Plan and structure of accreditation process in family medicine in - - PowerPoint PPT Presentation

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Plan and structure of accreditation process in family medicine in - - PowerPoint PPT Presentation

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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 Plan and structure of accreditation process in family

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Plan and structure of accreditation process in family medicine in Croatia

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

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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

Plan and structure of accreditation process in family medicine in Croatia

  • 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

  • f health care at all levels.
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ACT ON QUALITY ON HEALTH CARE (Official gazette no.107/07)

  • Article 24 -
  • conducting the procedure of granting, renewal and cancellation of accreditation
  • f 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,

Plan and structure of accreditation process in family medicine in Croatia

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.

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MANAGEMENT COUNCIL

SCHEMA of AGENCY

Plan and structure of accreditation process in family medicine in Croatia

DIRECTOR’S OFFICE DIRECTOR STAKEHOLDERS DEPARTMENT FOR ACCREDITATION DEPARTMENT FOR QUALITY AND EDUCATION IN HEALTH

DEPARTMENT FOR DEVELOPMENT, RESEARCH AND HEALTH TECHNOLOGY ASSESSMENT

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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

Plan and structure of accreditation process in family medicine in Croatia

  • 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

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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

Plan and structure of accreditation process in family medicine in Croatia

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
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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

Plan and structure of accreditation process in family medicine in Croatia

  • 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
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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:

Plan and structure of accreditation process in family medicine in Croatia

  • 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

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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

Plan and structure of accreditation process in family medicine in Croatia

family practice

  • Percentage of diabetes patients with HbA1c under 7%
  • Percentage of patients treated for hypertension with blood

pressure lower than 140/90 mmHg

  • Vaccination of children in primary healthcare
  • Percentage of adult systematic reviews
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ACCREDITATION IN CROATIA

  • Voluntary procedure
  • Our own model of education

– Education of educators – Education of hospital staff (27 hospitals)

  • introduction of accreditation system

Plan and structure of accreditation process in family medicine in Croatia

  • introduction of accreditation system
  • CroS standards- Croatian accreditation standards for

hospitals

  • Manual on Accreditation
  • By- law on Accreditation
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ACCREDITATION

MHSW AQAH CIHI

  • Proposing accreditation standards
  • Proposing by-laws
  • Providing a database of accreditated healthcare

providers

  • Accreditation reports of healthcare

providers

SCHEMA of ACCREDITATION

Plan and structure of accreditation process in family medicine in Croatia

ACCREDITATION STANDARDS

AQAH

HEALTHCARE PROVIDERS

CIHI

  • Incentive funding
  • Request for accreditation
  • Self- assessment process
  • Accreditation procedure
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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

Plan and structure of accreditation process in family medicine in Croatia

  • 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

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Accreditation of 10 hospitals in 2011

  • Public application for accreditation

(Official Gazette No. 79/11)

  • Hospitals participated in accreditation:

1 Clinical hospital centre

Plan and structure of accreditation process in family medicine in Croatia

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

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PREDICTIONS FOR 2012

  • Accreditation standards for primary healthcare
  • Education of primary healthcare staff

Plan and structure of accreditation process in family medicine in Croatia

  • Accreditation of health centres
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Thank you for your attention!

Plan and structure of accreditation process in family medicine in Croatia

Renato Mittermayer, MD Director of Agency for Quality and Accreditation in Health