Availability and quality of medical care. Accessibility and quality of medical care: components of success Maximum accessibility of medical care is achieved when

Yu.T. Sharabchiev, T. V. Dudina

Availability and quality 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 forms of medical services. 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 time, bureaucratic obstacles, exclusion of certain types of treatment from the list of paid services and 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 health care system be efficient, fair, professional and guarantee the possibility of obtaining high-quality medical care.

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

our specialists and medical institutions. Continuity in the provision of medical care is largely ensured by the 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, allowing timely start of treatment, a high level of training of doctors, standardization of the process of providing care and establishing 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, the relevant sectoral regulatory and legal framework and organizational structures have been created to ensure the activities of healthcare institutions and medical workers within 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 the “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 optimizing 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. To international organizations health technology assessment organizations include ANTA, the International Network of Health Technology Assessment Agencies, and HTA1, a public organization for health technology assessment.

In Russia, 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 are evaluating MT and standards.

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 states that this law does not regulate relations related to the prevention and provision of medical services.

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 ILC is carried out on various levels 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 the disease or insufficient preparation of the 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 the international judicial practice, defects in the organization of medical care account for at least 20% of all MT defects. 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 misdirection or side effects medicines. 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 expertise 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, usually expressed as a percentage, are used to assess the activities of health care facilities for forecasting development 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 important point in the field of quality improvement and cost minimization is the evaluation 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, patient management protocols, 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.

L I T E R A T U R A

1. Boyko A.T. Quality and standards of medical care (concept and fundamentals) // maps.spb.ru/ordinator/addelment/

2. Vishnyakov N.I., Stozharov V.V., Muratova E.Yu. // Economics of health care. - 1997. - No. 2. -S. 26-29.

3. Vlasov V.V. // Problems of standardization in healthcare. - 2001. - No. 1. - S. 9-18.

4. Glembotskaya G.T. // Remedium. - 2007. - No. 1.

5. Erofeev S.V. // Med. right. - 2006. - No. 2 (13).

6. Quality of medical care. Glossary. Russia-USA. Russian-American Intergovernmental Commission on Economic and Technological Cooperation Health Committee. Availability of quality medical care. - M., 1999.

7. Kolykhalova G.A. // Problems of healthcare management. - 2003. - No. 1. - S. 32-35.

8. R. V. Korotkikh, E. V. Zhilinskaya, N. V. Simakova, and N. Kh. // Healthcare (Moscow).

2000. - No. 7. - C. 49-65.

9. Mikhailova N.V., Gilyazetdinov D.F. // Standards and quality. - 1999. - No. 3.

10. Naigovzina N.B., Astovetsky A.G. // Healthcare Economics. - 1998. - No. 1. - S. 7-10.

11. Niv G.R. The space of Dr. Deming. - Tolyatti, 1998. - Book 1.

12. Evaluation of foreign health care systems: private opinions and the index of consumers of medical

services // Issues of Economics and Management for Healthcare Managers.-2008. - No. 2 (77). - S. 23-26.

13. Evaluation of the quality of health care in the United States // Issues of expertise and quality of honey. help. -2008. - No. 2 (26). - S. 61-64.

14. Polubentseva E.I., Ulumbekova G.E., Saitkulov K.I. Clinical guidelines and quality indicators in the quality management system of medical care: method. recommendations. -M.: GEOTAR-Media, 2007.

15. Samorodskaya I.V. // Healthcare. -2001. - No. 7. - S. 25-30.

16. Seversky A.V., Sergeeva E.O. // Problems of standardization in healthcare. - 2005.- No. 11. - P.6-12.

17. Siburina T.A., Badaev F.I. // Health manager. - 2006. - No. 1. - S.19-24.

18. Starodubov V.I., Vorobyov P.A., Yakimov O.S. etc. // Healthcare Economics. - 1997.- No. 10. - S. 5-10.

19. Stetsenko S.G. Medical law: textbook.

SPb., 2004.

20. Tatarnikov M.A. // Issues of expertise and quality of honey. help. - 2008. - No. 2 (26). - S. 4-10.

21. Sharabchiev Yu.T. // Med. news. - 2004. - No. 8. - S. 58-67.

22. Yakubovyak V. // Problems of standardization in health care. - 2002. - No. 4. - S. 3-5.

23 Council on Medical Service, American Medical Association. Quality care // JAMA. - 1986. - Vol. 256. - P. 1032-1034.

24. Donabedian A. // MMFQ. - 1966. - Vol. 44. - P. 166-206.

25. Human organ transplantation. A report on developments under the auspices of WHO // Intern. Digest of Health Legislation. - 1991.

Vol. 42, No. 23. - P. 393-394.

26. Jessee W.E., Schranz CM. // Quality Assurance in Health Care. - 1990. - N 2. - P. 137-144.

27. Leape L.L. // JAMA. - 1994. - Vol. 272. - P. 1851-1857.

28. Wells J.S. // J. Adv. Nurs. - 1995. - Vol. 22. - P. 738-744.

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 proportion 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,

share of hospitalizations in emergency form in the total volume of hospitalizations of the population attached to the 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 subject Russian Federation in the field of health,

share of state (municipal) medical organizations providing medical care in stationary conditions, the financing of which is carried out based on the results of activities for 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 inpatient conditions.

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;

proportion of patients who Ambulance provided within 15 minutes of the call.

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.

Medical care is an integral part of medical care. Sometimes it can be evaluated according to the same criteria of quality and accessibility as the actions of the doctor during the examination of the patient. However, even the obvious signs of the quality of treatment seem to the health care organizers rather controversial. For example, in 2013, the opinion was expressed that the quality of medical care should not be judged by ... the result of treatment. That is, if the patient did not survive, then this does not mean that medical care was of insufficient quality. Doctors could well act according to all the rules and standards.

Accessibility in today's realities has turned out to be an even more controversial concept than quality: a Russian patient almost constantly faces blocked access to a doctor. Somewhere they closed the hospital, somewhere you have to wait a month for a free appointment with an endocrinologist or a rheumatologist (although in the order of “paid services” you can get an appointment with a narrow specialist on the same day), somewhere you can’t get medicines under the preferential program drug supply.

AVAILABLE DOES NOT MEAN FREE

Let's return to the Federal Law-323 "On the basics of protecting the health of citizens." In accordance with Art. 10 of this law, the availability and quality of medical care are ensured by “the application of procedures for the provision of medical care and standards of medical care”, “the 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” and a number of other parameters, including "transport accessibility of medical organizations" and "the possibility of unimpeded 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."

At what distance from the patient's home should be the "nearest medical organization" is not specified. If the nearest polyclinic or hospital is located one hundred kilometers from the village, this does not contradict the law. Provided that between the settlement and the medical institution there is a road along which a car or bus is able to pass. If the patient does not have a car, and the bus runs three times a week - on Mondays, Wednesdays and Fridays, the law is still not violated: after all, transport accessibility (in the form of a road) is available. Yes, and "ambulance" no one bothers "to use vehicle to take a dangerously ill person to the hospital.

DOCTOR'S HELP IS NOT ALWAYS GUARANTEED

The concept of "guaranteed volume of medical care" introduces a contradiction into the seemingly obvious criteria of accessibility and quality. In accordance with the Constitution, everyone has the right to free medical care in state medical institutions. However, Art. 19 of the Federal Law “On the Fundamentals of Protecting the Health of Citizens” clarifies: every citizen really has the right to medical assistance, but it is provided free of charge “in a guaranteed volume”, “in accordance with the program of state guarantees”. Everything that is outside this guaranteed volume, apparently, belongs to the category of paid medical services - the right to which the citizens of the Russian Federation also have. This assumption is supported by Art. 80 of the same FZ-323, which relates directly to the program of state guarantees. In accordance with this article, within the framework of the state guarantees program, the following are established:

• a list of forms and conditions of medical care, the provision of which is free of charge;
• a list of diseases and conditions for which medical care is provided free of charge;
• categories of citizens to whom medical care is provided free of charge;
• a list of types, forms and conditions of medical care, the provision of which is carried out at the expense of budget allocations from the federal budget;
• a list of diseases, conditions, the provision of medical care for which is carried out at the expense of budget allocations from the federal budget;
• categories of citizens, the provision of medical care to which is carried out at the expense of the budgetary allocations of the federal budget.

For everything that is not included in these lists, Russian patients have to pay. For perfectly legal reasons. But taking into account financial position For many of our compatriots, affordability is the same as physical availability.

RURAL LIFE: MEDICINES TURN INTO PHARMACIES

As early as the end of 2011, a teacher at the Pyatigorsk Medical and Pharmaceutical Institute, Yulia Voshchanova, wrote: in Stavropol, in sparsely populated hard-to-reach areas with long-term seasonal isolation of the population, FAP medical workers - paramedics, midwives, nurses - performed a number of functions that were not characteristic of them. And they were forced to deal even with the issues of providing the population with medicines. To improve the availability of drug care in the FAP, pharmacies were organized for the sale of drugs and medical devices, as well as the issuance of prescription drugs under the ONLS program to certain categories of citizens.

According to the 2002 census, almost a third of Russians (38.8 million) live in rural areas. And there are about 150,000 rural settlements. Many residents of villages and other small settlements are older than working age. In other words, pensioners. Those who need medication. Pharmacy departments (or at least refrigerators with drugs) in rural stores could help them out. However, the question of selling medicines outside pharmacies are more often viewed in a different context.

ONCE AGAIN ABOUT FOOD RETAIL

On June 17, 2014, at a meeting of the Government Commission on Competition and the Development of Small and Medium-Sized Businesses, they again considered “ additional measures aimed at developing competition in the drug market”. More precisely, measures to increase the "availability" of drugs. More precisely, the possibility of selling medicines in retail food retail chains. The Ministry of Health, the Ministry of Industry and Trade, the Ministry of Economic Development of Russia and Rospotrebnadzor were instructed to determine a limited list of drugs and the procedure for their implementation in retail food trade networks. Today the list is already presented. Experts from the medical and pharmaceutical communities concluded that the sale of drugs outside pharmacies is currently unacceptable.

WHEN THE STORE RANGE COMES TO THE PHARMACY

You can object - but what about successful foreign experience? US pharmacies, for example, have long functioned as health-supply supermarkets. In addition to the usual for all of us pharmacy assortment, you can even find stationery, newspapers, magazines, postcards, toys, photographic products, household chemicals and even haberdashery in them. However, such diversity is not an example to follow, but one of the ways to survive. And slightly increase the same profitability. And most importantly: not medicines go to the store, but goods from the store go to the pharmacy. The buyer can purchase everything they need at the same time, while the medicines remain in their places - and under the control of the pharmacist.

WHEN A MEDICINE BECOMES A POISON

In the United States, 100,000-200,000 people die each year from prescription pills. This is more than the number of deaths in car accidents. There is even a rule in the country obliging a pharmaceutical manufacturer to determine the toxic dose of their drugs and conduct special experiments for this. By the way, both in Europe and overseas in the first place in terms of the number of cases of overdose and poisoning is the usual paracetamol. You can get poisoned even with "safe" medicines.

According to the WHO, drug-related deaths are among the top five causes of death in the world. Medications are in fifth place and second only to:

• injuries;
• cardiovascular diseases;
• malignant tumors;
• pulmonological diseases.

All other diseases turned out to be safer for the patient than drug poisoning.

According to the Moscow Research Institute for Emergency Medicine named after N.V. Sklifosovsky, acute drug poisoning - in second place in the structure acute poisoning. Medicines are second only to alcohol and its surrogates. St. Petersburg Research Institute of Emergency Medicine. I.I. Janelidze in 2013, out of 8252 patients of the toxicology department, 1174 ended up in a hospital with impaired vital functions and received intensive care. Half of these seriously ill patients were poisoned by drugs. Including such as Corvalol, paracetamol - the most simple and affordable.

It is not always the manufacturer who is guilty of drug poisoning. Dreaming of a quick recovery, many patients take a double or even triple dose of the drug ...

DRUGS AND SUPERMARKETS: PRICE GROWTH IS NOT THE MAIN DANGER

Contrary to expectations, the implementation medical preparations in the trading network will not lead to an increase in their availability. Large grocery supermarkets planning to sell medicines are located where pharmacies already exist. In rural areas, in sparsely populated areas, an American-style "pharma market" could be a salvation - provided that a specialist pharmacist would work in it. Or at least a medic. After all, even FAPs, who are forced to take on the functions of providing patients with drugs in addition to their workload, are far from being everywhere.

However, the situation with medicines in the grocery supermarket is completely different. Unlike a pharmacist, the seller is unlikely to be able to explain to the buyer how to take the medicine correctly. This is the first prerequisite for self-treatment and subsequent poisoning.

The second prerequisite is a violation of storage conditions. If medicines are stored with food or if the temperature regime is not observed, it is difficult to vouch for their effectiveness and safety. “It’s difficult to guarantee, but you can control it!” the reader may object. However, the burden on the control and supervisory authorities is already great. And violations of the regime of storage of drugs are one of the most frequent violations detected in pharmacies. And if the task, which pharmacists cannot always cope with, is transferred to people who have never been involved in pharmacy in their lives, Roszdravnadzor will urgently need additional human resources. And hospitals get new beds... We should not forget about the environmental situation. After all, non-specialists are unlikely to know how to properly dispose of drugs.

As for availability, it will decrease. If a part of the pharmacy assortment is “transferred” to stores, a rise in prices in pharmacies is inevitable. By the way, X5 Retail Group alone, represented by Perekrestok, Pyaterochka and Karusel supermarkets, has an annual turnover equal to the annual turnover of the entire Russian pharmacy business!

WHEN THE LISTS DO NOT COME WITH THE STANDARDS

In one way or another, the program of state guarantees, standards of medical care and lists of medicines are connected with the affordability of drug care. The relationship between these documents is not always clear. For example, what links the standards of medical care and list of vital and essential drugs if many drugs that doctors use most often (and are required to use in accordance with the standards) are not included in the number of life-saving drugs (and therefore free for the patient)? True, the standards of treatment, which should have become the main documents for a doctor, are now four times less than the number of diseases (24.29%). What if essential medicine is not included in the standard or list of vital and essential drugs, a sick person has a very high chance of paying for it out of his own pocket. So a contradiction on paper leads to additional costs in life.

VITAL AND… EVERYTHING ELSE

Decree of the Government of the Russian Federation No. 871 of August 28, 2014 approved the Rules for the formation of lists of medicines: Vital and Essential Drugs, expensive drugs, drugs for certain categories of citizens and the minimum range. The first of the lists must be updated annually. The other three are at least once every three years.

To be included in the list of Vital and Essential Drugs, it is necessary that this medicine:

• was registered in the country in the prescribed manner;
• used to diagnose, prevent, treat and rehabilitate diseases, syndromes and conditions, including those prevailing in the structure of morbidity in the Russian Federation;
• had an advantage over other drugs in the treatment of a particular disease or condition;
• was therapeutically equivalent to a drug with a similar mechanism of pharmacological action.

To be on the list of expensive drugs, medicine must:

• have an advantage over other drugs in the treatment of patients with hemophilia, cystic fibrosis, pituitary dwarfism, Gaucher's disease, malignant neoplasms lymphoid, hematopoietic and related tissues, multiple sclerosis, as well as patients after organ and/or tissue transplantation.

To be included in the list of drugs for certain categories of citizens, the drug must:

• be registered in the country in the prescribed manner;
• be included in the list of the most important medicinal products;
• have an advantage over other drugs in the treatment of persons entitled to receive state social assistance in the form of a set of social services.

To be included in the minimum range, the medicine must meet the following requirements:

• be registered in the country in the prescribed manner;
• be included in the list of the most important medicinal products;
• being in circulation on the territory of the Russian Federation, have at least 2 INN corresponding to it, or replacing such a name with a grouping or chemical name of reproduced drugs in similar dosage forms and dosages produced by two or more manufacturers (with the exception of drugs produced by a single domestic manufacturer);
• according to data on sales volumes in the domestic pharmaceutical market, be in demand by the healthcare system and the population throughout the calendar year.

Exclusion of drugs from the lists occurs according to the general rules:

• when included in the list of alternative drugs that have proven clinical and / or clinical and economic benefits, and / or features of the mechanism of action, and / or greater safety in the diagnosis, prevention, treatment or rehabilitation of diseases, syndromes and conditions;
• when there is information about toxicity or a high frequency of undesirable side effects when using the drug;
• upon suspension of the use of the drug in the country;
• upon cancellation of the state registration of funds;
• upon termination of the production of the medicinal product or its supply to the Russian Federation and / or the absence of the medicinal product in civil circulation in the Russian Federation for a period exceeding one calendar year.

In addition, a drug that is crossed out from the list of the most important drugs is also subject to exclusion from the other lists - the list of expensive drugs, the list of drugs to provide certain categories of citizens and the minimum range.

Whether the new rules will serve to improve the availability of medical care, and whether drug assistance will become more affordable, time will tell.

ANOTHER SIDE OF ACCESSIBILITY

Compared to the Russian drug market (and it amounted to 827 billion rubles in 2014), the market for medical devices in our country is relatively small (only 241 billion). Even in Moscow, patients are far from always provided with equipment for treatment and examinations. For example, in the dental department of one of the capital's polyclinics, equipment for x-raying teeth does not work. Residents of the area seal the canals to the touch.

The current market of medical devices is characterized not only by the predominance of foreign manufacturers (the share of domestic goods in this market is 19%), but also by an unformed regulatory framework, the absence of structures that evaluate medical devices for the needs of the state, as well as price dispersion. The cost of an ultrasound scanner ranges from 651,300 to 2,887,000 rubles, the cost of an MRI scanner is from 8,230,000 to 48,000,000 rubles, the cost of a mammograph is from 1,050,000 rubles. up to 5,350,000 rubles

To establish the true value for money, an independent examination is necessary. WHO recommends that it be carried out in the form of a health technology assessment: you cannot study equipment and products using the same methods. After all, it is much more difficult to replace an ineffective device than an ineffective medicine. And a technically perfect invention can be absolutely useless for a doctor and a patient, or it can be so difficult to use that it will be difficult for a specialist to avoid a mistake.

The first step towards the assessment of healthcare technologies has already been taken: in July, Roszdravnadzor presented a draft of a new nomenclature classifier of medical devices, developed on the basis of GMDN (International Medical Device Nomenclature). In the future, an objective examination will require the creation of unified methodological recommendations, the collection and analysis of data on the comparative effectiveness of technologies, the improvement of existing mechanisms for economic assessment, as well as the monitoring of regulatory requirements and the degree of influence of health technology assessment in the examination of medical equipment in European countries. High-quality medical equipment and specialists who know how to work with it is another side of the problem of accessibility…

Based on the materials of the session "Mechanisms for ensuring the availability of drug care" within the framework of the conference "PharmMedAppeal 2014"

Report of the Director of the Fund for independent monitoring of medical services and human health "Health", a member of the central headquarters of the ONF Eduard Gavrilov

Availability of medical care for the population of the Russian Federation

in preparation for the ONF Health Forum, 06/19/2015

Presentation. Click the left mouse button to change the slide.

Under the availability of medical care, we mean the possibility for a patient to receive the medical care he needs, regardless of social status, level of well-being and place of residence.

Accessibility is the most important condition for the provision of medical care to the population of the country and is declared by Federal Law No. 323 “On the Fundamentals of Protecting the Health of Citizens of the Russian Federation”.

The program of state guarantees of free provision of medical care to citizens for 2015 and for the planned period of 2016 and 2017 (approved by Decree of the Government of the Russian Federation of November 28, 2014 No. 1273) defines the criteria for the availability and quality of medical care.

The need to take measures to ensure the availability of medical care was reflected in the "May" decrees of the President of the Russian Federation.

ACHIEVEMENTS OF PAST YEARS

In 2005 - 2012, the Government of the Russian Federation launched a number of projects and programs aimed at increasing the birth rate and reducing the mortality rate, early detection diseases, preventing disability and maintaining the quality of life, including the national priority project "Health", regional programs for the modernization of healthcare in the constituent entities of the Russian Federation.

An analysis of the dynamics of demographic indicators shows that the activities, in general, have achieved their goal. Thus, the rate of decline in mortality from cardiovascular disease for the period 2005-2012 in all ages was 29%, while the maximum rate of reduction in mortality was observed in the age group of 40-59-year-olds. Mortality from external causes decreased from almost 320 thousand people in 2005 to 197 thousand in 2012. At the same time, the growth in the birth rate made it possible in 2012 for the first time in ten years to achieve an excess of birth rates over mortality and ensure natural population growth.

However, the reforms of health care carried out recently by the Russian Ministry of Health, including the so-called optimization of health care, which is carried out without methodological support from the Ministry of Health, are gradually nullifying the achievements of previous years.

CONSEQUENCES OF OPTIMIZATION

Thus, in 2014 there was an increase in overall mortality (2014: 13.1 per 1,000 population; 2013: 13.0). Compared to 2013, mortality rates from respiratory diseases increased by 6.2%, from diseases of the digestive system by 8.4%. The greatest concern is the increase in mortality from other causes by 24.4%, this indicator may hide uncomfortable statistics of mortality from diseases of the circulatory system, neoplasms, and tuberculosis.

Poll public opinion conducted by the Levada Center in October 2014, out of 3.5 thousand respondents who had Last year experience in receiving medical services, 32% noted a deterioration in the work of polyclinics and hospitals.

According to the comprehensive monitoring of living conditions conducted by Rosstat, in 2014 the number of respondents who are not satisfied with the work of medical organizations increased compared to 2011 from 19.5% to 30.3% of the number of respondents. On the effective treatment do not calculate 21.9%, while in 2011 - 13.9%. When asked about the impossibility of getting to a medical organization, 10.1% of respondents answered in the affirmative, which is almost twice as high as in 2011 - 5.9%.

Experts of the Health Foundation, making working trips to the regions, visiting medical institutions, conduct their own monitoring of population satisfaction with medical care, its availability and quality, and receive real evidence of the results of optimization in healthcare in the field.

As a rule, patients complain about queues to see doctors, lack of specialists, long waiting times for necessary tests and hospitalization, and poor transport accessibility of medical institutions.

First of all, these are the results of an unjustified reduction in the number of beds in the regions - during 2014, the number of beds in the country decreased by almost 30,000. In 2014 beds were reduced in 73 regions. In 56 regions, the number of hospitalizations decreased compared to 2013.

At the same time, the reduction in the number of beds did not lead to an increase in the days of bed operation per year: instead of the planned 329.0 days, we actually have 321.0 days.

The reduction in the number of beds led to an increase in the in-hospital mortality rate in 61 regions in 2014. In Russia as a whole, in-hospital mortality increased by 2.6% compared to 2013. In 49 regions, an increase in the number of deaths in a hospital occurs against a background of a decrease in the number of hospitalized patients. In 14 regions, the number of deaths at home increased, and in 13 of them, in-hospital mortality also increased.

RURAL SITUATION

The negative consequences of the ongoing optimization have particularly affected the rural population. Medical assistance is removed from the village, for some rural residents - at an inaccessible distance. The reduction in the number of beds as a result of optimization, which affected, first of all, rural and district hospitals led to the fact that in 2014 32.2 thousand rural residents were hospitalized less than in 2013. Mortality rural population in 2013 it was 16% higher than the urban one, in 2014 it was 15% higher, but the difference of 1% is due not to a decrease in the death rate of the rural population, but to an increase in the death rate of urban residents.

At the end of 2014, 35% of settlements in the Russian Federation are not covered by public transport routes. The development of mobile forms of work is extremely limited, while according to official reports, the number of mobile medical and medical teams is growing. So, for example, in the Ryazan region, the number of medical teams increased from 3 in 2013 to 39 in 2014, the number of mobile medical teams equipped with a vehicle and medical equipment is 32. However, when analyzing the distribution of field teams by region, it can be found that, in Basically, they are concentrated in the central regions with a high population density, and subjects that have a large extent, where the distance to the regional center can be measured by several hundred kilometers, do not have mobile teams. Among them are the Murmansk, Sverdlovsk, Omsk regions, Kamchatka and Primorsky territories, and a number of other regions. And where there are medical and mobile medical teams, they do not always work effectively, serving one or two calls per shift.

We add to this that in the Russian Federation, as part of the modernization at the end of 2013, out of the planned 1.4 thousand FAPs and 396 GP departments were not opened. Currently, about 17.5 thousand settlements with a population of over 100 people do not have medical infrastructure, of which 2,430 settlements with a population of over 700 people, and in almost 879 settlements, residents are not attached to any FAP or department at all. ORP. As for settlements with a population of less than 100 people, out of 79.1 thousand, 65 thousand (82.2%) are not covered by medical units. The lowest coverage of rural settlements with medical infrastructure is in the Moscow and Leningrad regions, the Republic of Mari El, the Tomsk and Kaliningrad regions, and the Perm Territory.

There are no air ambulance brigades in 27 regions, including Chelyabinsk, Kurgan, Novosibirsk, Tomsk, Omsk regions, and the Udmurt Republic. The development of air ambulance is limited by the high cost of one flight.

STAFF DEFICIENCY

Another important factor in the availability of medical care is staffing. An analysis of the implementation of Decrees 597 and 598 of the President of the Russian Federation, carried out by the Fund's experts in mid-2014, shows that the measures taken by the Ministry of Health of Russia are insufficient and do not ensure the achievement of the goals set in the Decrees.

So, for example, despite the formal approval (order of the Ministry of Health of Russia dated June 26, 2014 No. 322) of the methodology for calculating the need for medical personnel, the Ministry of Health still does not have reliable information about the true need of medical institutions for doctors, the idea of ​​​​the most popular specialties of medical workers also pretty subjective.

In 2012 the Ministry of Health and social development The Russian Federation stated that the country lacked 152 thousand doctors, in 2013 the Minister of Health V.I. Skvortsova announced other data - 40 thousand. part-time jobs, 104.7 thousand positions of doctors. The combination coefficient of doctors (increase in workload compared to the main work time) was 1.54.

That is, there are 1.5 times more existing jobs for doctors than doctors themselves. The given data begs the question, how was the number 40,000 obtained? It is obvious that the desired is presented as reality.

Medical personnel are aging catastrophically. According to Rosstat, today the proportion of doctors in the Russian Federation aged 51 years and older is 40%, over 56 years old - 26.5%. This significant "aging" of the medical staff will lead in a few years to a catastrophic shortage of medical personnel, when doctors over 55 years old retire.

The reduction of doctors, leading to a decrease in the availability of free medical care, guaranteed by Article 41 of the Constitution of the Russian Federation, occurs with the consent of the Russian Ministry of Health, which in 2014 revised the established values ​​​​of indicators of the provision of medical personnel. Thus, the target value of the indicator of provision with doctors established by the State Program for the Development of Health Care for 2013 was reduced from 44.2 per 10 thousand of the population to 40.2 per 10 thousand for 2014-2020.

What prompted the revision of this indicator? According to the Ministry of Health of Russia, in 2012, when forming the initial version of the State Program, the need for doctors and paramedical workers was calculated based on the procedures for the provision of medical care approved by the Ministry of Health and Social Development of Russia and the Ministry of Health of Russia, geographical features of the regions, population density, taking into account the need for doctors of clinical specialties .

The new version of the State Program did not reflect the problems of personnel planning of the health care system. Data on the availability of doctors and paramedical personnel in primary health care and hospitals is not presented, there is no list of scarce and surplus specialties.

As of January 1, 2015, the unfavorable situation with the provision of medical personnel, which, in addition, is characterized by an imbalance in certain medical specialties, has become even more aggravated. According to the results of last year, the average Russian indicator of provision with doctors was 39.7 per 10,000 population, which is lower than the value planned in the State Program "Health Development" - 40.2.

ABBREVIATIONS OF HEALTH WORKERS

In total, in 2014, 19,228 doctors of clinical specialties and 12,000 nurses were laid off. In rural areas, where there is already a shortage of doctors, another 400 were reduced in 2014. At the same time, the Russian Ministry of Health plans to further reduce doctors to 35.8 per 10 thousand of the population, which is 514.4 thousand people.

Until now, in most regions, only partially introduced or not introduced at all the mechanisms of economic incentives for health workers - an effective contract. In 19 regions in 2014 effective contracts were not concluded, including in the Tver, Ulyanovsk, Pskov, Leningrad, Kemerovo regions, the Republic of Bashkortostan and Primorsky Krai.

In conjunction with low level wages (according to the monitoring of the Health Fund, about 48% of the surveyed medical workers say that their income is below 20 thousand rubles a month), the unresolved housing problems, this creates social insecurity for a significant part of medical workers and undoubtedly negatively affects the availability and quality of medical care especially in rural areas. We add to this that in medical institutions, especially rural ones, there have been no repairs for years, there is not enough necessary medical equipment and medicines.

The current model of compulsory medical insurance, which in fact does not fulfill its intended functions, also leads to the restriction of the rights of citizens to affordable medical care. Insurance companies in this system are a financial intermediary between the state and state or municipal medical institutions, a channel for transferring federal budget funds to regional budgets to finance medical care. Significant funds are spent on their maintenance, which can be used to find the best and more effective application especially in the current economic conditions. Thus, the existing model of insurance medicine is contrary to common sense.

Let me remind you that at the end of 2014, in a message to the Federal Assembly, the head of state noted that insurance medicine did not work like that and instructed during 2015 to “complete the transition to insurance principles, debug all mechanisms so that there are no failures.”

GROWTH OF THE MARKET OF PAID SERVICES

The decrease in the availability of free medical care is also evidenced by the growth in the volume of paid services in medicine. There is an unregulated replacement of free medical services for the population provided by state and municipal medical institutions with private paid medical services. Thus, the volume of paid services grew by 24% last year and exceeded 450 billion rubles. Low-income citizens suffer the most from this. In general, we are currently witnessing a transition in health care from maintaining and promoting health to individual treatment of mainly neglected chronic diseases.

NEGATIVE TRENDS IN 2015

The absence of a clear program of action, the ill-conceived measures taken lead to serious negative consequences across the country.

This is evidenced by the latest data from Rosstat. Thus, in January-April 2015, the mortality rate of the population increased significantly. The increase in mortality amounted to 3.7% compared to the same period in 2014. According to Rosstat, mortality is growing in the age groups from 15 to 19 years old, from 30 to 39 years old, from 40 to 49 years old.

Experts of the Health Foundation note that the largest increase in mortality in January-April 2015 was noted in the North-Western Federal District - by 5.6%, in second place - the Urals Federal District (by 5.0%), in the third - the Volga Federal District (by 3.9%). Among the regions with the highest growth rates are the Yamalo-Nenets Autonomous Okrug, the Kostroma Region, the Republic of Karelia, the Arkhangelsk, Leningrad, Penza, Omsk, Lipetsk, Tyumen, and Sakhalin Regions.

The reason for this growth, according to the Fund's experts, is the lack of a clearly defined policy in the field of healthcare at the federal level, ill-conceived, uncontrolled optimization on the ground. And as a result - a decrease in the availability of medical care for a significant part of the population and an increase in the number of cases of its inadequate quality.

In this regard, I consider the following necessary:

Prepare a regulatory legal framework for the territorial planning of medical organizations and medical units, depending on the needs of the population, transport accessibility, population density and other geographical and demographic characteristics of the regions;

develop a methodology to evaluate the activities of medical organizations and revise approaches to planning medical care by types and profiles;

review measures for personnel planning and provision of the population with medical personnel;
take measures to adequately finance medical care;

make changes to the road maps and optimization agreements in terms of clarifying the list of ongoing activities and target indicators;

clarify the activities of the state program for the development of health care in terms of developing rural medicine and increasing the availability of medical care.

Assistance should be based on the provision of high-tech medical care, preventive measures, accurate diagnosis, conscientious treatment using modern technologies and productive comfortable rehabilitation.

General components and characteristics of the ILC

There is more than one definition of this concept in the literature. In many countries, the WHO definition is followed, which states that the quality of medical care is the optimal medical care for the patient's health in accordance with the current level of medical science, the patient's diagnosis, age, and response to treatment. It is important that minimal funds are used, the risk of injury and complications is minimized, the patient must be satisfied with the result of the assistance.

The definition of the Central Research Institute of Health of the Ministry of Health of the Russian Federation is simpler and more understandable. It states that the quality of medical care is the totality of all characteristics that confirm the compliance of the actions of providing medical care with the necessary needs of the population, modern technologies, medical science, patient expectations.

A medical care standard is a document that contains a specific list of manipulations necessary to perform when treating a specific disease or condition.

Characteristics of medical care

The characteristics of the CMP include:

• professional competence.
• Efficiency.
• Availability.
• Interpersonal relationship between patient and doctor.
• Continuity.
• Efficiency.
• Convenience.
• Safety.
• Satisfaction.

Professional competence is understood as the presence of skills and knowledge of health workers, as well as auxiliary staff, the ability to use them in work, in accordance with standards, clinical guidelines, and protocols. Poor professional competence is expressed not only in small deviations from the standards, but also in gross errors that can reduce the effectiveness of treatment, which can endanger human health and even life.

The accessibility of medical care is understood to mean that it should not depend in any way on such criteria as social status, culture, organization.

The quality of medical care will depend on the effectiveness and efficiency of the applied technologies in the field of medicine. To evaluate the effectiveness, you need to answer 2 questions:

1. Will the treatment prescribed by the doctor lead to the desired result?
2. Will the result be the best in specific conditions if the therapy prescribed by the doctor is applied?

Interpersonal relationships are understood as the relationship between a health worker and a patient, medical staff and management, in general, the health care system and the people.

Efficiency is defined as the ratio of resources spent to the result obtained. It is always a relative concept, so it is used to compare alternative solutions.

Continuity is understood as the fact that the patient can receive all the necessary medical care without delays, interruptions, unreasonable repetitions.

Quality control of medical care provides such a characteristic as safety. It is understood as the reduction of all possible risks from a side effect to a minimum during treatment, during diagnosis.

Convenience refers to cleanliness, comfort, confidentiality in medical facilities. The concept of patient satisfaction includes the fact that the healthcare system must meet the requirements of health workers, the needs, and expectations of the patient.

Overview of legislation

The normative acts that regulate the quality standard of medical care include:

1. Federal law, which is called "On the basics of the protection of citizens in the Russian Federation" No. 323.
2. entitled "On Compulsory Medical Insurance in the Russian Federation" No. 326.
3. Order of the Ministry of Health (“On approval of evaluation criteria”) No. 520n.

Federal Law No. 323 contains characteristics of the timeliness of the provision of medical care, the correctness in choosing the necessary method of treatment, the result of the achieved result of treatment. This law also contains information on the examination of the quality of medical care.

Federal Law No. 326 is intended to regulate the process of control of the ILC in medical institutions. There are clear rules, forms, conditions and terms for the provision of medical care. The law applies only to public clinics where the patient receives treatment under the CHI program. In private clinics, the relationship between the institution and the patient is based on an individual contract concluded between them.

The order of the Ministry of Health is a normative act that defines the standards and criteria that are used in assessing the quality of medical care.

Medical care: quality and evaluation

This issue is regulated under the title "On Compulsory Medical Insurance in the Russian Federation" No. 326. According to him, to evaluate the ILC, they use expertise, which is divided into planned and targeted.

Target examination is carried out in the following cases:

• Complaints from the patient.
• Complications of the course of the disease.
• Unpredictable death.
• In some individual cases, with repeated treatment of a patient with the same diagnosis.

With regard to the planned examination, it takes place according to the previously planned schedule, which is compiled by the interested organizations - compulsory medical insurance funds. This species assessments should be subject to at least 5% of cases of medical care for the entire reporting period.

Examination of the quality of medical care must be carried out only by the funds and insurance organizations of compulsory medical insurance. Speaking on their behalf, the examination is carried out by experts who meet professional requirements, which are regulated by law:

• At least 10 years experience.
• Higher education.
• Accredited Medical Expert.
• The position of a doctor in a specific required area.

The expert doctor evaluates the literacy of the medical documentation, its compliance with the requirements of the law and the possible impact on the patient's condition. They consider the correctness of the diagnosis, the timing of the treatment and the final result.

Management of the ILC

In order to competently organize the work of the healthcare system, there are special organizations that provide medical care based on meeting the necessary needs of patients. These organizations exist on the basis of the state program guaranteeing the provision of free medical care to all citizens of the Russian Federation.

The quality control system of medical care is based on the following principles:

• Continuity of control.
• Using the achievements of the evidence base of medicine.
• Conducting examinations based on the developed medical standards.
• Unity in approaches during examinations.
• Use of legal and economic methods.
• Monitoring of the ILC control system.
• Analysis of economic efficiency, cost ratio with the optimal level of ILC.
• The study of the opinion of the population on the quality of medical care.

Responsibility levels

The quality of medical care is the safety of medical activities and control. Now there are 3 levels of control over the activities of medical institutions:

1. State.
2. Internal (in the medical facility itself).
3. Departmental.

Such a system was created not to duplicate checks, but to establish a clear framework for responsibility for the proper provision of medical services.

State control is mainly aimed at licensing the activities of medical organizations and conducting various checks on the observance of human rights in the healthcare sector.

KMP in surgery

This issue is regulated by the order of the Ministry of Health of Russia No. 922n. The specific procedure for providing medical care in the field of surgery applies to all medical institutions. It comes in the following forms:

1. Stage of primary health care.
2. Specialized ambulance.

Medical care is provided on an outpatient basis (conditions that do not provide for treatment and observation by doctors around the clock), at a day hospital (treatment and observation only during the daytime), in stationary conditions (observation and treatment by medical staff around the clock).

In primary health care, measures are taken to prevent, diagnose, treat surgical diseases, as well as medical rehabilitation, and the formation of a healthy lifestyle. It includes:

• First aid primary health care.
• Primary health care medical care.
• Specialized primary health care.

Primary health care refers to a form of health care in which specialists treat in a day hospital or on an outpatient basis. The duties of pre-medical primary health care are performed by a health worker whose education must be at least secondary.

With regard to medical care, health care, it is performed by general practitioners (district) or a family doctor. If, during the examination by these specialists, indications for contacting a surgeon are revealed, then they give a referral to him.

In primary health care of a specialized nature, the surgeon examines the patient and prescribes treatment. If this is not enough, then he directs the patient to a medical organization that specializes in a surgical profile.

An ambulance is needed when surgery is urgently required. It is staffed by feldsher and medical teams on the basis of the order of the Ministry of Health and Social Development No. 179 dated November 1, 2004.

If it becomes necessary to evacuate the patient during examination by ambulance specialists, then they perform it in an urgent emergency form. An ambulance team delivers a person with a life-threatening condition to a round-the-clock department of anesthesiology, resuscitation or surgery. After the patient's life-threatening factors are eliminated, he is transferred to the surgical department for further medical care. If necessary, the surgeon involves other specialists to carry out adequate treatment.

According to the profile, surgery should be based on accurate diagnosis, conscientious treatment using advanced technologies and productive comfortable rehabilitation.

Planned care in surgery

Such medical assistance should be provided in cases of preventive measures. They are carried out only for simple diseases that do not require emergency care at the moment and do not pose a threat to the health and life of the patient.

To improve the quality of medical care, patients who have an atypical course of the disease are absent positive result during treatment, there is no final diagnosis, they are sent to more high-tech medical organizations.

Also, patients who have specific medical indications are sent for rehabilitation to sanatorium-resort complexes.

Protecting the rights of the patient

In the healthcare sector, unfortunately, there are still cases of imposition of paid services, unscrupulous doctors, financial losses or harm to health. Here, the law "On the Protection of the Rights of Consumers of Medical Services" No. 2300-1 takes the side of the patient. In Art. 31 of this law states that a period of 10 days is allotted for taking action on a claim, and the countdown begins from the date the complaint is received. In Art. 16 it is written that the provisions of the contract that violate the rights of the patient are recognized as invalid.

The quality of medical care is the adequate provision of conscientious, satisfying the population of medical services. The patient has the right to:

• Obtaining medical quality care in full and within the agreed time frame.
• Familiarization with full information about the contractor and upcoming services.
• Providing him with comprehensive information that affects the quality of medical services provided.

It is important to note that there is no difference on what basis (paid or free) the services are provided. Consumer protection implies high-quality and full service. The state controls the quality of medical care.

The rights of the patient in case of dishonest provision of medical services

In case of illiterate performance of services that do not comply with the concluded contract or state regulations, the consumer has the right to demand a reduction in the cost of treatment, eliminate the existing shortcomings by aftercare, reimburse the costs, terminate the contract with loss coverage, and also receive re-provided services.

A person who has received medical treatment in violation of the law can write an appeal to Roszdravnadzor and Rospotrebnadzor. These bodies are responsible for compliance with the criteria for the quality of care. They are obliged to conduct an inspection in the medical institution against which the complaint was received.