Decree No. 102 / 2012 Coll.
Decree on Quality and Safety of Bed Health Care
Valid
Effective from 01.04.2012
102
DECLARATION
of 22 March 2012
on quality and safety assessment of bed health care
The Ministry of Health provides, pursuant to § 120 of Act No. 372 / 2011 Coll., on health services and the conditions for their provision (Health Services Act), for the implementation of § 98 (7) of the Act:
(1) In assessing the quality and safety of the provided bed health care (hereinafter referred to as "quality and safety '), the following processes shall be assessed in the health care establishment:
(a) quality and safety management;
(b) patient care;
(c) human resources management; and
(d) ensuring a safe environment for patients and employees of the bed-care provider.
(2) The minimum evaluation standards, quality and safety indicators and the way in which they are produced and monitored are set out in Annex 1 to this Regulation.
(3) The requirements for staff security, quality and safety assessment methods and procedures are set out in Annex 2 to this Decree.
This Decree shall take effect on 1 April 2012.
Minister:
Doc. MUDr. Heger, CSc., v. r.
Příloha č. 1
Annex No 1 to Decree No. 102 / 2012 Coll.
Minimum evaluation standards and quality and safety indicators, and the way in which they are produced and monitored
1. Minimum Quality and Safety Management Standards
1.1. Standard: implementation of quality and safety improvement programme
The aim of the standard is to apply principles and activities leading to the improvement of quality and safety as an integral part of the bed health management system.
1.1.1. Quality and safety indicators to meet the standard
The standard is met if
(a) a quality and safety improvement programme is in place for the whole medical facility and the programme is regularly updated;
(b) the persons responsible for implementing the quality and safety improvement programme are identified;
(c) the principles and activities leading to the improvement of quality and safety are included in operational procedures put into practice which are updated at least once a year; and
(d) persons involved in the provision of bed health care are actively involved in the quality and safety improvement programme.
1.2. Standard: monitoring and evaluation of adverse events
The aim of the standard is to record and evaluate adverse events occurring in the provision of bed health care.
An adverse event is an event or circumstance that could result or result in physical damage to a patient that could be avoided. An unexpected worsening of the patient 's clinical condition is also considered an adverse event if it results in permanent physical damage or death, not the usual complication of the condition.
1.2.1. Quality and safety indicators to meet the standard
The standard is met if
(a) there is a record of adverse events, at least an unexpected deterioration in the clinical condition of the patient resulting in permanent physical damage or death of the patient, the occurrence of hospital diseases, falls, bedsores, drug administration or preparation events and events associated with therapeutic or diagnostic performance;
(b) evaluation of individual adverse events is carried out, including identification of their causes;
(c) the time trends in adverse events are evaluated; and
(d) preventive measures are taken to prevent adverse events.
1.3. Standard: monitoring patient satisfaction
The aim of the standard is to monitor and evaluate the satisfaction of patients with bed health care and the conditions for its provision.
1.3.1. Quality and safety indicators for compliance
The standard is met if:
(a) the satisfaction of patients with at least the conditions of residence in a healthcare facility, including catering, access to patients by healthcare professionals and other professionals and provision of information to patients on their health and diagnostic, medical and nursing performance; and
(b) evaluation of patient satisfaction and measures are taken to address the deficiencies identified.
1.4. Standard: monitoring and evaluation of complaints and suggestions concerning bed health care
The aim of the standard is to monitor and evaluate complaints and complaints concerning bed health care and to use the knowledge acquired to improve quality and safety.
1.4.1. Quality and safety indicators for compliance
The standard is met if
(a) record of all complaints and suggestions made by patients and other persons in connection with bed health care, including how they are handled;
(b) the assessment of complaints and initiatives is carried out, including the identification of their causes; and
(c) measures are taken to address identified deficiencies and the necessary preventive measures.
1.5. Standard: use of recommended diagnostic, medical and nursing procedures
The aim of the standard is to ensure the use of diagnostic, therapeutic and nursing procedures recommended by professional and professional organisations of health professionals and other health professionals.
1.5.1. Quality and safety indicators for compliance
The standard is met if
(a) the health care provider uses diagnostic, medical and nursing procedures recommended by professional and professional organisations of health professionals and other health professionals; and
(b) internal diagnostic, therapeutic and nursing procedures for patients with sensory or physical impairment are processed.
2. Minimum evaluation standards for patient care
2.1. Standard: respect for patients' and patients' rights
The aim of the standard is to respect the rights of patients and persons close to patients in the provision of bed health care.
2.1.1. Quality and safety indicator for compliance
The standard is met when monitoring and evaluation of respect for the rights of patients and persons close to them is carried out and measures are taken to address the deficiencies identified.
2.2. Standard: laying down internal rules for health documentation management
The aim of the standard is to maintain, handle, and look into medical documentation, following specific conditions for the provision of bed health care and the organisational structure of the healthcare facility.
2.2.1. Quality and safety indicators to meet the standard
The standard is met when established and observed
(a) the principles of the management of medical documentation, following specific conditions for the provision of bed health care and the organisational structure of the medical establishment;
(b) principles for ensuring consultation of medical documentation, following specific conditions for the provision of bed health care; and
(c) procedures for the storage and protection of medical documentation against misuse, loss and damage.
2.3. Standard: provision of consulting services
The aim of the standard is to provide consulting services for healthcare professionals in the provision of bed health care.
2.3.1. Quality and safety indicator for compliance
The standard is met when consulting services are provided for other fields needed for diagnostic and therapeutic care in individual cases where the patient's medical condition requires it.
2.4. Standard: safe handling of medicinal products and medical devices
The aim of the standard is to define activities that have an immediate impact on the safe handling of medicinal products and medical devices.
2.4.1. Quality and safety indicators for compliance
The standard is met if established, observed and evaluated
(a) internal procedures for ordering, receiving, storing, prescribing, adjusting and administering medicinal products and the disposal (disposal) of unused medicinal products, including documentation of the procedures and their control;
(b) internal procedures for ordering, receiving, storing, prescribing and using medical devices and the disposal (disposal) of unused medical devices, including documentation of procedures and their control;
(c) internal procedures for the use of unauthorised medicinal products;
(d) internal procedures for reporting adverse reactions of medicinal products and adverse events and side effects of medical devices; and
(e) the authorisations and duties of staff in carrying out the activities referred to in (a) to (d).
2.5. Standard: quality of patient eating and nutrition
The aim of the standard is to define activities that have an immediate impact on the quality of diet and medical nutrition of patients.
2.5.1. Quality and safety indicators for compliance
The standard is met if:
(a) a procedure for the organisation of nutritional care; and
(b) the diet system is processed.
2.6. Standard: provision of rehabilitation treatment
The aim of the standard is to provide therapeutic rehabilitation care following the provided bed health care.
2.6.1. Quality and safety indicators for compliance
The standard is met if
(a) a plan for treatment and evaluation of rehabilitation care is prepared following the provision of bed health care; and
(b) patients and healthcare professionals are familiar with the rehabilitation and evaluation plan to the extent necessary.
2.7. Standard: promoting health and disease prevention
The aim of the standard is to define health and disease prevention activities in relation to patients and employees.
2.7.1. Quality and safety indicators for compliance
The standard is met if
(a) a plan of activities aimed at essential areas of health promotion, disease prevention, in particular, depending on tobacco, alcohol and other addictive substances and psychological support is developed; and
(b) patients and workers shall have access to information on health factors at the health establishment.
2.8. Standard: Continuity of Health Care
The aim of the standard is to ensure the continuity of health care in health care facilities as well as in cooperation with other health service providers.
2.8.1. Quality and safety indicators for compliance
The standard is met if
(a) procedures are laid down for the transfer of patients between staff in successive work shifts at the workplace, for the transfer of patients between the workplace of a medical establishment, for the transfer of patients to another medical establishment and for the release of patients from the medical establishment, including the provision of additional outpatient healthcare; and
(b) a procedure is established for cooperation with other health service providers and, where appropriate, with social services providers.
2.9. Standard: Patient Identification
The aim of the standard is to eliminate the risk of confusion of patients in the provision of bed health care.
2.9.1. Quality and safety indicator for compliance
The standard is met if a procedure for unequivocal unmistakable identification of patients is developed and followed.
2.10. Standard: provision of cardiopulmonary resuscitation
The aim of the standard is to meet the requirements for cardiopulmonary resuscitation.
2.10.1. Quality and safety indicators for compliance
The standard is met if:
(a) the annual training plan, including the examination of medical staff in cardiopulmonary resuscitation, is drawn up and implemented;
(b) a plan for checks on the facilities of medicinal products and medical devices for the provision of cardiopulmonary resuscitation, including checks on their functionality, is drawn up and implemented; and
(c) documentation is kept on the conduct of the training and checking of health professionals referred to in (a) and on the carrying out of the checks referred to in (b).
3. Minimum human resources management evaluation standards
3.1. Standard: personal security of bed health care
The aim of the standard is to ensure the necessary staffing of bed health care.
3.1.1. Quality and safety indicators to meet the standard
The standard is met if
(a) the distribution of jobs is processed in accordance with the requirements for staffing of bed health care and the Lifelong Learning Programme for Health Workers;
(b) rules are laid down for the integration of workers when they are assigned to a post;
(c) descriptions of the working activities of individual health professionals and other professionals shall be drawn up in accordance with their competence to pursue the profession of health professional or other professional; and
(d) the satisfaction of staff with the working conditions for the performance of their duties is monitored and evaluated and measures are taken to address the deficiencies identified.
4. Minimum assessment standards for ensuring a safe environment for patients and employees
4.1. Standard: safe environment for patients and employees
The aim of the standard is to reduce safety risks related to bed health care.
4.1.1. Quality and safety indicators to meet the standard
The standard is met if:
(a) a programme to ensure a safe environment for patients and workers, including in particular the identification of risk sites and activities in terms of patient and employee safety; and
(b) a method of securing electricity, drinking water and medical gases, both in the normal supply regime and in the event of interruption of supply.
Příloha č. 2
Annex No 2 to Decree No. 102 / 2012 Coll.
Personnel security requirements, quality and safety assessment methods and procedures
1. Requirements for staff quality and safety assessment
Quality and safety assessments shall be carried out through an evaluation team drawn up by a person authorised to carry out quality and safety assessments. The evaluation team always consists of:
(a) a doctor or dental practitioner who has worked for at least 5 years as a doctor or dental practitioner in the provision of bed care;
(b) a health professional qualified to pursue a non-medical medical profession without specialised supervision (1) who has pursued a non-medical profession for at least 5 years in the provision of berth care; and
(c) a person with a technical or managerial higher education who has pursued for at least 5 years his profession in technical and economic operations or in quality and safety management activities with a health service provider.
All members of the evaluation team shall have knowledge of quality and safety management.
2. Requirements for quality and safety evaluation methods and procedures
2.1. The composition of the evaluation team must correspond to the bed health care that is evaluated in the medical institution. The lead evaluation team is a doctor or dentist.
2.2. Members of the evaluation team receive information for quality and safety assessment purposes
(a) an interview with staff,
(b) by interview with patients,
(c) a tour of the health facilities,
(d) by checking the documentation relating to standards; and
(e) monitoring working procedures concerning standards.
1) Act No. 96 / 2004 Coll., on the conditions for obtaining and recognising eligibility for the pursuit of non-medical medical professions and for carrying out activities related to the provision of healthcare and amending certain related laws (Law on non-medical medical professions), as amended.
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Regulation Information
| Citation | Decree No. 102 / 2012 Coll., on Quality Assessment and Safety of Bed Health Care |
|---|---|
| Regulation Type | - |
| Author | - |
| Collection | Code of Laws |
| Date of Promulgation | 30.03.2012 |
|---|---|
| Effective from | 01.04.2012 |
| Effective until | - |
| Status | Valid |
The regulation text is for informational purposes only.
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