DECISION

PROMULGATION OF The 2020’s CRITERIA FOR INSPECTION AND EVALUATION OF HOSPITAL QUALITY AND SATISFACTION OF PATIENTS AND HEALTH WORKERS

MINISTER OF HEALTH

Pursuant to the Law on Medical Examination and Treatment dated November 23, 2009;

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

Pursuant to Circular No. 19/2013/TT-BYT dated June 12, 2013 providing guidance on quality control of medical services at hospitals;

At the request of Director of Department of Medical Service Administration – the Ministry of Health,

DECIDES:

Article 1. Inspection and evaluation criteria

The 2020’s Criteria for Inspection and Evaluation of Hospital Quality and Satisfaction of Patients and Health Workers are promulgated together with this Decision:

1. Section A: Hospital operation information and figures

2. Section B: Hospital quality evaluation

a) Applied criteria: Vietnam Hospital Evaluation Criteria version 2.0 promulgated together with Decision No. 6858/QD-BYT dated November 18, 2016 of the Minister of Health and documents providing guidance on hospital quality evaluation.

b) Revisions to Vietnam Hospital Evaluation Criteria:

- Criterion C8.2.19 and C8.2.22: the phrase “meeting ISO 15189 requirements (equivalent or higher)” is replaced with the phrase “satisfying at least level 4 criteria in Decision No. 2429/QD-BYT dated 12/6/2017 promulgating the Medical Laboratory Quality Evaluation Criteria”.

- Addition to Criterion D2.3, Level 3: “satisfying at least level 3 criteria in the Surgical Safety Evaluation Criteria promulgated together with Decision No. 7482/QD-BYT dated 18/12/2018 of the Minister of Health”.

3. Section C: Satisfaction of patients and health workers

Apply the questionnaire forms and instructional documents about satisfaction survey promulgated together with Decision No. 3869/QD-BYT dated 28/8/2019 of the Minister of Health.

Article 2. Scope

The 2020’s Criteria for Inspection and Evaluation of Hospital Quality and Satisfaction of Patients and Health Workers apply to both state-owned and private hospitals.

Article 3. Responsibilities

1. Department of Medical Service Administration shall:

a) Provide guidance for relevant units on carrying out 2020’s hospital quality evaluation and inspection; submit a consolidated report to the Minister of Health.

b) Preside over cooperation of relevant departments, associations and units in quality evaluation and inspection of hospital affiliated to the Ministry of Health, Hanoi Medical University, Hue University of Medicine and Pharmacy, HCMC University of Medicine and Pharmacy, Can Tho University of Medicine and Pharmacy.

c) Carry out overall supervision of hospital quality evaluation and inspection; verify evaluation results given by regulatory bodies.

2. Traditional Medicine Department shall:

Provide guidance; carry out quality evaluation and inspection of traditional medicine hospitals affiliated to the Ministry of Health; verify results of evaluation of provincial traditional medicine hospitals where necessary.

3. Provincial Departments of Health shall:

a) Carry out quality evaluation and inspection of affiliated hospitals; submit detailed report to the Ministry of Health on the process of quality evaluation and inspection.

b) Preside over cooperation of health authorities of other Ministries and central authorities in quality evaluation and inspection of affiliated hospital in their provinces (except hospitals affiliated to the Ministry of National Defense and the Ministry of Public Security).

4. Health authorities of other Ministries and central authorities:

a) Health authorities of the Ministry of National Defense and the Ministry of Public Security shall:

Carry out quality evaluation and inspection of affiliated hospitals.

Submit reports on quality evaluation and inspection results to leaders of the Ministry of National Defense, the Ministry of Public Security and the Ministry of Health.

b) Health authorities of other Ministries and central authorities:

Cooperate with Departments of Health in quality evaluation and inspection of affiliated hospitals.

Article 4. Inspection/evaluation commission members

1. Provincial Departments of Health, health authorities of other Ministries and central authorities shall designate chiefs, secretaries and members of inspection/evaluation commissions as instructed by Department of Medical Service Administration. Inspection/evaluation commission members shall be experienced in evaluation or quality control. People without experience or relevant experience must not participate in the inspection/evaluation commission.

2. An inspection/evaluation commission shall also include representatives of regulatory bodies, health workers of affiliated hospitals and members of other organizations.

3. Inspection/evaluation commission members shall apply for evaluator’s numbers as instructed by Department of Medical Service Administration.

4. Inspection/evaluation commission members must grasp the inspection/evaluation criteria and methods.

Article 5. Inspection/evaluation time

1. Self-evaluation and self-inspection carried out by hospitals shall be completed by January 01, 2021.

2. Inspection and evaluation by regulatory bodies shall be carried out in the first quarter of 2021 and after self-evaluation and self-inspection carried out by the hospitals.

Article 6. Reporting:

Every inspection/evaluation commission shall submit the list of members and inspection/evaluation plan on the online software and submit a report after completion of the inspection/evaluation.

Article 7. Consolidating evaluation results

The evaluation result shall be converted into a score on the scale of 1 – 450. The maximum score of the Hospital Quality Evaluation Criteria is 300 (quality score x 60); maximum score of satisfaction of patients and health workers is 50 (average satisfaction score x 10).

Article 8. Announcing results

1. Department of Medical Service Administration shall announce results of evaluation of hospitals affiliated to the Ministry of Health, universities and those verified by the Ministry of Health.

2. Provincial Departments of Health shall announce results of evaluation of hospitals in their provinces that undergo inspection/evaluation by Provincial Departments of Health (except for results of self-inspection and other inspection methods).

3. The Ministry of Health and Provincial Departments of Health shall not recognize results of other inspection methods or those that do not comply with guidance of the Ministry of Health.

Article 9. Effect

This Decree comes into force from the day on which it is signed.

Article 10. Responsibility for implementation

The Chief of the Ministry Office, Director of Department of Medical Service Administration, Director of Traditional Medicine Department, the Ministerial Chief Inspector, Directors of Departments and hospitals affiliated to the Ministry of Health, Directors of Provincial Departments of Health, health authorities of other Ministries and central authorities and heads of relevant units are responsible for the implementation of this Decision./.

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