153-871 / Accreditation of Hospitals

GOP Information
Organisation sharing the GOP
Related practices from PaSQ database
National Commission for Hospital Accreditation (NCHA)


Surveillance of Patient Safety
GOP Description
Implementation level
Clinical settings
Accreditation is achieved in public and private hospitals in Romania.
• Patient safety and risk reduction;
• Increase public confidence in the quality of services;
• Improve the performance of hospitals;
• Increase hospitals responsibility to the financiers and the public.
All types of hospitals, public or private are subject if accreditation.During this whole process, health facility with beds will be approached as a whole, as an organization that provides health care, treatment and services to their patients, according to its structure, staff qualifications and available resources
Registration and participation in the accreditation process are regulated by law, and are subsequently obtaining the authorization for functioning.
Accreditation begins with an application submitted by a hospital to NCHA, requesting initiation of the accreditation process. Three major stages are following: preparation of the hospital and the evaluation team for the evaluation visit, the visit itself, and issuing the Assessment Report – the basis of the accreditation decision.
Assessment for accreditation is based on a set of standards and criteria developed by the NCHA organized in 11 groups related to all functional areas of the hospital: Strategic management, Information operational management, Human resources management, Hospital environment management, Quality services management, Patient right and communication, Patient data management, Health care management, Risk prevention and management, Nosocomial infection management, Transfusion and transplant safety.
Standards and criteria receive certain weights depending on their relative or perceived importance. The level of achievement of standards is determined by the fulfillment of criteria which details each standard; the degree of fulfillment of the criteria is assessed by indicators.
NCHA calculates the standard scores, determines the fulfillment of all standards and finally the accreditation report is developed; the decision of accreditation is based on this accreditation report.
Timeframe implementation
There were two years for capacity building of NCHA, preparation of standards, manuals, procedures, training. In 2011 started the accreditation process of hospitals and until now 1/6 of hospitals in Romania have been evaluated and rated. The complete cycle of accreditation lasts five years.
Implementation tools available
Methods used for accreditation of hospitals
The internal evaluation (self-evaluation) – preparation of a set of data about the hospital
The external evaluation – the hospital evaluation visit made by the evaluation committee.
The techniques and tools used during the evaluation visit of hospitals are:
For data collection:
Checking, direct observation, focus group, analysis, patient flow
The main instruments used for accreditation of hospitals are:
program evaluation visit, minute of the meeting, the list of required documents, questionnaire administered to patients and families, questionnaire to the hospital staff, checklists, sheet identifying and highlighting failures , sheet finding special situations
Implementation cost
The costs listed below are established by law and covers part of the cost incurred by hospital and NCHA. Other costs of the NCHA for its organizational capacity development, functioning, or hospital preparation for accreditation, etc are not evaluated until now.
• Costs at the hospital level: Accreditation fee – 240 lei / bed
• Costs at the level NCHA: funds allocated for the payment of the evaluation committees established by the hospital complexity evaluated, ranging between 7000lei-84000 lei / commission.
Method used to measure the results
The accreditation process results in a report that can be or not followed by a certificate of accreditation. When an organization is accredited, the accreditation is valid for a period of 5 years.
Following the assessment, organizations can receive one of the following results:
1. accreditation
2. accreditation with high level of confidence
3. accreditation with medium level of confidence
4. non-accreditation
In the period 2011-2013 a number of 62 hospitals were accredited out of 77 evaluated;
9 appreciated with high level of confidence and 6 with a medium level of confidence.
Analysis of the results
Analysis of the results will be available by the end of accreditation cycle.
Implementation barriers
Did you find implementation barriers?
Please describe implementation barriers
• budgetary constraints of hospitals are affecting the achievement of compliance to standards
• lack of adequate number and skills of the hospital staff for the preparation accreditation process
Describe the strategies used to overcome the barriers (If needed)
•Flexible formulas of accreditation fee payment. The accreditation fee will be paid in installments during the financial year when the evaluation visit is scheduled. Sanitary units submit mandatory self-assessment forms (FAE) accompanied by proof of payment of the accreditation fee, at least 30 days before the visit of the evaluation committee, according to Order of the Minister of Health.
• Interactive session on the accreditation of hospitals for managers of medical units, representatives of county councils, mayors, representatives of District Health Insurance Houses.
Other information
Other information about the GOP that you would like to add (Link or attached document)