Agency for quality and accreditation of the health care facilities Prof d-r Elizabeta Zisovska Republic of Macedonia Dani kvaliteta u zdravstvu Sarajevo,

Agency for quality and accreditation of the health care

facilities

Prof d-r Elizabeta ZisovskaRepublic of Macedonia

Dani kvaliteta u zdravstvuSarajevo, 15-16 Decembar 2014

MISSION

• The Agency ensures quality and safety in health care through the process of accreditation and re-accreditation of the health care facilities. • The Agency develops, revise and improves the

standards of the health care in HC facilities, monitors the implementation of the standards and facilitates the preparedness of the HC facility for successful external assessment.


VISION

The Agency for QAHCF is leading institution in the process of monitoring of the quality of the health care, and one of the key stakeholder within the HC system of the Republic of Macedonia contributing to the continuous improvement of the HC quality, in the favor of the patient safety and the wellbeing of all citizens of the country.


PRINCIPLES

• Dedication to the needs of the patients and health care system• Accordance with the highest ethical standards of

the transparency, respect, integrity, efficacy and efficiency• Efforts towards continuous improvement of the

quality and safety of the health care, patient-focused, his/her family and closest surrounding • Continuous improvement of the knowledge and

skills of the employees


QUALITY OF CARE

The core components of the health care are:

•Clinical decision making•Interpersonal skills•Infection prevention (not make harm!)•Record keeping


• Developing the care plan• Clinical Guidelines• Clinical pathways• Implementing the care plan• Treatment (evidence-based)• Clinical guidelines and protocols• Evaluating the care plan• Follow up of the outcome• Improved or maintained the general health

of the patients


NATIONAL (COUNTRY) APPROACH

-Health care improvement-top priority in any policy, program, law…-Continually assessing existing services in order to:•Build on strengths•Identify gaps•Work on practical solutions to fil gaps


CURRENT SITUATION IN MACEDONIA• Committees for monitoring and

improvement of the health care within the hospitals

-by the law (article 234, item 2, Law for Health Protection, “Official Gazette in Republic of Macedonia, number 43/12)

• Appointed teams for preparing the hospital for accreditation

-internal decision Dani kvaliteta u zdravstvu

Sarajevo, 15-16 Decembar 2014

Monitoring and improvement of the health care

•Data registry•Referring to the Health care Centers•Analysis•Reports


•Overall indicators• Internal diseases•Surgery•Gynecology and Obstetrics•Pediatrics

Indicators for quality of care in hospital facilities


Registering and referring

• Average age of the patients• Number of discharged patients• Number of died patients• Number of autopsies of the died patients• Number of deaths within the first 48 hours

following admission in the hospital• Number of cured patients following

myocardial infarct


• Number of died patients because of myocardial infarct• Number of died patients because of myocardial infarct

within the first 48 hours following the hospital admission• Number of patients cured of cerebrovascular insult• Number of patients died because of cerebrovascular

insult• Number of patients died because of cerebrovascular

insult within the first 48 hours following hospital admission• Number of surgically treated patients• Number of patient treated non-surgically • Number of died patients of those non-surgically treated • Number of died patients surgically treated

• Number of died pregnant and/or delivering women during hospitalization• Number of live born newborns died until discharge from

the maternity • Number of deliveries• Number of deliveries with caesarean section• Number of injuries during the delivery to the mother

and the newborn • Length of stay for each patient (sorted by disease)• Number of patients referred to other HC facility• Number of nurses per department• Number of beds within the facility

• Number of surgical interventions in operation theatre• Number of pre-operative days of treatment

for all surgical interventions• Number of operated patients in general, spinal

and epidural anesthesia• Number of doctors included in the operative

program


Integration of the quality into everyday practice in hospitals

AGENCY FOR QUALITY AND ACCREDITATION OF HEALTH CARE

FACILITIES



GENERAL ACHIEVEMENTS SINCE JULY 2014

• Initial contacts with the hospital teams for monitoring the quality of care and/or accreditation (49/53)• Development and second revision of the standards• Promotion at the media and in the region• Two workshops supported by TAIEX• Coordinators for quality of care• External surveyors

• Development of internal documents• Models of AZUS and AKAZ• Participation in external assessment in Belgrade


FUTURE STEPS• Intensive preparation of the hospitals• Development of self-evaluation tool• Continuous working on internal documents• New employments• Strengthening capacities of the staff• Team building• Intensive collaboration with the regional Agencies• Membership with ISQua• Waiting for the first applications, approximately the

end of 2015

Agency for quality and accreditation of the health care facilities Prof d-r Elizabeta Zisovska Republic of Macedonia Dani kvaliteta u zdravstvu Sarajevo,

Documents

health care systemaccordance

care planfollow

health protection

general health

hc quality

process of accreditation

hc facilities

patientsnumber of autopsies