home All hormones The availability and quality of medical care is ensured through. Availability of medical care: "little things" decide everything. Social protection of citizens in case of loss of health

The availability and quality of medical care is ensured through. Availability of medical care: "little things" decide everything. Social protection of citizens in case of loss of health

The availability and quality of medical care are ensured by:

1) organizing the provision of medical care on the principle of proximity to the place of residence, place of work or education;

2) the availability of the required number of medical workers and the level of their qualifications;

3) the possibility of choosing a medical organization and a doctor in accordance with this Federal Law;

4) application of procedures for the provision of medical care and standards of medical care;

5) provision by a medical organization of a guaranteed volume of medical care in accordance with the program of state guarantees of free provision of medical care to citizens;

6) establishing, in accordance with the legislation of the Russian Federation, requirements for the placement of medical organizations of the state healthcare system and the municipal healthcare system and other infrastructure facilities in the healthcare sector based on the needs of the population;

7) transport accessibility of medical organizations for all groups of the population, including the disabled and other groups of the population with limited mobility;

8) the possibility of unhindered and free use by a medical worker of means of communication or vehicles to transport a patient to the nearest medical organization in cases that threaten his life and health.

Article 11. Inadmissibility of refusal to provide medical care

1. Refusal to provide medical care in accordance with the program of state guarantees of free provision of medical care to citizens and collection of fees for its provision by a medical organization participating in the implementation of this program, and medical workers of such a medical organization are not allowed.

2. Medical assistance in an emergency form is provided by a medical organization and a medical worker to a citizen without delay and free of charge. Refusal to provide it is not allowed.

3. For violation of the requirements provided for in parts 1 and 2 of this article, medical organizations and medical workers are liable in accordance with the legislation of the Russian Federation.

Article 12. Priority of prevention in the field of health protection

The priority of prevention in the field of health protection is ensured by:

1) development and implementation of programs for the formation of a healthy lifestyle, including programs to reduce alcohol and tobacco consumption, prevent and combat the non-medical consumption of narcotic drugs and psychotropic substances;

2) implementation of sanitary and anti-epidemic (preventive) measures;

3) implementation of measures for the prevention and early detection of diseases, including the prevention and control of socially significant diseases;

4) carrying out preventive and other medical examinations, clinical examination, dispensary observation in accordance with the legislation of the Russian Federation;

5) implementation of measures to preserve the life and health of citizens in the process of their education and work in accordance with the legislation of the Russian Federation.

Article 18. Right to health care

1. Everyone has the right to health protection.

2. The right to health protection is ensured by environmental protection, the creation of safe working conditions, favorable working conditions, life, recreation, education and training of citizens, the production and sale of food products of appropriate quality, high-quality, safe and affordable medicines, as well as the provision of affordable and quality medical care.

Article 19. Right to medical assistance

1. Everyone has the right to medical care.

2. Everyone has the right to medical care in a guaranteed volume, provided free of charge in accordance with the program of state guarantees of free provision of medical care to citizens, as well as to receive paid medical services and other services, including in accordance with a voluntary medical insurance contract.

3. The right to medical care for foreign citizens residing and staying on the territory of the Russian Federation is established by the legislation of the Russian Federation and the relevant international treaties of the Russian Federation. Stateless persons permanently residing in the Russian Federation enjoy the right to medical care on an equal footing with citizens of the Russian Federation, unless otherwise provided by international treaties of the Russian Federation.

4. The procedure for rendering medical assistance to foreign citizens is determined by the Government of the Russian Federation.

5. The patient has the right to:

1) the choice of a doctor and the choice of a medical organization in accordance with this Federal Law;

2) prevention, diagnosis, treatment, medical rehabilitation in medical organizations in conditions that meet sanitary and hygienic requirements;

3) obtaining advice from medical specialists;

4) relief of pain associated with the disease and (or) medical intervention, available methods and drugs;

5) obtaining information about their rights and obligations, the state of their health, the choice of persons to whom, in the interests of the patient, information about the state of his health can be transferred;

6) receiving therapeutic nutrition in the case of a patient being treated in a hospital;

7) protection of information constituting a medical secret;

8) refusal of medical intervention;

9) compensation for harm caused to health during the provision of medical care to him;

10) admission to him of a lawyer or legal representative to protect his rights;

11) the admission of a clergyman to him, and in the case of a patient being treated in a hospital, to the provision of conditions for the performance of religious rites, which can be carried out in a hospital, including the provision of a separate room, if this does not violate the internal regulations of the medical organization.

The territorial program establishes target values for the criteria for the availability and quality of medical care, on the basis of which a comprehensive assessment of the level and dynamics of the following indicators is carried out:

1. General indicators.

1.1. Satisfaction of the population with medical care (% of the number of respondents):

1.2. morbidity, mortality and disability of the population:

mortality of the population (number of deaths per 1000 population),

mortality of the population of working age (the number of deaths in working age per 100 thousand people of the population),

mortality of the population from diseases of the circulatory system (the number of deaths from diseases of the circulatory system per 100 thousand people), in dynamics for 3 years,

mortality of the population of working age from diseases of the circulatory system (the number of deaths from diseases of the circulatory system at working age per 100 thousand people of the population),

mortality of the population from neoplasms (including malignant), (the number of deaths from neoplasms (including malignant) per 100 thousand people), in dynamics over 3 years,

mortality of the population from road traffic accidents (number of deaths from road traffic accidents per 100 thousand people), in dynamics for 3 years,

incidence of tuberculosis in the population (cases per 100 thousand people),

mortality of the population from tuberculosis (cases per 100 thousand people), in dynamics for 3 years,

maternal mortality (per 100 thousand live births),

infant mortality (per 1000 live births), in dynamics for 3 years,

the share of diseases detected in the early stages of the total number of newly diagnosed diseases;

the number of people of working age recognized as disabled for the first time (persons per 10,000 people of the working age population).

the number of persons under the age of 18 who are first recognized as disabled.

1.3. accessibility of medical care based on the assessment of the implementation of standards for the volume of medical care by type in accordance with the Program:

the waiting time for citizens to receive medical care provided in a planned form,

average waiting time for an appointment with a specialist doctor,

the number of justified complaints, including the refusal to provide medical care provided under the territorial program, including the territorial program of compulsory medical insurance,

the number of the population that made the choice of a medical organization,

the number of the population that made the choice of a doctor providing primary health care,

the share of medical organizations that apply standards of medical care in the total number of medical organizations operating under the territorial program,

the number of medical organizations that make an automated appointment with a doctor using the Internet and information and reference touch terminals;

1.4. efficiency in the use of healthcare resources (human resources, material and technical, financial and others):

provision of the population with doctors (persons per 10 thousand population), total, incl. terms of medical care,

provision of the population with medical workers with a secondary medical education (persons per 10 thousand population), total, incl. terms of medical care,

provision of the population with hospital beds (per 10 thousand population),

the proportion of medical organizations that have undergone major repairs in a timely manner, among those in need of it,

the number of specialized departments of medical organizations, the material and technical equipment of which has been brought into line with the procedures for providing medical care,

the ratio of the number of medical organizations transferred to a new (sectoral) performance-oriented remuneration system to the total number of medical organizations operating under the territorial program,

the ratio of the average monthly nominal accrued wages of doctors of state (municipal) medical organizations to the average monthly nominal accrued wages of employees employed in the region's economy,

the ratio of the average monthly nominal accrued wages of medical workers with a secondary medical education, state (municipal) medical organizations to the average monthly nominal accrued wages of workers employed in the region's economy;

the effectiveness of the activities of medical organizations based on the assessment of the performance of the function of medical activity, indicators of the rational and targeted use of the bed fund;

capital equipment and capital-labor ratio of medical organizations.

2. Performance indicators of medical organizations providing primary health care:

share of completed patronages of children of the first year of life from planned medical patronages of children of the first year of life,

completeness of coverage of preventive examinations of children from the number of children subject to preventive examinations,

the share of children hospitalized for medical care in a planned form, out of the total number of children under dispensary supervision and in need of such medical care,

the share of the number of completed individual programs for the rehabilitation of children with disabilities from the total number of children with disabilities,

the proportion of children under dispensary supervision in the total number of children attached to the pediatric site,

the proportion of children removed from dispensary observation for recovery, out of the total number of children under dispensary observation,

the proportion of children with improved health out of the total number of children under dispensary supervision,

share of preventive visits to the total number of visits to the polyclinic;

the level of hospitalization of the population attached to a medical organization providing primary health care (per 1000 population);

the percentage of discrepancies in diagnoses when referring to a medical organization providing medical care in an inpatient setting and the clinical diagnosis of the indicated medical organization out of the total number of referrals,

the share of hospitalizations in an emergency form in the total volume of hospitalizations of the population attached to a medical organization providing primary health care,

the share of medical organizations of the state (municipal) healthcare systems providing primary health care, the financing of which is carried out based on the results of their activities on the basis of the per capita standard for the attached population, in the total number of such medical organizations.

3. Performance indicators of medical organizations providing specialized, including high-tech, medical care:

the volume of medical care provided in day hospitals (number of patient days per 1 inhabitant, per 1 insured person);

the proportion of patients who received specialized, including high-tech, medical care according to the standards of medical care, to the total number of patients who received this type of medical care,

the share of citizens who received a justified refusal to provide high-tech medical care in the total number of citizens sent for the provision of high-tech medical care by the executive authority of the constituent entity of the Russian Federation in the field of healthcare,

the share of state (municipal) medical organizations providing medical care in inpatient conditions, the financing of which is carried out based on the results of activities on a completed case of treatment in accordance with the standard of financial costs calculated on the basis of clinical and statistical groups, to the total number of state (municipal) medical organizations, providing medical care in hospitals.

4. Indicators of the activities of medical organizations for the provision of emergency, including emergency specialized, medical care:

the number of ambulance calls per 1 inhabitant, the number of patients who received emergency medical care;

the proportion of patients who received an ambulance within 15 minutes of being called.

The territorial program may establish additional target values for the criteria for the availability and quality of medical care for medical organizations.

Equalization of financial conditions for the implementation of territorial programs of compulsory medical insurance, taking into account the total income sources of their financial support, as well as stimulating the effectiveness of the implementation of territorial programs are carried out in accordance with the legislation of the Russian Federation.

1. The state recognizes the protection of children's health as one of the most important and necessary conditions for the physical and mental development of children.

2. Children, regardless of their family and social well-being, are subject to special protection, including care for their health and proper legal protection in the field of health protection, and have priority rights in the provision of medical care.

3. Medical organizations, public associations and other organizations are obliged to recognize and observe the rights of children in the field of health care.

4. State authorities of the Russian Federation, state authorities of the constituent entities of the Russian Federation and local governments, in accordance with their powers, develop and implement programs aimed at the prevention, early detection and treatment of diseases, reduction of maternal and infant mortality, formation in children and their parents motivation for a healthy lifestyle, and take appropriate measures to organize the provision of children with medicines, specialized medical foods, and medical devices.

5. The state authorities of the Russian Federation and the state authorities of the constituent entities of the Russian Federation, in accordance with their powers, create and develop medical organizations that provide medical care to children, taking into account the provision of favorable conditions for the stay of children, including children with disabilities, and the possibility stay with them of parents and (or) other family members, as well as social infrastructure focused on organized recreation, improvement of children and restoration of their health.

9. Social protection of citizens in case of loss of health:

Social protection of citizens in case of loss of health is ensured by establishing and implementing legal, economic, organizational, medical, social and other measures that guarantee social security, including through compulsory social insurance, determining the citizen's need for social protection in accordance with the legislation of the Russian Federation. Federation, in rehabilitation and care in case of illness (condition), establishment of temporary incapacity for work, disability or in other cases determined by the legislation of the Russian Federation.

10. Responsibility of public authorities and local governments, officials of organizations for ensuring the rights of citizens in the field of health care:

1. Bodies of state power and bodies of local self-government, medical organizations and other organizations shall interact in order to ensure the rights of citizens in the field of health protection.

2. Bodies of state power and bodies of local self-government, officials of organizations shall, within their powers, be responsible for ensuring guarantees in the field of health protection established by the legislation of the Russian Federation.

11. The availability and quality of medical care are ensured by:

1) organizing the provision of medical care on the principle of proximity to the place of residence, place of work or education;

2) the availability of the required number of medical workers and the level of their qualifications;

3) the possibility of choosing a medical organization and a doctor in accordance with this Federal Law;

4) application of procedures for the provision of medical care and standards of medical care;

5) provision by a medical organization of a guaranteed volume of medical care in accordance with the program of state guarantees of free provision of medical care to citizens;

7) transport accessibility of medical organizations for all groups of the population, including the disabled and other groups of the population with limited mobility;

Yu.T. Sharabchiev, T. V. Dudina

Availability and quality of medical care: components of success

Republican Scientific and Practical Center for Medical Technologies, Informatization, Management and Health Economics, Ministry of Health of the Republic of Belarus, Minsk

The quality of medical care (QMC) is usually understood as a set of characteristics of medical care that reflects its ability to meet the needs of patients, taking into account healthcare standards that correspond to the current level of medical science, and the availability of medical care

This is a real opportunity for the population to receive the necessary medical care, regardless of social status, level of well-being and place of residence. In other words, quality medical care is timely medical care provided by qualified medical professionals and appropriate

statutory regulations, standards of care (case management protocols), contract terms, or customary requirements.

It is customary to attribute the following characteristics to the main criteria of the ILC:

1. Access to health care is free access to health services regardless of geographical, economic, social, cultural, organizational or language barriers.

The availability of medical care, declared in the constitutions of various countries, is regulated by national regulations (NLA), which determine the procedure and volume of free medical care, and is determined by a number of objective factors: the balance of the required volume of medical care to the population with the capabilities of the state, the availability and level of qualification of medical personnel, the availability of the necessary medical technologies in specific territories, the possibility of free choice by the patient of the attending physician and medical organization, the available transport facilities that ensure the timely receipt of medical

assistance, the level of public education on the problems of maintaining and promoting health, disease prevention.

Thus, the availability of medical care is the most important condition for the provision of medical care to the population in all countries of the world, reflecting both the economic capabilities of the state as a whole and the capabilities of a particular person. Nowhere is universal, equal and unrestricted access to all types of health care provided. It is believed that the way out of this situation is to reduce the cost of ineffective types of medical interventions and focus on providing citizens with equal access to the most effective medical services. This approach to the equitable use of scarce resources is called rationing and is practiced to varying degrees in all nations of the world. In poor countries, rationing is open and ubiquitous, affecting almost all types of medical care; in economically rich countries, it is usually limited to expensive types of care or certain groups of citizens. In addition, in many states there is hidden rationing: queues that make it impossible to receive treatment in

reasonable terms, bureaucratic obstacles, exclusion of certain types of treatment from the list of free services, etc.

The readiness of society to increase the availability of medical care largely depends on the economic condition of the country. But no country can spend more than 15% of GDP on the health of citizens, as these costs will negatively affect the prices of manufactured goods, which may lose competitiveness. Therefore, recognizing the limitations of the resources used to provide medical care is fundamental to understanding the possibilities of medicine in society. It is important that the rationing in the distribution of funds in the system of medical care be efficient, fair, professional and guarantee the possibility of obtaining quality medical care.

The mechanism that largely implements the right to access to medical care is its standardization. Medical standards (protocols of patient management) are drawn up with an understanding of the limited means and peculiarities of providing assistance in various medical and preventive organizations, therefore they lay down the minimum level of necessary assistance. Sometimes it comes in

contrary to the goal of providing technologically “modern” assistance. According to V. V. Vlasov, the availability of medical care can be realized by dividing the requirements into minimum (mandatory) and optimal care requirements, performed as needed (medical indications) and including expensive types of care. However, the second way, fixing expensive high-tech types of medical care in recommendations (standards), reduces its accessibility.

2. Adequacy. According to WHO experts, the adequacy of medical care is an indicator of the compliance of medical care technology with the needs and expectations of the population within the framework of an acceptable quality of life for the patient. According to a number of authors, adequacy includes the characteristics of the availability and timeliness of medical care, which is understood as the ability of the consumer to receive the assistance he needs at the right time, in a place convenient for him, in sufficient volume and at acceptable costs.

3. Continuity and continuity of medical care is the coordination of activities in the process of providing medical care to the patient at different times, different

mi specialists and medical institutions. Continuity in the provision of medical care is largely ensured by standard requirements for medical records, technical equipment, process and personnel. Such coordination of the activities of health workers guarantees the stability of the treatment process and its result.

4. Efficiency and effectiveness - the correspondence of the actually provided medical care to the optimal result for specific conditions. Effective health care should provide optimal (with available resources), and not maximum medical care, that is, meet quality standards and ethical norms. According to the WHO definition, optimal health care is the proper implementation (according to standards) of all activities that are safe and acceptable in terms of the costs used in this health care system.

5. Focus on the patient, his satisfaction means the participation of the patient in decision-making in the provision of medical care and satisfaction with its results. This criterion reflects the rights of patients not only to quality medical care,

but also on the attentive and sensitive attitude of the medical staff and includes the need for informed consent to medical intervention and respect for other rights of patients.

6. Safety of the treatment process - a criterion for guaranteeing safety for the life and health of the patient and the absence of harmful effects on the patient and doctor in a particular medical institution, taking into account sanitary and epidemiological safety.

The safety and efficacy of treatment for a particular patient largely depend on the completeness of the information available to the attending physician. Therefore, the safety of the treatment process, like other criteria, depends on the standardization of the treatment process and the training of the doctor. For example, in the United States, the training program for doctors, nurses, and pharmacists includes training in preventing medical errors, focusing on providing quality medical care, and testing healthcare professionals for their level of professionalism.

7. Timeliness of medical care: provision of medical care as needed, i.e. according to medical indications, quickly and in the absence of priority.

The timeliness of the provision of assistance specifies and complements the criterion of its availability and is largely ensured by highly effective diagnostic procedures that allow timely start of treatment, a high level of training of doctors, standardization of the process of providing assistance and the establishment of requirements for medical documentation.

8. The absence (minimization) of medical errors that impede recovery or increase the risk of progression of the patient's existing disease, as well as increase the risk of a new one. This component of quality medical care directly depends on the level of doctor’s training, the use of modern diagnostic and treatment technologies, as well as the establishment of qualification criteria for a particular workplace in the form of instructions, licenses, accreditations and the provision of sanitary and hygienic and metrological requirements.

9. Scientific and technical level. The most important component of the quality of medical care is the scientific and technical level of the applied methods of treatment, diagnosis and prevention, which makes it possible to assess the degree of completeness of care, taking into account modern achievements in the field of medical care.

knowledge and technology. This characteristic of the ILC is sometimes included in the criterion of adequacy.

Despite the right to affordable and high-quality medical care enshrined in the constitutions of many countries, the mechanisms for implementing this right differ in different states, which largely depends on the type of healthcare system in place. In most countries, the main mechanisms for ensuring the availability and appropriate quality of medical care are the legal and regulatory framework of the industry, which regulates the provision, management and control of medical care; standardization of the industry, carried out through normative and technical documents, and an examination system.

Obviously, effective management of the quality of medical care is impossible without the creation of a regulatory framework that regulates medical care at all levels of its provision. The legal framework of the industry is a system of interconnected legal acts from the law to the normative and technical document, binding on all healthcare institutions, regardless of the form of ownership and regulating the legal framework for the provision of medical care, its quality, accessibility and control.

la. In each country, the regulatory and legal framework of the industry is formed taking into account national traditions in the provision of medical care.

Industry standardization. An analysis of foreign experience indicates the effectiveness of using medical standards in the field of medical services as a regulatory framework for quality assurance and the main resource-saving tool that ensures the quality of medical care and protection of patients' rights. Standards act as the most important evidence-based mechanism for making decisions about the general availability or restriction of the availability of certain medical interventions. Over the past 10-15 years, in economically developed countries, appropriate industry-specific legal and regulatory frameworks and organizational structures have been created to ensure the activities of healthcare institutions and medical workers within the framework of professional standards and evidence-based medicine.

The approach to ensuring and assessing the quality of medical care based on the A. Donabedian triad has received worldwide recognition:

1) resources (or structure), including an assessment of the standards of the resource base (personnel, equipment and medical equipment; material

but-technical conditions for the stay of patients and the work of medical personnel);

2) a process (or technologies), including standards for treatment, diagnostics, and prevention technologies;

3) results (or outcomes), including standards for the results of treatment, prevention, diagnosis, rehabilitation, education, etc.

Ultimately, systemic standardization in the healthcare sector is aimed at creating and improving the regulatory framework for the industry, which ensures the availability and guarantee of high quality medical care in the following main areas of standardization:

medical technologies;

Sanitary and hygienic technologies;

educational standards;

Organizational and managerial technologies;

Information Technology;

Medicines circulation technologies;

Technologies regulating the issues of metrology and medical equipment.

The basis for creating a system for providing, evaluating and controlling the quality of medical care in all countries is the standardization of the organization of medical and diagnostic

process. The creation and implementation in each health facility of a system that provides an appropriate level of medical services includes the following main stages: the introduction of standards for the provision of medical care; licensing of medical activities; certification of medical services; licensing and accreditation of medical organizations; attestation and certification of specialists; creation of a material and technical base that allows meeting the standards of medical care.

The development of continuously updated standards in the field of medicine all over the world is carried out on the basis of a cost / effectiveness balance, based on the real situation, therefore, clinical and economic research is an essential component of a modern medical care quality management system that determines the development trends of the medical services market and allows you to optimize planning resource provision of health care.

The system of clinical and economic standards operating in a number of countries includes a methodology for a comprehensive assessment of the cMYP according to the criteria for minimizing errors and optimal use of resources. In other words-

Mi, medical care of proper quality is provided by a qualified doctor in accordance with the territorial standards of medical care and is expressed in the absence of medical errors.

Thus, the standard of medical care is a regulatory document that establishes the requirements for the process of providing medical care for a specific type of pathology (nosological form), taking into account modern ideas about the necessary methods of diagnosis, prevention, treatment, rehabilitation and the capabilities of a specific system of medical care, ensuring its proper quality. .

Medical technologies (MT), along with standards, play an important role in the system of improving the CMP, since the standards are updated when new MT are improved and put into practice. Since MTs require assessment and registration, each country has its own technologies and organizations that ensure their implementation in practice. International organizations for health technology assessment include ANTA - International Network of Health Technology Assessment Agencies and HTA1 - public organization for health technology assessment.

In Russia, the assessment of MT and standards is carried out by the interregional organization "Society for Pharmacoeconomic Research" and the Society of Evidence-Based Medicine Specialists, Technical Committee 466 for Medical Technologies under the Federal Agency for Technical Regulation and Metrology, the Ethics Committee, the Pharmaceutical Committee and other organizations.

Medical technologies in the Russian Federation are registered by the Federal Service for Surveillance in Healthcare and are divided into:

Registered in the State Register of New Medical Technologies of the Ministry of Health of the Russian Federation;

Approved by letters of the Ministry of Health of the Russian Federation;

Approved by orders of the Ministry of Health of the Russian Federation;

Approved by the current decisions of the congresses of doctors of specialists of the Ministry of Health of the Russian Federation;

Registered as inventions;

Not registered.

Systematization, assessment and registration of MT create the prerequisites for the unification of treatment standards. In some countries, in addition to treatment standards, medical and economic standards have been developed and used, clinical guidelines

guidelines, protocols for diagnosis and treatment.

In Belarus, standardized medical technologies have been used relatively recently and only in certain areas. While there is no single concept for the development of standardization of the industry, a program of work on standardization of health care has not been approved, the organizational structure of the service has not been developed, the parent and basic organizations for standardization in health care have not been identified, and the governing body organizing work on standardization in the industry has not been determined. There are significant gaps in the regulatory framework for standardization, there is no information support system for these processes. Due to the lack of backbone legal documents regulating the organization of work on standardization, the approved regulatory documents on the standardization of medical technologies are not "embedded" in real practice. The diagnostic and treatment protocols in force in our republic are approved by orders of the Ministry of Health of the Republic of Belarus, and not by the Decrees of the Ministry of Health of the Republic of Belarus, and are not published properly, therefore they are inaccessible and do not have proper legal force.

In addition, there is a certain legal conflict in understanding the mandatory use of treatment standards. From the point of view of the law "On technical regulation and standardization", the standards are used voluntarily, and from the point of view of the regulatory legal acts approved by the order of the Ministry of Health, their implementation is mandatory. In order to eliminate such a conflict, the Russian Federation adopted an amendment to the Federal Law “On Technical Regulation”, which notes that this law does not regulate relations related to the prevention and provision of MP.

Expertise and quality control of medical care. Expertise is a prerequisite and the main mechanism for ensuring and controlling the quality of MP. Examination of the CMP is carried out at various levels of the health care system and is regulated by special legal acts. Any examination is aimed at eliminating or identifying medical errors and defects in the provision of medical care.

The defect in the provision of medical care is understood as the improper implementation of diagnosis, treatment of the patient, organization of the process of providing medical care, which led or could lead to an unfavorable outcome of medical intervention.

A close and, in fact, identical concept in relation to defects

rendering MP is iatrogenic. Iatrogenic (iatrogenic pathology) is a defect in the provision of medical care, expressed as a new disease or pathological process that has arisen as a result of both lawful and illegal implementation of preventive, diagnostic, resuscitation, therapeutic and rehabilitation medical measures (manipulations).

Distinguish the following defects in medical care, which are a direct consequence of medical intervention:

1) intentional iatrogenies (intentional defect) - defects in the provision of MT associated with an intentional crime;

2) careless iatrogenic (careless defect) - defects in the provision of MC, containing signs of a careless crime;

3) erroneous iatrogenies (medical error) - defects in the provision of medical care associated with a conscientious misconception of a medical worker that does not contain signs of intent or negligence;

4) accidental iatrogenies (accident) - defects in the provision of medical care associated with an unforeseen set of circumstances during the lawful actions of medical workers.

In medical and legal

The Russian literature contains more than 60 definitions of medical error, while this concept is absent in the legislative acts of many countries. In an integrated form, a medical error is a harm to the health or life of a patient caused by an erroneous action or inaction of a medical worker, characterized by his conscientious error with a proper attitude to professional duties and the absence of signs of intent, negligence, negligence or negligence. In other words, a medical error is understood as a conscientious error of a doctor based on the imperfection of medical science and its methods, or the result of an atypical course of a disease or insufficient preparation of a doctor, if there are no elements of negligence, inattention or medical ignorance.

There are subjective and objective causes of medical errors. Subjective reasons include underestimation or overestimation of clinical, laboratory and anamnestic data, consultants' conclusions, insufficient qualifications of the doctor, inadequate and (or) belated examination of the patient, underestimation of the severity of his

states. The objective reasons include the short duration of the patient's stay in the clinic or his late hospitalization, the severity of the patient's condition, the complexity of diagnosis due to the atypical course of the disease and the lack of information about the pathological process, the lack of material resources and medicines.

Defects in the quality of medical care. An analysis of defects in the CMP is mandatory both from the point of view of investigating their causes, and in connection with the need to introduce professional liability insurance of medical workers into practice.

According to international statistics, the most significant causes of defects in the work of doctors include insufficient qualifications of medical workers - 24.7%, inadequate examination of patients - 14.7%, inattentive attitude towards the patient - 14.1%, shortcomings in the organization of the treatment process - 13, 8%, underestimation of the severity of the patient's condition - 2.6%. According to international judicial practice, defects in the organization of medical care account for at least 20% of all defects in medical care. According to the American Physicians Association, more than 200,000 deaths are caused by medical professionals every year in the United States.

Human . Approximately the same number of people die from the wrong prescription or side effects of drugs. From 3 to 5% of admissions of patients to hospitals are caused by side effects of drugs, which is ten times more than due to errors of surgeons. In Russia, according to experts, every third diagnosis is made incorrectly.

Examination of the CMP is carried out by identifying defects in its provision, to prove which, first of all, the licensed activities of the institution and compliance with the standards of medical care are studied. The main methods of examination are the study of the opinions of fellow experts and the comparison of the medical activities of the institution with world practice using quality indicators for assessing the correctness of the actions of medical personnel.

N.I. Vishnyakov et al. propose to single out three main links in the system of examination and quality control of medical care:

From the side of the manufacturer of medical services (internal quality control);

On the part of the consumer of medical services (consumer quality control);

From organizations independent of consumers and

manufacturers of medical services (external quality control).

Departmental examination and control of the ILC are carried out in a planned manner by order of higher officials. Departmental control of the quality and effectiveness of medical care is the main type of control closest to the providers of medical services. Its results are compared with the data of non-departmental expertise. Indicators of the quality and effectiveness of medical care can be used for differentiated remuneration of health workers.

In order to improve the system of supervision and control over compliance with the requirements of regulatory documents on the cMP, Russian experts recommend creating a Center for Standardization in Healthcare. At the same time, it is unlawful to assign supervisory functions to a body that implements standards. There is an opinion that the functions of licensing, accreditation and certification as components of a unified system of standardization in healthcare should be removed from the departmental system. Currently, these functions are dispersed among various structures that perform licensing and accreditation activities.

Non-departmental expertise and control of the CMP are carried out on the basis of an assessment of the resource and personnel capabilities of the healthcare facilities of the technologies used in the institution, as well as indicators of the volume and results of activities. Activities for the examination of the quality and volume of medical care are carried out at the initiative of any participant in civil law relations (licensing and accreditation commissions, insurance medical organizations, territorial compulsory medical insurance funds, insurers, professional medical associations, societies (associations) for protecting consumer rights, etc.) .

The main task of the subjects of non-departmental quality control of medical care is the organization of medical and medico-economic expertise in order to ensure the right of citizens to receive medical care of adequate quality and to verify the effectiveness of the use of health care resources, as well as financial resources of compulsory medical insurance (CHI) and social insurance.

In addition to these types of expertise, the ILC in many countries effectively operates a system of preventive control, which is an additional mechanism to ensure

ensuring the proper quality of medical care. As a rule, the system of preventive control is well developed in countries with MHI. In the Russian Federation, for example, preventive control is carried out by the licensing and accreditation commission before licensing and accreditation of a medical institution or individual. The purpose of preventive control is to assess the ability of a medical institution or individual to provide the declared types of medical care, as well as the compliance of their activities with established standards.

To date, the cMYP criteria used to distinguish between appropriate and improper medical care have been thoroughly developed only in forensic medicine and in the field of health insurance. With this in mind, there is a need to create unified approaches to assessing the ILC, based on generally accepted principles, criteria and indicators, which should be contained in professional standards and legislated.

Common to all criteria for evaluating the cMYP in all countries is the minimization of errors and the optimal use of financial resources with the mandatory standardization of the processes for providing medical care.

The most objective (and direct) criterion of the CMP remains the patient's condition (his quality of life).

In an integral assessment of the CMP, it is customary to consistently consider the following characteristics: the effectiveness of the treatment process, the effectiveness of medical care, the technical and technological competence of specialists, the safety of patients and medical personnel in the process of ongoing medical interventions, the availability of medical care and the principles of its provision. The interpersonal relations between the doctor and the patient, the continuity of the treatment process, the patient's satisfaction with the ongoing treatment and preventive measures are also subject to assessment.

Evaluation of the CMP is carried out at different levels: countries, regions, individual medical institutions. Accordingly, the criteria for its evaluation at each level will differ. At the national level of health care management, criteria for the quality of care include demographics, morbidity data, and other reported information from health care institutions. In the Republic of Belarus, for example, to assess the cMYP, you can use the criteria laid down in the territorial model of the final results.

The main indicators of the quality of medical care. According to the terminology adopted in the Russian Federation, indicators of the quality of medical care are numerical indicators used to evaluate medical care, indirectly reflecting its main components: resources (structure), processes and results. These quantitative indicators, expressed, as a rule, as a percentage, are used to evaluate the activities of medical facilities, predict the development of practical medicine, as well as differentiated wages depending on the quality of work. ILC is usually considered from the standpoint of:

The quality of the material and technical base of health facilities and medical personnel;

Availability of medical technologies with proven effectiveness;

Availability of approved technologies for the provision of medical services;

Availability of optimized organizational technologies;

Availability of indicators for assessing the health of patients and their assessment in the course of treatment;

Analysis of the correspondence between the obtained clinical results and the costs incurred.

Threshold (target) values of the KMP indicator is an interval of values set as target or acceptable (when assessing the frequency

such negative phenomena as complications, repeated hospitalizations, lethality, etc.) according to the control points of the treatment process. Sources for setting thresholds for quality indicators are clinical guidelines, systematic reviews, results of best practices, and expert opinions. The quality indicator can have a target and actually achieved value. The ratio of the actual value of the quality indicator to the target value, expressed as a percentage, is called the goal achievement index.

Resource indicators (structures) - quantitative indicators used to characterize individuals and organizations providing medical services. They can be used at any level of the healthcare system (industry, territory, individual health facility) and characterize the following areas:

Conditions for the provision of medical care;

Adequacy of financing and use of funds;

Technical equipment and efficiency of equipment use;

The number and qualifications of personnel;

Other resource components.

Medical process indicators are used to assess the right

the viability of the management (treatment) of patients in certain clinical situations (prevention, diagnosis, treatment and rehabilitation). The number of quality indicators selected for monitoring is determined by the complexity of the tasks. Therefore, in developed countries, the management of patients with diseases that have the highest weight in the structure of mortality is usually monitored.

Results indicators. Outcome evaluation is the determination of the patient's health status after treatment and comparison of the results with reference ones established on the basis of scientific experiments and clinical assessments. These are the main characteristics of medical care, when the expected results are compared with actually achieved. The most commonly used outcome indicators are readmission rates and in-hospital mortality.

In the countries of the European Union, for several years now, a system for evaluating the cMYP has been open to the public. The annual rating of medical institutions, ranked by points, makes it possible to judge the degree of openness of national health care systems for consumers of its services. In the European Healthcare Consumer Index 2007, Austria ranked first, out of

1000 possible points scored 806. According to the European Health Consumer Index 2007, the openness of health care systems is defined by criteria that reflect the extent to which a consumer can exercise his rights. For example, in Denmark, clinics are assigned categories of different stars, like hotels, not only for service and comfort, but also for reducing mortality and medical errors. In terms of the quality of treatment, Belgium and Sweden were ahead, and the quality of treatment was evaluated solely in accordance with the interests of the patient - in terms of survival after a serious illness. The criteria for the quality of treatment also include infant mortality, the number of cases of nosocomial infections, etc. . In addition, in the EU countries there is a public organization "Initiative group of consumers of medical services", which evaluates the performance of the system from the point of view of patients.

The health care system using the above criteria and indicators in our country would receive a low rating. This is primarily due to the fact that, despite the rights of patients declared in the basic laws in the healthcare sector of the Republic of Belarus, the mechanism for their

protection and the role of public organizations. In addition, there is no publicly available qualification register of doctors and clinics in the republic. A patient receiving medical care in the state healthcare system does not have a real opportunity to receive compensation in the pre-trial procedure in case of a medical error. There is a procedure that limits the patient's ability to go to the polyclinic to some highly specialized specialists, bypassing the therapist. This is convenient from the point of view of cost savings for a polyclinic institution, however, it makes the patient dependent on the competence of the therapist. Queues in polyclinics, the lack of a system of non-departmental expertise of the ILC and many other things that can be blamed on the domestic healthcare system, once again emphasize the importance of creating a system of adequate quality of medical care in the Republic of Belarus.

Methodology of quality management in health care. Quality management is not just an assessment of the end result, but the creation of a special technological process that ensures compliance with certain requirements and standards. Deviation from technological conditions (or what is called defects in the provision of medical

Qing aid) depends not only on the performers, but also on the system in which they work.

Each country uses its own quality management methodology in healthcare, legalized in national and international legal acts. In the Russian Federation, for example, the creation of a quality control system in healthcare and the definition of its legal framework is regulated by the Law on Health Insurance (1993), orders of the Ministry of Health of the Russian Federation and FFOMS on departmental and non-departmental quality control (1996), a government decree on the Program of State Guarantees of Free Medical Care ( 1998), Orders of the Ministry of Health of the Russian Federation "On the introduction of Protocols for the management of patients" (1999), "On the introduction of the institute of quality representatives" (2001) and other documents.

International experience in creating a quality management system for medical care includes the following main organizational tasks:

Interdepartmental interaction of management structures, medical institutions and institutions of the health insurance system, medical associations, public organizations and patients;

Development of a unified methodology for intra- and non-departmental expert

types of quality of medical care, as well as indicators (indicators) of the quality of medical care and methods for assessing these indicators;

Development and implementation of a system for monitoring the quality of medical care, aimed at collecting information with subsequent analysis and making management decisions to improve long-term planning;

Development of a system of standardization, licensing, certification, accreditation in healthcare;

Development and implementation of a motivation system and economic incentive mechanisms for medical workers, depending on the amount of work done, the quality and results of the medical care provided.

Thus, the essence of the concept of quality management of medical care is to make management decisions based on the analysis of target indicators (or results) of activities that have a multi-stage (hierarchical) structure and are formed according to the principle of a “tree of goals” for the institution as a whole, each management block (type activities) of a single unit and are expressed in quantitative terms.

The system of indicators is developed in each organization and

reflects its specifics and priorities. To do this, an optimal organizational structure is being formed in the institution, which is most adapted to solving strategic problems and implementing functional strategies. A special place is occupied by the assessment of resource provision, therefore, an important point in the field of improving quality and minimizing costs is the assessment of the so-called loss function. According to G. Taguchi, the characteristics of quality are the costs and losses resulting from any deviation from the required quality. G. Tagu-ti defines losses as a function of the loss factor multiplied by the square of the difference between the required and received quality level. At the same time, quality losses grow in a quadratic dependence as the quality values obtained deviate from the required indicators. For example, a 2-fold loss in patient service time leads to a 4-fold increase in the cost of medical care due to possible complications. The cost of defect prevention is 25% of the total cost of services, and the share of the cost of eliminating the consequences of defects reaches about 3/4 of the cost of services. In world practice, the upper and lower bounds are taken as the reference target quality standard.

tolerance for each indicator, located at a distance of ± 6 8 from the average value .

In modern conditions, the quality management system in healthcare is focused on the development and approval of standards (including patient management protocols), covering both the main activities and the work of supporting services, as well as the creation of a system of licensing and control mechanisms, the search for elimination and prevention measures. defects.

It is believed that improving the quality of MT inevitably requires additional time, effort and resources. However, the attraction of additional resources does not at all guarantee an increase in the ILC. At the same time, the introduction of standards can lead to a “leveling” of quality and minimization of costs. Improving the quality of medical care (correct diagnosis at the first stage) contributes to an increase in efficiency, a reduction in the duration of treatment, a decrease in the frequency of repeated hospitalizations and complications, which significantly reduces healthcare costs.

With the development of evidence-based medicine, it becomes obvious that many clinical and organizational aspects of medical care require a revision of legislative and regulatory

mechanisms, including in our republic. First of all, a multilevel system of management, assessment and monitoring of the quality and examination of medical care is needed, linked to a system for monitoring the resources spent on its provision, which can be the system of national accounts. Of great importance is the creation of an institution for the standardization of medical care, carried out on the basis of clinical guidelines, protocols for managing patients, diagnostic and treatment standards that have an appropriate legal status.

The creation and replication of centers of high-tech types of medical care throughout the regions of the republic undoubtedly contributes to improving the quality of medical care and shaping an opinion among the population and health workers about what the level of medical care, including medical service, should be. However, one should not forget that less than 1% of the volume of medical care and medical services is provided in the centers of high-tech types of MP; and in an ordinary polyclinic, hospital, and even in a clinical hospital, the quality of medical care, to put it mildly, leaves much to be desired. There is no need to talk about medical service.

In this regard, it is advisable to form several exemplary healthcare organizations (polyclinics, hospitals, clinical hospitals), which will resolve the issue of the quality of medical care and medical services with the required equipment of modern equipment and which will be staffed by well-paid, certified medical workers of high qualification and professional culture. .

The introduction of compulsory medical insurance in the republic (insurance of financial risks associated with the provision of medical care) is extremely important for creating a system for providing quality medical care. At present, Belarus has remained one of the few countries in the world where there is no compulsory medical insurance system (among the developed countries, it is probably the only one). Meanwhile, the introduction of the CHI system is a natural and evolutionary process in the development of health care in all socially oriented countries, which not only allows improving the quality of medical care through an independent examination system, but also contributes to the inflow of additional financial resources into health care, competition among medical organizations, and the formation of a market for medical

services, reduction of unit costs for the provision of medical care, introduction of new medical technologies, standardization of health care and real use in practice of standards and treatment protocols.

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