LEGAL BASIS

Accreditation of medical organizations (external comprehensive assessment) is a voluntary procedure in accordance with Article 25 of the Code of the Republic of Kazakhstan dated July 7, 2020 No. 360-VI ZRK “On the health of the people and the healthcare system” and Chapter 4 of the Order of the Minister of Health of the Republic of Kazakhstan dated December 21, 2020 No. KR DSM-299/2020 “On approval of accreditation rules in the field of healthcare”

ACCREDITATION

Accreditation of medical organizations is a key process for assessing the quality and safety of services provided, which is carried out on the basis of strictly defined standards and criteria. This procedure includes a thorough analysis of the activities of a medical organization by experts to confirm compliance with established standards and requirements. Accreditation ensures that the institution has the necessary level of competence and provides high quality medical care, as well as adheres to the principles of patient safety.

The importance of accreditation by medical organizations cannot be overestimated. Above all, it demonstrates the institution's commitment to high standards of medical practice, which in turn builds trust with patients and the public. Accreditation serves as official recognition of the quality of medical services, which makes a medical organization more attractive to patients and insurance companies. In addition, the accreditation process improves the internal efficiency of the institution by introducing best practices and standards into daily work, and encourages continuous improvement in the quality of service and management.

Thus, accreditation is not only a mechanism for ensuring the safety and quality of medical care, but also a powerful incentive for the continuous improvement of the work of medical institutions and maintaining their competitiveness in the healthcare market.

Preemptive right in the system of compulsory medical insurance and guaranteed volume of medical care

According to Article 25 of the Code on Public Health and the Health Care System

Exemption from proactive monitoring by the FSMS

Clause 55 of Paragraph 5 of Chapter 2 of the Acting Order. Ministry of Health of the Republic of Kazakhstan dated December 24, 2020

Exemption from preventive control

For the next calendar year in accordance with paragraph 14 of the Order of the MNE and the Ministry of Health of the Republic of Kazakhstan dated November 15, 2018

Accounting for accreditation status in the rating of medical organizations/Akimov rating

The rating of medical organizations is carried out by the RSE at the RPE "National Center for Health Development named after Salidat Kairbekovna" of the Ministry of Health of the Republic of Kazakhstan

PROCEDURE FOR OBTAINING PUBLIC SERVICES

- To obtain an accreditation certificate, a medical organization submits an application to the accrediting body in accordance with Appendix 9 of the Accreditation Rules

- Accreditation of medical organizations consists of the following stages:
1. self-esteem
2. external comprehensive assessment
3. post-accreditation monitoring

The period for accreditation on the basis of medical organizations is at least 2 (two) working days, depending on the size of the attached population, bed capacity and the number of structural units of the medical organization (branches, representative offices located outside the main facility). The number of expert group members involved in conducting an external comprehensive assessment depends on the structure, capacity of the medical organization and the volume of services provided. Before leaving (at least 3 days in advance) to a medical organization, the accrediting body sends a program for an external comprehensive assessment of the medical organization. For the work of the expert group, an office with office equipment and Internet access is allocated

DESCRIPTION OF THE ACCREDITATION PROCEDURE

Three types of tracers are used:
1. individual
2. system
3. profile
At the same time, a tracer is a targeted tracking of various stages of providing medical care to a patient and (or) assessment of interconnected processes in which employees of various departments of a medical organization are involved. One tracer lasts from 1 (one) to 3 (three) hours.

During an individual tracer, the stages of treatment and care of a specific patient are traced by reviewing medical records and interviewing workers involved in the care and treatment of patients, and in medical organizations that are subject to an external comprehensive assessment for compliance with the criteria for clinical sites, clinics of health education organizations, university hospitals, residency bases, integrated academic medical centers - also interviewing employees of clinical departments, as well as interns and residents. The examiner selects patients for assessment using purposive sampling (complex or atypical cases). The selected patient's medical record is the basis for tracking the services provided in the medical organization. The therapeutic, diagnostic and non-medical processes in which the patient took part in the provision of medical care are assessed. During the period of external comprehensive assessment, at least 3 (three) individual tracers of the patient are carried out.

With a system tracer, all stages of infection control, drug handling, building safety, and quality management systems are checked. Gathering information and assessing the organization during a system tracer includes interviewing staff, personal observation, and reviewing documents and/or patient medical records. In this case, different stages of one system are checked.

During the profile tracer, activities specific to the accredited medical organization are assessed with an analysis of unique characteristics and current issues in the profile.

In medical organizations for which an external comprehensive assessment is carried out for compliance with the requirements for clinical sites, clinics of educational organizations in the field of healthcare, university hospitals, residency bases, integrated academic medical centers, the conditions for clinical training of students of educational organizations (students, interns and residents) are additionally assessed. The purpose of a profile tracer is to identify patient safety problems at various stages of medical care, including within the framework of clinical training of students in educational institutions (students, interns and residents).

Observation is carried out to confirm the information obtained by experts during the review of documents and (or) interviewing personnel. Observation is carried out in parallel with staff interviews

ACCREDITATION RESULTS

Based on the results of the meeting of the accreditation commission, the accrediting body makes the following decisions:
1) accredit with assignment:
second category - if the standards (criteria) of the 1st rank are no less than 60%, the standards (criteria) of the 2nd rank are no less than 60%, the standards (criteria) of the rank 3 are no less than 60%;
first category - if the standards (criteria) of the 1st rank are met by at least 70%, the standards (criteria) of the 2nd rank are not less than 65%, the standards (criteria) of the rank 3 are not less than 60%;
highest category - if the standards (criteria) of the 1st rank are no less than 90%, the standards (criteria) of the 2nd rank are no less than 80%, the standards (criteria) of the rank 3 are no less than 70%;

2) do not accredit:
in the case of the result of an external comprehensive assessment below the threshold value required for the second category of accreditation.