Thông tư 25/2020/TT-BYT quy định về việc xét tặng Giải thưởng quốc gia về chất lượng bệnh viện do Bộ Y tế ban hành

CIRCULAR

PRESCRIBING NATIONAL HOSPITAL QUALITY AWARDS

Pursuant to the Law on emulation and commendation dated November 26, 2003; the Law on amendments to the Law on emulation and commendation dated June 14, 2005 and the Law on amendments to the Law on emulation and commendation dated November 16, 2013;

Pursuant to the Government's Decree No. 91/2017/ND-CP dated July 31, 2017 providing guidelines for implementation of the Law on emulation and commendation;

Pursuant to the Government’s Decree No. 75/2017/ND-CP dated June 20, 2017 defining functions, tasks, powers and organizational structure of the Ministry of Health;

At the request of the Director of the Department of Medical Service Administration,

The Minister of Health promulgates a Circular prescribing consideration and presentation of National hospital quality awards.

Chapter I

GENERAL PROVISIONS

Article 1. Scope and regulated entities

1. This Circular provides regulations on names of national hospital quality awards (hereinafter referred to as “awards”), standards and organization of consideration and presentation of such awards.

2. This Circular applies to:

a) Hospitals meeting quality requirements in the Hospital quality criteria and the Criteria for topic-specific quality assessment promulgated by the Minister of Health;

b) Regulatory authorities, organizations and individuals involved in consideration and presentation of awards.

Article 2. Time of award consideration and presentation

1. National hospital quality awards shall be considered and conferred every two years and announced on the occasion of the World Standards Day (October 14).

2. The organization of award consideration and presentation begins in 2021.

Article 3. Rules for award consideration and presentation

1. Awards must be presented to proper entities according to standards and procedures laid down herein.

2. Accuracy, democracy, openness and transparency must be ensured.

3. There is no limit on awarding times and titles conferred to each collective.

Chapter II

AWARD NAMES AND STANDARDS

Article 4. Award names

1. National quality awards:

a) National gold award for hospital quality: 01 award;

b) National silver award for hospital quality: 02 awards.

2. Topic-specific awards include 01 gold award and 01 silver award for each of the following topics:

a) Patient safety award;

b) Surgical safety award;

c) Clinical quality award;

d) Testing quality award;

dd) Hospital pharmacy award;

e) Patient care award;

g) Clinical nutrition award;

h) Bacterial contamination control award

i) Health workforce development award;

k) Award for improvement of medical examination and treatment process;

l) Award for application of information technology in hospital;

m) Patient satisfaction award.

Article 5. Award forms

1. The national awards shall be conferred in the form of certificate and gold or silver cup.

2. Topic-specific awards shall be conferred in the form of certificate and gold or silver award trophy.

Article 6. Standards for national quality awards

1. Minimum standards:

a) The hospital must obtain at least 4,00 points in the hospital quality assessment performed by a regulatory authority according to the Hospital quality criteria enclosed with the Decision No. 6858/QD-BYT dated November 18, 2016 of the Minister of Health (hereinafter referred to as “Hospital quality criteria”) and none of the criteria is assessed at level 3 within at least 02 consecutive years by the time of consideration;

b) The hospital has developed the system for compulsory and voluntary reporting on medical events in accordance with the Minister of Health’s regulations on prevention of medical events in health facilities for 2 years or more. It has not committed any medical errors causing death according to conclusions of the Professional Council as prescribed in the Law on Medical Examination and Treatment within at least 02 consecutive years by the time of consideration;

c) The hospital has conducted patient and healthcare worker satisfaction surveys according to the Ministry of Health’s guidelines and achieved at least 85% of patient and healthcare worker satisfaction;

d) The hospital has won at least a topic-specific award within the same consideration year (this standard shall not be applied in the first consideration in 2021).

2. Specific standards:

After obtaining the list of hospitals meeting the minimum standards prescribed in Clause 1 of this Article, the Quality assessment team of the Ministerial-level award consideration council shall re-assess such hospitals according to the Hospital quality criteria and conduct patient and healthcare worker satisfaction surveys for conferring the following awards:

a) 01 gold award shall be conferred to the hospital that achieves the first rank of hospital quality among the assessed hospitals;

b) 02 silver awards shall be conferred to the hospitals that achieve the second and third ranks of hospital quality among the assessed hospitals;

c) If two or more hospitals are given the same quality score for an award or their scores differ by 0,05 or less, the secondary standards shall be considered in the following order:

- The number of topic-specific awards achieved by the hospital;

- The hospital’s satisfaction of quality standards of international organizations such as JCI, HAS or equivalent;

- International specialty- or topic-specific awards achieved by the hospital;

- The hospital’s initiatives for quality improvement assessed by the council and recognized by competent authorities. Initiatives have considerable impacts, have been developed in a large scope or scale and actively influenced the patient and healthcare worker satisfaction as well as physicians' image and the hospital’s prestige;

- The hospital’s patient and healthcare worker satisfaction survey results given by the Quality assessment team of the Council.

Article 7. Standards for topic-specific awards

1. Minimum standards:

a) The hospital must obtain at least 3,75 points in the general hospital quality assessment performed by a regulatory authority according to the Hospital quality criteria promulgated by the Minister of Health and none of the criteria is assessed at level 2 in at least 02 consecutive years by the time of consideration;

b) The hospital must obtain at least quality 4,00 points for topic-specific criteria as prescribed in Clause 2 of this Article;

c) The hospital has developed the system for compulsory and voluntary reporting on medical events in accordance with the Minister of Health’s regulations on prevention of medical events in health facilities for 2 years or more. It has not committed any medical errors causing death according to conclusions of the Professional Council as prescribed in the Law on Medical Examination and Treatment within at least 02 consecutive years by the time of consideration;

d) The hospital has conducted patient and healthcare worker satisfaction surveys according to the Ministry of Health’s guidelines and achieved at least 85% of patient and healthcare worker satisfaction.

2. Specific standards for topic-specific awards:

After obtaining the list of hospitals meeting the minimum standards prescribed in Clause 1 of this Article, the Quality assessment team of the Ministerial-level award consideration council shall re-assess the quality of topics according to the following specific criteria:

a) Patient safety award: the criteria in C1.1, C1.2 and the entire of Party D of the Hospital quality criteria;

b) Surgical safety award: the Surgical safety assessment criteria enclosed with the Decision No. 7482/QD-BYT dated December 18, 2018 of the Minister of Health;

c) Clinical quality award: the criteria from C5.1 to C5.5 and Criteria C10.1 and C10.2 of the Hospital quality criteria;

d) Testing quality award: the criteria C8.1, C8.2 of the Hospital quality criteria and the Criteria for quality assessment of medical laboratories enclosed with the Decision No. 2429/QD-BYT dated June 12, 2017 of the Minister of Health;

dd) Hospital pharmacy award: the criteria C9.1 to C9.6 of the Hospital quality criteria;

e) Patient care award: the criteria A2.1 to A2.5, the criterion A4.2 and the criteria C6.1 to C6.3 of the Hospital quality criteria;

g) Clinical nutrition award: the criteria C7.1 to C7.5 of the Hospital quality criteria;

h) Bacterial contamination control award: the criteria A3.1, A3.2 and the criteria C4.1 to C4.6 of the Hospital quality criteria;

i) Health workforce development award: the criteria in Party B of the Hospital quality criteria;

k) Award for improvement of medical examination and treatment process: the criteria A1.1 to A1.6 and the criteria A4.1, A4.3, A4.4 of the Hospital quality criteria;

l) Award for application of information technology in hospital: the criteria C2.1, C2.2 and the criteria C3.1, C3.2 of the Hospital quality criteria; m) Patient satisfaction award: the criteria A4.5, A4.6 of the Hospital quality criteria and regulations on patient and healthcare worker satisfaction in the Decision No. 3869/QD-BYT dated August 28, 2019 of the Minister of Health.

3. Types of a topic-specific award and standards thereof:

a) 01 gold award shall be conferred to the hospital that achieves the first rank of topic-specific quality criteria among the assessed hospitals;

b) 01 silver award shall be conferred to the hospital that achieves the second rank of topic-specific quality criteria among the assessed hospitals;

c) If two or more hospitals are given the same quality score for a topic-specific award, the secondary standards shall be considered in the following order:

- The hospital has obtained certificate(s) of quality of the considered topic or specialty recognized or accredited by international organization(s);

- The hospital has won international award(s) for the considered topic or specialty;

- The hospital has more initiatives for improvement of quality of the considered topic which have been assessed by the council and recognized by competent authorities;

- The hospital has obtained higher results of patient and healthcare worker satisfaction surveys conducted by the Quality assessment team of the Council.

Chapter III

ORGANIZATION OF AWARD CONSIDERATION AND PRESENTATION

Article 8. Power to consider and present awards

The Minister of Health shall decide the consideration and presentation of awards according to the standards in Article 6 and Article 7 hereof at the request of the Award consideration council.

Article 9. Award consideration council and its standing unit

1. The Minister of Health shall establish the Award consideration council and its standing unit. The standing unit is located at the premises of Department of Medical Service Administration affiliated to Ministry of Health.

2. The Council’s composition:

The Council is composed of 09 - 11 members, including:

a) The Council’s Chairperson: a head of the Ministry of Health;

b) Council’s Vice Chairpersons: Director of Department of Medical Service Administration and Director of Department of Communication and Emulation, Commendation;

c) Council’s members: heads of Department of Medical Service Administration, Traditional Medicine Administration, Department of Legal Affairs, Department of Organization and Personnel, Inspector of the Ministry of Health, heads of relevant agencies/units and experts in the field of medical examination and treatment, representative(s) of Vietnam Medical Association or Vietnam Nurses Association or other trade associations.

3. The Council shall perform the following duties:

a) Organize the consideration and presentation of awards at the request of its standing unit;

b) Consider revoking awards according to Clause 2 Article 12 hereof.

4. The standing unit shall perform the following duties:

a) Perform duties as assigned by the Council’s Chairperson;

b) Compile the list of hospitals and inspect, review and examine their satisfaction of the minimum standards in Article 6 and Article 7 hereof;

c) Submit re-assessment results to the Council and consolidate and compile the list of qualified hospitals.

Article 10. Establishment of the Council’s quality assessment team

1. The Director of Department of Medical Service Administration shall establish the Council's quality assessment team to serve the consideration and presentation of awards.

2. The Quality assessment team is composed of 05 - 07 members, including:

a) Team’s head: a head of Department of Medical Service Administration;

b) Team’s members are experienced experts in the field of quality management.

3. The Quality assessment team shall perform the following duties:

a) Carry out re-assessment of hospitals according to the standards in Article 6 and Article 7 hereof.

b) Submit reports on assessment results to the Council’s standing unit.

Article 11. Process of assessment, consideration and presentation of awards

1. Topic-specific awards shall be assessed, considered and presented first. Then, assessment results of such topic-specific awards shall be used for consideration of national awards.

2. Assessment and consideration process:

a) Step 1: The Council’s standing unit compiles the list of hospitals satisfying the minimum standards in Article 6 and Article 7 hereof;

b) Step 2: Director of Department of Medical Service Administration establishes the Quality assessment team;

c) Step 3: The Quality assessment team carries out re-assessment of hospitals on the list;

d) Step 4: The Quality assessment team sends the report on assessment results to the standing unit;

dd) Step 5: The standing unit submits the report to the Council for meeting and consideration, selection of qualified hospitals;

e) Step 6: The Council’s standing unit requests the Minister of Health to sign the decision on award presentation.

3. Organization of award announcement and presentation ceremony:

Pursuant to the Decision on award presentation, the Ministry of Health shall organize the award announcement and presentation ceremony. The award announcement and presentation ceremony shall be organized according to the schedule prescribed in Clause 1 Article 2 hereof.

Article 12. Revocation of awards

1. Hospitals, Quality assessment team, standing unit and Council shall assume responsibility for the accuracy of hospital quality assessment results which are used as the basis for award presentation.

2. If any violation is found in the course of assessment and consideration of an award or assessment results are falsified, depending on the nature and severity of the violation, the Council shall consider and request the Minister of Health to revoke the conferred award and cancel award consideration result.

Chapter IV

IMPLEMENTATION

Article 13. Effect

This Circular comes into force from February 15, 2021.

Article 14. Reference

If any legislative documents referred to in this Circular are superseded or amended, the new ones shall apply.

Article 15. Responsibility for implementation

Director of Department of Medical Service Administration, heads of Ministry of Health’s affiliated agencies and units, Directors of Provincial Departments of Health, heads of health agencies of Ministries and central authorities, and relevant agencies, organizations and individuals shall implement this Circular.

Difficulties that arise during the implementation of this Circular should be promptly reported to the Ministry of Health (via Department of Medical Service Administration) for consideration./.

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