On The Evaluation Of The Quality And Safety Of Inpatient Health Care

Original Language Title: o hodnocení kvality a bezpečí lůžkové zdravotní péče

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Read the untranslated law here: https://portal.gov.cz/app/zakony/download?idBiblio=77221&nr=102~2F2012~20Sb.&ft=txt

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.