Research results and discussion
In the Message of the First President of the Republic of Kazakhstan N.A. Nazarbayev to the people of Kazakhstan ‘Kazakhstan – 2050. Prosperity, safety and improvement of the welfare of all Kazakhstanis’ the need is to improve the level of public health is emphasized which consists of many components of both medical and non-medical nature: ‘As we build our society, it is necessary to increase efforts to ensure that our citizens are healthy throughout their lives and that they live in a healthy natural environment’ [1].
Health of the Republic of Kazakhstan’s population is an indicator of state competitiveness and is one of the important factors of a country’s national security.
Medical assistance quality is still the world’s number one issue in providing medical services. Services become quality when each employee considers the needs of a particular patient; when safety, effectiveness and timeliness become principles for decisions made by medical personnel to achieve the desired result and comply with contemporary medical advances (definition of the US Institute of Medicine).
The main link determining the quality of medical assistance is accreditation, confirming the compliance of medical institutions with the standards approved by the authorized body. The system of accreditation and quality management in the healthcare system can only exist and be used in conditions of competitive environment, as a stimulus for an institution providing medical services to make it strive to the perfect management of medical services [2].
Accreditation is the procedure for recognizing the special status and powers of individuals and legal entities for carrying out medical and pharmaceutical activities, as well as for conducting independent expert assessment of the activities of the healthcare subjects under the established accreditation standards. The purpose of accreditation is to continuously improve the efficiency of the medical services concerning the minimum level.
International experience shows that patients’ expectations about the ability of the health care system to meet their needs increase in proportion to the increase in the level of technical equipment and training of personnel, the development of medical science, the prevalence of information technology and the effectiveness of organizational decisions. Indeed, in developed countries, investing significant financial resources in health care and continuously improving the organization of medical care, the number of patients dissatisfied with the work of the industry is constantly growing, which entails an increase in the number of complaints about poor quality service and unprofessional actions of health-care workers [3].
To coordinate and regulate issues related to improving the quality of medical services, medical institutions began to organize an internal audit service. In the Unitary Enterprise based on the Right of Economic Management ‘Almaty regional oncology dispensary’ (hereinafter, AROD), the internal audit service has been organized since 2013, by an internal order of the director. The Council for quality management of medical services, which meets once a month has been organized under the auspices of the Internal Audit Service. At meetings, the Council considers problematic issues related to the conditions of medical assistance management and the quality of medical services. The analysis of accounting and reporting documentation is carried out to provide comparative analysis of hospital performance indices for a certain period with indices for the previous working period. The evaluation of the dispensary’s activity at large and for each structural unit is carried out by the Internal Audit Service subject to the indicator assessment.
An integrated system for managing the efficiency and quality of medical institutions requires a smooth operation of all management levels and the coincidence of their interests to ensure the quality of medical assistance at all levels. A strict organization of medical assistance is ensured based on medical technologies and operations standardization, regulation of responsible parties’ labor, structure, volume of assistance at all stages of the medical process, the optimal allocation of all types of resources and control over their use are provided.
The standards are tools that help professionals in clinical processes and decision making, as well as improve the quality of patient care. [4].
The system of medical care quality evaluation of Unitary Enterprise based on the Right of Economic Management ‘AROD’ is based on a comparison of the standard with the actual medical assistance provided. The medical assistance quality management system of Unitary Enterprise based on the Right of Economic Management ‘AROD’ should be considered as an organizational form of management not just as a set of standards, but as a system of rational use of medical institutions resources aimed to provide the proper medical assistance level.
The first level of quality control of medical care analyzes the relationship in the system physician – patient (nurse – patient), which are divided into a large number of individual elements, forming at large, the organizational process. The main role at this level belongs to self-assessment and self-control of each physician, nurse, laboratory technician and others, the second place is occupied by the quality control of medical care, carried out by the head of the department and the head nurse.
Based on daily self-monitoring, a physician (nurse) determines the integral quality factor of the medical assistance provided. With this approach, the quality of the department’s work will be expressed by the averaged assessment of all individual levels of a particular unit, as well as the achievement of final results model.
An independent audit is the most suitable method for self-assessment of the medical institution quality since it is important to establish trusting relationships between the health worker, the administration, and also to relieve respondents from focusing on the guilt feelings and punishments that accompany any inspection.
The second level of medical assistance quality control evaluates the activity of providing medical assistance at the oncological dispensary level, in that the evaluation of the activity consists of an integrated evaluation of the activities of all individual levels, as well as the degree of achievement of the approved model of the dispensary end results. This level of control is exercised by the QC and internal audit service deputy director of the oncological dispensary.
Internal indicators are indices that characterize the effectiveness, completeness and compliance of the medical activities of each structural unit of a medical institution with health standards. During the examination of medical assistance quality, the internal audit service evaluates the feasibility of hospitalization, the quality of medical assistance, postoperative complications, mortality during planned hospitalizations, differences in diagnoses, nosocomial infections and citizens’ complaints.
The internal audit service manages complaints from patients and their families, investigates cases of ethics violations and deontology of medical workers, monitors grounded complaints of citizens in the context of the medical institution’s departments, and develops measures to systematically reduce the number of complaints about the improper quality of medical services.
Recently, the society has seen many qualitative changes in the health care system, including the introduction of patient-oriented approach, which is based on the principles of respect and focus on individual interests, taking into account his needs, values, as well as the principle of openness and involvement of patients in decision-making processes regarding medical services.
This indicator is the degree of satisfaction with the quality of medical services, it reflects the degree of compliance with the expectations of the patient, his interests, needs and ideas about what should be a health provider organization. Because this measurement parameter is implemented widely enough, it is possible to realize the optimal development of health provider organizations in the areas that are relevant to the population.
The issue of improving the quality of medical services can also be solved by introducing advanced management systems in medical institutions, in particular, quality management systems based on international standards ISO 9001 [3].
For the consumers and partners, the presence of a certified quality management system in an institution creates confidence that they will acquire service of the quality that was agreed in advance, within specified time limits and in the required volume. Today, an institutions’ reputation for quality is becoming a decisive factor in its ability to compete in both the domestic and international markets.
Currently, Unitary Enterprise based on the Right of Economic Management ‘AROD’ is working under the introduced quality management system according to the ISO standard. The quality management system of the dispensary is designed to ensure the quality of the services provided and focus this quality on the consumers’ requirements and expectations. At the same time, the main task of the QMS is not to control the result ‘at the output’, but to create a management model that would prevent the occurrence of errors leading to a decrease in the services quality.
The palliative care department and pain management whose bed capacity makes 20 beds, has been working in the Unitary Enterprise based on the Right of Economic Management since the beginning of 2018. A physician of pain therapy was admitted, who introduced new pain management methods for the first time in Kazakhstan, such as alternative methods of neurolysis blockades and new principles, schemes of pain management. In anaesthesia practice, intravenous ibuprofen was introduced in the intraoperative period. An application for a new endovideoscopic rack was made to the healthcare department of the Almaty region to introduce and expand the capabilities of minimally invasive technologies of all localizations. A two-bed sub-intensive ward has been functioning to improve the throughput of the intensive care unit since the beginning of 2019.
Additional application was made to Almaty regional Healthcare Department for purchasing ‘S-arc’ device to introduce such new trends as visualization of the majority of the invasive procedures: from relatively simple operations (with respect to visualization requirement) of percutaneous nephrostoscopy type with full postrenal block, to accurate and complex procedures including tumors chemoembolization of different localizations and for more effective performance of regional blocks, alternative chemical neurolysis epidural block, different neurolysis nerve block anaesthesia, to carry out spinal chemical cold ablution, which were conducted earlier without visualization relying just on a physician’s experience.
The Southern area of Almaty region experiences annual growth in oncological patients, in 2016, 7,272 patients were registered, in 2017 – 7,916, in 2018 – 8,473 sick persons. Increase in notification rate of 4.8 % is underway, mortality index decreased by 1.6 %, and the number of newly diagnosed patients with I – II stage increased by -1.8 %. Decrease in the number of newly diagnosed patients with malignant tumor of IV stage has been noted: if in 2017, the absolute number of sick persons was 203, in similar period of 2018, this number was 191.
New sick inspection rooms have been opened in Primary Health Care including ВА и СВА: if in 2017 their number was 67, then in the same period of 2018 – 149, 50 % increase is noted. 142 persons of middle grade medical staff have been trained on the ‘AROD’ basis, who work in male and female patient examination rooms.
The salary level tends to increase due to the active application of the quality management system. The average salary of medical staff increased in 2018 by 1.5 times, reaching 165,888 thousand tenge against 91,032 thousand tenge in 2016.
Unitary Enterprise based on the Right of Economic Management ‘AROD’ uses ISO 9001 standard under the principle: ‘Record things you performing, and perform the recorded things’.
The principles of quality management are a comprehensive fundamental rule for guidance and managing the process of continually improving an institution’s activities to meet the requirements of all its parties concerned. To ensure the systematic and open functioning, the quality management system relies on eight quality management principles [5]. These principles were defined so that top management could be guided by them to improve the institution’s performance.
In many institutions, implemented and certified quality management systems are often formal, not used by top management to solve real problems and do not produce the proper effect to an institution. Perhaps one of the reasons is that institutions initially set a goal to simply receive a certificate, without attaching importance to what practical benefits they can get by implementing a quality management system consciously and purposefully.
If a quality management system is implemented to obtain a certificate, an institution will receive a certificate, but it will still have the same unresolved problems, since, the issues of their identification and subsequent correction are basically not considered. Along with that, many institutions do not consider the fact that one of the eight fundamental principles of the QMS is the principle of continuous improvement.
To date, Unitary Enterprise based on the Right of Economic Management ‘AROD’ plans to certify the implemented quality management system, demonstrating a dynamically functioning system with a clear focus on improving the institutions’ business processes.
As a way to solve many problems related to the quality of services, training, self-study of employees immediately at the workplace are considered. Since, in the process of training, employees acquire new skills and expand their professional knowledge, this contributes to an increase in the efficiency of their work and the quality of the services provided. Naturally, each institution wants to introduce a quality management system using its staff, but there are cases when it is more rational to involve specialists in this field, leading auditors – consultants. The purpose of training and staff development is the development of the health provider organization through the development of its key employees, the ability to form “correct” ways to solve problems by the employees, personnel become change agents in the company, transferring the acquired knowledge to colleagues and subordinates; opportunity for professional development increases employee loyalty [6]. Therefore, when planning activities for the implementation of the QMS, management is recommended to take seriously the issue of evaluating the internal capabilities of an institution and the issues of providing the necessary resources. After all, today there are objective obstacles, such as a shortage of qualified personnel dealing with QMS issues, limited resources of the institutions themselves, poor management and a number of other obstacles. Services quality control is one of the quality management system’s elements, therefore, the greater popularity acquires the system based on the systematic approach to management which allows ensuring continuous improvement of any institutions’ functioning.
A corporate culture has been introduced in the RSE on REM “AROD” – this is a set of the supported by the organization fundamental values and standards, opinions, ethics, beliefs and expectations that are unprovenly accepted by a majority of employees give people guidelines for their activities and determine the way of combining and coordination of actions of the managerial staff, structural units and individual employees.
The organization has developed and approved the corporate code of AROD. The main result of successful work on the formation and development of the corporate culture of AROD is the commitment of employees, identification of a person with their organization, expressed in the desire to work in it and contribute to its success.
Key elements of commitment in the RSE on REM “AROD” are:
– integration – the assignment of organizational goals by employees, the unionization of employees around the goals of the organization;
– involvement – the desire of the employee to make personal efforts, to contribute to the achievement of the goals of the organization;
– loyalty – an emotional attachment to their organization, the desire to remain a member
Thus, we have considered one of the important lines outlined in the strategy and policy of the state – the implementation of a quality management system in medical institutions. We also focused on the need to introduce the principles of the QMS, as a proven concept, aimed at improving the management of the internal audit service in an institution.
As a rule, after the introduction of a quality management system in an institution, the policy, organizational structure, process monitoring indices and even the content of the processes, change. To a large extent, the QMS helps to effectively transform management decisions into concrete, documented and justified actions. If an institution does not change anything during the implementation of the quality management system, it can mean either that the strategy itself is written on paper only, without considering the institution’s capabilities and environmental realities, or that the QMS is implemented only formally.