at the same cost. In this aspect one of the most important tools is a technology of obtaining objective characteristics of health provider's performance which would serve to display their professional capacities, level and quality of care provision that guarantees both high quality and good outcomes of health services.
Development of such organizational tool was initiated in a number of countries in the world primarily because of the need to identify causes of health care cost growth. Further on it turned into an individual mean of improving provider's performance to prevent mistakes in health care provision. Accreditation system has been developed. It consists of the list of structure, performance, organization and quality standards that health providers should comply with if they claim to be accredited and to guarantee high level performance in practice.
The accreditation is evaluation of health provider's practice according to standard requirements which characterize structure, process and outcomes of facility performance.
Also, the accreditation is official recognition of provider's status to render specific types of health care on the level that makes facility eligible to be granted with a certain category of compliance with the standards. In the future this will be a valid reason for making a contract with an insurance company. The accreditation lies within health providers' interests and it credits to their prestige, competitive ability and financial stability. Availability of the accreditation certificate ranks provider's professional position and testifies to its public recognition.
In the majority of the countries the accreditation is performed by special committees which invite prominent health experts of the country to work on the project. For some time accreditation organization staff and invited experts work closely with health providers on specifically designed projects both preliminary and during the main event. Later on the results of evaluation are being generalized into a conclusion on the compliance of a specific health provider with existing standards.
The principal element of success of the whole accreditation procedure is a standardization of all methodological approaches of evaluating different health providers when all interested parties encourage the development of general unified standards and performance criteria which guarantee high quality health care.
INTRODUCTION
Analysis of the existing models of accreditation standards and their evolution in different countries of the world suggested the conventional approach to accreditation when health provider (facility) was regarded as an integration of separate department and subunits (thereby, first, department performance was matched against the standards, then integral evaluation was performed).
Up-to-date practice has not recognized this method any more and new forms of grouping standards take over. The most critical point is quality and effectiveness of integral practice of a provider free of anatomizing evaluation since many-year experience of accreditation committees in the developed countries showed that this factor creates the largest impact on treatment and health prevention outcomes which are considered the major indicator of health provider quality performance.
The basis of the present accreditation standards consists of the complex indicators which in experts' opinion can identify quality and effectiveness of health provider functioning as an integral "mechanism".
The suggested set of standards consists of wide range of up-to-date professional achievements and criteria which relate to different sectors of facility performance rather that just treatment and prevention. It is expected as well that the standards will be flexible enough for the application in small and large health providers both of private and public forms of property.
The standards in all sections are adjusted enough to different types of health facilities, grouped according to the scheme of services and care reference, including health facility structure, management, organization, administration, personnel, economics and finance, metrological provision, epidemiological safety etc., as necessary for integral picture of facility operations.
Quality monitoring is performed according to the conventional scheme of collecting information on patient services, periodical evaluation of the information to track down major challenges for the quality of services. Once those are identified, correspondent short- and long-term measures should be designed and implemented, their effectiveness evaluated and communicated to medical staff on a regular feedback basis.
The major task of quality improvement lies in achieving as low as possible morbidity, mortality and disability rates in population as well as the shortest possible health recovery terms utilizing available resources to the maximum. The quality of health care in the facility should not necessarily attain to the ideal level but should be the best under the conditions available. The keystone of accreditation process is the belief that administration and personnel of a health facility are willing to provide health care of the highest quality and what they need is consulting services how this could be achieved under the condition of scarce resources.
ACCREDITATION PROCESS
The standards are based on the principle of the facility being interested in the opportunity to use accreditation procedure as a tool of personnel training.
On the other hand, the standards contain a broad range of up-to-date professional criteria that refer to all the spheres of facility operations and serve as a guide in preparing and going though accreditation. As a rule, all comments and recommendations provided by the experts in their report make a substantial basis for performance improvement.
Therefore, accreditation standards contain recommendations for the facility personnel. They are designed to model operations of the administration and personnel following "how-to-do" principle, success and possible problem indicators.
The standards are based on the analysis of the existing health care legislation of Ukraine, experience of health care key specialists as well as results of the accreditation experiment which was run in different health care facilities of Ukraine.
In the present document the standards fall into a number of separate groups, including the standards that need to be followed by all health facilities regardless of their property form and types of health care provided. These are unified in "General Standards" section. This group is subdivided into 10 sub-groups, which present a standardized description of key components necessary for adequate operation of the facility. Non-compliance or particular compliance with the standards of this group may cause inefficiencies in performance and lead to substantial consequences such as quality deterioration in medical care delivery. Each of the sub-sections of the group “General Standards” contains from 8 to 33 standards.
Evaluating facility operations against accreditation standards is performed by means of granting points for each item/ subitem. The explanation to each item/ subitem is in italics. The points are marked in the table below every item/ subitem:
The sum of received points defines accreditation category:
· the highest category - total 92% and over the maximum;
· 1st category - total not less than 81% of the maximum possible;
· 2nd category - total not less that 75 % of the maximum possible;
Accreditation Certificate is not granted to a facility the has received less than 75% of the maximum possible after survey. Accreditation Committee provides recommendations to specific health authorities who will make decisions concerning further operations in the facility based on the MOH Decree #287 as of 09/29/97 "On Accreditation in Health Care Facilities".
SCHEME OF ACCREDITATION PROCESS
(Authorized by the Regulation of the Cabinet of Ministers #765 as of July 15, 1997) / · Compulsory for all health facilities regardless of their subordination and form of property;
· Being held once per three years;
· Being held by experts with consideration of the documents submitted by the facilities of the following profiles:
Primary health care units: till 01/01/99;
Secondary health care units, recreational and pharmaceutical facilities: till 07/01/99;
Tertiary health facilities, sanitary and epidemiology units: till 01/0/.2000.
· Three categories (second, first, highest)
/ PRINCIPAL ACCREDITATION COMMITTEE
OF MOH OF UKRAINE
Accreditation Committee of MOH of Autonomous Republic of Crimea
Accreditation Committee of Oblast Health Care Departments
Accreditation Committee of Kiev and Sevastopol' Municipal State Administrations
· authorizing decisions of accreditation committees;
· accreditation of Oblast hospitals; health facilities subordinate to MOH of Ukraine; health facilities of public property regardless of their subordination; health facilities of non-public property. / accreditation of communal property facilities (except Oblast hospitals).
LIST OF HEALTH FACILITIES WHICH WILL BE SURVEYED FOR ACCREDITATION
(Facilities and Subdivisions)
· Feldsher unit
· Feldsher/ OB unit
· Ambulatory
· Health care unit
· City polyclinic (internal medicine department)
· City children polyclinic (pediatrics department)
· Water transport polyclinic (sea line, in-port), (polyclinic internal medicine department)
· Railroad transport polyclinic (railroad line, railroad juncture, railroad department), (polyclinic internal medicine and pediatrics department)
· Railroad line ambulatory
· District hospital (ambulatory)
· Central rayon hospital (polyclinic internal medicine and pediatrics department)
· Health sanitary unit (internal medicine department of guild polyclinic)
· Kolhoz maternity unit
· Emergency unit
2. SECONDARY HEALTH CARE (specialized care)
· Central Rayon polyclinic
· OB/ GYN department
· Physio-therapy polyclinic
· Water transport polyclinic (water pool)
· Railroad transport polyclinic (railroad)
· Narcology ambulatory
· Territorial unit of urgent medical care
· Central city hospital
· Territorial medical amalgamation
· City hospital
· Central Rayon hospital
· Rayon hospital
· Children city hospital
· Children territorial medical amalgamation
· Children Rayon hospital
· City emergency hospital
· Water transport hospital (central, water pool, in-port)
· Railroad transport hospital (central, on-road, departmental, juncture, line, children)
· Oil Production Industry hospital
· World War II veterans hospital
· Ukrainian hospital for overseas veterans
· Specialized health department
· "Hospice" hospital
· Children infectious hospital
· Children TB hospital
· Infectious hospital
· TB hospital
· Health recreational hospital
· Physio-therapy hospital
· Maternity hospital
3. TERTIARY HEALTH CARE (highly specialized)
· Ukrainian consulting and diagnostic maternity center
· "Marriage and Family" consulting service
· Republican territory emergency center
· Diagnostic center
· Central water transport polyclinic
· Central railroad transport polyclinic
· Republican hospital
· Oblast hospital
· Ukrainian children hospital of MOH
· Children dermatology hospital
· Children psychiatric hospital
· Hospital of skin and ST diseases
· Traumatology hospital
· ENT hospital
· Narcology hospital
· Ophthalmology hospital
· Prenatal center
· Phsyco-neurology hospital
· Psychiatric hospital
· Cosmetology hospital
· Ukrainian allergology hospital
· Hospitals (clinics) of science research institutes
SPECIALIZED TERTIARY CARE UNITS (DISPENSARIES)
· Gastrointestinal disorders
· Cardiology
· Children cardio-rheumatology
· Substance abuse
· Oncology
· TB
· Phsyco-neurology
· Trachoma disease
· Skin and STD diseases
· Leprosarium
· AIDS prevention and treatment
· Center for rehabilitation of female reproductive functions
· Ukrainian specialized center for protection of population against radiation
· Oblast specialized center for protection of population against radiation
· City specialized center for protection of population against radiation
HEALTH RECREATION AND RESORT FACILITIES
· Balneology hospital
· Mud balneology hospital
· Children balneology hospital
· Resort polyclinic
· Preventive health recreation center
· Specialized children health recreation center
· Health recreation center for children and parents
· Children health recreation center
Sanitary and epidemiology facilities
· Central sanitary and epidemiology unit