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MINISTRY OF HEALTH OF UKRAINE
ABT ASSOCIATES INC.
ACCREDITATION STANDARDS FOR HEALTH
CARE FACILITIES
OF UKRAINE
Kyiv 1998
Accreditation standards of health care facilities of Ukraine //
I.B.Demchenko,
V.A.Pischikov, V.V.Omelchenko, A.P.Huk, V.M.Lekhan,
K.D.Babov, I.N.Shmatkova, T.O.Olexiyuk. - Kyiv: Ministry of Health of Ukraine
(MOH), 1998. - 113 p.
“Accreditation standards of health care facilities of Ukraine” are approved
by MOH decrees #2 of 1.18.98.
“Accreditation standards of health care facilities of Ukraine” are meant for
specialists who work in the health care orgnization and expertise sphere,
specifically in the area of accreditation of health care facilities.
The authors extend their gratitude to ZdravReform Program and all
health care professionals for additions and changes in the course of
preparation of the material.
@ Copyright of the Ministry of Health of Ukraine. All rights regarding this
edition are registered, including translation into foreign languages. Any copying
(printing, photocopying, taping etc) of this edition or its parts is prohibited unless
appropriate permission is granted by the Ministry of Health of Ukraine.
Order RN-20.05.98. UR-11. Print run amounts to 1500 copies.
Accreditation standards for health facilities in Ukraine  KYIV 1998
TABLE OF CONTENTS
ACCREDITATION STANDARDS FOR HEALTH FACILITIES IN UKRAINE
1. GENERAL STANDARDS
1.1 FACILITY MANAGEMENT
1.2 PERSONNEL
1.3 ORGANIZATION
1.4 SERVICE (STRUCTURAL DEPARTMENT) MANAGEMENT
1.5 PATIENT RIGHTS AND RESPONSIBILITIES
1.6 ECONOMICS AND FINANCE
1.7 HEALTH INFORMATION AND ANALYTICAL SERVICE
1.8 METROLOGICAL PROVISION
1.9 EPIDEMIOLOGICAL SAFETY
1.10 MEDICAL FACILITY BUILDING STANDARDS
2. QUALITY OF HEALTH CARE
3. MEDICAL CARE
3.1 GENERAL RELULATIONS ON THE PHYSICIAN
3.2 PRIMARY HEALTH CARE
3.3 EMERGENCY AND URGENT CARE SERVICE
3.4 OUT-PATIENT CARE
3.5 IN-PATIENT CARE
3.5.1 GENERAL REGULATIONS
3.5.2 SURGERY, ANESTHESIOLOGY AND INTENSIVE CARE
(RESUSCITATION)
3.5.3 REHABILITATION
3.5.5 MATERNITY AND CHILD CARE
3.6 ANCILLARY SERVICES (PARACTINICS)
3.7 MEDICINE UTILIZATION
3.8 SPECIALIZED SERVICES
3.8.1 BLOOD SERVICE
3.8.2 PATHOANATOMICAL SERVICE
3.9 SANATORIUM-RESORT CARE
Ministry of Health of Ukraine
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Accreditation standards for health facilities in Ukraine  KYIV 1998
GENERAL INFORMATION
The development of new relations in health care system, especially at the background of emerging
health insurance, requires thorough revision of quality issues, guarantees to provide health services free of
charge as well as operational conditions in health facilities so as to comply with up-to-date requirement to
render high quality care at the lowest cost. First of all, it assists to reason specific financing level and
amount of user fees depending on medical personnel qualification and quality of services provided at the
facility. Very often solving these challenges creates the conflict of interests between the state, companies,
health insurance organizations, health providers and patients, i.e. consumers of health services and health
care.
The process of decision-making in this sphere particularly in searching tools to implement
approved recommendations becomes more aggressive and more dynamic as a result of introduction of new
economic relations for the case of care, wider opportunities for insurance organizations and patients to
choose polyclinics and hospitals which are able to provide care of higher quality at the same cost. In this
aspect one of the most important tools is a technology of obtaining objective characteristics of health
provider's performance which would serve to display their professional capacities, level and quality of
care provision that guarantees both high quality and good outcomes of health services.
Development of such organizational tool was initiated in a number of countries in the world
primarily because of the need to identify causes of health care cost growth. Further on it turned into an
individual mean of improving provider's performance to prevent mistakes in health care provision.
Accreditation system has been developed. It consists of the list of structure, performance, organization and
quality standards that health providers should comply with if they claim to be accredited and to guarantee
high level performance in practice.
The accreditation is evaluation of health provider's practice according to standard requirements
which characterize structure, process and outcomes of facility performance.
Also, the accreditation is official recognition of provider's status to render specific types of health
care on the level that makes facility eligible to be granted with a certain category of compliance with the
standards. In the future this will be a valid reason for making a contract with an insurance company. The
accreditation lies within health providers' interests and it credits to their prestige, competitive ability and
financial stability. Availability of the accreditation certificate ranks provider's professional position and
testifies to its public recognition.
In the majority of the countries the accreditation is performed by special committees which invite
prominent health experts of the country to work on the project. For some time accreditation organization
staff and invited experts work closely with health providers on specifically designed projects both
preliminary and during the main event. Later on the results of evaluation are being generalized into a
conclusion on the compliance of a specific health provider with existing standards.
The principal element of success of the whole accreditation procedure is a standardization of all
methodological approaches of evaluating different health providers when all interested parties encourage
the development of general unified standards and performance criteria which guarantee high quality health
care.
Ministry of Health of Ukraine
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Accreditation standards for health facilities in Ukraine  KYIV 1998
INTRODUCTION
Analysis of the existing models of accreditation standards and their evolution in different
countries of the world suggested the conventional approach to accreditation when health provider
(facility) was regarded as an integration of separate department and subunits (thereby, first, department
performance was matched against the standards, then integral evaluation was performed).
Up-to-date practice has not recognized this method any more and new forms of grouping
standards take over. The most critical point is quality and effectiveness of integral practice of a provider
free of anatomizing evaluation since many-year experience of accreditation committees in the developed
countries showed that this factor creates the largest impact on treatment and health prevention outcomes
which are considered the major indicator of health provider quality performance.
The basis of the present accreditation standards consists of the complex indicators which in
experts' opinion can identify quality and effectiveness of health provider functioning as an integral
"mechanism".
The suggested set of standards consists of wide range of up-to-date professional achievements and
criteria which relate to different sectors of facility performance rather that just treatment and prevention. It
is expected as well that the standards will be flexible enough for the application in small and large health
providers both of private and public forms of property.
The standards in all sections are adjusted enough to different types of health facilities, grouped
according to the scheme of services and care reference, including health facility structure, management,
organization, administration, personnel, economics and finance, metrological provision, epidemiological
safety etc., as necessary for integral picture of facility operations.
Quality monitoring is performed according to the conventional scheme of collecting information
on patient services, periodical evaluation of the information to track down major challenges for the quality
of services. Once those are identified, correspondent short- and long-term measures should be designed
and implemented, their effectiveness evaluated and communicated to medical staff on a regular feedback
basis.
The major task of quality improvement lies in achieving as low as possible morbidity, mortality
and disability rates in population as well as the shortest possible health recovery terms utilizing available
resources to the maximum. The quality of health care in the facility should not necessarily attain to the
ideal level but should be the best under the conditions available. The keystone of accreditation process is
the belief that administration and personnel of a health facility are willing to provide health care of the
highest quality and what they need is consulting services how this could be achieved under the condition
of scarce resources.
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Accreditation standards for health facilities in Ukraine  KYIV 1998
ACCREDITATION PROCESS
Accreditation
standards
define the
quality and
efficiency
within
resources
available
Surveyors assess
facility
operations and
provide
+ recommendations
for performance
improvement
Accreditation
Committee concludes
whether the facility
deserves any
accreditation
+
category
=
The facility is
awarded an
appropriate
accreditation
category
The standards are based on the principle of the facility being interested in the opportunity to use
accreditation procedure as a tool of personnel training.
On the other hand, the standards contain a broad range of up-to-date professional criteria that refer
to all the spheres of facility operations and serve as a guide in preparing and going though accreditation.
As a rule, all comments and recommendations provided by the experts in their report make a substantial
basis for performance improvement.
Therefore, accreditation standards contain recommendations for the facility personnel. They are
designed to model operations of the administration and personnel following "how-to-do" principle,
success and possible problem indicators.
The standards are based on the analysis of the existing health care legislation of Ukraine,
experience of health care key specialists as well as results of the accreditation experiment which was run
in different health care facilities of Ukraine.
In the present document the standards fall into a number of separate groups, including the
standards that need to be followed by all health facilities regardless of their property form and types of
health care provided. These are unified in "General Standards" section. This group is subdivided into 10
sub-groups, which present a standardized description of key components necessary for adequate operation
of the facility. Non-compliance or particular compliance with the standards of this group may cause
inefficiencies in performance and lead to substantial consequences such as quality deterioration in
medical care delivery. Each of the sub-sections of the group “General Standards” contains from 8 to 33
standards.
Evaluating facility operations against accreditation standards is performed by means of granting
points for each item/ subitem. The explanation to each item/ subitem is in italics. The points are marked in
the table below every item/ subitem:
The sum of received points defines accreditation category:
 the highest category - total 92% and over the maximum;
 1st category - total not less than 81% of the maximum possible;
 2nd category - total not less that 75 % of the maximum possible;
Accreditation Certificate is not granted to a facility the has received less than 75% of the maximum
possible after survey. Accreditation Committee provides recommendations to specific health authorities
who will make decisions concerning further operations in the facility based on the MOH Decree #287 as
of 09/29/97 "On Accreditation in Health Care Facilities".
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Accreditation standards for health facilities in Ukraine  KYIV 1998
SCHEME OF ACCREDITATION PROCESS

PROCEDURE OF STATE ACCREDITATION OF
HEALTH FACILITIES
(Authorized by the Regulation of the Cabinet of
Ministers #765 as of July 15, 1997)
Compulsory for all health facilities
regardless of their subordination and
form of property;
 Being held once per three years;
 Being held by experts with consideration
of the documents submitted by the
facilities of the following profiles:
Primary health care units: till 01/01/99;
Secondary health care units, recreational
and pharmaceutical facilities: till
07/01/99;
Tertiary health facilities, sanitary and
epidemiology units: till 01/0/.2000.
 Three categories (second, first, highest)
PRINCIPAL ACCREDITATION COMMITTEE
OF MOH OF UKRAINE
Accreditation Committee of MOH of Autonomous
Republic of Crimea
Accreditation Committee of Oblast Health Care
Departments
Accreditation Committee of Kiev and Sevastopol'
Municipal State Administrations
 authorizing decisions of
accreditation committees;
 accreditation of Oblast hospitals;
health facilities subordinate to
MOH of Ukraine; health
facilities of public property
regardless of their
subordination; health facilities of
non-public property.
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accreditation of communal property facilities
(except Oblast hospitals).
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Accreditation standards for health facilities in Ukraine  KYIV 1998
LIST OF HEALTH FACILITIES WHICH WILL BE SURVEYED FOR ACCREDITATION
1. PRIMARY HEALTH CARE
(Facilities and Subdivisions)

Feldsher unit

Feldsher/ OB unit

Ambulatory

Health care unit

City polyclinic (internal medicine department)

City children polyclinic (pediatrics department)

Water transport polyclinic (sea line, in-port), (polyclinic internal medicine department)

Railroad transport polyclinic (railroad line, railroad juncture, railroad department),
(polyclinic internal medicine and pediatrics department)

Railroad line ambulatory

District hospital (ambulatory)

Central rayon hospital (polyclinic internal medicine and pediatrics department)

Health sanitary unit (internal medicine department of guild polyclinic)

Kolhoz maternity unit

Emergency unit
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Accreditation standards for health facilities in Ukraine  KYIV 1998
2. SECONDARY HEALTH CARE (specialized care)
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Central Rayon polyclinic
OB/ GYN department
Physio-therapy polyclinic
Water transport polyclinic (water pool)
Railroad transport polyclinic (railroad)
Narcology ambulatory
Territorial unit of urgent medical care
Central city hospital
Territorial medical amalgamation
City hospital
Central Rayon hospital
Rayon hospital
Children city hospital
Children territorial medical amalgamation
Children Rayon hospital
City emergency hospital
Water transport hospital (central, water pool, in-port)
Railroad transport hospital (central, on-road, departmental, juncture, line, children)
Oil Production Industry hospital
World War II veterans hospital
Ukrainian hospital for overseas veterans
Specialized health department
"Hospice" hospital
Children infectious hospital
Children TB hospital
Infectious hospital
TB hospital
Health recreational hospital
Physio-therapy hospital
Maternity hospital
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Accreditation standards for health facilities in Ukraine  KYIV 1998
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3. TERTIARY HEALTH CARE (highly specialized)
Ukrainian consulting and diagnostic maternity center
"Marriage and Family" consulting service
Republican territory emergency center
Diagnostic center
Central water transport polyclinic
Central railroad transport polyclinic
Republican hospital
Oblast hospital
Ukrainian children hospital of MOH
Children dermatology hospital
Children psychiatric hospital
Hospital of skin and ST diseases
Traumatology hospital
ENT hospital
Narcology hospital
Ophthalmology hospital
Prenatal center
Phsyco-neurology hospital
Psychiatric hospital
Cosmetology hospital
Ukrainian allergology hospital
Hospitals (clinics) of science research institutes
SPECIALIZED TERTIARY CARE UNITS (DISPENSARIES)
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Gastrointestinal disorders
Cardiology
Children cardio-rheumatology
Substance abuse
Oncology
TB
Phsyco-neurology
Trachoma disease
Skin and STD diseases
Leprosarium
AIDS prevention and treatment
Center for rehabilitation of female reproductive functions
Ukrainian specialized center for protection of population against radiation
Oblast specialized center for protection of population against radiation
City specialized center for protection of population against radiation
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Accreditation standards for health facilities in Ukraine  KYIV 1998
HEALTH RECREATION AND RESORT FACILITIES

Balneology hospital

Mud balneology hospital

Children balneology hospital

Resort polyclinic

Preventive health recreation center

Specialized children health recreation center

Health recreation center for children and parents

Children health recreation center
SANITARY AND EPIDEMIOLOGY FACILITIES
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Central sanitary and epidemiology unit
Republican sanitary and epidemiology unit
Oblast sanitary and epidemiology unit
State Oblast Association of population health care
City sanitary and epidemiology unit
City territory medical amalgamation " Sanitary and Epidemiology Service"
Rayon sanitary and epidemiology unit
Sanitary and epidemiology unit at hazardous industrial objects
Anti-plague unit
Disaffection unit
Preventive disinfection unit
City amalgamation "Medical Disinfection Service"
Oblast amalgamation "Medical Disinfection Service"
Oblast amalgamation (enterprise) “Occupational Disinfection"
City amalgamation (enterprise) “Occupational Disinfection"
Water transport sanitary and epidemiology unit (water pool, in-port)
Railroad transport sanitary and epidemiology unit (central, on-road)
HEALTH EDUCATION CENTERS
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Ukrainian health center
Republican health center
Oblast health center
City health center
Rayon health center
PHARMACEUTICAL FACILITIES
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Pharmacy
Pharmacy storehouse
Monitoring laboratory
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Accreditation standards for health facilities in Ukraine  KYIV 1998
OTHER FACILITIES
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Pathology center of Ukraine
Republican pathology office
Oblast pathology office
City pathology office
Oblast children pathology office
Oblast office of forensic medicine
Principal office of forensic medicine
Republican office of forensic medicine
Medical statistics center of MOH of Ukraine
Oblast medical statistics center
"Milk kitchen" center
Medical equipment storehouse
Medical equipment store
Medical optics store
MEDICAL AND SOCIAL PROTECTION FACILITIES

Oblast office of medical and social expertise

Orphanage
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Accreditation standards for health facilities in Ukraine  KYIV 1998
EXPLANATION
(according to the MOH Decrees of 06/22/95 #114 "On Authorization of Health Care Facilities,
Occupational List of Health Care and Pharmaceutical Personnel"):
1. Facility which provides patients with health care of one or several major medical specialty is an
outpatient, many-specialty facility is a polyclinic. Both ambulatory and polyclinic can provide health
care at patient's home.
2. Hospital is a medical facility designed for provision of inpatient care. Hospital which provide
inpatient care of a single medical specialty is called specialized, the one which renders multi-specialty
care is multi-profile. Both multi-profile and specialized hospitals may encompass a polyclinic or an
ambulatory.
3. Two or more polyclinics may be formed within a hospital if they correspond to the effective typical
categories set for municipal polyclinics.
4. Central Rayon Hospital is the one which carries out the functions of health care authority in Rayon/
Village/ City (in the cities of republican and Oblast subordination where Rayon health care
department is unavailable).
5. Central City Hospital is the one which carries out the functions of health care authority in the City (in
the cities of republican and Oblast subordination where Rayon administrative division is unavailable).
6. District hospitals and feldsher/OB units are organized in rural populated areas as well as at
construction sites outside populated areas.
7. If populated area has two or more health facilities of the same type each of them is entitled with
numerical number. If rural administrative area has two or more Rayon hospitals each of them (except
Central Rayon hospital) is given a numerical number.
8. In Oblast (Republic) Oblast (Republican) hospitals, Oblast (Republican) children hospitals may be
organized as well as Oblast (Republican) sanitary and epidemiology units.
9. Specialized tertiary health care facilities (dispensaries) may contain hospital (inpatient). One
cardiology dispensary may be organized within Oblast (Republic). It carries out Oblast (Republic)
facility functions and, correspondingly, provides care to Oblast (Republican) population. Dispensaries
with less that five outpatient consulting physicians cannot be organized.
10. Health units are organized at enterprises (plants), facilities and organizations and work as a part of a
polyclinic or an ambulatory.
11. Health sanitary unit is a municipal polyclinic or municipal hospital with polyclinic which exclusively
provide health care to employees of industrial, construction and transport companies. Health sanitary
unit may include other health facilities too.
12. "Hospital facilities", except specialized hospitals, should encompass polyclinic (ambulatory). City
hospital and children hospital (city and water transport) may not include polyclinic (ambulatory).
13. Health facilities (hospitals, maternity houses, etc.), which work as a part of or are subordinate to
health research institutions are called clinics.
14. Health facilities (hospitals dispensaries, prenatal facilities, etc.) are called clinical hospitals if they
serve a practical basis for higher medical educational institutions, health research institutes and
cooperate with the latter providing health care, training and re-training health personnel and
conducting scientific research (not less that 50% of total operation volume).
15. Centers are health facilities or their structural subunits, dispensaries, prenatal houses, etc. which carry
out the functions of a principal unit of the facility managing and providing health and medicine care to
the assigned population.
16. District (Rayon, Oblast, Republican) hospital may organize a mobile ambulatory which works as a
structural subdivision of the hospital and functions as its department.
17. The title "City Emergency Hospital" is granted to the municipal hospital which is utilized exclusively
for urgent inpatient care.
18. Free-standing milk kitchen units may be organized if their scope of work makes more than 12,000
milk and milk mixture helpings per day.
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Accreditation standards for health facilities in Ukraine  KYIV 1998
19. Health units (physician or feldsher units), mother and child rooms are organized at railroad stations,
docks, stations at railroad, water, air and automobile transport and belong structurally to specific
health facilities.
20. Rayon sanitary and epidemiology Units are organized in rural administrative areas and cities which
have Rayon (district) administrative division. Work capacity of sanitary and epidemiology units,
number of employed specialists is determined by the type and category of health facility and depends
on the amount of assigned population.
21. Disinfection units which provide purely preventive disinfecting services receive free-standing status.
22. Pharmacy is a health facility functioning as permitted and controlled by state authorities pursuing
major goal of provision of population, health facilities, resort centers, health research organizations
and other institutions with medicines, medical supplies and other products of health destination.
23. The pharmacy which takes over administrative, organizational and methodological authority for other
pharmacies in the Rayon (City) is named Central Rayon (City) Pharmacy.
24. The pharmacy exclusively committed to provide one or a number of health facilities with medicines,
medical supplies and other products of health destination is named Hospital Pharmacy or interHospital Pharmacy correspondingly.
25. “Hospice” Hospital is a health facility which provides health care to incurable patients financed by
local public budget, additional revenues from enterprises, sponsors, charity contributions of other
organizations, physical and legal entities.
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Accreditation standards for health facilities in Ukraine  KYIV 1998
1.GENERAL STANDARDS
The present standards concern the structure and performance of the subunits and services that
health facility consists of.
All types of health facilities as well as their departments are considered primarily on the basis of
the present standards.
Selected peculiar features of some services are viewed through additional groups of standards.
1.1 FACILITY MANAGEMENT
1.1.1
1.1.1.1
Organizational and legal basis for the facility is established.
The decree on facility opening is available.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
Evaluation Criteria of Compliance with the Standard (EC):
Non-compliance (NC) - the decree is unavailable.
Full Compliance (FC) - the decree is available.
1.1.1.2
The approved Statute is available.
The Statute of a health facility is approved by higher authorities and registered by local
authorities. The Statute contains the following chapters “General Data”, “Major Goal and Tasks
of Facility”, “Organizational Structure”, “Organization of Operations in the Facility”.
The Statute should reflect the peculiarities of health facility operations due to the set tasks, its
type, capacity, structure and local circumstances(geographical location, area size and assigned
population as well as socio-demographic data).
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - the approved Statute is unavailable.
FC - the approved Statute is available.
1.1.2
The facility management is executed by the administration embodied by
Chief Physician (Chief Administrator) and his/her Deputies, Board of Director. The management
of appointed person or group of people (further below administration)
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - the facility management body is not clearly outlined.
FC - the facility management structure is available, the supporting documents are available too.
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Accreditation standards for health facilities in Ukraine  KYIV 1998
1.1.3
Facility Chief Administrator is responsible for day-to-day management
in the facility. The scope of his responsibilities includes (but is not limited to) the following:
1.1.3.1
0
points
noncompliance
Approve and implement system of health care quality assurance.
1 points
minimal
compliance
2
points
partial
compliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - the health care quality assurance system is unavailable in the facility.
Minimum Compliance (MC) - the system exists but is not implemented.
Partial Compliance (PC) - the system exists and but it does not function in every department.
FC - the system exists and is implemented in all departments of the facility.
1.1.3.2
Control the purchase of equipment, medicines, supplies according to
the facility priorities.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- insufficient control, the purchases do not meet the facility priorities (without consideration of
departmental needs and requests).
FC- facility administration controls if the purchases meet priorities of the facility and requests of the
departments.
1.1.3.3
Control over the provision of user fee services.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- insufficient control, there are cases of violations of user fee regulations.
FC- stable control over the adherence to user fee regulations.
1.1.3.4
0
points
noncompliance
Approve and implement labor protection rules for patients and personnel.
1
points
mincompliance
2
points
partialcompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- no approved labor protection rules in the facility.
MC - approved but not utilized.
PC - approved and implemented but not in all of the departments.
FC - approved and implemented in all of the departments.
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Accreditation standards for health facilities in Ukraine  KYIV 1998
1.1.3.5
Approve and implement short-term and long-term plans for practical
operations and facility finance. The evaluation of developed plans to the needs of assigned
population.
0
points
noncompliance
1
points
mincompliance
2
points
partialcompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- no plans.
MC - either short-term or long-term plans are approved and implemented for less than 50%.
PC - both short- and long-term plans are approved and implemented for more than 50%.
FC - approved both short- and long-term plans which are implemented for not less than 90%.
1.1.3.6
Conduct operational meetings with the Deputies, heads of Departments and
chief nurses.
At meetings the personnel discusses reports by departments, considers their performance,
solves operational issues, considers urgent situations and make mutual decision concerning the
most optimal ways-out.
0
points
noncompliance
2
points
partialcompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- the meeting are not held.
PC - the meetings are not held on a regular basis, discussion is constrained with operational issues, shortterm plans are not considered.
FC - the meetings are held on a regular basis with the participation of the heads of departments and
subunits, both operational and long-term issues are considered.
The day-to-day control over health care provision is performed by
1.1.4
Deputy Chief Physician (Medical Director). Deputy Chief reports to the Chief Administrator. His
sphere of responsibilities includes (but is not limited in) the following:
1.1.4.1
Health care provision evaluation with the help of appropriate Final
Outcomes Models. The unsatisfactory treatment outcomes are analyzed, the measures which would
prevent such cases in future are worked out.
0
points
noncompliance
1
points
mincompliance
2
points
partialcompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - the outcomes evaluation is not held.
MC - the evaluation is held haphazardly, it lacks clear evaluation criteria.
PC - the evaluation is held on the basis of clear evaluation criteria, though not in all departments.
FC - the evaluation is held systematically in every department on the basis of clear evaluation criteria.
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Accreditation standards for health facilities in Ukraine  KYIV 1998
1.1.4.2
Defining patient satisfaction by means of random surveys.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
Secondary
Tertiary
EC:
FC- the surveys are not held.
NC- the surveys are held.
1.1.4.3
Planning and conducting hospital conferences and workshops
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
EC:
NC- conferences and workshops are not held.
FC- conferences and workshops are held.
Nursing services are administered by a skilled medical nurse (chief nurse)
1.1.5
who has specialized training.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- the nurse who lacks specialized training is appointed to the post.
FC- the nurse at the post has taken specialized course of training.
Chief medical nurse approves the rules for nursing care according to the
1.1.6
nurse qualification and type of work.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
FC - the nursing care rules approved by the chief nurse are not available.
NC - the nursing care rules approved by the chief nurse are available.
Facility administration establishes the standards for nursing services as well
1.1.7
as the quality evaluation system.
0
points
noncompliance
1
points
mincompliance
2
points
partialcompliance
Ministry of Health of Ukraine
ZdravReform Project (Abt Associates Inc.)
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
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Accreditation standards for health facilities in Ukraine  KYIV 1998
EC:
NC- the standards are unavailable.
MC - the standards are developed but they are not implemented and communicated to nurses.
PC - the standards are developed but they are not implemented in all departments.
FC - the standards are implemented in all departments, the clear system of their execution is available too.
Day-to day control over financial balance of a health facility is provided by
1.1.8
the Deputy Chief Doctor on Financial Issues.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- such control is either unavailable or unsystematic.
FC- control measures are taken systematically.
Day-to-day control of physicians’, nurses’, attendants’ performance is
1.1.99
provided by the Chief of personnel department.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- such control is either unavailable or unsystematic.
FC- control measures are taken systematically.
Day-to-day control of the facility maintenance is provided by the Deputy
1.1.10
Head Doctor on Administrative Maintenance or by the Principal Maintenance Manager.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- such control is either unavailable or unsystematic.
FC- control measures are taken systematically.
Day-to-day control over the compliance with the labor protection rules is
1.1.11
provided by the labor protection manager (engineer).
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- such control is either unavailable or unsystematic.
FC- control measures are taken systematically.
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Accreditation standards for health facilities in Ukraine  KYIV 1998
The training and testing of the departmental administration on knowledge of
1.1.12
labor protection issues.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- training and testing is not conducted or it is not systematic.
 - training and testing is held on a regular basis proven by documentation.
1.1.13
determined.
The causes for accidents are analyzed as well as the preventive measures are
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- such analysis is not conducted as well as preventive measure are not determined.
FC- such control is provided on a regular basis, the violations are documented and considered in detail.
1.2 PERSONNEL
Personnel policies should be developed, approved and maintained appropriately for the purpose of
achieving the goal of providing the facility with a number of skilled staff for operations. Personnel
policies should regard facility operations of employment, contracting (if such is stipulated), promotion and
dismissal of staff. Personnel operations and policies should cover all personnel; personnel regulations and
documents should be accessible to and discussed with all people employed by the health facility for the
first time.
1.2.1
Health facility has sufficient number of physicians.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- insufficient number of skilled personnel, some posts are vacant (not provided with actual employees).
FC- sufficient number, the vacancies are provided with actual people.
1.2.2
Health facility has sufficient number of nurses.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- insufficient number of skilled personnel, some posts are vacant (not provided with actual employees).
FC- sufficient number, the vacancies are provided with actual employees.
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Accreditation standards for health facilities in Ukraine  KYIV 1998
1.2.3
1.2.3.1
Personnel policies and documents regulate the following:
Benefits for personnel (length of vacation, social insurance, etc.)
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- no documents regulating provision of benefits for personnel or the personnel is not familiar with
those.
FC- such documents are available and accessible to personnel.
1.2.3.2
Regulations on employment and contracting (if such is stipulated).
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
Type of
health
care:
Primary
Secondary
Tertiary
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- unavailable
FC- available
1.2.3.3
Regulations of personnel training.
0
points
noncompliance
3
points
full
compliance
EC:
NC- unavailable
FC- available
1.2.3.4
Regulations of grievance examination.
0
points
noncompliance
EC:
NC- unavailable
FC- available
1.2.3.5
Disciplinary penalties.
0
points
noncompliance
EC:
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Accreditation standards for health facilities in Ukraine  KYIV 1998
NC- no documents which regulate applying disciplinary penalties to personnel, or such documents are
inaccessible to personnel.
FC- the documents are available and accessible to personnel.
1.2.3.6
Regulations of dismissal
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- no documents which regulate dismissals of personnel, or such documents are inaccessible to
personnel.
FC- the documents are available and accessible to personnel.
1.2.3.7
Regulations of wages and worktime.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- no documents which stipulate the calculation of salary or regulate the worktime, or such documents
are inaccessible to personnel.
FC- the documents are available and accessible to personnel.
1.2.3.8
Rules of internal labor discipline..
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- no rules of internal labor discipline, or such documents are inaccessible to personnel.
FC- the documents are available and accessible to personnel.
Chief of Personnel Department is responsible for the implementation and
1.2.4
coordination of personnel policies and personnel management. In his/her operations he/she is
subordinate to the Chief Doctor (Chief Administrator), his/her liabilities include (but are not
limited in) the following:
1.2.4.1
Control of compliance with legality when employing and dismissing personnel.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- such control is not implemented, cases of violation of legislative documents when dismissing and
employing personnel.
FC- such control is implemented, no cases of violation of legislative documents when dismissing and
employing personnel.
1.2.4.2
Control of compliance with the staffing regulations.
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Accreditation standards for health facilities in Ukraine  KYIV 1998
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- such control is not implemented, staffing policy is not implemented
FC- this type of control as well as the staffing policy is implemented.
1.2.4.3
Control of communicating current changes in personnel policies to the
facility personnel.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- such control is not implemented, majority of the personnel is not familiar with the changes in staff
policies.
FC- such control measures are proved to be taken on a regular basis, majority of the personnel is familiar
with the changes in staff policies.
1.2.4.4
Control of the correct documenting of employment and dismissal procedures.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - such control is not implemented, violations of documenting of the procedures.
FC - control of Labor Book and Personnel Records documentation.
1.2.4.5
Development and implementation of the plan for Personnel Department operations.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- such plan is either unavailable or is not executed without any valid reasons.
FC- the plan is available and implemented.
1.2.4.6
Preparation of annual statistic report on personnel issues.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- annual reports on personnel policy issues are not available.
FC - annual reports on personnel policy issues are available.
Plans of training and retraining of administrative, clinical and
1.2.5
ancillary personnel.
Plans of training and retraining of specialists should reflect the changes in service provision,
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Accreditation standards for health facilities in Ukraine  KYIV 1998
facility administration, assure specific qualification level and prepare personnel for promotion and
expanding of their responsibilities.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- the plans for personnel training and retraining are not available.
FC- the plans for personnel training and retraining are not available.
1.2.6
Developed programs for on-job personnel refreshment training.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- the programs are either unavailable or not executed.
FC- the programs are available and executed.
1.2.7
1.2.7.1
Administration provides control of training/ retraining plan implementation.
Control of physician training/ retraining program implementation.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
Secondary
Tertiary
EC:
NC- control is not implemented.
FC- control is implemented.
1.2.7.2
Control of nurse training/ retraining program implementation.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
EC:
NC- control is not implemented.
FC- control is implemented.
1.2.7.3
Control over medical attendants and ancillary personnel training/ retraining
programs
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- control is not implemented.
FC- control is implemented.
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Accreditation standards for health facilities in Ukraine  KYIV 1998
1.2.8
Interviews and introduction sessions are planned for the employed for the first time.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- such interviews are not conducted.
FC- introduction sessions are planned and conducted with the employed for the first time.
Administration (Personnel Department) keeps documentation of individual
1.2.9
labor records of qualification.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- more than 30% of the reviewed records do not reflect the level of personnel qualification.
FC- more than 70% of the reviewed records provide full information on the level of personnel
qualification.
1.3 ORGANIZATION
1.3.1
The list of patient groups is available.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- the list is unavailable.
FC- the list is available.
1.3.2
Every district physician has a list of the population assigned to the area.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
Primary
Secondary
Tertiary
EC:
NC- such registration system is not available.
 - the list is available.
1.3.3
Patient has the right to choose a primary physician.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
EC:
NC- free choice is unavailable.
FC- available.
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Accreditation standards for health facilities in Ukraine  KYIV 1998
1.3.4
Staffing regulation approved by the Chief Doctor (Chief Administrator).
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- staffing regulation approved by the Chief Doctor (Chief Administrator)is not available.
FC- staffing regulation approved by the Chief Doctor (Chief Administrator) is available.
1.3.5
1.3.5.1
The administration approves rules and instructions on the following:
Communication between different departments of the facility and other facilities
The communication system is officially documented, the documents are kept in all
departments and are accessible to health personnel. The organizational chart is approved by the
Chief Administrator; it points out the responsibilities, subordination, service (departmental)
management as well as the communication between different services (departments). The
regulations for operations of each employee are documented in job description.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- documented methods of communication between different departments and other facilities are not
available. There are defects which say about violations in communication structure. The violations happen
on a regular basis.
 - documented methods of communication between different departments and other facilities are
available. No defects which may violate such structure.
1.3.5.2
Instructions on utilizing equipment.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
Secondary
Tertiary
EC:
NC- such instructions are not available.
FC- approved instructions are available.
1.3.5.3
Personnel is familiar with rules and technical instructions.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
EC:
NC- more than 30% of the interviewed personnel are not familiar with the rules and technical instructions
which concern their job operations.
FC- more than 70% of the interviewed personnel are familiar with the rules and technical instructions
which concern their job operations.
Ministry of Health of Ukraine
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Accreditation standards for health facilities in Ukraine  KYIV 1998
1.3.5.4
Personnel keeps to the rules and instructions.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- more than 30% of the interviewed personnel do not keep to the rules and instructions which concern
their job operations.
FC- more than 70% of the interviewed personnel keeps to the rules and instructions which concern their
job operations.
1.3.5.5
Rules and instructions are revised on a regular basis and changed if so is required.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- instructions do not correspond to reality; they are not revised and not changes.
FC- they are revised and changed if so is required.
1.3.5.6
0
points
noncompliance
Job descriptions are developed and implemented for the employees.
1
points
mincompliance
2
points
partialcompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- job descriptions are unavailable in the facility.
MC - job descriptions are developed but not implemented in day-day work, majority of the personnel is
not quite familiar with those.
PC - job descriptions are developed but not implemented in all facility departments. Majority of the
personnel is familiar with them.
FC - job description are developed and implemented in all departments. The personnel is familiar with
them.
1.3.5.7
Job description contains information about the following:
1.3.5.7.1
General part (major tasks for an employee, regulations for dismissal and
contract termination. Principal legal acts which serve a guideline for employee operations).
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- such information is unavailable.
FC- such information is available.
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Accreditation standards for health facilities in Ukraine  KYIV 1998
1.3.5.7.2
Qualification requirements.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
Secondary
Tertiary
EC:
NC- such information is unavailable.
FC- such information is available.
1.3.5.7.3
Rights and responsibilities.
0
points
noncompliance
EC:
NC- such information is unavailable.
FC- such information is available.
1.3.5.7.4
Scope of work.
0
points
noncompliance
EC:
NC- such information is unavailable.
FC- such information is available.
1.3.5.7.5
System of subordination and communication structure.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
EC:
NC- such information is unavailable.
FC- such information is available.
1.3.5.7.6
Level of responsibility for the work and evaluation criteria for its execution.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- such information is unavailable.
FC- such information is available.
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Accreditation standards for health facilities in Ukraine  KYIV 1998
1.3.5.7.7
Location of the place of work, supplies and equipment (if there is any).
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- such information is unavailable.
FC- such information is available.
1.3.7
Occupational responsibilities are communicated to each employee.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- more than 30% of the interviewed personnel do not have complete knowledge about their
occupational responsibilities
FC- more than 70% of the interviewed personnel have complete knowledge of their occupational
responsibilities.
1.4 SERVICE (STRUCTURAL DEPARTMENT) MANAGEMENT
1.4.1
The approved Regulation on the status of a Service (structural department).
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- such Regulation is unavailable.
FC- such Regulation is available.
1.4.2
Service (structural department) management is executed by the person
whose job experience in the field makes not less than 5 years, who has the highest or the first
professional category, specific knowledge and skills in organizing department operations.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- department management is executed by the person whose experience in the field is less than 5 years;
he/she is not accredited for the first/highest category and lacks organizational knowledge and skills.
1.4.3
The service (structural department) manager executes the following (is not limited in
this):
1.4.3.1
Executes departmental planning,
1.4.3.1.1
Work plan are available
0
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28
Accreditation standards for health facilities in Ukraine  KYIV 1998
points
noncompliance
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
Type of
health
care:
Primary
Secondary
Tertiary
Primary
Secondary
Tertiary
EC:
NC- the plans are unavailable
FC- the plans are approved and available.
1.4.3.1.2
0
points
noncompliance
The work plans are implemented.
1
points
mincompliance
2
points
partialcompliance
3
points
full
compliance
EC:
NC- less than 30% of the plan is implemented.
MC - from 30% to 50% is implemented.
PC - implementation rate is from 51% to 70%.
FC - implementation rate is more than 70%.
1.4.3.2
Controls rational utilization of resources.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
EC:
NC- no evidence of the control of water, electricity, medicines, supplies utilization.
FC- the control of water, electric power, medicines and supplies is implemented.
1.4.3.3
Executes direct control over the operations in entire department as well as
over the performance of each employee in the department.
The control measures are taken on a regular basis, for example, personnel meeting
where the staff discusses execution of job responsibilities and evaluates department performance.
0
points
noncompliance
2
points
partialcompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - no evidence that such control is implemented.
PC - the control is not systematic, circle of issues discussed at meetings is rather limited.
FC - the control is systematic, personnel considers variety of issues at their meetings.
1.4.3.4
Provides direct control of the maintenance and improvement of the physical
plant of the department.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- no evidence that such control is implemented, physical plant of the department does not correspond
to its needs.
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Accreditation standards for health facilities in Ukraine  KYIV 1998
FC - the control is systematic, department searches the ways to enrich physical plant of the department
from alternative finance sources, the physical plant corresponds to the department needs.
1.4.3.5
Establishes the priorities in purchases of medicines, supplies and medical equipment
for the department.
The Chief of the department sets priorities in purchasing medicines, supplies and
medical equipment on the basis of analysis of department performance, new therapy techniques
and marketing research data.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- no evidence about such activities.
FC- priorities in purchasing medicines, equipment, supplies are set on a regular basis taking into account
the departmental performance analysis.
1.4.3.6
Executes control over the maintenance of conditions appropriate for patient stay.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- no evidence of such activities, the conditions for patient stay are unsatisfactory.
FC- the control is provided on a regular basis, the conditions are satisfactory.
1.4.3.7
Provides control and analysis of health care quality.
The Chief of the Department reviews 10% of patient records in the department and
conducts patient examination in the hospital at least once a week. If require he/she organizes
physician concillium. If clinical mistakes are revealed he/she develops, implements and submits to
the administration the plan for their prevention.
0
points
noncompliance
1
points
mincompliance
2
points
partialcompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- no evidence of such activities.
MC - control is not conducted on a regular basis; the mistakes revealed are not analyzed.
PC - the control is implemented; 10% of medical records are not reviewed; department patient
examinations are not regular; the measures to prevent mistakes in the future are not developed;
FC - the reviews of 10% of medical records are held on a regular basis; department patient examinations
are systematic; the measures to prevent mistakes in the future are developed;
1.4.3.8
Monitors and develops up-to-date technologies in diagnostics and therapy
with their follow-up implementation.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- no evidence of such activity, up-to-date technologies are not utilized;
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Accreditation standards for health facilities in Ukraine  KYIV 1998
FC- the Chief of Department monitors and develops up-to-date technologies in diagnostics and therapy,
the latter are practiced in the department.
1.4.3.9
Provides control over adherence to sanitary and hygienic standards and labor
protection regulations in the department.
1.4.3.9.1
Cases of pediculosis in department patients are documented.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
Secondary
Tertiary
EC:
NC- no evidence of such operations in the department.
FC- every case of pediculosis is documented and subject to detailed analysis.
1.4.3.9.2
Infectious epidemic outbreaks are documented.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
EC:
NC- no evidence of such operations in the department.
FC- every case is documented and analyzed in detail.
1.4.3.10
Provides participation of all employees in the refreshment programs.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- no evidence of such operations being implemented in the department.
FC- the plans for refreshment programs and the attendance schedule are available in the department.
1.4.3.11
1.4.3.11.1
Provides control over the adherence to the process of health care succession.
Available information on services succession in urgent cases and poisonings can be
easily accessed.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
Primary
Secondary
Tertiary
EC:
NC- the information in either unavailable or inaccessible.
 - the information is available and accessible.
1.4.3.11.2
Vaccination rules are easily accessible.
0
points
noncompliance
Ministry of Health of Ukraine
ZdravReform Project (Abt Associates Inc.)
3
points
full
compliance
Type of
health
care:
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Accreditation standards for health facilities in Ukraine  KYIV 1998
EC:
NC - vaccination rules are either unavailable or inaccessible.
FC - vaccination rules are available or accessible.
1.4.3.11.3
Patient examinations are not duplicated unless required.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- it is apparent that the examinations are duplicated even if it is not required.
FC- if examinations are duplicated there is a solid reason for that.
1.4.4
Available list of clinical indicator which say that patients need to be
referred to specialty health care level.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- the list is unavailable.
FC- the list is available.
1.4.5
Patients are referred to higher specialty facilities after being examined as
completely as possible.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- available evidence of the patients being referred to higher specialty facilities without necessary
examinations and tests.
FC- the maximum of necessary examinations and tests are performed before the referral to a specialty
unit.
1.5 PATIENT RIGHTS AND RESPONSIBILITIES
1.5.1
The information about patient rights and responsibilities is easily accessible.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- information is either unavailable or inaccessible.
FC- information is easily accessible.
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Accreditation standards for health facilities in Ukraine  KYIV 1998
Easily accessible information about the groups of population who have
1.5.2
benefits as well as the volume of benefits.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- information is either unavailable or inaccessible.
FC- information is easily accessible.
Patient is familiar with his/her rights and informed about all aspects related
1.5.3
to the disease and the treatment:
1.5.3.1
Patient and/or his/her relatives are familiar with the succession of
examination, treatment and risks the patient may take in the case of medical interventions/
operations.
Patient record contains such information as well as the patient’s signature that he has
received this information (except the patients with mental disorders). Patient is also explained the
right to refuse from suggested methods of treatment well as the possible negative effects of such
decision.
0
points
noncompliance
1
points
mincompliance
2
points
partialcompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- no evidence of such activities.
MC - less than 30% of the interviewed patients confirm that such sessions took place.
PC - from 30% to 70% of the patients confirm that such sessions took place.
FC - the interviews show that the information is provided to every patient. Every patient record contains a
correspondent note.
1.5.3.2
Information about patient (died patient) diagnosis, terms and length of
treatment is confidential. It may be delivered to authorized organizations at the request of
Prosecution Office and in other cases stipulated by law.
Administration makes detailed records of requests for such information. The log
record of information requests is available.
0
points
noncompliance
1
points
mincompliance
2
points
partialcompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- no evidence of maintaining information confidentiality; it is easily accessible; no regulations
concerning delivery of such information.
FC - the information is delivered only according to the facility regulations.
1.5.3.3
Patients are familiar with the rules of stay in the facility.
Patient is responsible to provide physicians with full information about former
diseases, hospitalizations and other health-related issues, to adhere to the regulations of stay at
the facility, plan of treatment, to execute physician’s recommendations and prescriptions (except
the patient with mental disorders). Patient record should contain his/her signature so that he/she is
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Accreditation standards for health facilities in Ukraine  KYIV 1998
familiar with the rule of inpatient stay and liability to keep to them.
0
points
noncompliance
1
points
mincompliance
2
points
partialcompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- no evidence of such activities.
MC - less than 30% of the interviewed patients confirm that they have received such notification.
PC - from 30% to 70% of the patients confirm that they have received such notification.
FC - the interviews show that every patient has been notified. Every patient record contains a required
information.
1.5.3.4
Patients are notified of participation in experimental programs. In this case
patient record contains specific information.
If patient takes part in experimental program (clinical testing of medicines, new treatment
methods, etc.) his/her patient record should contain such information including the mentioned
further paragraphs:
1.5.3.4.1
Process of experiment.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- less than 30% of the interviewed patients participating in experimental programs confirm that they
have not been notified.
FC- interviews show that every patient participating in experimental program is notified . The mentioned
information is included into patient record.
1.5.3.4.2
Advantages of experimental method if compared to the other ones.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- less than 30% of the interviewed patients participating in experimental programs confirm that they
have not been notified.
FC- interviews show that every patient participating in experimental program is notified . The mentioned
information is included in the patient record.
1.5.3.4.3
Risk to patient’s health.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- less than 30% of the interviewed patients participating in experimental programs confirm that they
have not been notified.
FC- interviews show that every patient participating in experimental program is notified . The mentioned
information is included in the patient record.
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Accreditation standards for health facilities in Ukraine  KYIV 1998
1.6 ECONOMICS AND FINANCE
Economics and finance department (EFD) of the health facility provides accounting, accumulation
and rational utilization of financial and material resources for stable functioning of the facility.
The major goal of EFD concerns development and maintenance of financial stability in the
facility.
EFD is a structural part of the facility functioning. It interacts with other
1.6.1
departments and services on a large scale in relation to all financial and administrative issues. The
EFD structure is clearly determined.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- no evidence of cooperation with other departments and services; the EFD is not clearly determined.
FC- available evidence of cooperation with other departments and services in the facility; the EFD
structure is clearly determined.
1.6.2
The EFD regardless of the scope of work performs the following functions:
1.6.2.1
Control of the supply provision and equipment maintenance.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- no evidence of such activities.
FC- available evidence of systematic control of the supply provision and equipment maintenance.
1.6.2.2
Financial and cost accounting.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- no evidence of such activities.
FC- available evidence of financial and cost accounting.
The EFD employees have specialized education or training, Diploma or
1.6.3
Certificate according to the requirements of Occupational Qualification Directory.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- less than 70% of employees have specialized education or training, Diploma or Certificate according
to the requirements of Occupational Qualification Directory.
FC- 70% and more employees have specialized education or training, Diploma or Certificate according to
the requirements of Occupational Qualification Directory.
Ministry of Health of Ukraine
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Accreditation standards for health facilities in Ukraine  KYIV 1998
EFD department is headed by the Chief of EFD, the chief accountant or
1.6.4
financial manager. In his/her operations he/she is subordinate to the Chief Doctor (Administrator)
and the sphere of his responsibilities includes (but is not limited in) the following:
1.6.4.1
Projection, planning and allocation of financial resources among the departments.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- no evidence that such activity is implemented.
FC- available evidence of projection, planning and allocation of financial resources among the
departments.
1.6.4.2
Timely provision of all types of activity in the facility with financial resources.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- available evidence of breakdowns in finance provision through the fault of EFD Chief or his
subordinates.
1.6.4.3
Control of the execution of contracts and agreements with materially liable
people, departments and organizations which provide services to the facility.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- no evidence of such control.
FC- systematic control of the execution of contracts and agreements.
1.6.4.4
Control over the adherence of personnel to financial discipline (accounting,
reporting, inventory).
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- no evidence of such control.
FC- systematic control is implemented; it is proven by the documents and personnel surveys.
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Accreditation standards for health facilities in Ukraine  KYIV 1998
1.6.4.5
facility.
Making staffing lists, cost accounting according to the scope of work in the
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- no evidence that such work is conducted; or conducted regardless of the scope of work in the facility.
 - staffing lists, cost accounting issues are developed in regard to the scope of work conducted and
revised on a regular basis.
1.6.4.6
Control of the rational utilization of allocations and material resources
in entire facility and in departmental distribution.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- no evidence of such control.
 - systematic control proven by documents and by personnel surveys.
1.6.4.7
Systematic analysis of financial and economic activity in the facility
according to established indicators, timely informing of the administration about revealed
shortcomings.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- no evidence that such control is implemented.
FC- systematic control proven by documents and by personnel surveys.
1.6.4.8
Control of the adherence to financial and cost accounting requirements
as stipulated by effective regulations and laws.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
Secondary
Tertiary
EC:
NC- facts of violation of cost and financial accounting requirements.
FC- no facts of violation of cost and financial accounting requirements.
1.6.4.9
Control of the fee revenues collected from providing user fees.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
EC:
NC- facts of violations of fee revenues accounting.
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Accreditation standards for health facilities in Ukraine  KYIV 1998
FC- no facts of violations; the control measures are taken on a regular basis; it is proven by documents
and personnel surveys.
1.6.4.10
Control of timely payments for the services provided to other organizations
and facilities.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- facts of ill-time payments.
FC- facts of ill-time payments are unavailable; control measures are taken on a regular basis; it is proven
by documents and personnel surveys.
1.6.4.11
Analysis of actual costs of the facility.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- unavailable evidence of implemented actual cost analysis.
FC- actual cost analysis is conducted systematically as proven by documents and personnel surveys.
1.6.4.12
Break-even analysis for the implementation of new medical equipment and
therapy methods (specifically, decrease of prime cost for service).
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
Í - no evidence that such calculations are conducted.
 - such calculations are conducted as proven by documents and personnel surveys.
1.6.4.13
Determining cost for services.
EC:
NC- no evidence that such calculation are made.
FC- such calculations are made as proven by documents.
1.6.4.14
Adherence to the effective legal framework concerning financial and
economic activities.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- evidence of violations of the effective legal framework concerning financial and economic activities
as proven by documents.
FC- evidence of violations of the effective legal acts are unavailable.
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Accreditation standards for health facilities in Ukraine  KYIV 1998
1.6.4.15
Control of the revenues and expenditures:
The items subject to continuos control:
1.6.4.15.1
Public budget allocations:
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
Secondary
Tertiary
EC:
NC- control is not implemented or is not taken on a regular basis.
FC- control is taken on a regular basis as proven by documents.
1.6.4.15.2 Payments for the provision of user fee services to the facilities
which do voluntary health insurance.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
EC:
NC- control is not implemented or is not taken on a regular basis.
FC- control is taken on a regular basis as proven by documents.
1.6.4.14.3 Payments for the provision of additional better quality services within the
facility (quality foods, telephones and refrigerators in the rooms, etc.).
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- control is not implemented or is not taken on a regular basis.
FC- control is taken on a regular basis as proven by documents.
1.6.4.14.4 Rent payments for the space, transport and equipment leased by other
organizations.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- control is not implemented or is not taken on a regular basis.
FC- control is taken on a regular basis as proven by documents.
1.6.4.14.5 Profit from marketing product left-overs produced by additional enterprises
in the facility.
0
points
noncompliance
Ministry of Health of Ukraine
ZdravReform Project (Abt Associates Inc.)
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
39
Accreditation standards for health facilities in Ukraine  KYIV 1998
EC:
NC- control is not implemented or is not taken on a regular basis.
FC- control is taken on a regular basis as proven by documents.
1.6.4.14.6
Sponsorship, charity contributions and investments.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- control is not implemented or is not taken on a regular basis.
FC- control is taken on a regular basis as proven by documents.
1.6.4.15
Regular and thorough analysis of financial activities of the facility.
The results of such analysis in the form of the report are submitted to the Chief Doctor
(Administrator) on a quarterly basis. The items subject to such analysis are:
1.6.4.15.1
Annual report (annually):
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
Secondary
Tertiary
EC:
NC- evidence of conducting analysis of annual report is unavailable.
FC- analysis of annual reports is conducted as proven by documents.
1.6.4.15.2
Balance of revenues and expenditures (on a quarterly basis).
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
EC:
NC- evidence of conducting analysis of revenues and expenditures balance is unavailable; otherwise it is
not conducted on a quarterly basis.
FC- analysis of revenues and expenditures balance is conducted on a quarterly basis as proven by
documents.
1.6.4.15.3
Paid receipts (monthly).
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- evidence of conducting analysis of paid receipts is unavailable; otherwise it is not conducted on a
monthly basis.
FC- analysis of paid receipts is conducted on a monthly basis as proven by documents.
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Accreditation standards for health facilities in Ukraine  KYIV 1998
1.6.4.15.4
Current payable debts (monthly).
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- evidence of conducting analysis of current payable debts or such analysis is not conducted on a
monthly basis.
FC- analysis of current payable debts is conducted on a monthly basis as proven by documents.
1.6.4.15.5
Inventory of major assets (annually).
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- evidence of conducting assets inventory analysis is unavailable or such analysis is not conducted
annually.
FC- assets inventory analysis is conducted annually as proven by documents.
1.6.4.15.6
Inventory of supplies and equipment (annually).
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- evidence of conducting supplies and equipment inventory analysis is unavailable or such analysis is
not conducted annually.
FC- inventory analysis is conducted annually as proven by documents.
1.6.4.15.7
Inventory of circulatory assets (annually).
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- unavailable evidence that inventory analysis is conducted; otherwise it is not conducted annually.
FC- circulatory assets analysis is conducted annually as proven by documentation.
1.6.4.15.8 Inventory of financial resources and documents, forms of strict
accountability (monthly).
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- unavailable evidence that inventory analysis is conducted; otherwise it is not conducted monthly.
FC- the inventory analysis is conducted on a monthly basis as proven by documentation.
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Accreditation standards for health facilities in Ukraine  KYIV 1998
1.6.4.15.9
Payments inventory (quarterly).
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- unavailable evidence that such analysis is conducted; otherwise it is not conducted quarterly.
 - the inventory analysis is conducted quarterly as proven by documentation.
1.7 HEALTH INFORMATION AND ANALYTICAL SERVICE
The work of Health Information and Analytical Service (HIAS) is provided by Organization and
Methodology Department, Organization and Methodology Office and Accounting and Statistical Office
which function in close contact with other departments of the facility.
Accounting and Statistical Office collects health information. Organization and Methodology
Department as well as Organization and Methodology Office provides analysis of this information and
develops recommendations for managerial decision-making.
The regulations for completion of health reporting documents as well as the ways of submitting
them are developed by the Accounting and Statistical Office and are approved by the Chief Doctor (Chief
Administrator).
The system of management information provision should be developed within the facility; it
determines the volume of information and time framework (daily, weekly, monthly, etc.).
Facility management takes measures to update methods of information collection which will
enhance care provision and resources utilization and initiate information computerization.
Planning of facility operations (financial, organizational, clinical) is executed on the basis of
statistical data analysis and the derived results.
Health Information Service organizes communication with Municipal, Rayon State Authorities
and other organizations which provide territory for the facility. It also receives directive and regulating
documents and develops measures as to their execution. It completes State and sector reports and submits
them to the Chief Doctor who provides them to the Municipal, Rayon and Oblast level according to the
correspondent regulations of higher authorities.
All data collected by the HIAS are analyzed and utilized for management
1.7.1
of a health facility.
All information comes to the Accounting and Statistical Office where it is being process, checked
for its faithfulness and calculated for specific indicators; after it is delivered to the Chief Doctor
and specific structural departments.
1.7.1.1
The results of statistical data analysis are delivered to the Chief
Administrator according to the terms established by facility administration.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- no evidence that such information is delivered within the terms stipulated by administration.
FC- such information is delivered within the set terms as proven by documentation and personnel surveys.
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Accreditation standards for health facilities in Ukraine  KYIV 1998
1.7.1.2.
The department managers are updated on the results of brief analysis of
statistical data not later than five days after calculations.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- no evidence that such information is delivered within the terms stipulated by administration.
FC- such information is delivered within the set terms as proven by documentation and personnel surveys.
The carrier of health information is a patient record and statistical
1.7.2
document. The facility keeps the following forms of statistical documentation (but is not limited in
those):
1.7.2.1
Statistical card for the discharged inpatient (Ô ¹066/0).
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- available evidence of inaccurate or incomplete (unavailable diagnosis code or surgery intervention
records) completion of cards.
FC- the card is completed for every discharged inpatient, in an accurate and complete manner as proven
by the review.
1.7.2.2
Card of patient admission and referral (Ô ¹007/0).
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- ill-time or incomplete completion of admission and referral cards; do not meet format requirements
approved by the MOH.
 - the cards are completed timely and completely according to the instructions; they reach the required
destination as proven by the review.
1.7.2.3
Outpatient card (Ô ¹025-2/0, 025-6/0, 025-7/0).
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- available evidence of ill-time or incomplete completion of outpatient cards; the diagnosis codes are
unavailable.
 - the cards are completed in a timely and complete manner as proven by the review; the diagnosis
coding is accurate and meets the formal requirements.
Ministry of Health of Ukraine
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Accreditation standards for health facilities in Ukraine  KYIV 1998
1.7.2.4
Outpatient registration log (074/0).
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
Primary
Secondary
Tertiary
Secondary
Tertiary
EC:
NC- evidence of ill-time and incomplete completion of the log.
 - the log is completed timely and fully as proven by the review.
1.7.2.5
Outpatient physician performance card (Ô¹039/0).
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
EC:
NC- evidence of ill-time or not full completion.
FC- the cards are filled in timely and completely as proven by the review.
1.7.2.6
The registration log of corpse intake and delivery.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
EC:
NC- evidence of ill-time and not full completion of the log.
FC- the log is completed timely and fully as proven by the review.
1.7.2.7
(Ô ¹001/0).
The registration log of patient admissions and hospitalization refusals
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
Secondary
Tertiary
EC:
NC- evidence of ill-time and not full completion of the log.
FC- the log is completed timely and fully as proven by the review.
1.7.2.8
The registration log of infectious diseases (Ô ¹060/0).
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
EC:
NC- evidence of ill-time and not full completion of the log; ill-time message about infectious disease.
FC- the log is completed timely and fully as proven by the review.
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Accreditation standards for health facilities in Ukraine  KYIV 1998
1.7.2.9
The registration log of liquid transfusion operations (Ô ¹009/0).
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- evidence of ill-time and not full completion of the log.
FC- the log is completed timely and fully; it exists in every department as proven by the review.
1.7.2.10
The registration log of surgery interventions in the inpatient unit (Ô ¹008/0).
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- evidence of ill-time and not full completion of the log.
FC- the log is completed timely and fully according to the official format as proven by the review.
1.8 METROLOGICAL PROVISION
The specialist responsible for the metrological provision has a required
1.8.1
training and is appointed to the post by the administrative regulation.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- the specialist responsible for metrological provision does not have a required training or the
administration regulation on his/her appointment is unavailable.
FC- he/she has a required training and is appointed by the administrative regulation.
1.8.2
The list of measuring equipment is available in the facility.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
Secondary
Tertiary
EC:
NC- such list is unavailable.
FC- available.
1.8.3
required.
All measuring equipment is metrologically accredited if it is
0
points
noncompliance
Ministry of Health of Ukraine
ZdravReform Project (Abt Associates Inc.)
3
points
full
compliance
Type of
health
care:
Primary
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Accreditation standards for health facilities in Ukraine  KYIV 1998
EC:
NC- some equipment is not metrologically accredited.
FC- no measuring equipment which is not accredited.
1.8.4
The schedule of authorized review of measuring equipment is available.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- such schedule is unavailable.
FC- it is available.
Specific measuring equipment is marked as for training purposes or
1.8.5
to be used an indicator.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- measuring equipment used for training purposes or as indicators is not marked; otherwise the
equipment which needs to be referred to these groups, is not utilized in such a manner.
FC- measuring equipment used for training purposes or as an indicator is marked.
1.8.6
The measuring equipment which is not in use temporarily, is properly kept.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- there is an evidence that the measuring equipment is not properly kept if it is not used temporarily.
FC- all the equipment is properly kept if it is not used temporarily.
According to the schedule of authorized review the measuring equipment
1.8.7
involved in diagnostic and therapy procedures is checked.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- there is an evidence that regular reviews and checks are not conducted or are conducted
unsystematically.
FC- all measuring equipment is subject to a regular reviews and checks as proven by the documentation.
1.8.8
Metrological service is provided with required legal documents.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
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Accreditation standards for health facilities in Ukraine  KYIV 1998
NC- the required documents are totally or partially unavailable.
FC- full set of required documents is available.
Clinical and diagnostic laboratories are provided metrologically
1.8.9
with the accredited methodologies of measuring.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- evidence of application of the methodologies which are not accredited; otherwise any methodologies
are unavailable.
FC- the methodologies applied are metrologically accredited.
In case of biological research the control measures are taken as to
1.8.10
the application of the set of reagents approved by the MOH of Ukraine. The research components
should be reviewed to verify their quality.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- unavailable control of the reagent application; there is no control of the research component so as to
verify their quality.
FC- such control is implemented as proven by documentation.
Clinical and diagnostic laboratories are provided with a required amount of
1.8.11
serum for systematic control of the biochemical research quality.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- serum is unavailable or available in insufficient amount; otherwise control measures are not
systematic;
FC- there is a required amount of serum available; systematic control of the quality of biochemical
research as proven by documentation.
Hematological and coagulological research is provided with control
1.8.12
materials; therefore quality assessment is conducted on a regular basis.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- control materials unavailable; quality assessment unsystematic.
FC- there is required amount of control materials available; quality assessment of hematological and
coagulological research is conducted on a regular basis as proven by documentation.
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Accreditation standards for health facilities in Ukraine  KYIV 1998
Systematic control is implemented so as to reveal and prevent the
1.8.13
application of non-unified methods of research.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- no evidence of systematic implementation of such control; non-unified methods of research are used.
FC- control is systematic; non-unified methods of research are not used as proven by documentation.
1.8.14
operations.
Control of the adherence to the methodologies in measuring
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- evidence that such control is implemented, measuring operations are conducted with methodologies
violations.
FC- control is systematic, measuring operations are conducted according to the approved methodologies
as proven by documentation.
Control of the compliance with the format of methodological
1.8.15
research documentation, standard requirements, metrological rules and regulations.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- no evidence that such control is implemented; facts of non-compliance with requirement standards.
FC- control is systematic; methodological documentation meets standard requirements as proven by
documentation.
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Accreditation standards for health facilities in Ukraine  KYIV 1998
1.9 EPIDEMIOLOGICAL SAFETY
A complex of prevention and anti-epidemiological measures is undertaken when
1.9.1
infectious diseases are identified within the facility.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - there is evidence that the facility does not carry out these measures or does not carry them out on
time.
FC - the measures are carried out and documented.
1.9.2
0
points
noncompliance
Status of the wards correspond to the sanitary norms.
1
points
mincompliance
2
points
partialcompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - most of the facility wards do not correspond to the sanitary norms, there are no plans to eliminate
discrepancies.
МC - most of the facility wards do not correspond to the state norms, there is a clear plan to eliminate
discrepancies but it is not implemented.
PC - most of the wards correspond to the sanitary norms, there is a developed plan to eliminate
discrepancies in the wards that do not comply with the state norms, the plan is implemented.
FC - there are no wards that do not comply with the sanitary norms in the facility.
1.9.3
0
points
noncompliance
Interior of the facility space corresponds to its functional purpose.
2
points
partialcompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
NC - interior of the most of facility space does not comply with the state norms, there are no plans to
eliminate discrepancies.
PC - interior of the most of facility space complies with the state norms, there is a developed plan to
eliminate discrepancies in the rooms that do not correspond to the state norms, the plan is implemented.
FC - there is no space in the facility that does not comply to the state norms.
1.9.4
0
points
noncompliance
Provision of running cold and hot water supply.
2
points
partialcompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
NC - the facility does not have cold or hot water supply.
PC - the facility water supply is not permanent.
FC - the facility has permanent cold and hot water supply.
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Accreditation standards for health facilities in Ukraine  KYIV 1998
1.9.5
Provision of uninterrupted and effective sewerage system.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
NC - the facility sewerage system is not effective, there is evidence about its frequent deficiencies or the
measures are not undertaken to eliminate them.
FC - the facility has an effective sewerage system, the measures to eliminate deficiencies are constantly
undertaken which is documented.
1.9.6
Provision of timely and complied with the sanitary standards refuse disposal.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
NC - there are no refuse disposal containers on the facility territory or the refuse is not disposed timely or
the refuse disposal does not comply with the sanitary norms.
FC - the facility undertakes timely and complied with the sanitary norms refuse disposal.
1.9.7
Provision of timely and safe disposal of biologically hazardous materials.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
NC - the facility does not have a clearly set order for the elimination of biologically hazardous materials.
FC - the facility undertakes safe and timely elimination of biologically hazardous materials.
1.9.8
Heating and ventilation systems operate effectively.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - the facility heating and ventilation systems do not operate effectively, there is evidence about their
frequent deficiencies, and the measures to eliminate deficiencies are not undertaken.
FC - the facility has effective heating and ventilation systems, the measures to eliminate deficiencies are
constantly undertaken which is documented.
Changes of the facility space planning are implemented on the compliance
1.9.9
with the Epidemiology Service Authorities.
0
points
noncompliance
2
points
partialcompliance
Ministry of Health of Ukraine
ZdravReform Project (Abt Associates Inc.)
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
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Accreditation standards for health facilities in Ukraine  KYIV 1998
NC - there are space planning changes without compliance with the Epidemiology Service Authorities in
the facility, the space is not used according to its direct destination.
PC - part of the facility space is not used according to its direct functional destination.
FC - there are no space planning changes in the facility.
Natural and artificial light in the facility space complies with its
1.9.10
functional destination.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
NC - the facility lighting system does not comply with its functional destination.
FC - the facility has an effective lighting system, the measures to eliminate deficiencies are constantly
undertaken which documented.
1.9.11
Canteen and buffet location requirements are preserved.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
NC - canteen and kitchen do not comply with sanitary standards.
FC - canteen and kitchen are located in a separate building which is not detached to the principal building,
there is convenient ground or underground communication with other buildings, except infectious ones.
The requirements to canteen/ kitchen and buffet equipment and maintenance
1.9.12
are preserved.
0
points
noncompliance
1
points
mincompliance
2
points
partialcompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
NC - equipment and maintenance of the canteen/ kitchen and buffets do not comply with the state
standards, there are no plans to eliminate deficiencies.
MC - most of the buffets do not comply with the state norms, there is a clear plan to eliminate
deficiencies, but it is not implemented.
PC - most of the buffets comply with the state requirements, there is a developed plan to eliminate
deficiencies in the buffets that do not comply with the national standards, the plan is implemented.
FC - the facility canteen/ kitchen and buffets comply with the state norms.
1.9.13
The requirements concerning equipment, stock, ware and tare are preserved.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
NC - canteen/ kitchen and buffet equipment, stock, ware and tare do not comply with the sanitary norms.
FC - canteen/ kitchen and buffet equipment, stock, ware and tare comply with the sanitary norms and
regulations.
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Accreditation standards for health facilities in Ukraine  KYIV 1998
The requirements concerning transportation, acceptance and preservation of food
1.9.14
and food products are kept to.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
NC - food and food products are transported, accepted and preserved in the kitchen and buffets according
to the set sanitary standards.
FC - transportation, acceptance and preservation of food and food products in the facility comply with
the sanitary regulations.
1.9.15
Requirements concerning food products production are preserved.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
NC - the requirements concerning food products production are violated.
FC - the requirements are preserved.
The requirements concerning portion-menu composition, planned
1.9.16
menu development and provision of patients with dietary food are complied.
0
points
noncompliance
1
points
mincompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
NC - portion-menu is not composed in the facility, there is a planned menu developed, patients are not
provided with the dietary food.
MC - portion-menu is composed in the facility, there is a planned menu developed, though the patients
who need dietary nutrition are not provided with dietary food.
FC - there is a composed portion-menu in the facility, planned menu is developed, patients are provided
with dietary food which is documented and proved during interviews.
The requirements concerning ready dish rejection as well as selection and
1.9.17
preservation of day samples.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
NC - there are no ready dish rejection, selection and preservation of day samples.
FC - ready dish rejection, as well as selection and preservation of day samples is done according to the
sanitary standards which is documented.
There is a systematic control over the quality and safety requirements to the foods
1.9.18
and food products provided to the patients.
0
points
noncompliance
Ministry of Health of Ukraine
ZdravReform Project (Abt Associates Inc.)
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
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Accreditation standards for health facilities in Ukraine  KYIV 1998
NC - the facility does not carry out the control over quality and safety requirements to foods and food
products provided to the patients, or the control is not done systematically.
FC - the facility carries out full and systematic control over the quality and safety requirements to foods
and food products provided to the patients, which is documented.
1.9.19
Safety requirements concerning the nutrition of children under 1 are preserved.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
Secondary
Tertiary
NC - the requirements are not preserved.
FC - the requirements are preserved.
1.9.20
Nutrition of medical and ancillary personnel is well-organized.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
NC - nutrition of medical and ancillary personnel is not organized.
FC - well-organized.
1.10 MEDICAL FACILITY BUILDING STANDARDS
This standard is aimed at provision of the facility building functioning safe for patients, personnel
and visitors. It also provides sufficient conditions for diagnostic and therapeutical procedures.
1.10.1
There are instructions on fire emergency measures, and personnel is informed about
it.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - there are no instructions on fire emergency measures, or most of the interviewed personnel is not
aware of it.
FC - most of the personnel is informed about the fire emergency instructions which is documented and
proved by the personnel interviews.
The activities are undertaken to provide reliable and safe exploitation of the
1.10.2
buildings, constructions and engineer networks.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - these activities are not undertaken, there is no register of the buildings, constructions or engineer
networks that are in unsatisfactory technical or emergency conditions.
FC - these activities are carried out which is proved by the documents review.
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Accreditation standards for health facilities in Ukraine  KYIV 1998
The buildings comply with the construction norms and regulations (CNR).
1.10.3
Issues connected with the maintenance of proper unit conditions are considered by the Chief
Doctor (Director) Deputy who is in charge for maintenance and physical plant.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - most of the buildings do not comply with the CNR, there are no plans on deficiency elimination.
FC - most of the buildings comply with the CNR, there are plans to eliminate deficiencies.
Chief Doctor (Director) Deputy on maintenance and physical plant acts to provide
1.10.4
the following:
1.10.4.1
Compliance with the exploitation norms of the buildings, engineer equipment,
networks and systems.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - these activities are not carried out, the exploitation norms are constantly violated without valid
reasons.
FC - there are activities focused on identification and elimination of the reasons of exploitation norms
violations.
1.10.4.2
Provision of the predictions and the plan for systems and building maintenance.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - there is no evidence about these activities.
FC - these activities are carried out which is documented and proved by the personnel interviews.
1.10.4.3
Provision of operations of all facility subunits.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - there is no evidence about these activities.
FC - these activities are carried out which is documented and proved by the personnel interviews.
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Accreditation standards for health facilities in Ukraine  KYIV 1998
1.10.4.4
Determination of the facility demand for equipment and supplies
in accordance with the facility profile.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - the priorities are not identified, there is no a set program for priority equipment and supply
purchases.
FC - set priorities comply with the priorities of the facility.
1.10.4.5
Provision of the control over fulfillment of the contracts (if any stipulated),
agreements (transportation services, medical equipment, supplies, medicine, etc. delivery), etc.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - the control is not undertaken, there are cases of contract condition violations, no prevention
measures are taken.
FC - there is a constant control, violation cases are noted and thoroughly considered.
1.10.4.6
Provision of control the consumption of energy and water resources.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - the control is not carried out, measures to prevent resource overutilization are not undertaken.
FC - there is a constant control, violation cases are noted and thoroughly considered.
1.10.4.7
Organization of the control and analysis over the maintenance activities of
each of the facility subunits.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - there is no evidence about these activities.
FC - these activities are carried out which is documented and proved by the personnel interviews.
1.10.4.8
Timely informing of the chief doctor on the emergencies and possible
failures in the maintenance service.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
Ministry of Health of Ukraine
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Accreditation standards for health facilities in Ukraine  KYIV 1998
NC - there is no evidence about these activities.
FC - these activities are carried out which is documented and proved by the personnel interviews.
Facility departments are provided with the medical equipment, devices and
1.10.5
instruments according to the effective standards.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - most of the departments are underequipped with medical equipment, devices and instruments.
FC - most of the departments are equipped with medical equipment, devices and instruments which is
proved by the documents and through monitoring.
The facility is provided with the furniture and linens in compliance with the
1.10.6
current standards.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - most of the departments are underequipped with the furniture and linens.
FC - most of the departments are equipped with the furniture and linens which is proved by the documents
and through monitoring.
Administration provides facility with the necessary transportation services.
1.10.7
The facility can have its vehicles, otherwise make contract with an outside company which would
provide transportation.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - the facility is not provided with the necessary transportation means.
FC - the facility is provided with the necessary transportation means.
The building and the area of the facility have electric light, heating, water supply,
1.10.8
sewerage, ventilation, sidewalks, refuse disposal sites, etc. in accordance with the Epidemiology
Service requirements.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - most of the buildings and area of the facility do not comply with such Epidemiology Service
requirements.
FC - most of the buildings and area of the facility comply with such requirements.
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Accreditation standards for health facilities in Ukraine  KYIV 1998
Emergency care services (maternity house, neonatal department, operational
1.10.9
theater, intensive care unit, ambulance service, blood bank, etc.) are provided with emergency
lighting, heating and water supply.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - not or partially provided.
FC - provided.
1.10.10
Services and departments are provided with internal and external communications.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - not provided at all or provided with only internal communications.
FC - provided.
2. QUALITY OF HEALTH CARE
Each service (subunit) are included in the general quality assurance program. Quality of treatment
and diagnostics is constantly evaluated and controlled.
Health care facility develops the health care quality control system:
2.1
2.1.1
Quality assurance activities include the following elements:
Monitoring.
Day-to-day collection of the information on the aspects of service (subunit) activities.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - no evidence on day-to-day information collection.
FC - is carried out, which is documented and proved though the personnel interviews.
2.1.2
Analysis.
Periodical evaluation of the information to identify problems and solutions.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - no evidence that the analysis is carried out.
FC - analysis of the information is constantly carried out, there are identified problems and their
solutions, which is documented and is proved through personnel interviews.
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Accreditation standards for health facilities in Ukraine  KYIV 1998
2.1.3
Actions.
As the problems are identified specific actions are implemented to solve the problem.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - no evidence about these activities.
FC - specific actions are undertaken to solve the problems, which is documented and proved through
personnel interviews.
2.1.4
Evaluation.
Effectiveness of the actions taken is evaluated.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - there is no evidence about the evaluation of effectiveness of the actions taken to solve the problem.
FC - the evaluation of effectiveness of the actions is carried out, which is documented and proved through
personnel interviews.
2.1.5
Feedback.
Personnel is regularly informed on the overall performance.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - there is no evidence that the personnel is informed about the overall performance regarding problemsolving.
FC - overall performance is regularly delivered to the personnel (staff meetings, etc.), which is
documented and proved through personnel interviews.
Each structural subunit has its quality standards based on the typical set
2.2
that are used in everyday activities. There is a quality assurance system of standard
implementation.
0
points
noncompliance
1
points
mincompliance
2
points
partialcompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - there are no quality standards.
MC - quality standards are developed but not implemented.
PC - quality standards are developed and implemented but not in all the departments.
FC - the standards are developed and implemented in each subunit, which is documented and proved
though personnel interviews.
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There is a maintained and updated data base that characterizes the treatment process
2.3
(for the appropriate facilities):
0
points
noncompliance
1
points
mincompliance
2
points
partialcompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - the data base is not maintained.
MC - the data base is maintained but it is not updated.
ЧВ - the data base is maintained and updated but it does not cover all the subunits.
FC - the data base is maintained and updated, it covers indicators from all the subunits which is
documented and proved though the interviews with the subunit managers.
The data base includes (but is not limited to):
For the Primary Health Care (PHC) Facilities (Subunits)
2.3.1
Number of the population covered at the district.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - the data base does not include this indicator.
FC - this indicator is included.
2.3.2
Hospitalization (hospital admission) rate for the population covered by the
PHC facility (subunit) by districts.
0
points
noncompliance
1
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - the data base does not include this indicator
FC - this indicator is included.
2.3.3
Frequency of the emergency calls from the served population by districts.
0
points
noncompliance
1
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - the data base does not include this indicator
FC - this indicator is included.
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2.3.4
Frequency of the referrals to the specialists by districts.
0
points
noncompliance
1
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
Secondary
Tertiary
EC:
NC - the data base does not include this indicator
FC - this indicator is included.
2.3.5
Percentage of women over 50 monitored for breast cancer.
0
points
noncompliance
1
points
full
compliance
Type of
health
care:
Primary
EC:
NC - the data base does not include this indicator
FC - this indicator is included.
2.3.6
control.
0
points
noncompliance
Percentage of women aged 20-65 monitored for uterus cancer with pap smear
1
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - the data base does not include this indicator
FC - this indicator is included.
2.3.7
(IUD, OC).
0
points
noncompliance
Percentage of women aged 15-49 that use modern contraception techniques
1
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
Secondary
Tertiary
EC:
NC - the data base does not include this indicator
FC - this indicator is included.
2.3.8
Immunization rate for adult and children population.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
EC:
NC - the data base does not include this indicator
FC - this indicator is included.
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2.3.9
Percentage of deviations between out-patient and clinical diagnosis.
0
points
noncompliance
1
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - the data base does not include this indicator
FC - this indicator is included.
2.3.10
Identified cases of neglected patients (at decompensation stage).
0
points
noncompliance
1
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
Type of
health
care:
Primary
Secondary
Tertiary
Primary
Secondary
Tertiary
Primary
Secondary
Tertiary
EC:
NC - the data base does not include this indicator.
FC - this indicator is included.
2.3.11
Number of smoking patients.
0
points
noncompliance
1
points
full
compliance
EC:
NC - the data base does not include this indicator.
FC - this indicator is included.
2.3.12
Number of the patients that stopped smoking.
0
points
noncompliance
1
points
full
compliance
Type of
health
care:
EC:
NC - the data base does not include this indicator.
FC - this indicator is included.
2.3.13
0
points
noncompliance
Mortality cases of children under 1 by districts.
1
points
full
compliance
Type of
health
care:
EC:
NC - the data base does not include this indicator.
FC - this indicator is included.
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2.3.14
0
points
noncompliance
Mortality rate at active age (under 65) by districts.
1
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - the data base does not include this indicator.
FC - this indicator is included.
2.3.15
by districts.
0
points
noncompliance
Cases of death at home of the patients that were not monitored by a physician
1
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
Type of
health
care:
Primary
Secondary
Tertiary
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - the data base does not include this indicator.
FC - this indicator is included.
2.3.16
0
points
noncompliance
Cases of primary disability by districts.
1
points
full
compliance
EC:
NC - the data base does not include this indicator.
FC - this indicator is included.
2.3.17
Number of patient complains.
0
points
noncompliance
3
points
full
compliance
EC:
NC - the data base does not include this indicator.
FC - this indicator is included.
2.3.18
by districts.
0
points
noncompliance
Number of patients that have changed a primary care physician during one year
1
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - the data base does not include this indicator.
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FC - this indicator is included.
For Hospitals and Other Facilities:
2.3.19
Bed turn-over.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
Type of
health
care:
Primary
Secondary
Tertiary
Type of
health
care:
Primary
Secondary
Tertiary
Secondary
Tertiary
EC:
NC - the data base does not include this indicator.
FC - this indicator is included.
2.3.20
Bed-day fulfillment.
0
points
noncompliance
3
points
full
compliance
EC:
NC - the data base does not include this indicator.
FC - this indicator is included.
2.3.21
Number of surgeries by diseases.
0
points
noncompliance
3
points
full
compliance
EC:
NC - the data base does not include this indicator.
FC - this indicator is included.
2.3.22
Average length of stay (total, pre-surgery, post-surgery).
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
EC:
NC - the data base does not include this indicator.
FC - this indicator is included.
2.3.23
Percentage of repeated hospital admissions as a result of complications after
primary hospitalization.
0
points
noncompliance
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points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
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EC:
NC - the data base does not include this indicator.
FC - this indicator is included.
2.3.24
Post-surgery complication rate.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - the data base does not include this indicator.
FC - this indicator is included.
2.3.25
Lethality (crude, post-surgery)
0
points
noncompliance
3
points
full
compliance
EC:
NC - the data base does not include this indicator.
FC - this indicator is included.
2.3.26
Percentage of deviations between diagnosis (clinical and pathoanatomical).
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - the data base does not include this indicator.
FC - this indicator is included.
2.3.27
Number of patient complaints.
0
points
noncompliance
3
points
full
compliance
EC:
NC - the data base does not include this indicator.
FC - this indicator is included.
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2.3.28
Outbursts of nosocomial infections.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - the data base does not include this indicator.
FC - this indicator is included.
2.3.29
Percentage of patients that could have received medical care in the facility of
a lower level of health care (tertiary -> secondary -> primary).
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - the data base does not include this indicator.
FC - this indicator is included.
2.3.30
The list of tests and diagnostic procedures adjusted to the level of appropriateness
for the department demand.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - the data base does not include this indicator.
FC - this indicator is included.
The data base analysis is made systematically by the department (subunit) head,
2.4
conclusions on the department quality level are based on the analysis results, then the guidelines
for further quality improvement are identified.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - there is no evidence that the data analysis is made, or it is not made systematically.
FC - the analysis is made systematically, which is documented and proved though interviews.
At the end of each year, the department (subunit) head prepares a written report on
2.5
the activities of the department, which sets guidelines for further development and ways to solve
existing problems.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
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NC - the report does not contain specific recommendations and the action plan for further development
and problem solution.
FC - the report has specific recommendations and the action plan for further development and problem
solution.
3. MEDICAL CARE
3.1 GENERAL REGULATIONS ON THE PHYSICIAN
The role of a physician includes performance of diagnostic and treatment
3.1.1
procedures, as well as other services that comply with the facility internal regulations. The
physician should input all the patient health data into the medical record, including data on
prescribed medicine, diagnostic procedures and undertaken treatment, diagnosis and prognosis:
3.1.1.1
procedures.
Identification of the type and volume of tests, diagnostic and treatment
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - there is no evidence that most of the physicians identify type and volume of diagnostic and treatment
procedures, medical record data is irregular and incomplete.
FC - most of the physicians constantly identify the type and volume of diagnostic and treatment
procedures, medical record data are input regularly and reflect completely the disease process.
3.1.1.2
Explanation to the patients about possible risk connected with the prescribed
tests, diagnostic and treatment procedures, their necessity, as well as possible consequences in the
case if the latter are not performed.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - there is no evidence that most of the physicians perform these activities (including the absence of
data in the medical records).
FC - physicians perform these activities which is documented in the medical records.
3.1.1.3
Setting of clinical diagnosis and taking decision about the place for further
treatment (out-patient, in-patient, or at home).
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - there is no evidence that most of the physicians perform these activities (including the absence of
data in the medical records).
FC - physicians perform these activities which is documented in the medical records.
3.1.1.4
In questionable cases when setting diagnosis or prescribing diagnostic and
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treatment procedures, the physician addresses his colleagues for assistance or consultations. The
physician provides consultations to his colleagues when needed.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - there is no evidence that most of the physicians perform these activities (including the absence of
data in the medical records).
FC - physicians perform these activities which is documented in the medical records.
3.2 PRIMARY HEALTH CARE
The facility is located in an easy accessible for population place or in the area
3.2.1
with a developed system of public transportation.
0
points
noncompliance
3
points
full
compliance
Type of
health care:
Primary
EC:
NC - catchment area radius is more than 2 km in the cities, and more than 7 km in the rural areas.
FC - catchment area radius is up to 2 km in the cities, and up to 7 km in rural areas.
PHC facility is equipped with the following:
3.2.2
3.2.2.1
Registration system for visitors (registration office, files, etc.)
Patients are registered in this department to see a physician, medical documentation is
properly kept in this subunit (i.e.: registration books for home calls, bills for treatment, insurance
or other services are issued here).
0
points
noncompliance
3
points
full
compliance
Type of
health care:
Primary
EC:
NC - there is no visitor registration system, or the existing system does not function properly, which is
proved by the activity reviews and interviews with the patients.
FC - there is a properly functioning registration system, which is proved by the activity reviews and
interviews with the patients.
3.2.2.2
Necessary set of the rooms
For the PHC subunit with one physician, the list of the rooms includes: patient waiting room,
physician's office, procedures-room, bandaging room, office for the personnel, toilet, sanitary
room.
For the PHC subunit with a few physicians, the list includes the following: patients waiting
room, registration office (can be located in the hall or patient waiting room), physician's offices
(depending on the number and schedule of the physicians), procedures room, bandaging room,
OB/GYN block (reception, procedures room -- if OB/GYN specialist is included into the group
practice), surgical block (reception, operational theater --if a physician has a certificate for
surgical procedures), toilets, sanitary room, personnel room, manager's office).
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points
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points
full
compli-
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health care:
Primary
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Accreditation standards for health facilities in Ukraine  KYIV 1998
ance
ance
EC:
NC - the facility does not have a necessary set of rooms.
FC - the facility is provided with the necessary set of rooms.
3.2.2.3
equipment.
Diagnostic equipment and medical instruments according to the table of
0
points
noncompliance
3
points
full
compliance
Type of
health care:
Primary
EC:
NC - the facility is not equipped with the equipment and medical instruments according to the table of
equipment.
FC - the facility is equipped with the equipment and medical instruments according to the table of
equipment.
3.2.2.4
Furniture and linens according to the table of equipment.
0
points
noncompliance
3
points
full
compliance
Type of
health care:
Primary
EC:
NC - the facility is not equipped with the furniture and linens according to the table of equipment.
FC - the facility is equipped.
3.2.2.5
Medicine, medical supplies, and disinfection materials for provision of a
determined volume of care.
0
points
noncompliance
3
points
full
compliance
Type of
health care:
Primary
EC:
NC - the facility is not provided.
FC - the facility is provided.
3.2.2.6
Means for PT and rehabilitation treatment.
These services are provided in the necessary determined by the administration volume
to fulfill physicians' prescriptions using available equipment and space.
0
points
noncompliance
3
points
full
compliance
Type of
health care:
Primary
EC:
NC - the facility is not provided with the means for PT and rehabilitation treatment.
FC - the facility is provided.
3.2.2.7
Health promotion materials.
Administration provides brochures, there are prepared other informative visual aid
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materials (posters, stands) that are available for the visitors.
0
points
noncompliance
2
points
partial
compliance
3
points
full
compliance
Type of
health care:
Primary
EC:
NC - there are no materials available.
PC - the available material are limited (no posters, stands).
FC - brochures, newsletters, posters, stands are available for visitors in sufficient quantities.
The administration staffs the facility with certified physicians that are
3.2.3
specialized in general practice/ family medicine, nurses, and ancillary medical personnel according
to the number of population served.
0
points
noncompliance
1
points
full
compliance
Type of
health care:
Primary
EC:
NC - most of the physicians do not have appropriate specialization, insufficient medical personnel
quantity.
FC - most of the physicians have appropriate specialization, the facility is staffed with medical personnel.
PHC subunit (facility) has an available physicians' schedule.
3.2.4
Physician's schedule (hours for seeing patients in the office, visiting hours, specialists'
consultations for patients, logistics) is set by the facility administration, regarding the
characteristics of the assigned population, visit dynamics over one day and one week, facility
location, availability of public transportation, etc.
0
points
noncompliance
1
points
full
compliance
Type of
health care:
Primary
EC:
NC - physician's schedule is composed disregarding patient visit dynamics and the specific characteristics
of the catchment area.
FC - physician's schedule is composed basing on the patients' needs and specific characteristics of the
catchment area.
PHC facility (subunit) medical personnel (physician, nurse) provide medical care
3.2.5
(prevention, diagnostics, and treatment of the most common diseases) to the catchment area
population, as well as to the all the visitors that addressed the facility. PHC physician organizes
and integrates provision of all the types of medical care to the catchment area population.
3.2.5.1
PHC physician provides medical care (prevention, treatment, diagnostics, health
education) to all the served population groups disregarding their age.
0
points
noncompliance
1
points
mincompliance
2
points
partial
compliance
3
points
full
compliance
Type of
health care:
Primary
EC:
NC - medical care is provided to the children only (aged 0-14) or to the adults only (aged over 15).
MC - medical care is provided to the children over 7, adolescents, adult population.
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PC - medical care is provided to the children over 3, adolescents, and adult population.
FC - medical care is provided to all the population age categories.
3.2.5.2
Volume of medical interference provided by the PHC physician complies with his
qualification characteristics.
List of the diseases, conditions and the appropriate volume of interference that can be
performed at the primary level is determined by the qualification characteristics.
0
points
noncompliance
2
points
partial
compliance
3
points
full
compliance
Type of
health care:
Primary
EC:
NC - the volume of medical care is less that stipulated by the qualification characteristics, or it includes
the types of interference that are not stipulated by the document.
PC - the volume of medical interference generally complies with the determined one for the specialty.
FC - the volume of medical care is higher that it is stipulated by the qualification category, and a
physician has a permission (appropriate certification) to perform it.
3.2.5.3
The volume of medical interference performed by the PHC nurses complies with
the qualification characteristics.
0
points
noncompliance
2
points
partial
compliance
3
points
full
compliance
Type of
health care:
Primary
EC:
NC - the volume of medical care is limited to selected simple procedures prescribed by the physician.
PC - the volume of interference generally complies with the determine qualification characteristics.
FC - the volume of medical interference complies with the qualification characteristics. Separate types of
activities are officially selected and performed (in particular, independent diagnostics and treatment of the
patients with determined common diseases within the scope of competence, provision of emergency care,
patient preparation before the visit to a physician, etc.)
3.2.5.4
The facility provides emergency medical care.
0
points
noncompliance
1
points
full
compliance
Type of
health care:
Primary
EC:
NC - the facility does not provide this type of care.
FC - this type of care is provided in the facility within the level of medical personnel competence.
Preventive care is a priority activity of the PHC facility. The facility activities
3.2.6
include (but are not limited to):
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3.2.6.1
Dynamic monitoring of the assigned population to identity the risk factors and
lethal forms of diseases not less than once each three years, and annually for the children.
0
points
noncompliance
1
points
mincompliance
2
points
partial
compliance
3
points
full
compliance
Type of
health care:
Primary
EC:
NC - this type of activities is not planned and is not carried out.
MC - this type of activities is not planned, but is carried out covering up to 50% of the population.
PC - this type of activities is planned and carried out covering up to 70% of the population.
FC - this type of activities is planned and carried out covering over 70% of the population.
3.2.6.2
0
points
noncompliance
Immunization of children and adult population.
1
points
mincompliance
2
points
partial
compliance
3
points
full
compliance
Type of
health care:
Primary
EC:
NC - this work is not planned and is carried out not systematically.
MC - this work is planned and carried out covering up to 70% of the population.
PC - this work is planned and carried out covering up to 80% of the population.
FC - this work is planned and carried out covering up to 90% of the population.
3.2.6.3
Preventive care monitoring of women aged 20-65 to identify uterus cancer with
the pap smear.
0
points
noncompliance
1
points
mincompliance
2
points
partial
compliance
3
points
full
compliance
Type of
health care:
Primary
EC:
NC - this work is not planned and is not carried out.
MC - this work is not planned and is carried out covering up to 50% of the population category.
PC - this work is planned and is carried out covering up to 70% of the population category.
FC - this work is planned and is carried out covering over 70% of the population category.
3.2.6.4
0
points
noncompliance
Preventive care monitoring of women over 50 to identify breast cancer.
1
points
mincompliance
2
points
partial
compliance
3
points
full
compliance
Type of
health care:
Primary
EC:
NC - this work is not planned and is not carried out.
MC - this work is not planned but is carried out covering up to 50% of the population category.
PC - this work is planned and is carried out covering up to 70% of the population category.
FC - this work is planned and is carried out covering over 70% of the population category.
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3.2.6.5
Consultations of the family planning issues.
0
points
noncompliance
3
points
full
compliance
Type of
health care:
Primary
EC:
NC - this work is not carried out.
FC - this work is carried out which is proved by interviews with the population and review of the patient
records.
3.2.6.6
Planned examinations and health care to patients with the pathology and risk
of developing the following diseases: hypertension, ishemic heart disease, rheumatism, diabetes,
bronchial asthma, TB, stomach ulcer.
0
points
noncompliance
1
points
mincompliance
2
points
partial
compliance
3
points
full
compliance
Type of
health care:
Primary
EC:
NC - planned examinations are not performed.
MC - planned examinations are performed and cover up to 50% of the appropriate population category.
PC - planned examinations are performed and cover up to 75% of the appropriate population category.
FC - planned examinations cover over 90% of the appropriate population category.
PHC physician organizes provision of medical care at the higher levels
3.2.7
(out-patient specialized and in-patient) to the catchment area patients.
PHC physician determines the necessity of specialized in-patient care for the patient and
refers him/ her to appropriate specialists and medical facilities if required.
There are regulated issues concerning volume of care, conditions and the order
3.2.8
of patient referrals for specialized out-patient and in-patient care.
There are approved written instructions that are periodically reviewed.
0
points
noncompliance
1
points
full
compliance
Type of
health care:
Primary
EC:
NC - there is no evidence that the issues concerning volume of care, conditions and the order of patient
referrals are regulated.
FC - there are instructions regulating these issues that are approved by the administration and all the PHC
physicians are aware of them.
3.2.9
preserved.
0
points
noncompliance
The order of patient referrals for specialized out-patient and in-patient care is
2
points
partial
compliance
3
points
full
compliance
Type of
health care:
Primary
EC:
NC - the order is not preserved, patients determine the necessity of turning for specialized out-patient and
in-patient care without PHC physician referral.
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PC - up to 50% of all the referrals are authorized by a physician.
FC - all the patient referrals, except emergency cases, are done by the physician.
3.2.10
There is a provided continuity of medical care.
3.2.10.1
There is a developed system of informing a PHC physician about the results of
patient consultations and treatment in other medical facilities and by specialists.
0
points
noncompliance
1
points
full
compliance
Type of
health care:
Primary
EC:
NC - this system does not exist.
FC - there is an approved order to receive information about the medical care delivered to patients beyond
the primary health care level.
3.2.10.2
PHC physician implements the recommendations of the specialists and the
recommendations given at patient discharge from the hospital.
0
points
noncompliance
1
points
full
compliance
Type of
health care:
Primary
EC:
NC - recommendations given by narrow specialists and hospital physicians are implemented partially or
not timely, which is proved by the review of medical records and by the interview with the patients.
FC - such recommendations are coordinated with the PHC physician are fully implemented.
3.2.10.3
PHC physician provides rehabilitation services for the patients that received
other (except PHC) types of medical care.
0
points
noncompliance
1
points
full
compliance
Type of
health care:
Primary
EC:
NC - this work is not carried out or is done in selected cases.
FC - this work is carried out (if required) which is proved by the records in medical documents and by the
interviews with the patients.
In order to reduce the workload of the hospital, the facility provides broad
3.2.11
spectrum of medical services:
3.2.11.1
Provision of home care.
0
points
noncompliance
3
points
full
compliance
Type of
health care:
Primary
EC:
NC - there is no evidence that this form of medical care is provided.
FC - this form of care is provided.
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Accreditation standards for health facilities in Ukraine  KYIV 1998
3.2.11.2
Physician's workload when providing home care should amount to 12-14
patients a day (if a separate FTE is allocated).
0
points
noncompliance
3
points
full
compliance
Type of
health care:
Primary
EC:
NC - physician's workload for home care is less than 12 patients a day under condition that a separate FTE
is allocated.
FC - physician's workload makes 12-14 patients.
3.2.11.3
Provision of medical care in day-stay departments.
0
points
noncompliance
3
points
full
compliance
Type of
health care:
Primary
EC:
NC - there is no evidence that such a type of medical care is provided.
FC - this type of care is provided.
3.2.11.4
Physician's workload at day-stay department amounts to 20-25 patients a day
(if a separate FTE is allocated).
0
points
noncompliance
3
points
full
compliance
Type of
health care:
Primary
EC:
NC - physician's workload is less than 20 patients a day.
FC - physician's workload makes 20-25 patients a day.
3.2.12
facility.
A determined minimum set of ancillary examination is performed in the
Anthropometric data, eyesight and hearing acuteness, body temperature, eye pressure,
blood pressure, and EKG are taken at the facility. Laboratory examination includes all the
necessary express-diagnostics tests, blood and urine general tests, blood sugar test. For more
complicated types of laboratory, biochemical, immunological, serum and bacteriological tests, the
material is taken at the facility and then sent to the main laboratory. For female population
screening, cytological and other pap smears are taken. There is a referral system to the
appropriate facilities if more complicated highly specialized examinations are required.
0
points
noncompliance
3
points
full
compliance
Type of
health care:
Primary
EC:
NC - the facility does not have a determined set of ancillary examinations, or this set is available but most
of the tests are not provided.
FC - the facility has an approved set of ancillary examinations that is provided; this is proved by the
medical records and by the interviews with personnel.
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Out-patient medical records is filled in for all the patients that received
3.2.13
out-patient medical care. The information included into the medical records is as follows:
3.2.13.1
Passport data.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - there are medical records that do not include this information.
FC - all the medical records (without exception) include this information.
3.2.13.2
in the past.
Anamnesis of the disease, its symptoms, traumas and surgeries that took place
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - there are medical records that do not include this information or it is not complete.
FC - all the medical records (without exception) include this information.
3.2.13.3
Clinical examinations.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - there are medical records that do not include this information or it is not complete.
FC - all the medical records (without exception) include this information.
3.2.13.4
Diagnostics and treatment prescriptions and their outcomes.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - there are medical records that do not include this information or it is not complete.
FC - all the medical records (without exception) include this information.
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Accreditation standards for health facilities in Ukraine  KYIV 1998
3.2.13.5
Diagnosis (primary and/ or final) and treatment outcomes.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - there are medical records that do not include this information or it is not complete.
FC - all the medical records (without exception) include this information.
3.2.13.6
There is an available list of final diagnosis.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - there are available medical records that do not include this list.
FC - all the medical records (without exception) include the list of final diagnosis.
3.2.13.7
There are available extracts from the in-patient medical records.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - there are available medical records that do not include the extract about the provided in-patient
treatment.
FC - all the medical records (without exception) include the extract about the provided in-patient
treatment.
3.3 EMERGENCY AND URGENT CARE SERVICE
The primary purpose of this service is to provide high level of emergency and urgent care to the
catchment area population in the cases of emergency, acute forms of the diseases and traumas.
3.3.1
The service functions 24 hours a day.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
EC:
NC - the service does not provide emergency and urgent care 24 hours a day.
FC - the service provides 24 hours a day emergency and urgent care.
The service is provided with the specially equipped ambulance car(s) and the
3.3.2
medical personnel according to the existing standards.
0
points
Ministry of Health of Ukraine
ZdravReform Project (Abt Associates Inc.)
3
points
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Accreditation standards for health facilities in Ukraine  KYIV 1998
noncompliance
full
compliance
Type of
health
care:
Primary
Secondary
EC:
NC - the service is not provided with the sufficient number of ambulance cars and medical personnel.
FC - the service is provided with the ambulance cars and personnel according to the standards.
The emergency and urgent care brigades are provided with the necessary quantity
3.3.3
of equipment according to the existing standards:
3.3.3.1
Supply of oxygen and masks for oxygen therapy.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Type of
health
care:
Primary
Secondary
3
points
full
compliance
Type of
health
care:
Primary
Secondary
3
points
full
compliance
Type of
health
care:
Primary
Secondary
EC:
NC - not provided.
FC - provided.
3.3.3.2
Sets of medicine including IV fluids and IV sets.
0
points
noncompliance
3
points
full
compliance
EC:
NC - not provided.
FC - provided.
3.3.3.3
The set for conic(tracheo)ctomy.
0
points
noncompliance
EC:
NC - not provided.
FC - provided.
3.3.3.4
Small surgery kit.
0
points
noncompliance
EC:
NC - not provided.
FC - provided.
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Accreditation standards for health facilities in Ukraine  KYIV 1998
3.3.3.5
Splints and splint collars.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
3
points
full
compliance
Type of
health
care:
Primary
Secondary
3
points
full
compliance
Type of
health
care:
Primary
Secondary
3
points
full
compliance
Type of
health
care:
Primary
Secondary
EC:
NC - not provided with splints or splint collars.
FC - provided with splints and splint collars.
3.3.3.6
EKG machine.
0
points
noncompliance
EC:
NC - not provided.
FC - provided.
3.3.3.7
Suction pump.
0
points
noncompliance
EC:
NC - not provided.
FC - provided.
3.3.3.8
Defibrillator.
0
points
noncompliance
EC:
NC - not provided.
FC - provided.
There are available standards for emergency care delivery including the time
3.3.4
given to get to the place of emergency.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
EC:
NC - not available.
FC - available.
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There is a developed interaction system between emergency care service and
3.3.5
the hospitals located in the catchment area.
There are available on-duty schedules for hospitals and departments, there are
appropriate instructions that stipulate the order for hospital admission and interaction with other
facilities.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
EC:
NC - the clear system of patient referrals to medical facilities is not available.
FC - is available.
There is a developed interaction system between emergency care service and
3.3.6
out-patient facilities located in the catchment area.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
EC:
NC - there is no clear system that informs out-patient facilities about emergency and urgent care provided
to the catchment area population.
FC - there is such a system.
The issues of care provision to the patients and victims of calamities, catastrophes
3.3.7
and emergencies are considered according to the developed regulations.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
EC:
NC - there is no approved plan of action for calamities, catastrophes and emergencies.
FC - it is available.
3.4 OUT-PATIENT CARE
3.4.1
For efficient operations, out-patient department is provided with the following:
3.4.1.1
Reception office.
Reception office is responsible for patient registration and referrals, registration of
physician's home visits, discharge of bills for treatment, insurance or preparation of other payable
documents. There is available information on physicians' names, physicians' working and on-duty
schedules, register of physicians' home calls, information about administration, etc. Patient's
medical record, as well as all the payable documents follow the patient through all the stages of
treatment and return to the reception or accountant's office after the visit is over.
0
points
noncompliance
Ministry of Health of Ukraine
ZdravReform Project (Abt Associates Inc.)
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
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Accreditation standards for health facilities in Ukraine  KYIV 1998
EC:
NC - there is no reception office available at the facility, or there is one, but it does not perform all the
functions, which is proved by the activity review.
FC - the reception office performs all the assigned functions which is proved by documents and activity
review.
3.4.1.2
Offices (wards) for diagnostics and treatment.
Patients are examined and treated in the conditions that correspond to the complexity
and type of the disease or trauma. Offices (wards) are equipped according to the treatment
requirements and comply with the number of patients.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - the facility is not provided with the equipped space for diagnostics and treatment.
FC - the facility is provided with the above mentioned.
3.4.1.3
Laboratory and ancillary examinations.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - the facility does not provide the determined minimum of ancillary examinations, or it does, but most
of the services are not performed.
FC - the facility has an approved minimum of ancillary examinations that is performed, which is proved
by the documents and by the interviews with personnel.
3.4.1.4
X-ray office.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - the facility does not have an X-ray office.
FC - the facility has an X-ray office.
3.4.1.5
There is a clear referral system for complicated diagnostic examinations that
are available in the nearest diagnostic center.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - there is no clear referral system for complicated diagnostic examinations that as a result extends the
length of diagnostic process, which is proved through the review of medical records.
FC - the facility has an approved clear referral system for complicated diagnostic examinations that
provides prompt diagnostics.
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Accreditation standards for health facilities in Ukraine  KYIV 1998
3.4.1.6
Physiotherapy services.
PT services are provided in the volume sufficient to implement physician's
prescriptions.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - the PT services are not available, or they are available but not in the volume sufficient to implement
physician's prescriptions, which is proved by the documents and interviews with personnel and patients.
FC - the volume of PT services is sufficient to implement physician's prescriptions, which is proved by
the documents and activity review.
3.4.2
3.4.2.1
The out-patient medical record includes the following information:
Passport data.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - there are available medical records that do not include this information.
FC - all the medical records (without exception) include this information.
3.4.2.2
in the past.
Anamnesis of the disease, its symptoms, traumas and surgeries that took place
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - there are available medical records that do not include this information or it is incomplete.
FC - all the medical records (without exception) include this information.
3.4.2.3
Clinical examinations.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - there are available medical records that do not include this information or it is incomplete.
FC - all the medical records (without exception) include this information.
3.4.2.4
Diagnostic and treatment prescriptions, as well as their outcomes.
0
points
nonMinistry of Health of Ukraine
ZdravReform Project (Abt Associates Inc.)
3
points
full
Type of
Primary
Secondary
Tertiary
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Accreditation standards for health facilities in Ukraine  KYIV 1998
compliance
compliance
health
care:
EC:
NC - there are available medical records that do not include this information or it is incomplete.
FC - all the medical records (without exception) include this information.
3.4.2.5
Diagnosis (primary and/ or final) and treatment outcomes.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - there are available medical records that do not include this information or it is incomplete.
FC - all the medical records (without exception) include this information.
3.4.2.6
There is an available list of final diagnosis.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - there are available medical records that do not include this list.
FC - all the medical records (without exception) include this list.
3.4.2.7
There are available extracts from the in-patient medical records.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - there are available medical records that do not include extracts about received in-patient treatment.
FC - all the medical records (without exception) include extracts about received in-patient treatment.
3.5 IN-PATIENT CARE
3.5.1 GENERAL REGULATIONS
3.5.1.1
Each patient admitted to the hospital is examined by the physician in the
necessary volume:
3.5.1.1.1
The physician determines volume and depth of patient examination and sets
clinical diagnosis (not later than 72 hours after admission).
The physician develops and implements patient examination plan to set a clinical
diagnosis, which is recorded in the medical record.
0
points
noncompliMinistry of Health of Ukraine
ZdravReform Project (Abt Associates Inc.)
3
points
full
compli-
Type of
health
Primary
Secondary
Tertiary
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Accreditation standards for health facilities in Ukraine  KYIV 1998
ance
ance
care:
EC:
NC - there are available medical records that do not include an examination plan and a clinical diagnosis
determined during 72 hours after admission.
FC - each medical record has an available examination plan and a clinical diagnosis that was determined
during 72 hours after patient admission.
3.5.1.1.2
Every day the physician examines a patient and writes in the in-patient medical
record about the disease dynamics as well as corrects prescriptions.
Medical record should contain reasoning for the necessity of further stay of the patient in
this facility, records about the performed medical interference.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - there are available medical records, that do not contain records about the disease dynamics and
performed medical interference.
FC - all the medical records have available records about the disease dynamics and performed medical
interference.
3.5.1.1.3
When the patient is transferred to another facility subunits, the physician prepares a
detailed staged report in the medical record.
The physician prepares a detailed staged report stating the disease dynamics and the
patient status at the time of examination, as well as diagnostic procedure outcomes and received
treatment.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - there are available medical records that do not include staged reports.
FC - detailed staged report is attached to the medical record in all the cases when a patient was transferred
to other subunits.
Examination and treatment plans are developed for each patient.
Examination and treatment plans are developed and input in the medical record for each
patient personally; this is done according to the quality standards approved for each department.
3.5.1.2
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - examination and treatment plan based on the quality standards are not available for each patient,
which is proved by the medical record review.
FC - examination and treatment plans are based on the approved department quality standards and
developed for each patient.
In complex cases and the cases of complicated disease dynamics, department
3.5.1.3
administration calls together a physicians concillium that is chaired by the facility medical director.
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Accreditation standards for health facilities in Ukraine  KYIV 1998
A treating physician is responsible for the implementation of concillium decision.
The physician that provides treatment to the patient inputs concillium decision into the
medical record, and further on implements all the recommendations concerning diagnostics and
treatment of the patient.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - medical records of the patients with complicated disease dynamics do not have concillium records;
there is an evidence that concillium decisions and recommendations are not implemented, which is proved
by the medical record review and interviews with the personnel.
FC - all the medical records (without exception) of the patients with complicated disease dynamics
include records about conducted concillium as well as concillium recommendations and decisions that are
implemented under constant control of the treating physician; this should be proved by the medical record
review and interviews with personnel.
The medical record has an available list of physician's prescriptions and
3.5.1.4
temperature list (according to the format set by the Ministry of Health) that are properly filled in.
According to the data given by a physician in the list of physician's prescriptions, nurses
implement diagnostic and treatment prescriptions. The nurse that implements a prescription
clearly sings to state that it was performed. In the case of negative outcome (allergic,
inflammatory, pain, temperature, etc. reactions), the nurse should immediately inform a physician.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - there are available medical records that do not include prescription and temperature lists;
prescription and body temperature lists are not kept systematically, there are no personnel records about
the prescriptions performed.
FC - all the medical records include prescription and temperature lists that are filled in properly, which is
proved by the medical record review.
3.5.2 SURGERY, ANESTHESIOLOGY AND INTENSIVE CARE (RESUSCITATION)
Organization of effective anesthesiological provision and surgical activity stipulates (but is not
limited to) the following:
Patients for planned (elective) surgery are admitted after the examination at the
3.5.2.1
pre-hospital stage..
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Secondary
Tertiary
EC:
NC - patients are admitted for elective surgery without examination done at the pre-hospital stage which
causes increase in pre-surgery length of stay.
FC - patients are admitted for elective surgery after the maximum possible examination took place at the
preliminary stag, which is proved by the medical record review and interviews with physician personnel.
Schedule of all the planned surgeries is approved in the department not less than 24
3.5.2.2
hours before the surgery, the schedule includes the names of an operating surgeon, his assistant and
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Accreditation standards for health facilities in Ukraine  KYIV 1998
an anesthesiologist, as well as the type of surgery, blood transfusion and medicine planned.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Secondary
Tertiary
EC:
NC - there is no available schedule of planned surgeries or the schedule does not include the data about
the surgeon, assistants, or the type of surgery and blood transfusion planned.
FC - there is an available schedule of planned surgeries that contains the data about surgeon and
assistants, type of surgery and blood transfusion planned.
The department has an operation block equipped in compliance with
3.5.2.3
the standards on surgical service organization.
The operation theater is equipped with the necessary number of surgical instruments, medicine
and supplies, anesthesiological equipment, linens and other equipment. Skilled specialists work in
this department. Department administration and operation block personnel in compliance with the
job descriptions are responsible for keeping to the epidemiology regulations in the operation
block.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Secondary
Tertiary
EC:
NC - operation block is not equipped in the compliance with standard regulations.
FC - operation block is equipped in compliance with standard regulations on surgical service organization
which is proved by the review.
3.5.2.3.1
There are available acts of epidemiology service control.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Secondary
Tertiary
EC:
NC - epidemiology service acts are not available or they verify epidemiological regulation violations.
FC - the acts are available and they confirm absence of violations.
3.5.2.3.2
There are available results of control washings.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Secondary
Tertiary
EC:
NC - not available or verify epidemiological regulation violations.
FC - available and confirm of absence of violations.
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Accreditation standards for health facilities in Ukraine  KYIV 1998
3.5.2.3.3
There is available equipment for hemotransfusions: serum, labware for blood
group identification and blood compatibility tests.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Secondary
Tertiary
EC:
NC - not available or is not operating.
FC - is available and is operating.
An anesthesiologist examines patient before the anesthesia; the notification is made
3.5.2.4
in the medical record.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Secondary
Tertiary
EC:
NC - there is no evidence about anesthesiologist's examination before operational interference.
FC - an anesthesiologist examines patient before surgical interference which notified in the medical
record.
3.5.2.5
Anesthesiologist's record reflects patient's objective health status.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Secondary
Tertiary
EC:
NC - anesthesiologist's record does not include data on patient objective status.
FC - include.
The test results are analyzed by the anesthesiologist not later than 12 hours after
3.5.2.6
the planned surgical interference.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Secondary
Tertiary
EC:
NC - the test results are not analyzed or are analyzed at a later stage, which is proved by the medical
record review and interviews.
FC - the test results are analyzed timely.
The anesthesiologist checks up the status and sterility of the equipment before
3.5.2.7
the very surgery.
There is a shift-to-shift system of passing over the equipment, which is documented (in the
shift log, etc.)
0
points
noncompliance
Ministry of Health of Ukraine
ZdravReform Project (Abt Associates Inc.)
3
points
full
compliance
Type of
health
care:
Secondary
Tertiary
86
Accreditation standards for health facilities in Ukraine  KYIV 1998
EC:
NC - no check-ups and no shift-to-shift system of passing over the equipment.
FC - the anesthesiologist does equipment check-ups and provides shift-to-shift equipment passing over.
In the nearest post-surgery period, patients stay in post-surgery wards monitored
3.5.2.8
by medical personnel.
There are specially-equipped post-surgery wards (oxygen, blood pressure control, pulse,
breathing monitoring), where the patients are transferred right after the surgery to be monitored
by physicians and nurses. There is a possibility of transferring a patient to the intensive care unit.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Secondary
Tertiary
EC:
NC - there is no clear system of post-surgery monitoring, there are no post-surgery wards where the
patients are transferred to be monitored.
FC - there is a clear system of post-surgery monitoring, post-surgery wards are available where the
patients are transferred to be monitored.
3.5.2.9
3.5.2.9.1
The post-surgery care includes (but is not limited to) the following:
Physician's control
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Secondary
Tertiary
EC:
NC - no data on adequate physician's control that includes patient's examination by an anesthesiologist
during post-surgery period, examinations by a treating physician at least twice a day, which is proved by
the medical record review and interviews with patients.
FC - anesthesiologist does patient examination right after the surgery as well as after patient is transferred
to the general ward to evaluate patient's health status. The treating physician examines a patient at least
twice a day which is proved by the interviews with patients and medical record review.
3.5.2.9.2
Nursing care.
The nurse checks consciousness status, blood pressure, pulse, and breathing frequency of
the post-surgery patients and performs physician's prescriptions.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Secondary
Tertiary
EC:
NC - there is no evidence about adequate nursing care that includes monitoring of patient's consciousness
status, breathing indicators, pulse, and performing of physician's prescriptions which is proved by the
interviews with medical personnel and patients.
FC - adequate nursing care which is proved by the interviews with medical personnel and patients.
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3.5.2.9.3
Prevention of infectious complications.
Prevention of infectious complications is done by means of: a) strict preservation of
aseptic and antiseptic rules; b) preventive rational intra- and post-surgery antibiotic therapy; c)
control of sterility of surgical instruments, linens, threading, surgeon hands, air of the operation
theater, breathing associated equipment; d) personnel examinations for carriage of bacilli, chronic
infections, syphilis, AIDS (there is a check of sanitary books with the valid permission for work).
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Secondary
Tertiary
EC:
NC - no evidence about adequate performance of prevention measures for post-surgery infectious
complications, high infectious complication rate is present.
FC - prevention of post-surgery infectious complications is done at a proper level, which is proved by the
low infectious complication rate.
The results of pathohistological and cytological tests of removed tissues are input
3.5.2.10
by the attending physician into the medical record as well as into the medical record extract (if
express-biopsy was performed during the surgery its results are input into the surgery protocol).
Results of the above mentioned examinations are input into the medical record stating
the date and the number of the test, as well as the name of a person performing the test. There is a
record book of pathohistological and cytological tests in the department.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Secondary
Tertiary
EC:
NC - there are medical records available that do not include information on the number, dates and results
of pathohistological and cytological tests of removed tissues. There is no record book for
pathohistological and cytological tests.
FC - in each case, pathohistological and cytological test results are input into the medical records. There
is a recording system for performed tests.
Detailed analysis of the reasons for the following cases is a part of quality
3.5.2.11
control system:
3.5.2.11.1
Elective surgery did not take place at the time appointed.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Secondary
Tertiary
EC:
NC - such cases are not analyzed, the reasons are not determined.
FC - each case is analyzed in details, there are developed prevention measures for the future.
3.5.2.11.2
The patient was not properly prepared for the surgery.
0
points
nonMinistry of Health of Ukraine
ZdravReform Project (Abt Associates Inc.)
3
points
full
Type of
Secondary
Tertiary
88
Accreditation standards for health facilities in Ukraine  KYIV 1998
compliance
compliance
health
care:
EC:
NC - such cases are not analyzed, the reasons are not determined.
FC - each case is analyzed in details, there are developed prevention measures for the future.
3.5.2.11.3 The patient was transferred from the intensive care unit or post-surgery ward earlier
than his/ her health status allowed to do so.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Secondary
Tertiary
EC:
NC - such cases are not analyzed, the reasons are not determined.
FC - each case is analyzed in details, there are developed prevention measures for the future.
3.5.2.11.4
Repeated surgical interference (except for planned ones).
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Secondary
Tertiary
EC:
NC - such cases are not analyzed, the reasons are not determined.
FC - each case is analyzed in details, there are developed prevention measures for the future.
3.5.2.11.5
Surgical infectious complications.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Secondary
Tertiary
EC:
NC - such cases are not analyzed, the reasons are not determined.
FC - each case is analyzed in details, there are developed prevention measures for the future.
3.5.2.11.6 Myocardial infarction, bleeding, hematoma, pneumonia, thromboembolism of
the lung artery or heart attack.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Secondary
Tertiary
EC:
NC - such cases are not analyzed, the reasons are not determined.
FC - each case is analyzed in details, there are developed prevention measures for the future.
3.5.2.11.7
Death for other reasons after the surgical interference.
0
points
nonMinistry of Health of Ukraine
ZdravReform Project (Abt Associates Inc.)
3
points
full
Type of
Secondary
Tertiary
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Accreditation standards for health facilities in Ukraine  KYIV 1998
compliance
compliance
health
care:
EC:
NC - such cases are not analyzed, the reasons are not determined.
FC - each case is analyzed in details, there are developed prevention measures for the future.
3.5.3 REHABILITATION
3.5.3.1
If needed patient's personal rehabilitation plan is developed.
The plan includes time-frame for rehabilitation activities, their succession, and expected
outcomes.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - patient's personal rehabilitation plans are not available.
FC - rehabilitation plan is developed for each patient personally.
All the changes made in the rehabilitation plan are input into the medical record
3.5.3.2
with the reasoning given.
If needed the changes are made to the rehabilitation plan with the reasoning provided, the
notification is included into the medical record.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - the dynamics of rehabilitation activities is not recorded, the changes to the rehabilitation plan are
not reasoned or input into the medical record.
FC - changes to the rehabilitation plan are reasoned and input into the medical record.
3.5.4 MATERNITY AND CHILD CARE
Maternity and child care service can be a part of a general hospital or organized as a separate
medical facility. These specialized facilities can combine maternity house with a children hospital;
maternity house can stand apart from the children hospital.
OB/ GYN service of general profile medical facilities provide health services
3.5.4.1
in accordance with the needs of female population assigned to the facility.
The number of subunits depends upon the facility capacity and includes:
3.5.4.1.1
Physiological delivery department (40% of total number of OB beds).
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Secondary
Tertiary
EC:
NC - absent.
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Accreditation standards for health facilities in Ukraine  KYIV 1998
FC - present.
3.5.4.1.2
Department of mother and child joint stay.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Secondary
Tertiary
EC:
NC - absent.
FC - present,
3.5.4.1.3
Observation department (30% of total number of beds of the maternity house).
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Secondary
Tertiary
EC:
NC - absent.
FC - present.
3.5.4.1.4
GYN department (20% of total number of beds of the maternity house).
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Secondary
Tertiary
EC:
NC - absent.
FC - present.
3.5.4.1.5
Department of pregnancy pathology (30% of total number of the OB beds).
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Secondary
Tertiary
3
points
full
compliance
Type of
health
care:
Secondary
Tertiary
EC:
NC - absent.
FC - present.
3.5.4.1.6
Neonatal department.
0
points
noncompliance
EC:
NC - absent.
Ministry of Health of Ukraine
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Accreditation standards for health facilities in Ukraine  KYIV 1998
FC - present.
3.5.4.1.7
Surgery block.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Secondary
Tertiary
Secondary
Tertiary
EC:
NC - absent.
FC - present.
3.5.4.1.8
Block of intensive therapy/ anesthesiology.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
EC:
NC - absent.
FC - present.
Delivery department is staffed with an appropriate number of OB/GYN specialists,
3.5.4.2
neonatologists, anesthesiologists.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Secondary
Tertiary
EC:
NC - not staffed.
FC - staffed.
3.5.4.3
The OB department has a separate admission office for primary examination.
On the admission, a female patient is examined by a physician who determines a primary
diagnosis, puts information into the medical record and refers the patient to an appropriate
department, wards. If needed, the patient is referred to another specialized facility. Patient's body
temperature, blood pressure, weight are measured, necessary samples are taken for testing and
other diagnostic procedures, sanitary treatment, filling in a medical record and other documents
(register log of referrals and admissions, etc.).
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Secondary
Tertiary
EC:
NC - there is no separate admission office.
FC - a separate admission office is available.
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ZdravReform Project (Abt Associates Inc.)
92
Accreditation standards for health facilities in Ukraine  KYIV 1998
Observation department has a separate admission office for primary
3.5.4.4
examinations.
In the admission office, a female patient is examined by a physician who determines a
primary diagnosis, puts information into the medical record and refers the pregnant to an
appropriate department, ward. If needed the patient is referred to other specialized facility.
Patient's body temperature, blood pressure, weight are measured, necessary samples are taken for
testing and other diagnostic procedures, sanitary treatment, filling in a medical record and other
documents (register log of referrals and admissions, etc.).
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Secondary
Tertiary
EC:
NC - there is no separate admission office.
FC - a separate admission office is available.
3.5.4.5
The facility providing normal delivery services includes a neonatal department.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Secondary
Tertiary
EC:
NC - the facility does not include a neonatal department.
FC - a neonatal department is included to the facility.
Neonatal department is staffed with an appropriate number of neonatologists and
3.5.4.6
nurses who take care of newborns. Neonatologists and nurses have taken special training to work in
this department including the training in newborn intensive therapy and resuscitation.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Secondary
Tertiary
EC:
NC - the department is not staffed with an appropriate number of personnel or the personnel has not taken
special training.
FC - the department is staffed appropriately, the personnel has taken special training.
3.5.4.7
newborns.
The neonatal department has an intensive therapy block for critical
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Secondary
Tertiary
EC:
NC - there is no intensive therapy block.
FC - present.
Ministry of Health of Ukraine
ZdravReform Project (Abt Associates Inc.)
93
Accreditation standards for health facilities in Ukraine  KYIV 1998
Neonatal department has a room for collection and pasteurization of breast milk
3.5.4.8
with the assigned trained medical personnel. The method of early breast-feeding is applied.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Secondary
Tertiary
EC:
NC - there is no room for collection and pasteurization of breast milk, the method of early breast-feeding
of newborns is not applied.
FC - there is a room available with the assigned trained personnel, the method of early breast-feeding of
newborns is applied.
Each case of the death of mother is studied at a clinical conference.
3.5.4.9
Administration invites leading specialists from departments, pathoanatomical service,
representatives of Medical University departments and other medical facilities (if any available).
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Secondary
Tertiary
EC:
NC - there is evidence, that the leading specialists from departments, pathoanatomical service, University
department representatives are not invited to study these cases.
FC - each case is studied in details, prevention measures are developed for future.
Appropriateness of the diagnostics, treatment tactics and clinical outcome of
3.5.4.10
each case is analyzed in details for the patients with the following diagnosis:
3.5.4.10.1
Eklampcia.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Secondary
Tertiary
3
points
full
compliance
Type of
health
care:
Secondary
Tertiary
EC:
NC - not analyzed.
FC - analyzed.
3.5.4.10.2
Cases of uterus laceration.
0
points
noncompliance
EC:
NC - not analyzed.
FC - analyzed.
Ministry of Health of Ukraine
ZdravReform Project (Abt Associates Inc.)
94
Accreditation standards for health facilities in Ukraine  KYIV 1998
3.5.4.10.3
Profuse uterus hemorrhage complicated by hemorrhage shock.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Secondary
Tertiary
EC:
NC - not analyzed.
FC - analyzed.
Appropriateness of the diagnostics, treatment tactics and clinical outcome of
3.5.4.11
each case is analyzed in details for premature, immature or injured at birth newborns as well as
infants with hard birth defects admitted to neonatal intensive therapy department.
The department head, medical director, consultants and other department representatives
regularly supervise the quality and indicators of health care provided for such infants.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Secondary
Tertiary
EC:
NC - not analyzed.
FC - analyzed.
Death cases of infants over 500g are analyzed in details.
3.5.4.12
Each case of infant death is considered at the clinical conference. Administration invites
leading specialists of the departments, pathoanatomical service, representatives of the University
departments and other facilities (if any available).
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Secondary
Tertiary
EC:
NC - not analyzed.
FC - analyzed.
Given below is the list of indicators that are constantly analyzed. Increase of their frequency
indicates insufficient quality of care, each of given below cases is studied in details, measures are
developed to prevent this occurrence in the future.
3.5.4.13
Delivery infectious complications.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Secondary
Tertiary
EC:
NC - not analyzed or analyzed but not regularly.
FC - regularly analyzed.
Ministry of Health of Ukraine
ZdravReform Project (Abt Associates Inc.)
95
Accreditation standards for health facilities in Ukraine  KYIV 1998
3.5.4.14
Prenatal mortality.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Secondary
Tertiary
Type of
health
care:
Secondary
Tertiary
EC:
NC - not analyzed or analyzed but not regularly.
FC - regularly analyzed.
3.5.4.15
Parturient traumas.
0
points
noncompliance
3
points
full
compliance
EC:
NC - not analyzed or analyzed but not regularly.
FC - regularly analyzed.
Children department has a separate admission office.
3.5.4.16
In the children department admission office, all the patients go through primary examination
with the assessment of complexity level and determination of primary diagnosis.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Secondary
Tertiary
EC:
NC - no separate admission office.
FC - available.
3.6 ANCILLARY SERVICES (PARACLINICS)
Ancillary services -- diagnostic and treatment (laboratories, X-ray, departments of functional
diagnostics and physiotherapy, gym and massage rooms, etc.) -- are included into the most of medical
facilities. Type and volume of the services provided by these subunits should be sufficient to satisfy
facility needs and have to be determined by the number and type patients according to the current
standards.
Test and diagnostic procedure results are passed over to physicians in the
3.6.1
shortest period of time (that does not exceed technological necessity).
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - evidence of unreasoned test result delays.
FC - test results are passed over to physicians without delays.
There is a control of timely check up and calibration of diagnostic
3.6.2
measuring equipment.
0
points
non-
1
points
min-
2
points
partial-
Ministry of Health of Ukraine
ZdravReform Project (Abt Associates Inc.)
3
points
full
Type of
Primary
Secondary
Tertiary
96
Accreditation standards for health facilities in Ukraine  KYIV 1998
compliance
compliance
compliance
compliance
health
care:
EC:
NC - no evidence of this control to be carried out.
FC - each occurrence of irregular equipment check-up and calibration are analyzed in detail and
discussed.
3.6.3
There is an approved list of tests and examinations available in the facility.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - absent.
FC - available.
The laboratory is provided with the equipment, reagents and materials necessary
3.6.4
to perform the tests according to the list.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - not provided.
FC - provided.
Facility X-ray department (office) is provided with X-ray equipment to perform
3.6.5
examinations according to the list approved.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - not provided.
FC - provided.
Correctness of test sampling is controlled.
3.6.6
All these cases are monitored, reasons are identified, decisions are taken to prevent future
occurrence.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - not controlled.
FC - controlled.
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Accreditation standards for health facilities in Ukraine  KYIV 1998
Ancillary subunits (physiotherapy, exercises and massage rooms, etc.)
3.6.7
have a list of services and procedures available.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - the list is absent.
FC - available.
3.6.8
Ancillary medical subunits are provided with all the necessary equipment.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
Primary
Secondary
Tertiary
EC:
NC - not provided.
FC - provided.
3.6.9
All the procedures are properly registered.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
EC:
NC - no evidence of such registration.
FC - procedures are registered which is proved by documents.
3.7 MEDICINE UTILIZATION.
Facility pharmaceutical chemist (clinical pharmacist) (if there is any on the staff)
3.7.1
informs medical personnel about the availability of medicine and new drug inflows; together with
the facility administration, he/ she regularly checks the expire term of the drugs stored. This
mechanism is characterized by the following:
3.7.1.2
physicians.
Informational letters and instructions on drug utilization are available for the
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - the facility does not a mechanism that stipulates informing the physicians about the available
medicine.
FC - the facility has a mechanism that stipulates informing the physicians about the available medicine,
which is proved by the document review and interviews with the personnel.
Ministry of Health of Ukraine
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98
Accreditation standards for health facilities in Ukraine  KYIV 1998
3.7.1.3
The regulations on drug storage are kept to.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - no evidence of systematic checks of the medicine storage regulations; storage rules are violate which
is proved by the examination of the storage places and interviews with personnel.
FC - the facility systematically checks the medicine storage regulations; no evidence of storage regulation
violations. "A" group drugs and narcotic substances are stored in the safe.
3.7.1.4
Medicine prescription, allocation and accounting rules are kept to.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - there is evidence of violation of prescription, allocation and accounting regulations which is proved
by document review and interviews with personnel.
FC - all the medicine is strictly accounted, and allocated on the basis of orders given by departments, the
allocation is done regarding the specific characteristics of each department.
3.7.1.5
The medicine utilized is within its expire term.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - the medicine utilized is out of expire term, there are no special permissions for prolongation of this
medicine storage.
FC - medicine expire terms are regularly checked, medicine with overdue expire term is not utilized
without special permission.
3.7.1.3
Prescription of narcotic substances is reasoned.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- there is evidence of unreasoned narcotic substance prescriptions..
FC- there is a clear reasoning for each case of narcotic substance prescription
3.7.1.4
There is a control system of disposal of empty ampoules from narcotic substances.
0
points
nonMinistry of Health of Ukraine
ZdravReform Project (Abt Associates Inc.)
3
points
full
Type of
Primary
Secondary
Tertiary
99
Accreditation standards for health facilities in Ukraine  KYIV 1998
compliance
compliance
health
care:
EC:
NC - there is no control system of disposal of empty ampoules from narcotic substances.
FC - there is a developed control system of disposal of empty ampoules from narcotic substances that
ensures proper utilization of narcotic substances.
Nurse (feldsher) registers each medicine allocation in the prescription list,
3.7.2
nurse (feldsher) puts his /her personal signature after the physicians prescription is performed.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC- available prescription lists without nurse's signature about given out medicine.
FC- each prescription list includes a mark about medicine given out to the patient, nurse's signature is
available.
Medicine used for emergency care provision is stored in a special place under
3.7.3
constant control and available for medical personnel 24 hours a day.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Primary
Secondary
Tertiary
EC:
NC - there is no special place where the emergency care medicine is stored, or the medicine is not
available at all or not available 24 hours a day.
FC - there are available special places where the emergency care medicine is stored, as the medicine is
utilized the storage is renewed, the medicine is available 24 hours a day.
3.8 SPECIALIZED SERVICES
3.8.1 BLOOD SERVICE
The facility has an available store of blood and blood preparations which is
3.8.1.1
periodically renewed and is under constant control of the administration.
The store is registered, quantity calculations and the list are prepared depending on the
department specific characteristics.
0
points
noncompliance
3
points
full
compliance
Type of
health
care:
Secondary
Tertiary
EC:
NC - no system of the need calculation, blood and blood preparation renewal.
FC - the system is available, which is proved by document review and interviews with personnel.
Utilization of blood and blood preparations is registered.
3.8.1.2
The departments have registration logs for blood and blood preparations utilization.
0
points
noncompliMinistry of Health of Ukraine
ZdravReform Project (Abt Associates Inc.)
3
points
full
compli-
Type of
health
Secondary
Tertiary
100
Accreditation standards for health facilities in Ukraine  KYIV 1998
ance
ance
care:
EC:
NC - there is evidence that the registration of blood and blood preparation utilization is not present or is
insufficient. No registration logs for blood and blood preparations utilization.
FC - there is a clear system of registration of blood and blood preparation utilization.
3.8.2 PATHOANATOMICAL SERVICE (DEPARTMENT)
Autopsy is done in the presence of the physicians, results are input into the
3.8.2.1
protocol (Ф №013/У), pathoanatomical diagnosis is determined not later than 7 days, with
obligatory histological, and, if needed, histochemical, bacteriological, viral, biochemical,
biophysical and other tests. If needed micro-, macrophoto-, and videotaping is used.
0
points
noncompliance
3
points
full
compliance
EC:
NC - there is evidence of autopsy done without a physician present, pathoanatomical diagnosis is set after
7 days.
FC - autopsies are done in the presence of a physician, the results are input into the protocol,
pathoanatomical diagnosis is set not later than 7 days.
Results of pathomorphological examinations are sent to the clinical department
3.8.2.2
not later than 5 days after receiving biopsy and operational material. Intake of material and
submission of pathomorphological examination results are documented.
If neвd be, histochemical (not less than 10-15 methods), bacterioscopical, luminescent and
other ancillary methods of morphological examinations are used. The term for bone tissue and
biopsy processing, that needs additional coloring techniques and special examinations, can be
extended.
0
points
noncompliance
3
points
full
compliance
EC:
NC - there is evidence that pathomorphological and cytological test results are sent to the clinical
department overdue to 5-day term after the material is received.
FC - the results are sent not later than in 5 days which is proved by the document review.
Protocols of pathoanatomical examinations (Ф №013/У) are kept in
3.8.2.3
segregators or brochured in a chronological by facilities with the notification of deviation reason
between diagnosis and late diagnostics.
0
points
noncompliance
3
points
full
compliance
EC:
NC - there is evidence of non-timely or incomplete protocol filling-in, these cases are not studied, clinicalpathoanatomical conferences are not conducted or conducted irregularly.
FC - the protocols are filled in timely and completely, clinical-pathoanatomical conferences are regularly
conducted.
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Space (rooms) and technical provision of the pathoanatomical service
3.8.2.4
complies with the major requirements to the facilities of the type.
0
points
noncompliance
3
points
full
compliance
EC:
NC - space and technical provision does not comply with the requirements.
FC - space and technical provision comply with the requirements.
3.9 SANATORIUM-RESORT CARE
In the complex of medical and preventative measures as to public health sanatorium-resort care
takes special position. The influence of physical factors (favorable climate, healing mud, mineral waters
and spas, motor activity regime) is aimed at the stimulation of defense and adaptation systems, improving
of functional activity of body`s parts and systems.
Taking into account the population morbidity structure and its tendencies there are specialized
sanatoriums and resuscitation departments for treating people with the deceases of blood circulation,
nervous system, digestion, metabolism, rspiratory system of non specific character, motor system ,
gynecological, skin, kidneys and urethral canals etc.
To get the accreditation of sanatorium-resort care facility which utilizes hydro-mineral resources,
it is essential to obtain: the balneological reqirements comtatibility, licence on exploitation of natural
resource, regular control over the sanitary situation of hydro-mineral resources, the availability of
passports on hydro-mineral and balneo-technical resources.
3.9.1
Sanatorium-resort facility (SRF) is located in the resort area, in an easily accissible place
with the well-developed public transportation system
0
points
noncompliance
3
points
full
compliance
EC:
NC - SRF is located in a hard accessiblr place, which is not properly served
FC - SRF is located in a resort area in an easily accissible place, which is served
3.9.2
SRF has an approved system of patients registration who come to receive SR
treatmnet
0
points
noncompliance
3
points
full
compliance
EC:
NC - Registration office and records etc. are absent
FC - Registartion office and records etc. are present
3.9.3
SRF is equipped with rooms, wards, manipulation rooms, facilities for
laboratories, physio-therapeutical, balneological and mud-treatment departments
which corresponds to the number of patients and the facility type
.
0
points
1
points
2
points
Ministry of Health of Ukraine
ZdravReform Project (Abt Associates Inc.)
3 points
102
Accreditation standards for health facilities in Ukraine  KYIV 1998
noncompliance
mincompliance
partialcompliance
full
compliance
EC:
NC - manipulation rooms, facilities for laboratoris, physio-therapeutical, balneological and mudtreatment departments, essential as to a facility type are absent
MC - balneological and mud treatment departments are partially absent
PC - SRF is equipped with rooms, wards, manipulation rooms, facilities for laboratories, physiotherapeutical, balneological and mud-treatment departments etc, though the number of diagnosis facilities
is limited which does not provide adequate volume of diagnosis and treatment for 100% of patients
FC - SRF is completely equipped with rooms, wards, manipulation rooms, facilities for laboratories,
phsio-therapeutical, balneological and mud treatment departments according to the number of patients.
3.9.4
SRF is equipped with of functional, laboratory and radio diagnosis devices
according to facility type
.
0
points
noncompliance
1
points
mincompliance
2
points
partialcompliance
3
points
full
compliance
EC:
NC - devices for functional and laboratory diagnosis regarding facility type are absent
MC - devices for functional and laboratory diagnosis according to SRF profile are available but they don`t
correspond to contemporary conditions
PC - equipped with devices of functional and laboratory diagnosis according to SRF type which have
partial compliance to contemporary requirements
FC - completely equipped with devices of functional, laboratory X ray diagnosis etc according to SRF
type which completely correspond to patients number and SRF type.
3.9.5
SRF is staffed with medications, medical supplies and desinfection materials for
rendering health services within SRF
0
points
noncompliance
3
points
full
compliance
EC:
NC - is not staffed
FC - is staffed
3.9.6.
SRF is equipped with physiotherapy devices
.
. To specify physiotherapy devices it is necessary to consider their type, manufacturing
country, date of purchase, quantitity of the devices, average lenght of life, ratio of devices,
manufactured in the recent five years and their general number, percentage of obsolete
equipment and the equipment which is not exploited, frequency of control procedures, number of
procedures per 24 hours, per year regarding implementation of new physiotherapy methods. It
also necessary to have more than 10 methods, including the combined ones and gradual
introduction of new physiotherapy methods
0
points
nonMinistry of Health of Ukraine
ZdravReform Project (Abt Associates Inc.)
3
points
full
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Accreditation standards for health facilities in Ukraine  KYIV 1998
compliance
compliance
EC:
NC - facility does not have the defined minimun of physiotherepy services or it is available but its
majority does not correspond to modern requirements or it is not exploited
FC - facility does have the defined volume of physiotherapy equipment, which corresponds to modern
requirements. This should be documented and reflected at meetings with personnel.
3.9.6.1
SRF is equipped with electrotherapy devices
0
points
noncompliance
3
points
full
compliance
EC:
NC - defined minimum of electrotherapy equipment is absent at rhe facility or it is present but the
majority of which does not correspond to modern requirements or is not utilized
FC - defined volume of equipment is present, which corresponds to modern requirements and is
documented
3.9.6.1.1
SRF is equipped with halvanic and electrophoresis devices
0
points
noncompliance
3
points
full
compliance
EC:
NC - definined minimum of halvanic and electrophoresis devices is absent at the facility or it is present
but the majority of which does not correspond to modern requirements or is not utilized
FC - defined volume of equipment is present, which corresponds to modern requirements and is
documented.
3.9.6.1.2
SRF is equipped with devices for diadynamic currents
0
points
noncompliance
3
points
full
compliance
EC:
NC - defined minimum of devices for diadynamic currents is absent at the facility or it is present but the
majority of which does not correspond to modern requirements or is not utilized
FC - defined volume of equipment is present, which corresponds to modern requirements and is
documented
3.9.6.1.3
SRF is equipped with devices for sinus modulated currents
0
points
noncompliance
3
points
full
compliance
EC:
Ministry of Health of Ukraine
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Accreditation standards for health facilities in Ukraine  KYIV 1998
NC - defined minimum of devices for sinus modulated currents is absent at the facility or it is present but
the majority of which does not correspond to modern requirements or is not utilized
FC - defined volume of equipment is present, which corresponds to modern requirements and is
documented
3.9.6.1.4
SRF is equipped with devices for inteferential currents therapy
0
points
noncompliance
3
points
full
compliance
EC:
NC - defined minimum of devices for interferential currents therapy is absent at the fascility or it is
present but the majority of which does not correspond to modern requirements or is not utilized
FC - defined volume of equipment is present, which corresponds to modern requirements and is
documented
3.9.6.1.5
SRF is equipped with devices for fluctuation currents therapy
0
points
noncompliance
3
points
full
compliance
EC:
NC - defined minimum of devices for fluctuation currents therapy is absent at the facility or it is present
but the majority of which does not correspond to modern requirements or is not utilized
FC - defined volume of equipment is present, which corresponds to modern requirements and is
documented
3.9.6.1.6
SRF is equipped with devices for cerebral impulse electric influences (electrosleep,
lenar, infita etc)
0
points
noncompliance
3
points
full
compliance
EC:
NC - defined minimum of devices for cerebral impulse electric influences is absent at the facility or it is
present but the majority of which does not correspond to modern requirements or is not utilized
FC - defined volume of equipment is present, which corresponds to modern requirements and is
documented
3.9.6.1.7
SRF is equipped with devices for electrostimulation
0
points
noncompliance
3
points
full
compliance
EC:
NC - defined minimum of devices for electrostimulation is absent or it is present but the majority of
which does not correspond to modern requirements or is not utilized
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FC - defined volume of equipment is present, which corresponds to modern requirements and is
documented
3.9.6.1.8
SRF is equipped with devices for high frequency electrotherapy
0
points
noncompliance
3
points
full
compliance
EC:
NC - defined minimum of devices for high frequency electrotherapy is absent or it is present but the
majority of which does not correspond to modern requirements or is not utilized
FC - defined volume of equipment is present, which corresponds to modern requirements and is
documented
SRF is equipped with devices for ultrasonic therapy
3.9.6.2
.
It is essential to have a wide array of methods for autonomous utilization of ultrasound (low and
high frequency modulations) alongside methods of ultrafonophoresis with the use of medical and
natural origin products( mud, bishofit, products of apiculture, etc), different methods procedures
and also combined ultrasonic therapy methods (vacuum, ultrafonophoresis, electroultrafonophoresis, etc.)
0
points
noncompliance
3
points
full
compliance
EC:
NC - defined minimum of devices for ultrasonic therapy is absent or it is present but the majority of
which does not correspond to modern requirements or is not utilized
FC - defined volume of equipment is present, which corresponds to modern requirements and is
documented
SRF is equipped with devices for magnetotherapy
3.9.6.3
.
It is essential to have a range of devices for different magnetotherapy methods (direct,
alternative, impulse magnetic field) together with combined methods(vacuum magnetotherapy,
magnetolazertherapy etc.)
0
points
noncompliance
3
points
full
compliance
EC:
NC - defined minimum of devices for magnetherapy absent or it is present, but the majority of which
does not correspond to modern requirements or is not utilized
FC - defined volume of equipment is present, which corresponds to modern requirements and is
documented.
3.9.6.4
SRF is equipped with radiotherapy appliances (infra-red radiation, unltraviolet,
laser).
.
There is a wide range of appliances and various radiotherapy technique (laser puncture, blood
intravessel laser and ultraviolet radiation? Radiation of organs, tissues etc.,) as well as related
Ministry of Health of Ukraine
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techniques (laser shower, laser magnet therapy, helium-neon and ultra-red laser etc.
0
points
noncompliance
3
points
full
compliance
EC:
NC - defined minimum of radioherapy equipment is absent or it is present, but most of them do not
correspond to up-to-date requirements or is not used
FC - defined volume of equipment is present, which corresponds to up-to-date requirements and is
documented.
3.9.6.5
SRF is equipped with vacum therapy appliances.
.
There is a wide range of vacum therapy techniques, as well as vacum electrophoresis, vacum
ultrasound-phoresis combined with usage of medications and natural drugs (mud, apiarian
products, mineral; wateers, etc), vacum magnet therapy, vacum ultra-tono therapy, vacum
magmet-laser therapy etc.)
0
points
noncompliance
3
points
full
compliance
EC:
NC - defined minimum of vacum therapy equipment is absent or it is present, but most of it does not
correspond to up-to-date requirements or is not used
FC - defined volume of equipment is present, which corresponds to up-to-date requirements and is
documented.
3.9.6.6
SRF is equipped with machnies for local and genaral pressure therapy.
.
0
points
noncompliance
3
points
full
compliance
EC:
NC - defined minimum of machines for local and general pressure therapy is absent or it is present, but
most of it does not correspond to up-to-date requirements or is not used
FC - defined volume of machines for local and general pressure therapy is present, which corresponds to
up-to-date requirements and which is documented.
3.9.6.7
SRF is equipped with machnies for aerosolic therapy.
.
0
points
noncompliance
3
points
full
compliance
EC:
NC - defined minimum of aerosolic therapy machines is absent or it is present, but most of it does not
correspond to up-to-date requirements or is not used
Ministry of Health of Ukraine
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FC - defined volume of aerosolic machines is present, which corresponds to up-to-date requirements and
which is documented.
SRF is equipped with traction therapy machnies.
3.9.6.8
There is a wide range of machines for dry and underwater extension (in the pool, baths of
various chemical content) and with different techniques (vertical, horixontal).
0
points
noncompliance
3
points
full
compliance
EC:
NC - defined minimum of traction therapy machines is absent or it is present, but most of it does not
correspond to up-to-date requirements or is not used
FC - defined volume of traction therapy machines is present, which corresponds to up-to-date
requirements and which is documented.
SRF is equipped with massage and manual therapy machnies.
3.9.6.9
There is a wide range of machines for dry and underwater extension (in the pool, baths of
various chemical content) and with different techniques (vertical, horixontal).
0
points
noncompliance
3
points
full
compliance
EC:
NC - defined minimum of massage and manual therapy machnies is absent or it is present, but most of it
does not correspond to up-to-date requirements or is not used
FC - defined volume of massage and manual therapy machnies is present, which corresponds to up-todate requirements and which is documented.
3.9.7
SRF is equipped with appliances, medicinal solutions, reagents, mineral waters for
water and balneological therapy.
While describing natural resort resources used for balneological therapy, it is necessary to
consider: available approved sanitary protection zone, the state of sanitary protection zone; list
and characteristics of existing springs with daily debit indicated (in litres); physical, chemical and
gas content, temperature etc.; the state of captation and balneological constructions (pipelines,
reservoirs, mixers and pump-rooms); round-the clock need of the resort in mineral water in litres
(separately for baths and drinking) and the degree of satisfaction of this need; shown reserves of
mineral water or approved reserves of, available license for extracting underground waters;
bottling of mineral water, who is the bottler, annual produce of the plant (in bottles); operational
characteristics of the supervision station.
0
points
noncompliance
3
points
full
compliance
EC:
NC - defined minimum of appliances, medicinal solutions, reagents, mineral waters for water and
balneological therapy is absent or it is present, but most of it does not correspond to up-to-date
requirements or is not used
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FC - defined volume of appliances, medicinal solutions, reagents, mineral waters for water and
balneological therapy is present, which corresponds to up-to-date requirements and which is documented.
3.9.7.1
SRF is equipped with appliances for therapeutic showers.
0
points
noncompliance
3
points
full
compliance
EC:
NC - such appliances are absent.
FC - such appliances are available.
3.9.7.2
SRF is equipped appliances, medicinal solutions, reagents, mineral waters for
baths.
A wide range of methodologies using various gases (oxygen, rodon, sulfurretted hydregen, azote
etc., ), medicinal (pine needle, sage, iodine-bromine, turpentine etc.) and natural solutions for
baths (mud, mineral waters etc.), different procedures (full baths, half baths, two/four-cell baths),
as well as combined balneotherapy techniques (bubble, whirlpool, dry, immersion, underwater
massage douche bath etc).
0
points
noncompliance
3
points
full
compliance
EC:
NC - such appliances, techniques, medicinal solutions are absent.
FC - such appliances, techniques, medicinal solutions are available in wide range.
3.9.7.3
SRF is equipped with pool hydrotherapy appliances.
0
points
noncompliance
3
points
full
compliance
EC:
NC - pool or such appliances are absent.
FC - pool or such appliances are available in wide range.
3.9.7.4
SRF is equipped with appliances and machnies for hydrotherapy (douche, wet
wrappings etc.).
0
points
noncompliance
3
points
full
compliance
EC:
NC - absent.
FC - available.
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3.9.7.5
Availability of use of mineral waters.
There is approved reserves of mineral waters. Documents regulating the utilization of mineral
waters (usage permission, act of acceptance and conveyance, flow chart, sanitation zone,
monitoring program, license for use of deposits etc.) A round-the-clock need proportionate to the
existing bed capacity or number of voucher patients. There is a mineral waters exploitation
system. Existing system of transportation, storage, heating of mineral waters. Dumping of the
used waters, an existing system of preparation of waters of approapriate concentration and
temperature. Supervision over mineral water (supervision service is available; regular sanitary,
physical and chemical, quantitative control). Variaty of baths in terms of chemical content and
techniques.
0
points
noncompliance
1
points
minimal
compliance
2
points
partial
compliance
3
points
full
compliance
EC:
NC - such appliances, techniques, medicinal solutions are absent.
MC - minimally complies with the requirements.
PC - partially complies with the requirements.
FC - fully complies with the requirements.
3.9.8
Availability of use of mud therapy.
To evaluate the mud udes for therapy, it is necessary to consider the characteristics of the mud
deposit, the area, length, width, depth of the mud lake, thicknees of the mud or peat layer, water
regime (annual cycle), the degree of driness; type of the mud its chemical content, sanitary and
bacteriological state of the mud deposit; method of extraction, delivery, storage of mud (peat),
methods of mud regeneration; prospected deposits of mud (peat) in tonns, existing license for
extration and utilization of mud; need of the health resourt for mud (daily need in tonns) and the
degree of meeting this need.
0
points
noncompliance
1
points
minimal
compliance
2
points
partial
compliance
3
points
full
compliance
EC:
NC - such appliances, techniques, medicinal solutions are absent.
MC - minimally complies with the requirements.
PC - partially complies with the requirements.
FC - fully complies with the requirements.
3.9.8.1
Availability of different mud therapy techniques.
(application mud therapy, galvanic mud therapy, electric mud therapy with impulse current,
induced mud therapy, decimeter-wave mud therapy, combined application of mud with ultrasound, cavity mud therapy, mud baths etc.).
0
points
noncompliance
1
points
minimal
compliance
2
points
partial
compliance
3
points
full
compliance
EC:
NC - the facility has no such mud therapy techniques.
MC - such techniques are minimally available.
PC - such techniques are partially available.
FC - such techniques are fully available.
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3.9.8.2
Key physical and chemical readings of the mud, quality assurance, chracteristics of
the utilization of deposits.
Exterior qulities, humidity, volume weight, grid leak, pollution with particles, degree of pollution,
heat capacity, organic substance, heat-caused loss, mud pH etc.) Key sanitary indicators (total
number of microbes, titer koli, titer perfringens etc.). Need for mud, sq.m per year (existing,
calculated, prospective). Quantity of mud which is delivered, sq.m per year. Terms of mud
delivery, type of transport. The existing exploitation system (state of the mud depository and
regeneration pools). The existing system of mud preparation for procedures (added water, method
of purefication, mixing, warm-up, bringing to the point of procedure temperature). Terms and
conditions of regeneration (fixed, actual). System of washing and drying tarpaulins. Forms of
control over mud usage (presence of the control service, sanitary, physical and chemical, oxigen
control, its regularity).
0
points
noncompliance
1
points
minimal
compliance
2
points
partial
compliance
3
points
full
compliance
EC:
NC - the facility has no such range of control services and utilization techniques .
MC - such range is minimally available.
PC - such range is partially available.
FC - such range is available.
3.9.9
SRF is equipped with appliaces, machines, techniques for heat therapy (ozocerite,
paraffin therapy
Key physical and chemical readings. Key sanitary indicators (total number of microbes, titer
koli, titer perfringens etc.). Need for heat carrier, sq.m per year (existing, calculated, prospective).
Number of substances used for heat therapy, sq.m per year. Regularity of delivery of heat therapy
substances, type of transportation. Existing exploitation system. System of supply of substances
for procedurs and abstraction of the employed substance during heat therapy. Multiplicity of
usage of a heat therapy substance. System of washing and drying materials. Forms of control over
the used heat therapy substance (presence of the control service, sanitary, physical and chemical,
oxigen control, its regularity).
0
points
noncompliance
1
points
minimal
compliance
2
points
partial
compliance
3
points
full
compliance
EC:
NC - the facility has no such range of control services and utilization techniques .
MC - such range is minimally available.
PC - such range is partially available.
FC - such range is available.
3.9.10
SRF is equipped with appliaces, machines, techniques for hypothermia,
criotherapy.
0
points
non-compliance
3
points
full compliance
NC - absent.
FC - present.
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3.9.11
Availability of climatic therapy ( aerotherapy, heliotherapy, talasotoherapy etc.)
Within the climatic therapy it is necessary to take into consideration: the availability of meteorological
station close or nearby sea resort ( show exact location ), exact name of the station, its subordination, type
of the station, if organized, brief and appropriate climatic characteristics taken from years-long observations;
were microclimatic resort observations done in the past years, who did it and when, where were these
materials published; if the materials were not out, where are they stored? Availability of a solarium (number
of beds, area for aereotherapy etc.). Availability of out-of-door pools for bathing (sea, river, lake etc.) and
appropriate sanitary and epidemiological and medical control. Availability of a beach area. Lanes for
constitutionals. Pedestrian routes. Appliances and means for spalaean therapy (caverns with natural
microclimate, therapeutic properties: salt pits, caves etc., artificial chambers for aerosol-,
aerosolphitotherapy).
0
1
2
3
points
points
points
points
nonminimal
partial
full
complicomplicompli
compli
ance
ance
-ance
-ance
EC:
NC - the facility has no such range of control services and utilization techniques .
MC - such range is minimally available.
PC - such range is partially available.
FC - such range is available.
3.9.12
SRF is equipped with the psychotherapy room. .
Availability of a room for group and induvidual psychotherapy, necessary equipment and patients
per day.
0
points
noncompliance
3
points
full
compliance
EC:
NC - absent.
FC - available.
3.9.13
SRF is equipped with rooms (halls), spaces, facilities for theraputic physical
exercises in closed premesis and out-of-doors.
0
points
noncompliance
3
points
full
compliance
EC:
NC - absent.
FC - available.
3.9.14
SRF is equipped with rooms (halls), spaces, facilities for mechanic therapy.
0
points
noncompliance
3
points
full compliance
EC:
NC - absent.
FC - available.
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