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 public health 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. ҚР ДСМ-299/2020 "On approval of the rules for accreditation 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 norms and requirements. Accreditation serves as a guarantee that the institution has the required level of competence and provides high quality medical care, and adheres to the principles of patient safety.

The importance of accreditation for medical organizations cannot be overestimated. First of all, it demonstrates the institution's commitment to high standards of medical practice, which in turn strengthens the trust of 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 helps to increase the internal efficiency of the institution, since it involves the implementation of best practices and standards in daily work, and also encourages continuous improvement of 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 continuous improvement of medical institutions, maintaining their competitiveness in the healthcare market.

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

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

Exemption from proactive monitoring of the Federal Compulsory Medical Insurance Fund

Clause 55 of Paragraph 5 of Chapter 2 of the Order of the Acting Minister 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 Ministry of National Economy and the Ministry of Health of the Republic of Kazakhstan dated November 15, 2018

Taking into account the accreditation status in the rating of medical organizations/rating of Akimov

The rating of medical organizations is conducted by the Republican State Enterprise on the Right of Economic Management "National Center for Health Development named after Salidat Kairbekovna" of the Ministry of Health of the Republic of Kazakhstan

PROCEDURE FOR OBTAINING A STATE SERVICE

- 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-assessment
2. external comprehensive assessment
3. post-accreditation monitoring

The period for conducting accreditation on the basis of medical organizations is at least 2 (two) working days, depending on the number of attached population, bed capacity and the number of structural divisions of the medical organization (branches, representative offices located outside the main facility). The number of members of the expert group 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) for the medical organization, the accrediting body sends a program for an external comprehensive assessment of the medical organization. An office with office equipment and Internet access is allocated for the work of the expert group

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 medical care provided to a patient and (or) an assessment of interrelated processes involving employees of various departments of a medical organization. One tracer lasts from 1 (one) to 3 (three) hours.

During an individual tracer, the stages of treatment and care for a specific patient are tracked by reviewing medical records and interviewing employees involved in the care and treatment of patients, and in medical organizations that undergo an external comprehensive assessment for compliance with the criteria for clinical sites, clinics of educational organizations in the field of healthcare, university hospitals, residency bases, integrated academic medical centers - also a survey of employees of clinical departments, as well as interns and residents. The expert selects patients for assessment using a targeted sampling method (a complex or atypical case). The medical record of the selected patient is the basis for tracking the services provided in the medical organization. The therapeutic, diagnostic and non-medical processes in which the patient participated in the provision of medical care are assessed. During the external comprehensive assessment, at least 3 (three) individual patient tracers are conducted.

During a systemic tracer, all stages of infection control systems, drug handling, building safety, and quality management are checked. Collection of information and assessment of the organization during a systemic tracer includes staff interviews, personal observation, review of documents and (or) patient medical records. In this case, different stages of one system are checked.

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

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

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

ACCREDITATION RESULTS

Following the meeting of the accreditation committee, the accrediting body makes the following decisions:
1) accredit and assign:
second category - if at least 60% of the standards (criteria) of rank I meet, at least 60% of the standards (criteria) of rank II meet, at least 60% of the standards (criteria) of rank III meet;
first category - if at least 70% of the standards (criteria) of rank I meet, at least 65% of the standards (criteria) of rank II meet, at least 60% of the standards (criteria) of rank III meet;
highest category - if at least 90% of the standards (criteria) of rank I meet, at least 80% of the standards (criteria) of rank II meet, at least 70% of the standards (criteria) of rank III meet;

2) not to accredit:
if the result of the external comprehensive assessment is below the threshold value required for the second category of accreditation.