SENDING AN APPLICATION FOR ACCREDITATION

To initiate the accreditation process, you must submit an application in electronic format, indicating your preferred date for the assessment. Once your application has been processed, your organization will be included in the external due diligence (accreditation) plan and you will be notified accordingly.

RESULT

Our employee will contact you to clarify all the necessary details and provide instructions for preparing and sending the required set of documentation

PROCESSING A PACKAGE OF DOCUMENTS

- Fill out the application in Word, send for verification (form in the attachment);
- Fill out the form of the person responsible for self-assessment (form in the attachment);
- Organizational structure diagram for the current year, PDF format, approved;
- Approved staffing table, PDF format;
- Certificate of registration, rus/kaz, PDF with egov;
- Licenses for medical/pharmaceutical activities with applications for everything from egov;.
- Charter, PDF format;
- Presentation of the organization, strengths, achievements;
- Details of the Moscow Region, full name of the director/chief physician in Word.

CONCLUSION OF AN AGREEMENT OR ACCESSING THE PORTAL

The conclusion of an agreement for the provision of accreditation services is carried out directly for private medical organizations. In relation to state medical organizations, the procedure for concluding a contract is carried out through participation in the public procurement system, in accordance with current legislation

DO YOU HAVE ANY QUESTIONS ABOUT CONCLUSION OF THE AGREEMENT?

Contact the number: +7 702 316 67 72

COMPLETING THE SELF-ASSESSMENT

The self-assessment process is typically initiated between one and three weeks before the start of the accreditation procedure. In this context, responsible persons in a medical organization gain access to the information system of the accreditation body - login and password - which allows them to familiarize themselves with the format for presenting accreditation standards in the system with which accreditation experts will work. This stage is provided in order to provide the opportunity for responsible employees of a medical organization to directly familiarize themselves with and adequately evaluate the assessment procedure, as well as independently conduct a final assessment of the level of preparedness of their institution for accreditation, analyzing the compliance of each of the standards and criteria. This allows you to eliminate possible gaps and close unresolved issues that arose in the process of preparing for accreditation. Self-assessment serves as a key element in the accreditation process, providing the medical organization with the necessary support in preparing for this procedure.

WANT TO BECOME AN EXPERT?

FORMATION OF AN EXPERT GROUP

The accrediting body is responsible for the formation of expert groups consisting of employees of this body and/or external experts. The leader of this group is appointed by the accrediting body. The size of the expert group involved in the process of conducting an external comprehensive assessment is determined based on the structure, size and range of services of the medical organization (at least 2 people). Before a visit to a medical organization, the manager, together with members of the expert group, develops an external assessment program, which is drawn up in accordance with the approved form prescribed by Appendix 11 to the Accreditation Rules.
The accrediting body provides members of the expert group with individual logins and passwords for documenting the assessment results in the information system. To confirm the identity of the expert entering the data, an electronic digital signature is used. Information about logins and passwords is confidential and should not be disclosed or transferred to third parties. If confidentiality violations are detected, the expert will be excluded from the accreditation process, and the data he entered into the information system will be canceled. The responsibilities of the excluded expert are assigned to the head of the expert group.

MORE ABOUT ACCREDITATION

PROCEDURE FOR EXTERNAL COMPREHENSIVE ASSESSMENT (ACREDITATION)

The duration of an external comprehensive assessment of a medical organization cannot be less than two working days and is determined depending on the size of the population served, the volume of beds and the number of structural units of the institution (branches, representative offices) located outside the main building.
Assessment of compliance with accreditation standards (criteria) is carried out by an expert group based on the following methods:
1. Documentation analysis;
2. Employee survey;
3. Application of tracer techniques;
4. Direct observation.
All materials collected by the expert group during the accreditation process, including photos and videos, have a confidential status and cannot be used for distribution or personal purposes. Based on the results of the external comprehensive assessment, a final event is organized - a briefing with the participation of the staff of the medical organization, at which experts present preliminary conclusions about the results of the assessment. To document the process and ensure transparency, the briefing is accompanied by audio and video recordings.

REPORTS

Upon completion of the external comprehensive assessment (accreditation) procedure, the accrediting body undertakes to send the medical organization a report on the results of this assessment no later than five working days before the date of the meeting of the accreditation commission. This action is carried out by sending a document to the electronic address of the medical organization, in accordance with the format established by Appendix 13 to the accreditation rules.

If a medical organization has any objections regarding the contents of the report, it has the right to provide its comments to the accrediting body within two working days from the date of its receipt by sending the appropriate justification to the specified email address.

Based on the results of the external comprehensive assessment and the decision of the accrediting body, the medical organization develops a Corrective Action Plan in accordance with the template provided in Appendix 14 to the current accreditation rules. This plan, approved by the management of the medical organization, is sent to the accrediting body no later than 30 calendar days after receiving the report, in order to eliminate identified inconsistencies with accreditation requirements.

ACCREDITATION COMMISSION

COMMISSION MEETING

Within the framework of the accrediting body, there is a permanent accreditation commission, which includes at least five members. The composition of the commission is formed on a competitive basis annually, according to the established schedule. To conduct meetings of the commission, the presence of at least two thirds of the total number of its members is required.

Based on the results of the commission’s work, the accrediting body may make one of the following decisions:
1. Assignment of accreditation:
- Second category, if compliance with the standards (criteria) of the first, second and third ranks is at least 60%;
- First category, if the standards (criteria) of the first rank are not less than 70%, the second rank is not less than 65% and the third rank is not less than 60%;
- Highest category, if compliance with the standards (criteria) of the first rank is not less than 90%, the second rank is not less than 80% and the third rank is not less than 70%.
2. Refusal of accreditation if the results of the external comprehensive assessment were below the established thresholds for assignment to the second category.
The decisions of the accrediting body are formalized by an official order. The period from registration of a medical organization’s application to the decision by the accrediting body does not exceed 27 working days. As a result of the provision of public services to a medical organization, an accreditation certificate is issued for a period of three years or a reasoned refusal issued in any form

POST ACCREDITATION MONITORING

Regardless of the accreditation category received, each medical organization is subject to post-accreditation monitoring throughout the entire period of validity of the accreditation certificate. This process includes analyzing publications in the media and on social networking platforms in order to identify possible complaints about the activities of a medical organization, as well as processing special requests coming directly from the accrediting body.

During the post-accreditation period, the accreditation commission has the right to decide on the need to conduct an on-site focused assessment of the activities of a medical organization. This action is taken to closely examine compliance with certain standards, especially in cases where there have been valid complaints or publicity on social media indicating potential violations.