Česky
"Hořovice Hospital can be proud of the certificate repeatedly since 2014, when it first underwent such a complex and detailed external audit focused on external evaluation of quality and safety in the provision of health services. Since then, it has not fallen from its standard, but rather strives to push its quality ever higher each year. This was followed by accreditation surveys in, 2017, 2021 and now this September." says the director of the hospital in Hořovice, MUDr. Michal Průša, MBA.
The SAK or Joint Accreditation Commission, o.p.s. deals with the evaluation of quality in healthcare facilities such as hospitals, outpatient medical facilities, aftercare facilities, emergency medical services and residential social services facilities. It has been active since 1998. The main objective of the accreditation survey is to evaluate the actual quality of services provided, which is standardised and generally recognised. It always takes a comprehensive approach to the entity under assessment.
Based on these facts, the accreditation certificate is issued for 3 years, after which the certificate must be defended in a new accreditation investigation. Should the healthcare facility fail to meet the established quality standards, the accreditation will be withdrawn.
All areas of the healthcare facility are audited as part of the accreditation investigation, in particular the area of healthcare provision, medical record keeping, patient contact, protection of personal and sensitive patient data, medical devices and many other processes characteristic of the operation of a healthcare facility. An integral part of the audit is the evaluation of the operational services of the organisation, such as the catering department, laundry, cleaning, maintenance, warehouse management, filing room, etc., as well as the management of the company.
"Preparing for such an audit is a continuous and never-ending process involving almost every employee. In my opinion, the word process is the most apt and correct definition. In the field of quality and safety management in the provision of health services, one can never say 'so and so is done now'. The evolution of medicine, new technologies and changes in legislation are the basic premise." Mgr. Blanka Hošková.
The accreditation itself took place in the form of a 2-day external audit, when the hospital was visited by a 3-member committee of auditors, consisting of a physician, a non-medical health worker and an auditor for the operational and technical sections.
The audit was carried out according to a predetermined plan, in almost all departments. It started with an introductory meeting with the hospital management, presentation of the organizational structure, introduction to the range of services provided and presentation of the Quality and Safety Improvement Program.
"The main method of the audit was the Tracer method. This is a specific method of auditing in the health sector, where the auditor chooses a patient, and follows the "tracking" of the patient's passage through the health facility, based on interviews with hospital staff, interviews with the patient, review of medical documentation and the observation method, taking into account related activities," explains Mgr. Blanka Hošková
Every hospital that applies for an accreditation survey must fulfil and implement the required accreditation standards in its operation, if it fails to do so, it is not possible to apply for an accreditation survey at all. It is a complex and demanding process for the organisation and each employee. The whole audit is based on the assessment of the compliance between the set processes defined by the standards and the actual practice.
What to say in conclusion? We have vindicated ourselves, and that is encouraging.
