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SELF-ASSESSMENT GUIDELINES FOR USERS (HOSPITALS) 3
Purpose of these guidelines: This guidelines is aimed at the end-users of the hospital Ac-
creditation Standards and of the accreditation methodology, for them to understand the phases and
the general activities that they must undertake throughout the accreditation process and how
should they assess their own level of compliance with the requirements included in the accreditation
- Information for the hospitals on the concepts of quality management in health and of ac-
- Proper knowledge by hospitals of the activities and responsibilities that they have to under-
take during the accreditation process;
- Achievement by hospitals of quality standards for hospitals and provision of instruments that
could be used for self-assessment purposes;
- Providing to the hospitals a clear instrument for self-assessment of own level of compliance
with the requirements included in the accreditation standards.
The current guidelines help to a better understanding, by the end-users of the principles of
quality in health and the philosophy underlying the accreditation process in health services, as well
of the results and benefits of accreditation. The second part of the guidelines reviews the accredita-
tion process, from the perspective of end-users (hospitals), underlining the administrative, meth-
odological or procedural and communication requirements, matching the rights and duties that
they have when undertaking this process, until it is resumed for re-accreditation purposes.
The main phases of this route are described: the request for accreditation and preparations
made for the user in order to get accredited, the evaluation process including the pre-visit, the visit
and the post-visit stage, the ongoing monitoring process undertaken in order to maintain the ac-
creditation level, which is initiated after the level of accreditation is communicated and which is
concluded through the registration within a new evaluation process, for re-accreditation purposes.
The final aim of this document is to inform the users and to bring them on board the ongoing
process of improving the quality of health services, as the outcomes could be measured through
the patients’ satisfaction degree, simultaneous with an increase in the measurable quality of medi-
cal services and with the an increase in the level of efficiency in the provision of health services.
4 SELF-ASSESSMENT GUIDELINES FOR USERS (HOSPITALS)
The Co-ordinating group for
Mr. Vasile CEPOI - President of ANMCS
Mr. Sorin UNGUREANU - Assistant Director ANMCS
Mr. Marius FILIP - Director USSS Mrs. Nicoleta MANU - Head office
BSSSS Mr. Andrei ȘTEFAN - Counselor BSSSS Mrs. Adina GEANĂ - Expert ANMCS
Co-ordinator: dr. Vasile CEPOI,
Psih. Alexandru DICU
SELF-ASSESSMENT GUIDELINES FOR USERS (HOSPITALS) 5
1.1. Quality assessment - the philosophy underlying the accredi-
tation of hospital-based services.
Hospital-based services represent an atypical economic market, on one hand, as the health-
care market does not rely on the classical economic relation between supply and demand, where
“the supply creates the demand”. As regards demand, the patient has no possibility to take deci-
sions, as the doctor interposes himself/herself in the decision chain on care and treatment deemed
as most convenient; as regards supply, the service provider (the hospital) is not able to set the price.
The health services market is also atypical due to the fact that the “end-product” of these ser-
vices is intangible and difficult to measure and standardize - health, recovered or restored. More-
over, the patients’ expectation are different from their genuine needs for care, while various behav-
iours and habits, deemed useful by the patient, may interfere with his/her health.
The accreditation standards are considered, from a motivational perspective, to be the opti-
mal and achievable level and they are meant to encourage ongoing efforts for the improvement of
the activity within the accredited organizations.
Accreditation is a process in which the need to register and participate is determined by the
The decision to issue accreditation for a specific hospital ensues an evaluation visit performed
by a team of evaluators, under normal circumstances, once every 5 years.
The choice for the precise moment when the actual visit should take place is subject to an
agreement between each registered hospital and the National Authority for Quality Management in
Health (ANMCS), over the entire 5-year period, representing an accreditation cycle.
Chapter 1. General presentation
6 SELF-ASSESSMENT GUIDELINES FOR USERS (HOSPITALS)
According to A.N.M.C.S. understanding, the philosophy behind accreditation relies on the fol-
lowing relevant values:
The ANMCS accreditation programme starts from the assumption that hospitals are capable to
develop their strategies in order to fulfil the quality standards, without any need for stimuli of any
nature, as what is required is the mere reorganization of the existing resources: the financial, human
or organizational ones.
1.1.1 What is A.N.M.C.S.
National Authority for Quality Management in Health (ANMCS) is a public institution with a
legal capacity, specialized body of central public administration in the field of quality management
in the health sector, which operates as a subordinate body to the Government and under the coor-
dination of the Prime-Minister, through the Prime-Minister’s Chancery.
ANMCS deals with the accreditation of healthcare units, as these are established in consulta-
tion with the Ministry of Health. Healthcare units are those entities with or without a legal capacity
whose scope of work is represented by the provision of medical care, at any level: primary health-
care/GP healthcare, outpatient healthcare, hospital-based healthcare, no matter the type of owner-
ship. Accreditation is awarded over a 5 year period, after that the respective healthcare unit must
SELF-ASSESSMENT GUIDELINES FOR USERS (HOSPITALS) 7
The ANMCS purpose consists from ensuring and ongoing improvement of quality in health ser-
vices and patient safety, through standardization and evaluation of health services and accreditation
of healthcare units.
ANMCS is financed through own revenues and subsidies provided by the state budget,
through the budget of the General Secretariat of the Government.
The mission of the National Authority for Quality Management in Health is to determine qual-
ity assurance and continuous improvement of the health services and patient safety through a
change in the culture of organizations operating in the health sector, standardization, evaluation of
health services and accreditation of healthcare units.
A.N.M.C.S. will disseminate the concept of quality to the professionals within the health sys-
tem, for the purpose of changing the organizational mind-set in order to ensure the implementation
of the quality management system.
The objectives of the National Authority for Quality Management in Health:
The horizon of the national quality system in health: Development in the health ser-
vices through quality, efficiency and performance.
8 SELF-ASSESSMENT GUIDELINES FOR USERS (HOSPITALS)
1.1.2 What is accreditation?
Accreditation is the method which demonstrates that a healthcare unit makes efforts to
provide medical care that should satisfy the patients’ expectations, from the point of view
of results, as well as from the point of view of conditions and processes through which accreditation
is being awarded.