SUBMITTING AN APPLICATION FOR ACCREDITATION

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

RESULT

Our employee will contact you to clarify all the necessary details and to provide instructions on how to prepare and submit the required set of documentation.

PROCESSING A PACKAGE OF DOCUMENTS

- Fill out an application in Word, send for review (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 schedule, PDF format;
- Certificate of registration, Russian/Kazakh, PDF from egov;
- Licenses for medical/pharmaceutical activities with appendices for everything from egov;.
- Charter, PDF format;
- Presentation of the organization, strengths, achievements;
- Details of the MO, full name of the director/chief physician in Word.

CONCLUSION OF AN AGREEMENT OR LOGIN TO THE PORTAL

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

DO YOU HAVE ANY QUESTIONS REMAINING ABOUT THE CONCLUSION OF THE AGREEMENT?

Contact by number: +7 702 316 67 72

COMPLETING THE SELF-ASSESSMENT

The self-assessment process is usually initiated one to three weeks before the accreditation procedure. In this context, responsible persons in the medical organization are granted access to the information system of the accreditation body — login and password — which allows them to familiarize themselves with the format of presentation of accreditation standards in the system with which accreditation experts will work. This stage is provided for the purpose of providing the opportunity for responsible employees of the 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 readiness 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 have arisen in the process of preparation 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 invited experts. The head 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 visiting the medical organization, the head together with the 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 the members of the expert group with individual logins and passwords for documenting the assessment results in the information system. An electronic digital signature is used to confirm the identity of the expert entering the data. Information about logins and passwords is confidential and must not be disclosed or transferred to third parties. In the event of a breach of confidentiality, the expert will be excluded from the accreditation process, and the data entered by him into the information system will be canceled. The duties of the excluded expert are assigned to the head of the expert group.

MORE ABOUT ACCREDITATION

EXTERNAL COMPREHENSIVE ASSESSMENT (ACCREDITATION) PROCEDURE

The duration of the external comprehensive assessment of a medical organization cannot be less than two working days and is determined depending on the number of people served, the volume of hospital beds and the number of structural divisions of the institution (branches, representative offices) located outside the main building.
The assessment of compliance with the accreditation standards (criteria) is carried out by an expert group based on the following methods:
1. Analysis of documentation;
2. Survey of employees;
3. Use of tracer methods;
4. Direct observation.
All materials collected by the expert group during the accreditation process, including photos and videos, have confidentiality 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 personnel of the medical organization, at which the experts present preliminary conclusions on the results of the assessment. To record the process and ensure transparency, the briefing is accompanied by audio and video recording.

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 committee. This action is carried out by sending a document to the e-mail address of the medical organization, in accordance with the format established by Appendix 13 to the accreditation rules.

If the medical organization has objections regarding the content 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, sending the corresponding justification to the specified e-mail address.

Based on the results of the external comprehensive assessment and the decision taken by the accrediting body, the medical organization develops a Corrective Action Plan according to 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 the identified discrepancies with accreditation requirements.

ACCREDITATION COMMISSION

COMMISSION MEETING

The accrediting body has 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. The presence of at least two-thirds of the total number of its members is required for holding meetings of the commission.

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

POST-ACCREDITATION MONITORING

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

Within the post-accreditation period, the accreditation commission has the right to decide on the need to conduct an on-site focus assessment of the activities of the medical organization. Such a measure is taken in order to thoroughly check compliance with certain standards, especially in cases where justified complaints have been received or there has been resonance in social networks indicating potential violations.