Focus Group regarding the Guide for

evaluators on the accreditation

standards, process and methodology

Preparatory document

Project: “Quality Standards for Primary Care and

Ambulatory Care in Romania”

8th June 2021

Quality Standards for Primary Care and Ambulatory Care in Romania
Focus Group on the Guidelines for Evaluators

Table of Contents

1. Introduction...................................................................................................................2
2. Agenda of the Focus Group.........................................................................................2
3. Structure of the Guidelines for Evaluators.................................................................2
4. Instructions for completing the feedback form..........................................................3
5. Feedback form...............................................................................................................3

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 Quality Standards for Primary Care and Ambulatory Care in Romania
Focus Group on the Guidelines for Evaluators

1. Introduction
The aim of this Focus Group will be discussing the draft Guidelines for Evaluators of the
Ambulatory Healthcare Standards.
The purpose of the Guidelines for Evaluators is to provide ANMCS evaluators with a clear
understanding of the steps they need to undertake during the evaluation process for
Ambulatory Healthcare Services. It aims to help the evaluators to understand the stages of
the accreditation process and their roles at every stage of that process.
The guideline contains information on how evaluators need to prepare for the role, training
and education provided to evaluators, how the evaluation visit is to be conducted and the
techniques and tools to use, to assess for compliance with the standards and how to deliver
consistent, high quality evaluation, to support the accreditation process.
Guidelines will be prepared for the five services which are in the scope of the project:
paraclinical radiology and medical imaging, primary care, dentistry, pre-hospital emergency
care (ambulance) and personalised medical devices.
This focus group covers one out of the five guides for evaluators. It has been shared with
you for your review:
► Guidelines for ambulatory healthcare services – Paraclinical Radiology and Medical
Imaging.
The input received from your organisation and the other stakeholders on this guide will also
be replicated to the guidelines for the remaining four services in the scope of the project.

2. Agenda of the Focus Group

Subject Time interval Speaker

PARTICIPANTS SIGN-IN
15:00 – 15:05

Introductory remarks 15:05 – 15:10 ► ANMCS

Introduction to the project and to the ► EY

15:10 – 15:20
guideline for evaluators ► ISQua

Feedback on the Guideline for

15:20 – 16:45 ► ISQua
evaluators

► EY
Q&A 16:45 – 17:00
► ISQua

3. Structure of the Guidelines for Evaluators

The guidelines are structured along four chapters.
The structure follows the requirements as per the Terms of Reference of the project:
► Introduction: the purpose of the evaluator guideline.
► Chapter 1 - Introduction to quality assessment: the national and international context;
the need for quality management in Romanian healthcare; the principles of quality
assessment for accreditation of primary care and ambulatory healthcare providers; the
role of ANMCS; the role of the evaluator; the training for evaluators; the benefits of
accreditation.

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Quality Standards for Primary Care and Ambulatory Care in Romania
Focus Group on the Guidelines for Evaluators

► Chapter 2 – The ANMCS accreditation process: an overview of the standards, criteria

and requirements; steps undertaken by providers in the accreditation process;
description of the evaluation process; evaluators and the evaluation committee;
evaluation visit arrangements; ANMCS role post-evaluation visit to determine
accreditation level; monitoring compliance with standards and maintaining the
accreditation; high level description of the evaluators’ obligations and responsibilities.
► Chapter 3 - The evaluation stages and the role of the evaluators at each stage:
appointment to an evaluation committee; assessment of documents to prepare for the
evaluation visit; pre-visit meeting of the committee; the opening meeting; undertaking
evaluation of compliance with the standards using the checklists; the final evaluation visit
meeting; drafting the evaluation report and finalising the report. The techniques to be
used by the evaluators: analysis of the documents provided by healthcare providers;
direct observation - the on-the-spot assessment of compliance with the requirements of
the standards, in the way that healthcare services are provided; interview – collection of
information through discussion between the evaluator and members of the healthcare
provider’s staff during the revaluation visit ; specific documentation to be assessed for
paraclinical radiology and medical imaging healthcare services - by standard; what to
look for, issues to explore by observation and interviews in relation to the specific
standards; professional conduct of evaluators and what NOT to do.
► Chapter 4 – Tools used by the evaluator: a description of the main tools that will be
used by the evaluators to assess the compliance of paraclinical radiology and medical
imaging healthcare services to the quality management standards.
► Appendix 1 – Timeline for the evaluation process and activities of the
evaluators.
► Appendix 2 – Master list (will be added at a later date by ANMCS).
► Appendix 3 – Validation method for suggested evidences (indicators) (will be
added at a later date by ANMCS).

4. Instructions for completing the feedback form

The purpose of the feedback is to review at a high level the structure and content of the
Guidelines describing the ANMCS’s accreditation process and methodology for evaluators.
The intent is not to make any major amendments but to ensure the overall content and
layout within is fit for purpose and implementation.
Please use this form for any comments relating to the guideline of relevance to your
organisation/area of interest. Individual comments can also be made throughout the
guidelines.
Kindly send the completed feedback forms by 11th June 2021, if possible. Having the
feedback forms completed in advance of the Focus Group would help the team to better
organise the meeting to answer the suggestions or questions raised in the feedback forms.

5. Feedback form
Q1 The reviewed structure of the Guidelines for Evaluators is fit for purpose (i.e.
acceptable/appropriate)
Disagree Agree
1 2 3 4 5 6

Comment

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Quality Standards for Primary Care and Ambulatory Care in Romania
Focus Group on the Guidelines for Evaluators

Q2 The reviewed content of the Guidelines for Evaluators is fit for purpose (i.e.
acceptable/appropriate)
Disagree Agree
1 2 3 4 5 6

Comment

Q3 The reviewed format of the Guidelines for Evaluators is fit for purpose (i.e.
acceptable/appropriate)
Disagree Agree
1 2 3 4 5 6

Comment