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  • User Guidelines

    for

    Self-Assessment Purposes

    2017

  • SELF-ASSESSMENT GUIDELINES FOR USERS (HOSPITALS) 3

    Introduction

    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

    standards.

    Expected outcomes:

    - Information for the hospitals on the concepts of quality management in health and of ac-

    creditation;

    - 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

    Standards Elaboration

    Experts Group:

    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

    Vasile Astărăstoae

    Carmen Angheluță

    Mariana Brudașcă

    Daniel Burghelea

    Ana-Maria Dădulescu

    Adina Geană

    Nirvana Georgescu

    Daniela Marghidan

    Doina Miron

    Daniela Moșoiu

    Antonia Nițescu

    Georgel Rusu

    Relu Chițac

    Guide Authors:

    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

    law.

    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

    be re-accredited.

  • 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.

    This activi

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