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Section 8. Medical science
Yusupaliev Bakhodir Kahramonovich, Tashkent institute of doctor's post-graduate education, Assistant of department of public health care E-mail: yusupaliev.b@gov.uz
Working out and inculcation organizing measures of accreditation of Health. Care primary units institutions activity — rural medical centers (RMC)
Abstract: The developed system of self — estimation of therapeutic-prophylactic institutions can be used for any type level of Healthcare institutions, as it gives the opportunity to motivate the process of medical help administration, to receive objective marks based on the facts and it is directed to increase in formativeness of the institutions of Healthcare on existing problems, demanding the solutions.
Keywords: accreditation, Health Care, primary Health, external evaluation.
Urgency. By the order of the President of the Republic of Uzbekistan “About the further development of reformation system of Health Care" the main role in this sphere is given to the wide availability and high quality of primary medical-sanitary aid to the population especially in rural districts [1]. The high quality of this kind of help can be provided through the introduction of quality control mechanisms and safety of medical aid which include legalization and accreditation if the principles of the process of legalization legally and by standard documents [2; 3; 4] but there are publications in scientific literature dedicated to some directions of accreditation of medical institutions [5; 6; 7].
Modern structure of Health Care in Uzbekistan shows necessity of realization in the research work on working out and inculcation of organizing measures of accreditation of primary health care activity, primarily, of rural medical center’s (RMC).
Purpose of the investigation: Work out science — based proposals and to introduce organizing measures on accreditation and external evaluation of activity of RMC.
Materials to methods: The objects of research were the RMC of the republic.
Analysis of statistics of Health Institute, medical statistics, internal audit/self — evaluation, external audit/evaluation of experts, directs observation/interviewing, study of medical documents and therapeutic — diagnosing process, analytic, statistic methods have been used.
Results and discussions. The review of international scientific research shows that accreditation began to be used in some countries of the West Europe and USA in early XXth century.
In the USA, first, special standards to control sanitarian condition and the patients condition in the medical institutions were used. Then accreditation procedures have been worked out in other parts of the world, particularly, in the countries of South — East Asia.
In most countries accreditation of medical institutions is obligatorily carried out on the national level by special representative state organ. There are several international organizations dealing with accreditation such as: International society
for quality in Health, The society for International Healthcare Accreditation — SOFIHA.
Organizations, mentioned above, created several generally acknowledged system of accreditation: Trent Accreditation Scheme, Saint Commission International (SCI), Australian Council for Healthcare Standards International (ACHSI), Canadian Council on Health Services Regulation (CCHSA).
We performed the research in several stages.
The First dealt with standards (criteria) of accreditation for self-evaluation — internal audit activity of institutions in primary Healthcare units according to the following directions: effectiveness of organization, management and finance of medical aid; process of administration of high — quality and safe medical assistance; staff potential; material and technical bases; information-resource bank.
At the second stage medical workers of RMC were taught methodology of accreditation and self-evaluation of the institution (internal audit) that was carried out on-sight.
At the third stage internal audit (self-evaluation) of RMC was carried out. After detailed analysis of the results practical recommendations were given to improve the activity of RMC: increase of qualification in organizing and management in Healthcare; revision of organization structure and the fund of financial stimuli zing; improvement in dyspansariation females of fertile age, birthrate, having observative measures, informativeness of patients about medical procedures, their results and possible complications; trainings of medical staff; strengthening of material and technical basis; applying of protocols of diagnostics and treatment in practice.
Analysis of RMC self-evaluation showed the data ranged in 66 % - 73 %, that is an average indication of the medical services level. Also, significant differences in personnel training has been noted both in organization of assistance administration and in problems of patients observation and its quality with patients different conditions.
This fact enabled to conclude on the necessity of personnel training courses according to the programme of quality improvement in Healthcare institutions.
At the fourth stage, in the framework of scientific research on accreditation of primary Healthcare institutions
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Working out and inculcation organizing measures of accreditation of Health
the training of medical RMC personnel has been performed on the course of “Accreditation and increase of quality in medical aid administration"
The task of the fifth stage was to carry out external experts evaluation/accreditation of pilot RMC.
The evaluation of RMC was done by using the list of indicators for each standard according to “Guidance for pilot accreditation of RMC”, then, each indicator was given a quality mark with the report and recommendations.
According to the results of the research, done in cooperation with independent experts, the analysis of accreditation indicator has been performed and each RMC was given a proper category. At the same time the recommendations on the improvement the process of medical aid administration have been suggested as well as the steps on elimination of the reproves according to the final results of external expertising of rural medical centers the average value of resource standards and standards of organization and service in RMC is 80 %. For improvement of resource provision the institutions were given recommendations, concerning adequate water supply, electricity, heating. Planning and realization of control program, testing and service of medical equipment, documents after the testing has been recommended. Special attention is paid to the matter of qualification improvement and continuous professional development (CPD) of the RMC staff. All the institutions were recommended to improve: the order of patients’ reference to the specialists or other level of medical aid administration; to make better the content of clinical records; completeness, details, accuracy, diagnose-proof, laboratory tests, treatment, directions to specialists, and timely hospitalization.
At the next stage of external control clinical work of RMC was estimated according to the list of prioritive conditions and measures for primary Healthcare unit. Average value of standard diagnostics and treatment of arterial hypertension (A. H.) in pilot RMC is 74 %. All the institutions were recommended to identify tonometers for measuring BP; prophylaxis, diagnosing and treatment of AH are to be performed strictly according to the clinical guidance.
Average value of I-II degree (ischemic cardiac disease) ICD diagnosing 2 treatment standards also rose to 70 %. Recommendation were directed mainly, to improve rotation of documents of the institution (making and fixing medical notes in patients cards, their completeness, clearness and analysis); optimization of directions — referrals of the patients to the higher level of the service; search of the control methods of proper medicine taking by the patients; also, organization of therapy processes) strictly according to the standards.
On average the fulfillment of standards on iron — deficiency anemia in children and adults composed 75 %. In this direction recommendations mainly concerned the problems of screening diagnostics and treatment.
Average results of fulfillment the standards on antenatal care composed 88 %. In this field the recommendationswere
given for working out the measures of taking medicine regularly and the control of the regularity.
The standard of postnatal care showed higher results — 93 %. Recommendations were addressed to improve medical assistance mostly in home nursing document rotation.
All RMC have not high score in the standards of “malignant tumors” such as; breast cancer, cancer of cervix, gastric and respiratory organs carcinomas.
Average standard value composes 65 %. Among the recommendations; giving clear explanations to wide range of population on increasing the knowledge about the symptoms of the diseases; the work on documents rotation, working out and realization of risk group screening at early stages of malignant tumors.
Our investigation shows that the most perfect and well-organized direction in primary unit of Healthcare is immunization. This is certified by 100 % of accreditation standards on the immunization of the population. Also, the percent of “medical assistance” to up to 5 year old children with pneumonia is 92 %.
Apparently, this is the result of the organization, working out and introduction into the practice of clinical standards in medical assistance through arear mentioned above.
Making the conclusions, it can be noted that 8 RMCs successfully passed the pilot accreditation, according to the tasks and the worked-out program. They received a category.
At the sixth stage, the analysis of problems revealed during pilot accreditation of RMC enabled to create a questionnaire on RMCs activity and their effectiveness. According to the results of this stage consolidation of RMC net by liquidation of small ineffective working RMC was suggested; also, it is advised to introduce the position of deputy of the head doctor of the polyclinic — RMC activity coordinator. The chief nurse additionally motivate general practitioners working in long — distant regions, localized in mountain areas as well as the visiting nurses; to introduce new staff norms concerning duties of the nurses.
At the seventh stage Timely Order on the order of evaluation of home nursing RMC activity according to which the work of 684 visiting nurses was evaluated in 96 Bostan-lik, Uzbekistan, Shahrisabz, Khivin, Djambay regions of therepublic.
As the result of this stage the evaluation of the efficiency of home nursing activity in 9 main directions and 30 indicators has been introduced; functional duties of the nurses have been determined, also, their every day work activity has been organized; the mechanism of the control in nurses activity with GPs and chief nurse has been worked out; the efficiency of the work of nurses and quality of the population dispensary has been improved.
Taking into account the positive experience in home nursing nurses activity evaluation and the experiment on accreditation of RMC in the Republic of Karakalpakstan and Andijan region recommendations on evaluation mechanism of RMC activity have been given and it was the 8th stage of the research.
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As a whole, according to the results of the research:
1. Estimation of activity efficiency of 684 home nursing nurses in 96 rural medical centers of 5 regions of the Republic has been introduced and enabled:
- To increase the quality of dyspanserization of local population, consequently raised patients detection and the number of hospitalized ones. So, the number of patients reffered to the hospitals from medical centers elevated from 53.1 % to 58.5 %.
- To minimize the number of patients treated in the departments of emergency care during the period of 9 month, 2013 - 9 month, 2014 from 12.8 % to 11.6 % in the correlation to the general number of treated patients in the hospitals also, the number of calls to first-aid to 4 %, this certifies the proper prophylaxis work timely reveal and planned treatment of the patients in rural medical centers included into the experiment
- To lower the number of patients reffered to labour medical examination during 9 month, 2013 - 9 month, 2014 to 5 %, and the number of sick leaves given to the patients in this period to 12.9 %.
2. Recommendations on estimation mechanisms in rural medical centers proved by Introductions of ministry of Health of the Republic of Uzbekistan on January 5th 2015 hae been worked out and are being introduced in 319 RMC of 18 regions of the Republic.
Conclusion:
- The system of self — estimation of therapeutic — prophylactic institutions (TPI) can be used for any type level of Healthcare institutions, as it gives the opportunity to motivate
the process of medical help administration, to receive objective marks based on the facts and it is directed to increase in formativeness of the institutions of Healthcare on existing problems, demanding the solutions.
- The estimation of experts requires disciplinary skills, so the experts team has to include specialists of all main directions for determination of exact problems requiring improvement.
- For the successful process of accreditation and taking categories, the personnel have to study and adopt the changes of the management of their institution into the standards and indicators of accreditation.
- The introduction of scientifically proved model of RMC accreditation into practical Healthcare provides the improvement of medical help quality without any exive directions foe state level, it means, it can be applideternal investment and resources.
- Standards and indicators of accreditation worked out for the management system of medical help quality in primary healthcare unit can be sugested to be used in the system of financial support of medical workers.
- Scientifically proved organizing model of accreditation of primary healthcare units enables to determine prioritive directions for state level, it means, it can be applied for accreditation of other medical institutions of the Republic of Uzbekistan.
- Taking into account the system structure formed in republic healthcare, evaluation of Completeness and quality of medical help administration in RMCs can be suggested as intermediate stage before introducing of accreditation in the republic.
References:
1. About measures on further strengthening of reforms system of Healthcare. - Resolution of the President of Republic of Uzbekistan of November 28th, 2011. - № 1652.
2. Temporary principles order of legalization of GPs.//Healthcare of Uzbekistan. - Tashkent, 2006. - № 2. - Р. 4-5.
3. Grebenyuk I. V Legalization in the field of Healthcare.//Chef Nurse. - 2000. - № 3. - Р. 155-158.
4. Larin A. B., Tyukov Yu. A. Development of law standards of legalization in healthcare.//Economy and management matters for director in healthcare. - M., 2008. - № 1. - Р. 5-10.
5. About measures on fur the development of the order of legalization in medical activity. Resolution of the Cabinet of the Republic of Uzbekistan of April 3rd, 2008. - № 61.
6. Kochorova L. V. Actual matters of legalization and accreditation of psychiatric services and perspectives of their development in St.Petersburg.//Russia psychiatric journal. - 2001. - № 1. - Р. 61-63.
7. Minn L. State accreditation of healthcare institutions in France.//Russia psychiatric journal. - 2001. - № 3. - Р. 57-60.
Yusupaliev Bakhodir Kahramonovich, Tashkent institute of doctor's post-graduate education, Assistant of department of public health care E-mail: yusupaliev.b@gov.uz
Evaluation of patronage nurse at rural medical centre
Abstract: The system of evaluation quality and effectiveness of medical care must functionate constantly, that allows to get operatively the necessary information for control. By that the main factor of turning from quality evaluation and effectiveness to their increase is education and constantly improvement knowledge and skills
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