Circular No. 19/2013/TT-BYT guiding the implementation of quality management for medical examination and treatment services at hospitals

CIRCULAR

Guidelines for Implementing Quality Management of Medical Services

at Hospitals

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This Circular prescribes procedures for receiving, providing health care for domestic violence victims and statistical reports on domestic violence victims at medical facilities.

The Ministry of Health issues this Circular to provide guidelines on implementing quality management of medical services at hospitals.

PART I

GENERAL PROVISIONS

Article 1. Scope of application

This Circular provides guidance on the management of quality of medical services at hospitals (hereinafter referred to as hospital quality management), including:

1. Content of Implementing Hospital Quality Management.

2. Organizational System for Hospital Quality Management.

3. Responsibilities for Implementing Hospital Quality Management.

Article 2. Principles for Organizing and Implementing Hospital Quality Management

1. Patient-centered approach.

2. Ensuring and improving quality is a central and continuous task of the hospital, carried out regularly, consistently, and stably.

3. Decisions related to quality management activities in the hospital are based on legal grounds, scientific foundations with specific evidence and meet the practical needs to improve hospital quality.

4. The hospital director is responsible for hospital quality. All staff members, civil servants, employees, and workers (collectively referred to as healthcare personnel) in the hospital have the responsibility to participate in quality management activities.

Chapter II

CONTENT OF IMPLEMENTING QUALITY MANAGEMENT IN HOSPITALS

QUALITY MANAGEMENT IN HOSPITALS

Article 3. Developing Plans and Programs to Ensure and Improve Quality in Hospitals

1. The hospital establishes, promulgates, and disseminates quality goals so that healthcare personnel, patients, and the community are aware. Quality goals must be consistent with relevant policies, laws concerning quality and hospital resources.

2. The hospital develops, approves plans, and implements programs to ensure and improve quality through prioritizing key issues. The content of the quality plan is integrated into the annual and five-year activity plans, consistent with hospital resources.

Article 4. Maintaining National Technical Standards for Hospitals

1. The hospital ensures conditions to obtain an operating permit according to the schedule specified in Government Decree No. 87/2011/NĐ-CP dated September 27, 2011.

2. Hospitals that have been granted permits are responsible for continuing to maintain activities to meet national technical standards and other conditions stipulated by the Ministry of Health.

Article 5. Establishing Quality Indicators, Data Bases, and Measuring Hospital Quality

1. Develop a set of hospital quality indicators based on the Ministry of Health's guidelines and referencing domestic or international hospital quality indicator sets.

2. Conduct measurements of hospital quality indicators.

3. Organize data collection, management, storage, exploitation, and utilization related to hospital quality.

4. Integrate quality reports into the hospital's general activity reports.

5. Apply information technology to build databases, analyze, and process information related to hospital quality management.

Article 6. Implementation of Professional Regulations and Guidelines in Medical Examination and Treatment

1. Organize the implementation of professional regulations and guidelines issued by the Ministry of Health and the hospital, including diagnostic and treatment guidelines, technical procedure guidelines, care procedure guidelines, and other professional guidance documents.

2. Organize the implementation of quality certification to evaluate the execution of professional regulations and guidelines by the hospital; systematically analyze the quality of diagnosis, treatment, and patient care, including clinical and paraclinical procedures used in diagnosis, treatment, and patient care.

Article 7. Implement measures to ensure patient and healthcare worker safety

1. Establish programs and develop specific regulations to ensure patient and healthcare worker safety, including the following main contents:

a) Accurately identify patients to avoid confusion when providing services;

b) Surgical and procedural safety;

c) Medication safety;

d) Hospital infection prevention and control;

đ) Prevent risks and errors due to miscommunication among healthcare workers;

e) Prevent patient falls;

g) Safety in the use of medical equipment.

2. Ensure a safe working environment for patients, visitors, and healthcare workers; prevent accidents, risks, and occupational exposure.

3. Establish a system for collecting and reporting medical errors and adverse events in clinical departments and throughout the hospital, including mandatory and voluntary reports.

4. Develop procedures to evaluate medical errors and adverse events to determine root causes, systemic causes, and subjective causes of healthcare workers; assess potential risks that may occur.

5. Address medical errors and adverse events and take corrective actions for root causes, systemic causes, and subjective causes of healthcare workers to minimize errors, adverse events, and prevent risks.

Article 8. Apply hospital quality management standards

1. Hospitals base on the quality management criteria and standards issued or recognized by the Ministry of Health to select appropriate criteria and standards and implement them at the hospital.

2. The process of implementing quality management criteria and standards is carried out according to the guidance of the issuing agency or the quality certification organization.

3. After receiving a quality certification, hospitals must continue to maintain and improve quality.

Article 9. Evaluate hospital quality

1. Implement internal hospital quality evaluations based on quality management criteria and standards issued or recognized by the Ministry of Health.

2. Evaluate the effectiveness of applying quality management criteria, standards, models, and methods at the hospital to make decisions on selecting appropriate criteria, standards, models, and methods.

3. Hospitals regularly conduct surveys and evaluate patient and family satisfaction, as well as healthcare worker satisfaction, at least once every three months, serving as a basis for improving patient service quality and healthcare worker satisfaction.

4. Hospitals establish quality reports and publicly release quality reports according to the guidelines of the Ministry of Health.

5. Management agencies conduct hospital quality evaluations or review quality reports based on quality management criteria and standards issued or recognized by the Ministry of Health annually or as needed.

Chapter III

QUALITY MANAGEMENT SYSTEM IN HOSPITALS

Article 10. Organize the quality management system in hospitals

1. The quality management system in hospitals includes: the hospital quality management council chaired by the hospital director and vice-director responsible for professional matters as deputy chairman; the quality management department/team; dedicated quality management staff; a quality management network suitable for the scale of the hospital.

2. Special-class hospitals and first-class general hospitals establish a quality management department; other hospitals decide to establish a department or team based on their scale, conditions, and needs. The quality management department/team closely coordinates with departments and functional units to perform hospital quality management tasks.

3. The hospital quality management network: established from the hospital level down to departments, units within the hospital, coordinated by the quality management department/team.

4. Activities of the hospital quality management council:

a) The chairman assigns tasks to members and establishes the operation rules of the hospital quality management council;

b) The chairman sets up the quality management system, develops and issues quality management documents in the hospital;

c) The hospital quality management council organizes regular and ad hoc meetings to support, monitor, and provide recommendations related to quality management.

5. Organization and tasks of the hospital quality management council; quality management department/team; duties and powers of the head of the quality management department/team and network members are implemented according to Articles 11, 12, 13, 14, and 15 of this Circular.

Article 11. Organization and tasks of the Quality Management Council

1. Organization:

The Quality Management Council in the hospital is established, regulated, and maintained in operation by the hospital director's decision; the permanent secretary is the head of the quality management department or the head of the quality management team in the hospital. The number of council members depends on the scale of the hospital, including representatives from departments and units related to hospital quality improvement activities and patient safety.

2. Tasks:

a) Identifying quality issues, potential risks to patient safety, prioritizing activities, and proposing projects to ensure and improve hospital quality and patient safety for the hospital director's approval;

b) Assisting the director in implementing the quality management criteria and standards issued or recognized by the Ministry of Health, suitable for the hospital's conditions;

c) Participating in organizing the implementation of quality management criteria and standards, internal quality assessment of the hospital, and approving the hospital's quality report;

d) Providing technical support to departments and units to implement activities under quality assurance and improvement projects approved by the hospital director.

Article 12. Organization and tasks of the Quality Management Department/Team

1. Organization:

a) The hospital's quality management department has a head, deputy head, and staff, depending on the hospital's scale and decided by the director;

b) The hospital's quality management team is directly managed by the director or is part of a functional department managed by the department leader.

2. Tasks:

It serves as the main unit to implement and advise the director and the hospital's quality management council on hospital quality management work:

a) Developing plans and contents of quality management activities in the hospital to be submitted for the director's approval;

b) Organizing the implementation, monitoring, supervising, evaluating, reporting, coordinating, and supporting the implementation of quality management activities and quality assurance and improvement projects in departments and units;

c) Serving as the focal point for establishing a system to manage errors and incidents, including detection, consolidation, analysis, reporting, and researching solutions to address them;

d) Serving as the focal point for coordinating with departments and units to resolve complaints, reports, accusations, and issues related to patient satisfaction;

đ) Collecting, consolidating, analyzing data, managing, and securing information related to hospital quality. Coordinating with the hospital's statistics and IT department to measure hospital quality indicators;

e) Implementing or coordinating the organization of training, instruction, and capacity building on quality management;

g) Organizing internal quality assessments of the hospital based on quality management criteria and standards issued or recognized by the Ministry of Health;

h) Implementing evaluations of compliance with professional regulations and guidelines of the Ministry of Health;

i) Building and implementing a patient safety program.

Article 13. Tasks and Authorities of the Head of the Quality Management Department/Team

1. Duties:

a) Organizing the full implementation of the tasks of the quality management department/team and being responsible for the activities of the quality management department/team.

b) Summarizing and reporting the activities of the quality management department/team, results of hospital quality improvement work, and patient safety;

c) Supporting quality groups in departments and units in implementing quality assurance and improvement projects;

d) Participating in hospital quality assessments;

đ) Serving as the secretary of the hospital's quality management council.

2. Authorities:

a) Inspecting and requiring departments, units, and individuals to comply with the hospital's quality management plan;

b) Proposing rewards and disciplinary actions for individuals and groups in the implementation of quality management tasks to the director.

Article 14. Duties and Authorities of Hospital Quality Management Department Personnel

1. Duties:

a) Perform tasks according to the job description of the hospital quality management department and other tasks assigned by the head of the hospital quality management department;

b) Collect, analyze, manage, and secure data related to hospital quality management in the assigned field;

c) Supporting quality groups in departments and units in implementing quality assurance and improvement projects;

d) Participate in training, instruction, seminars, and capacity building for hospital quality management and evaluate hospital quality.

2. Authorities:

a) Inspect and supervise hospital quality management activities of departments and units;

b) Urge individuals and units to implement corrective measures following inspections and supervision;

c) Propose rewards for units and individuals who perform well in hospital quality management work.

Article 15. Members of the Hospital Quality Management Network

1. Each department, unit (referred to as unit) of the hospital shall appoint at least one staff member to concurrently participate in the hospital quality management network.

2. Duties of members of the hospital quality management network at the unit level:

a) Serve as a liaison to assist unit leadership in implementing, executing, and monitoring activities related to hospital quality management;

b) Carry out plans of the hospital quality management network activities at the unit level;

c) Participate in hospital quality inspections and evaluations as assigned by the Hospital Quality Management Council.

Chapter IV

RESPONSIBILITIES FOR HOSPITAL QUALITY MANAGEMENT

Article 16. Responsibilities of the Hospital Director

1. Direct, disseminate, and enforce the contents of this Circular to all officials, civil servants, and employees in the hospital.

2. Establish a hospital quality management organizational system in accordance with the guidelines set forth in Articles 10, 11, 12, and 15 of this Circular.

3. Implement and apply quality management criteria and standards issued or recognized by the Ministry of Health.

4. The hospital director shall allocate funds for quality management activities:

a) Implement activities applying quality management criteria and standards issued or recognized by the Ministry of Health;

b) Maintain and improve quality;

c) Organize and assign personnel for training, instruction, seminars, and capacity building on quality management;

d) Reward outstanding collectives and individuals in hospital quality management activities;

đ) Contract for quality consulting, evaluation, and certification services.

e) Other quality improvement activities and patient safety initiatives based on hospital needs.

5. Ensure human resources and training in quality management, including:

a) Invest in human resources for quality management, establish a quality management department or team, and assign medical personnel to be responsible for or concurrently engaged in quality management;

b) Organize or send medical personnel to participate in quality management training, instruction, seminars, and capacity building programs conducted by domestic and international organizations;

c) Send medical personnel specializing in hospital quality management to attend advanced quality management training programs.

6. Ensure conditions for equipment and facilities:

a) Equip tools for analyzing, processing, and storing quality management data;

b) Develop quality management tools and guidance documents.

7. Direct scientific research, inspection, and supervision of quality management implementation.

8. Participate in quality management training, instruction, seminars, and capacity building programs conducted by domestic and international organizations.

Article 17. Responsibilities of Heads of Functional Departments of Hospitals

1. Disseminate the contents of this Circular to all staff members in the department.

2. Establish quality targets, integrate quality management activities into the department's work plan and the assigned field.

3. Implement and coordinate with other departments to apply the quality management criteria and standards issued or recognized by the Ministry of Health in the department and the assigned field.

4. Coordinate with the hospital’s quality management department/team to develop plans and implement activities to ensure and improve hospital quality.

5. Participate in training, instruction, courses, and capacity building programs on quality management conducted by domestic and foreign agencies and organizations.

6. Participate in hospital quality assessments.

Article 18. Responsibilities of Department Heads

1. Disseminate the contents of this Circular to all staff members in the department.

2. Identify priority quality issues in the department for proactive improvement or propose them to the hospital’s quality management council.

3. Implement and coordinate with other departments and units to research and apply the quality management criteria and standards issued or recognized by the Ministry of Health in the assigned department.

4. Assign staff to carry out quality assurance and improvement activities and evaluate their implementation results.

5. Report on the results of quality assurance and improvement activities to the hospital’s quality management council.

6. Coordinate with the hospital’s quality management department/team and related units to implement quality assurance and improvement projects.

7. Participate in training, instruction, courses, and capacity building programs on quality management conducted by domestic and foreign agencies and organizations.

8. Participate in hospital quality assessments.

Article 19. Responsibilities of Healthcare Personnel in Hospitals

1. Participate in quality improvement programs, plans, and activities according to their responsibilities and tasks.

2. Participate in training, instruction, courses, and capacity building programs on quality management conducted by domestic and foreign agencies and organizations.

Chapter V

IMPLEMENTING PROVISIONS

Article 20. Implementation Roadmap for Quality Management at Hospitals

1. Stage I: 2013-2015

a) Complete the organizational structure for quality management at provincial health services, sectoral health services, and hospitals;

b) Each hospital organizes or sends employees to participate in training, instruction, courses, and capacity building programs on quality management conducted by domestic and foreign agencies and organizations;

c) Hospitals apply the quality management criteria and standards issued or recognized by the Ministry of Health for self-assessment and quality improvement;

d) Encourage hospitals to pilot various quality models, methods, and management standards.

2. Stage II: 2016-2018

a) Hospitals assess the effectiveness of applying quality management criteria, standards, indices, models, and methods;

b) Train specialized personnel for hospital quality management;

c) Voluntarily register with quality certification organizations to have their hospital quality assessed;

d) Regulatory agencies conduct evaluations, appraisals, and recognition of hospital quality.

3. Stage III: After 2018

Hospitals continue to apply quality management criteria, standards, indices, models, and methods and register for quality certification according to the guidelines of the Ministry of Health and independent quality certification organizations.

Article 21. Effective Date

This Circular takes effect from September 15, 2013.

Article 22. Implementation organization

1. The Department of Medical Examination and Treatment shall be responsible for:

a) Serve as the lead unit organizing the implementation, inspection, and evaluation of this Circular in subordinate hospitals and localities;

b) Take the lead or coordinate with relevant units to establish quality standards, regulations, criteria, standards, and indices for hospitals;

c) Perform other tasks related to hospital quality management as assigned by the Minister of Health.

2. Relevant Departments and Bureaus, according to their assigned functions and tasks, participate in directing and implementing hospital quality management activities.

3. Provincial Health Services, Municipal Health Services directly under the Central Government; Sectoral Health Services have the responsibility:

a) Assign a leader from the provincial health service/sectoral health service, a leader from the medical affairs department, and a specialist to be responsible for the quality management of hospitals managed by the provincial health service, sectoral health service;

b) Develop a plan to enhance hospital quality for the provincial/sectoral hospital system and submit it for approval by the competent authority;

c) Disseminate, direct, inspect, and evaluate the implementation of this Circular in subordinate hospitals; report to the Ministry of Health annually and upon request.

During the implementation process, if there are difficulties or obstacles, units should reflect them to the Department of Medical Examination and Treatment - Ministry of Health for guidance, answers, or consideration for resolution./.