Plan and structure of accreditation process in family medicine in Croatia
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1 Plan and structure of accreditation process in family medicine in Croatia Renato Mittermayer, MD Director of Agency for Quality and Accreditation in Health Care Zagreb, 4th November 2011
2 AGENCY FOR QUALITY AND ACCREDITATION IN HEALTH CARE Professional and independent public (non-profit) institution Established in 2007 by Act on quality in health care Officially start working in 2009 MAIN GOAL to establish quality and safety in healthcare through planning, implementation and evaluation of measures to ensure, improve, promote and monitor the quality of health care at all levels.
3 ACT ON QUALITY ON HEALTH CARE (Official gazette no.107/07) - Article 24 - conducting the procedure of granting, renewal and cancellation of accreditation of healthcare providers, proposing to the Minister, in cooperation with professional associations, the plan and program for healthcare quality assurance, improvement, promotion and monitoring, proposing the healthcare quality standards to the Minister, proposing to the Minister the healthcare quality standards on the primary healthcare level, proposing the accreditation standards to the Minister, conducting the procedure of assessment of healthcare technologies, keeping a register of accreditations and providing a database related to accreditation, healthcare quality improvement, education and evaluation of medical technologies, providing education in the field of healthcare quality assurance, improvement and promotion, supervising the healthcare insurance standards, providing other services in the field of healthcare quality assurance, improvement, promotion and monitoring, according to this Act and regulations based hereon.
4 SCHEMA of AGENCY MANAGEMENT COUNCIL DIRECTOR S OFFICE DIRECTOR STAKEHOLDERS DEPARTMENT FOR ACCREDITATION DEPARTMENT FOR QUALITY AND EDUCATION IN HEALTH DEPARTMENT FOR DEVELOPMENT, RESEARCH AND HEALTH TECHNOLOGY ASSESSMENT
5 DEPARTMENT FOR ACCREDITATION development and improvement of accreditation standards development of procedures for assessment of standards self- assessment, external evaluation and training of evaluators for accreditation procedure in collaboration with the Department for Quality and Education in Health, development of educational programs for hospital management, partner institutions preparation of accreditation reports development and conducting a database and register of accreditations
6 DEPARTMENT FOR QUALITY AND EDUCATION IN HEALTH CARE establishment of obligatory system of healthcare quality and safety through: uniform system of quality and safety standards clinical quality indicators development of educational programs for stakeholders, surveyors and healthcare providers managing programs for improvement of healthcare quality and safety promotion of healthcare quality and safety culture proposing and providing clinical protocols and guidelines
7 UNIFORM SYSTEM OF HEALTHCARE QUALITY AND SAFETY STANDARDS AND CLINICAL QUALITY INDICATORS mandatoy procedure Ordinance on Standards of Healthcare Quality and the Method of Their Implementation (Official Gazette No. 79/11) Set of 9 obligatory standards Continuously quality improvement of clinical and non-clinical procedures Patient and staff safety Medical documentation Patient rights and experiences, staff satisfaction Infection control Deaths and autopsy Monitoring of drug side effects and adverse events related to medical devices Internal ratings Supervision of healthcare quality improvement and assurance system
8 UNIFORM SYSTEM OF HEALTHCARE QUALITY AND SAFETY STANDARDS AND CLINICAL QUALITY INDICATORS Manual on Standards of Healthcare Quality and the Method of Their Implementation includes: Healthcare quality indicators (for primary and secondary healthcare) Patient safety indicators Questionnaries of patients satisfaction in primary and secondary healthcare, and satisfaction of staff Templates for monitoring of healthcare quality indicators
9 UNIFORM SYSTEM OF HEALTHCARE QUALITY AND SAFETY STANDARDS AND CLINICAL QUALITY INDICATORS Manual on Standards of Healthcare Quality and the Method of Their Implementation Healthcare quality indicators for primary healthcare- family practice o Percentage of diabetes patients with HbA1c under 7% o Percentage of patients treated for hypertension with blood pressure lower than 140/90 mmhg o Vaccination of children in primary healthcare o Percentage of adult systematic reviews
10 ACCREDITATION IN CROATIA Voluntary procedure Our own model of education Education of educators Education of hospital staff (27 hospitals) introduction of accreditation system CroS standards- Croatian accreditation standards for hospitals Manual on Accreditation By- law on Accreditation
11 SCHEMA of ACCREDITATION Proposing accreditation standards Proposing by-laws Providing a database of accreditated healthcare providers MHSW Accreditation reports of healthcare providers AQAH ACCREDITATION STANDARDS CIHI Request for accreditation Self- assessment process Accreditation procedure HEALTHCARE PROVIDERS Incentive funding
12 CroS- Croatian accreditation standards Ordinance of the Accreditation Standards for Hospitals (Official Gazette No. 31/2011) 1. System of healthcare quality assurance and improvement 2. Governing body 3. Employees 4. Health service use review 5. Patient rights 6. Medical records service 7. Health care 8. Discharge planning 9. Infection control 10.Safety management system
13 Accreditation of 10 hospitals in 2011 Public application for accreditation (Official Gazette No. 79/11) Hospitals participated in accreditation: 1 Clinical hospital centre 2 Clinical hospitals 7 Hospitals Costs of accreditation procedure for 10 elected hospitals will be funded by Croatian Institute for Healthcare Insurance
14 PREDICTIONS FOR 2012 Accreditation standards for primary healthcare Education of primary healthcare staff Accreditation of health centres
15 Thank you for your attention! Renato Mittermayer, MD Director of Agency for Quality and Accreditation in Health
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