Improvement of Quality Management of Pre-Physician Medical Care for Rural Population

The dissertation is devoted to the improvement of the system for managing the quality of pre-physician medical care for rural population. The work comprehensively examines socio-hygienic and medical-organizational aspects of primary healthcare provision in rural areas, identifies unfavorable factors affecting the quality of pre-physician care. Criteria for expert assessment and methodology for conducting expert assessment of the quality of the diagnostic and therapeutic process at the pre-physician stage, as well as a system for managing the quality of pre-physician medical care based on expert assessment of the activity of middle-level medical workers of feldsher-obstetric stations, have been developed.

Relevance of the Problem.

One of the difficult problems of practical healthcare in Russia has always been and remains the problem of organizing quality medical care for rural residents.

The rural population (40 million people) constitutes approximately 27% of the total population of the Russian Federation, and agriculture plays a huge role in the socio-economic potential of our country. However, over the last decade, characterized by a sharp decline in agricultural production and deterioration of the financial situation in the sector, the destruction of old organizational and economic mechanisms of social development in rural areas and social protection of the population, an increase in the lag of the countryside behind the city in the level and conditions of life has occurred. This is convincingly evidenced by the materials of the meeting of the Government of the Russian Federation dated 22.05.02 on the question of "On the draft Federal Target Program 'Social Development of the Village until 2010'.

Historically, the majority of villages and settlements have been characterized by poor living conditions. Out of 153 thousand rural localities, only 10 thousand settlements have comprehensive construction and amenities. On average in Russia, for every 100 rural localities there are 26 preschool institutions, 32 schools, and 30 healthcare facilities. A significant portion of rural settlements are located 10-20 km away from service centers and have no regular transportation communication with them. The major part of the rural housing fund, of which 85% is private housing, lacks elementary communal amenities: 39% of the rural housing fund is equipped with water supply, 37% with central heating, 30% with sewage, and 17% with hot water supply. Centralized water supply covers 73 thousand localities with a population of 25.4 million people, or 64.8% of the rural population of the country. The majority of water supply systems lack the necessary structures and technological equipment to improve water quality or operate inefficiently, as a result, 75% of the rural population is forced to use water that does not meet sanitary norms. The existing rural road-transport network does not meet the needs. One third of rural localities still have no road connection with hard surface to the network of roads of general use. The demand for roads with hard surface amounts to 590.6 thousand km, while the existing length is 320.5 thousand km. Due to the lack of passable roads, over 40 thousand rural settlements remain without bus service.

The existing infrastructure of rural districts, the remoteness of villages from central district hospitals, the unsatisfactory condition of roads, and the difficult conditions of work and daily life of rural residents create additional difficulties in providing medical care.

The role of middle-level medical workers is significant in rural areas, where, as a rule, there is a chronic shortage of doctors. Under these conditions, control over the quality of the provided pre-physician medical care is extremely necessary. Despite such an obvious need, in modern literature, essentially, there is not a single work concerning the methodology of conducting expert assessment of the quality of the diagnostic and therapeutic process at the pre-physician stage in rural areas. In the early 1990s, V.P. Mozhaev [116] conducted an assessment of the work of FAP personnel, proposing as one of the methods of analyzing the results of FAP work a rating system. R.S. Gadzhiev [38] developed a sample program for expert assessment of medical care quality in rural hospitals, ambulatory clinics; expert assessment of FAP activity was proposed to be evaluated based on the analysis of entries in the registration journal of ambulatory patients according to a specially developed program, as well as on the basis of review of entries in medical records of ambulatory patients by physicians of district hospitals during planned visits. T.G. Svetlichnaya, O.V. Kovalev [156], when conducting an assessment of medical care quality in village hospitals, indirectly touched upon only certain aspects of medical care at the FAP level.

Thus, it can be stated that comprehensive studies of the quality of work of middle-level medical personnel in rural areas based on the method of expert assessments, as well as from socio-hygienic positions, have not been conducted previously.

The aim of the research is the development of a system for managing the quality of pre-physician medical care for rural population, based on a comprehensive study of socio-hygienic, medical-organizational aspects of care and expert assessment of the activity of middle-level medical workers of FAPs.

Research tasks.

1. Study of socio-hygienic, medical-organizational aspects of rural population satisfaction with the quality of pre-physician medical care.

2. Assessment of the influence of socio-hygienic, medical-organizational aspects of living conditions and professional activity of feldshers of FAPs on the quality of their work.

3. Development of expert criteria and methodology for conducting expert assessment of the quality of pre-physician medical care for rural population.

4. Organization of a system for managing the quality of pre-physician medical care for rural population.

The scientific novelty of the research lies in the fact that for the first time in the Republic of Tatarstan a study of the quality of primary healthcare activity was conducted, negative social and medical-organizational factors of rural population dissatisfaction with the quality of pre-physician medical care were identified, the significance of unfavorable socio-hygienic factors of middle-level medical workers on the formation of the quality of pre-physician care was established, and criteria for expert assessment and systems for managing the quality of pre-physician medical care were developed.

Practical significance of the work. The results of the research can be used in rural, district healthcare institutions for managing the quality of pre-physician medical care for rural population, in planning the prospective development of primary healthcare in rural areas, and in compiling comprehensive programs for the social development of agricultural districts. The introduction into practice of a system of constantly functioning expert assessment in the Central District Hospital of the rural district will contribute to the improvement of the level of pre-physician medical care for rural population.

Propositions to be defended:

1. The main elements of comprehensive assessment of the quality of pre-physician medical care should be: study of rural population satisfaction with the quality of this care, analysis of the influence of socio-hygienic, medical-organizational and other factors on the quality of work of middle-level medical workers, identification of deficiencies in the provision of pre-physician medical care in diagnostic, therapeutic, and organizational processes.

2. The system for managing the quality of pre-physician medical care for rural population should be based on regularly conducted expert assessment of FAP work in this care, with identification of deficiencies in diagnostic, therapeutic, and organizational processes, and development and implementation of organizational and managerial measures contributing to the improvement of the quality of pre-physician care.

Introduction of results into practice.

1. The studied "Methodological Recommendations for Expert Assessment of the Quality of Pre-Physician Medical Care for Rural Population" (2004) were approved by the Ministry of Health of the Republic of Tatarstan and introduced into practice in central district and district hospitals of rural districts.

2. The materials of the research are used in organizational and methodological work with middle-level medical workers of FAPs of rural districts of the Republic of Tatarstan, in the preparation and conduct of expert councils and administrative meetings at the Ministry of Health of the Republic of Tatarstan, in the educational process in cycles of thematic advanced training.

Dissertation materials were reported and discussed:

1. At expert councils at the Ministry of Health of the Republic of Tatarstan (2000-2003)

2. At republican meetings of chief physicians of central district hospitals (2000-2003)

3. At the scientific-practical conference "Actual Questions of Development of Rehabilitation Medicine and Prevention of the Most Important Non-Epidemic Diseases" Kazan, 2004.

4. At the meeting of the Public Organization of Specialists in Public Health and Healthcare of the Republic of Tatarstan (OSOZ RT). 2004.

5. At the Republican Scientific-Practical Conference "State and Prospects of Development of Outpatient Care". (Elabuga - 2004).

Structure and volume of the dissertation.

The dissertation consists of an introduction, five chapters, a conclusion, conclusions, practical recommendations, a list of references, and appendices, is presented on 190 pages of typed text, contains 17 figures, 25 tables. The list of references contains 240 sources, including 25 foreign ones.