The head of the department evaluates the level of quality of the patient’s treatment and the level of quality of the medical care provided by individual doctors according to the medical histories in the process of the patient’s sanatorium treatment and those who completed the treatment 1-2 days before discharge.
The assessment of the quality of medical care for a particular patient is carried out in 100% of cases for the timely correction of the treatment and diagnostic process during joint examinations with the attending physicians.
Examination of the process of providing medical care is carried out on individual completed cases in this unit. The examination is carried out according to medical documentation (medical history). If necessary, a face-to-face examination can also be carried out. The results of the examination are recorded in the register of volumes of the results of assessing the quality of medical care.
The following cases are subject to expert control:
– getting injured;
– intercurrent diseases;
– prolongation of sanatorium-and-spa treatment;
– complaints of patients and relatives;
– exacerbations and relapses of the underlying disease.
The assessment of the quality of medical care for a particular patient is recorded in the primary medical documentation.
The results of the examination of the CMP for a completed case in the presence of defects are recorded in the journal of form No. 035 / y-02.
Quality control of medical care at the 2nd level is carried out on the basis of:
analysis of primary medical documentation,
personal examination of patients,
when going around the departments of the institution,
at meetings of Medical Commissions.
Accounting for cases of quality control of the 2nd level is kept in the journal of form No. 035 / y-02.
Target examination of the ILC of individual cases of medical care is carried out when:
– receipt of written complaints from the patient, his legal representative or the insured to the ILC in a medical organization;
– receipt of requests from law enforcement agencies;
– cases of nosocomial infection and complications.
The head of the department monthly analyzes information on the volumes and results of quality control and examinations of the quality of medical care.
Based on the results of the evaluation of the CMP, analytical reports are prepared (quarterly, semi-annual, annual), as well as recommendations, draft management decisions aimed at improving the quality of medical care in the sanatorium.
The head nurse oversees the work of the nursing staff.
The quality of nursing care is assessed according to the following criteria:
· Availability – the opportunity to receive the necessary medical care and care;
· Continuity and continuity – the patient receives the necessary medical care without delay and interruption;
Safety – minimizing the risk of possible complications, side effects of treatment;
· Efficiency – the effectiveness of nursing interventions that improve the health of the patient.
The chief nurse prepares a quarterly incremental report on the results of quality control of nursing activities and provides the head of the pediatric department with a report on the work of the commission for monitoring compliance with biological safety requirements and the prevention of nosocomial infections and provides the chief physician.
The head nurse exercises internal control over the safety of medical activities, which include: working conditions for medical workers; use and operation of medical devices, their disposal (destruction); compliance with the restrictions established for medical and pharmaceutical workers.
In the course of monitoring the safety of working conditions, the use and operation of medical devices, and their disposal (destruction), the following is assessed:
1) compliance with the requirements of labor legislation and other regulatory legal acts containing labor law norms;
2) compliance with state regulatory requirements for labor protection;
• state of jobs;
• provision of employees with personal protective equipment;
3) compliance with the requirements for the safe use and operation of medical devices and their disposal (destruction), including training employees in safe methods and techniques for the use and operation of medical devices;
4) compliance with the requirements for the condition of the premises in which medical devices are located or their destruction is carried out
• safety requirements for medical devices provided for by the technical and operational documentation of the manufacturer:
• requirements for the disposal (destruction) of medical devices provided for by the technical and operational documentation of the manufacturer;
• rules for the circulation of medical devices approved by the Ministry of Health of the Russian Federation:
• obligation to provide information specified in Part 3 of Article 96 of Federal Law No. 323-FZ dated November 2, 2011 “On the Fundamentals of Protecting the Health of Citizens in the Russian Federation”.