Sb 102/2012.
The DECREE
of 22 March. March 2012
on the evaluation of the quality and safety of inpatient health care
The Ministry of health shall determine pursuant to section 120 of Act No. 372/2011 Sb.
on health services and conditions of their provision (law on the
health services), for the implementation of section, paragraph 98. 7 of the Act:
§ 1
(1) when assessing the quality and safety provided by inpatient health care
(hereinafter referred to as "quality and safety") are in the medical equipment
assessed the following processes:
and quality management and security),
(b)) the care of patients,
(c)), human resource management and
(d) to ensure a safe environment for) patients and staff
inpatient health care providers.
(2) the minimum evaluation standards and indicators of quality and security, and
the method of their creation and monitoring are set out in annex 1 to this
the Decree.
(3) the requirements for security personnel, method and evaluation procedures
quality and safety are set out in annex 2 to this Decree.
§ 2
This Decree shall take effect on 1 January 2005. April 2012.
Minister:
doc. MUDr. Heger, CSc., r.
Annex 1
The minimum evaluation standards and indicators of quality and security and how the
their creation and tracking
1. the minimum evaluation standards of quality control and safety
1.1. Standard:
the introduction of a programme for improving quality and safety
The aim of the standard is the application of the principles and activities leading to the raising of the
quality and safety as an integral part of the management of inpatient
health care.
1.1.1. the indicators of quality and security for compliance with the standard
Standard is met if
and) is introduced the program of enhancing quality and safety for the entire medical
device and this program is updated regularly,
(b)) are determined by the persons responsible for the implementation of the programme for improving quality and
safe,
(c)), the principles and the activities leading to the improvement of the quality and security are
included in the operating procedures established in practice, which are at least
updated once a year, and
(d)) persons involved in the provision of inpatient health care are
actively involved in the program for improving quality and safety.
1.2. Standard:
monitoring and evaluation of adverse events
The aim of the standard is the registration and evaluation of adverse events, which
occur during the provision of inpatient health care.
Adverse event is an event or circumstance that might result, or
resulted in physical damage to the patient, which can be avoided.
For the side event is also considered an unexpected deterioration of the clinical
the patient's condition if it is to result in permanent physical damage, or
death of a patient, unless it is a common complication of health status.
1.2.1. the indicators of quality and security for compliance with the standard
Standard is met if
and evidence) adverse events, and at least
an unexpected deterioration of the clinical condition of the patient, that has the effect of
the permanent physical harm or death of a patient, the occurrence of hospital
diseases, falls, bedsores, events associated with serving or preparing
pharmaceuticals and related events with therapeutic or diagnostic performance
(b)) is done by evaluating individual adverse events, including
detection of their causes,
(c)) are evaluated the time trends in the numbers of adverse events and
(d)) are taken preventive measures to prevent unwanted
events.
1.3. Standard:
monitoring the satisfaction of patients
The aim of the standard is the monitoring and evaluation of the satisfaction of patients with
in-patient health care and the terms of its provision.
1.3.1. the indicators of quality and security for compliance with the standard
Standard is met when the
and monitored patients at least satisfaction) with the conditions of the stay in
medical equipment including catering, access to medical
workers and other specialists to patients and to the provision of
information to patients about their health and diagnostic,
medical and nursing procedures and
(b) evaluation of the satisfaction of the patients) and are taken
measures to remedy any identified deficiencies.
1.4. Standard:
monitoring and evaluation of the complaints and initiatives relating to the bed
health care
The aim of the standard is the monitoring and evaluation of the complaints and suggestions
concerning inpatient medical care and use of acquired knowledge for
improving quality and safety.
1.4.1. the indicators of quality and security for compliance with the standard
Standard is met if
and is guided by the evidence of all) complaints and complaints of the patients and other persons
filed in connection with the in-patient health care, including how their
discharge,
(b)) is carried out the evaluation of the complaints and initiatives including survey
their causes and
(c)) are taken measures to correct the identified deficiencies and
the necessary preventive measures.
1.5. Standard:
the use of the recommended diagnostic, therapeutic and nursing
procedures
The aim of the standard is to ensure the use of diagnostic, therapeutic and
Nursing procedures recommended by the professional and professional
organisations, health professionals and other professional workers in
health care.
1.5.1. the indicators of quality and security for compliance with the standard
Standard is met if
and inpatient health care provider) uses a diagnostic, therapeutic and
Nursing procedures recommended by specialist and professional organisations
health care workers and other professional workers in
health care and
(b)) are handled by the internal diagnostic, therapeutic and nursing
procedures for the care of patients with sensory or physical disabilities.
2. the minimum evaluation standards of care for patients
2.1. Standard:
respect for the rights of patients and people close to patients
The aim of the standard is the respect for the rights of patients and people close to patients
When providing inpatient health care.
2.1.1. Indicator of quality and security for compliance with the standard
Standard is met if it is carried out by monitoring and evaluation
respect for the rights of patients and people close to patients and are taken
measures to remedy any identified deficiencies.
2.2. Standard:
the determination of the internal rules of the management of medical records
The aim of the standard is the keeping of medical records, the management of this
documentation and inspection of her building on specific conditions
provision of inpatient health care and organizational structure
medical equipment.
2.2.1. the indicators of quality and security for compliance with the standard
The standard is met, if they are established and observed
and medical records management policy) following up on specific
the conditions of provision of inpatient health care and organizational structure
medical equipment,
(b)) to ensure access to medical records in the
following the specific conditions for the provision of inpatient health care and
(c) procedures for storing medical) documentation and its protection
unauthorised use, loss and damage.
2.3. Standard:
provide consulting services
The aim of the standard is to provide consulting services to health care
workers in the provision of inpatient health care.
2.3.1. Indicator of quality and security for compliance with the standard
The standard is met, if they are provided consulting services for
other disciplines required for the diagnostic and therapeutic care in the individual
the cases, when it requires the health status of the patient.
2.4. Standard:
safe handling of medicinal products and medical devices
The aim of the standard is to define the activities that have an immediate impact on the
safe handling of medicinal products and medical devices.
2.4.1. Indicators of quality and security for compliance with the standard
The standard is met, if they are established, respected and evaluated
and) internal procedures for ordering, receipt, storage, prescribing,
adjustment and administration of medicinal products and removal (disposal)
of unusable medicinal products, including documentation of the individual
procedures and controls,
(b)) internal procedures for ordering, receipt, storage, prescribing and
the use of medical resources and the removal (disposal)
unusable medical devices including documentation
individual procedures and their control
c) internal procedures in the use of unregistered medicinal products,
d) internal procedures adverse effects of medicinal products and
adverse events and side-effects of medical devices and
e) privileges and responsibilities of personnel in carrying out the activities referred to
in points (a) to (d)).)
2.5. Standard:
the quality of eating patients and nutrice
The aim of the standard is to define the activities that have an immediate impact on the
the quality of food and therapeutic nutrition of patients.
2.5.1. the indicators of quality and security for compliance with the standard
Standard is met when the
and the organisation of procedure) nutritional care and
(b)), the system is processed diet.
2.6. Standard:
ensure the hospital rehabilitation care
The aim of the standard is to ensure hospital rehabilitation care following the
provided in-patient care.
2.6.1. the indicators of quality and security for compliance with the standard
Standard is met if
and the plan is processed) Therapeutic rehabilitative care and its evaluation
following up on the health care provided by the bed and
(b)) patients and health care workers are with the plan of hospital
rehabilitation care and its evaluation of the familiar in the required
the range.
2.7. Standard:
health promotion and disease prevention
The aim of the standard is to define the activities aimed at promoting the health and
Prevention of diseases in relation to patients and employees.
2.7.1. the indicators of quality and security for compliance with the standard
Standard is met if
and the plan is processed) activities aiming at the base area of support
health, disease prevention, in particular depending on tobacco, alcohol and
other addictive substances and on psychological support and
(b)) patients and employees have access to health facilities
information on the factors affecting health.
2.8. Standard:
the continuity of health care
The aim of the standard is to ensure continuity of health care in health care
the device and also in cooperation with other health providers
services.
2.8.1. the indicators of quality and security for compliance with the standard
Standard is met if
and) are set out procedures for the transfer of patients between staff in
follow-up work shifts in the workplace, for the transfer of patients
between workplace medical equipment, for the transfer of patients to
other medical devices and for the release of patients from
medical equipment, including ensuring follow-up outpatient
health care and
(b)) is a procedure for cooperation with other providers
health services and, where appropriate, also with the providers of social services.
2.9. Standard:
identification of patients
The aim of the standard is to avoid the risk of confusion on the part of patients in providing
inpatient medical care.
2.9.1. Indicator of quality and security for compliance with the standard
Standard is met if it is drawn up and followed the procedure for
unique unmistakable identification of patients.
2.10. Standard:
ensure the cardiopulmonary resuscitation
The aim of the standard is to ensure the compliance of cardiopulmonary
resuscitation.
2.10.1. the indicators of quality and security for compliance with the standard
Standard is met when the
and processed and implemented plan) annual training, including the examination of the
health care workers in cardiopulmonary resuscitation,
(b)) is processed and fulfilled plan checks the equipment of workplaces medicinal products
and medical devices to provide cardiopulmonary
resuscitation including checks of their functionality and
(c) the documentation of the implementation) conducted training and examination
health care workers under (a)) and on the implementation of the checks referred to in
(a) (b)).
3. the minimum evaluation standards for human resources management
3.1. Standard:
personnel security-bed health care
The aim of the standard is to ensure that the necessary personnel security bed
health care.
3.1.1. the indicators of quality and security for compliance with the standard
Standard is met if
and distribution) is processed jobs in accordance with the requirements of the
personnel security-bed health care and lifelong
education of health workers,
(b)) are laid down the rules for the incorporation of workers at their
inclusion on the working place,
(c)) are handled by the descriptions of the business activities of each
medical personnel and other professional staff in accordance with the
their competence to exercise the profession of medical worker or
another specialist and
(d)) is monitored and evaluated employee satisfaction with working
terms and conditions for the performance of their tasks and are taken
to correct the shortcomings noted.
4. the minimum evaluation standards to ensure a safe environment for
patients and staff
4.1. Standard:
a safe environment for patients and staff
The aim of the standard is to reduce the security risks associated with the
in-patient health care.
4.1.1. the indicators of quality and security for compliance with the standard
Standard is met when the
and introduced the program ensure safe) environment for patients and
the employee, part of which is in particular the identification of high-risk locations and
activities in terms of the safety of patients and staff and
(b)) was established to ensure electricity, drinking water and
medical gases, as in the usual mode of supply, so when
interruption of supply.
Annex 2
Requirements for security personnel, way and quality evaluation procedures
and safe
1. requirements for personnel security assessment of the quality and safety of
The evaluation of quality and safety is carried out through the
hodnotitelského team assembled by a person authorised to conduct
the evaluation of quality and safety. Evaluation team always forms the
and the doctor or the dentist) with a specialized device ^ 1), which in
the last 10 years at least 6 years, the profession of a physician or
dentist in providing inpatient health care
(b)) a health care professional qualified to the performance of non-medical
the medical profession without mentorship ^ 2), which in the last 10
years of at least 6 years pursued allied health professions in
provision of inpatient medical care, and
(c)) a person with a university degree of technical specialization, which in
the last 10 years at least 6 years has pursued his occupation in
technical-marketing service provider of health services.
All members of the hodnotitelského team must have knowledge in the field of management
the quality.
2. the requirements on the method and procedures for assessment of the quality and safety of
2.1. The composition of the team of hodnotitelského must match the inpatient health
care, which is in the medical device. The head of the
hodnotitelského team is a doctor or dentist.
2.2. The members of the hodnotitelského team obtained the information for the purposes of
evaluation of the quality and safety of
and interview with staff,)
(b)) the interview with patients,
(c) exploring the sites of medical equipment),
(d)) the control of documentation concerning the standards and
(e)) by monitoring the working procedures relating to standards.
1) Law No. 95/2004 Coll., on conditions for the acquisition and recognition of professional
competence and specialized competence to perform medical
the professions of doctor, dentist and pharmacist, as amended
regulations.
2) Law No 96/2004 Coll., on conditions for the acquisition and recognition of eligibility
to the exercise of paramedical professions and to pursue activities
related to the provision of health care and to change some of the
related laws (the law on the paramedical professions),
in the wording of later regulations.
