The quality of medical and social expertise of the contingent of children with disabilities in the City Children’s Polyclinic

The quality control of the provision of the State Service of passing the Medical and Social Examination (SS MSE) is carried out as part of the implementation of a set of measures to achieve the indicators of the Decree of the President of the Russian Federation (RF) No. 601 (assessment of the level of satisfaction of citizens with the quality of state services). The purpose of the study was to determine the quality of the provision of SS MSE and possible reserves for its improvement. The analysis of 566 referrals for the passage of the SS MSE of a medical organization, submitted by official representatives of children - patients of the state budgetary healthcare institution of the Republic of Komi “Syktyvkar Children’s Clinic No. 3”, and a survey of official representatives of children who were diagnosed with disability, according to the questionnaire for assessing the level of satisfaction of citizens with the quality of the provision of SS MSE. Methods of analysis included: analytical and comparison. The following techniques were used for the analysis: grouping, absolute and relative values, average values, detailing, and generalization. The reliability of the results obtained was assessed by calculating the Student’s coefficients. The depth of the study was 3 years. Experts now have the opportunity to determine disability for children with severe persistent pathology not for 1 - 2 years, but for 10 - 15 years, in some cases, according to indications, and more, up to the age of 18. Some children and adolescents are permanently disabled. This significantly reduces the annual burden for patients to undergo examinations by medical specialists, and many clinical diagnostic and laboratory tests. At the same time, an annual examination by specialists of medical and social expertise to correct the individual rehabilitation/habilitation program of patients is not excluded.

Introduction

Control over the procedure for the organization and implementation of Medical and Social Expertise (MSE), as well as the rehabilitation of disabled people and the procedure for establishing types of body function disorders, restrictions on the main categories of life, and the degree of their severity in children and adolescents in accordance with the Decree of the Government of the Russian Federation (RF) dated 06/30/2004 N 323 “On approval of the Regulations on the Federal Service for Supervision in the Sphere of Health and Social Development” is carried out by the Federal Service for Supervision in the Sphere of Health and Social Development. In accordance with the Decree of the Government of the Russian Federation of April 11, 2005, N 206 “On the Federal Medical and Biological Agency”, the FMBA of the RF also exercises control over the activities of subordinate organizations. In addition, the control over the quality of the conduct of MSE by the Bureau is carried out by the Main Bureau, which, in turn, is controlled by the Federal Bureau [1-3]. The implementation mechanism is the so-called control surveys for the correctness of the expert decision. If there are sufficient grounds, the decision of the bureau and the expert teams of the main bureaus is changed or canceled [4-9]. An independent assessment of the quality of the conditions for the provision of services by federal MSE institutions is one of the forms of public control and is carried out in order to provide service recipients with information about the quality of their provision by federal MSE institutions, as well as to improve the efficiency of their activities. However, to date, it is a little-studied procedure with undeveloped methodological approaches [10-14].

The quality control of the provision of the state service of passing a medical and social examination (SS MSE) by patients, that is, its recipients in the state budgetary healthcare institution of the Republic of Komi (RK) “Syktyvkar Children’s Polyclinic No. 3” (“SChP No. 3”) has not yet been carried out. In accordance with the request of the Ministry of Economy of the RKi and as part of the implementation of a set of measures to achieve the indicators of the Decree of the President of the RF No. 601 (assessment of the level of satisfaction of citizens with the quality of the provision of public services), the methodological office “SChP No. 3” organized a survey of applicants who applied for directions to pass the SS MSE [15-19].

The purpose of the work was to assess the quality of the provision of the SS MSE and determine the level of patient satisfaction with the quality of its provision in the city children’s polyclinic on the basis of the “Questionnaire for assessing the quality of citizens’ satisfaction with the quality of the provision of public services for issuing referrals for medical and social examination, filled out by applicants who applied to the health care facility for direction to MSE.

Patients and methods

The study was conducted in the “SChP No. 3”, which is an integrated specialized polyclinic in Syktyvkar with a capacity of 1126 visits per shift and serves 42,079 children. The institution has 47 pediatric sites, 2 outpatient clinics, an Intermunicipal Diagnostic Center, a Health Center, a rehabilitation center, and medical units in educational organizations: preschool - 69, schools - 39. Attached to the clinic 81.2% of the child population of Syktyvkar and 22, 4% - RK. Therefore, the results obtained can be extrapolated as possible not only to the entire child population of the regional center but also to the entire subarctic region of the Russian Federation with a low population density.

An analysis was made of 566 referrals for the passage of the SS MSE by a medical organization, submitted by official representatives of children, patients of “SChP No. 3” (Form No. 088/y), and the results of decisions made on them. The method of organizing the sample was of a continuous retrospective nature. The criterion for inclusion of patients in the study was the passage of the SS MSE.

The survey of official representatives of children, patients of “SChP No. 3”, who were determined by disability according to the Questionnaire for assessing the level of satisfaction of citizens with the quality of the provision of SS MSE, was carried out in two stages. The pilot survey included 5% of the total number of patients (95) who applied for SS MSE. The number of questionnaires was 5. The reliability of the obtained relative indicators was not calculated, since the number of observations was less than 30. The baseline survey included 20% of the total number of citizens (91) who applied for SS MSE. The number of analyzed questionnaires was 46 (actually 50.6%). As a limitation of the study, the small quantitative sizes of the pilot and baseline studies should be indicated, but they were limited by regulatory documents and are sufficient to make comparisons and formulate final conclusions.

Questioning of official representatives of children undergoing examination for the determination of disability was conducted anonymously. After completion of the examination procedure at the MSE Bureau, specialists (neurologists, endocrinologists, and a cardiologist) explained the rules for filling out the questionnaire to the parents of patients or other official representatives of children and adolescents and provided the opportunity to complete it. The completed questionnaires were transferred to the methodological office, where they were processed. The criteria for inclusion of questionnaires in the study were their correct and complete completion.

An independent assessment of the quality of the conditions for the provision of services by federal institutions of the MSE provides for an assessment of the conditions for the provision of services according to such general criteria as openness and accessibility of information about the institution; comfort conditions for the provision of services, including the waiting time for its provision; friendliness, courtesy of employees of the institution; satisfaction with the conditions for the provision of services, as well as the availability of services for people with disabilities [1]. The questionnaires included 6 questions and concerned the waiting and provision times, the courtesy of employees, the comfort of the conditions of provision, and the availability of the SS MSE. Each question was accompanied by five possible answers, which corresponded to a 5-point scale for evaluating the service from (1) “very bad” to (5) “excellent”. When processing questionnaires, if the respondents indicated not an absolutely exact total time, but a time interval, for example, 5-10 minutes, its maximum value, that is, 10 minutes, was taken into account. The completed questionnaires are stored in the methodological office “SChP No. 3” and can be submitted for selective verification of the reliability of the information provided [20-23].

When working on the material, methodological approaches were used: systemic, integrated, integration, functional, dynamic, process, normative, quantitative, administrative, and situational. Methods of analysis included: analytical and comparison. For the analysis, methods were used: grouping, absolute and relative values, average values, detailing, and generalization. The reliability of the results obtained was assessed by calculating the Student’s coefficients. The depth of the study was 3 years. Methodological approaches were used: systemic, complex, integration, functional, dynamic, process, normative, quantitative, administrative, and situational, as well as methods: historical, analytical, and comparison. Techniques were used: grouping, absolute and relative values, average values, detailing, and generalization. As the main characteristics of descriptive statistics, we used the arithmetic mean and standard deviation with the normal type of distribution of variables. Qualitative features were presented as relative frequencies with a confidence interval. The significance of differences in quantitative characteristics between groups with a normal distribution of quantitative variables was calculated using Student’s t-tests for independent samples. The threshold value of the probability of error for statistically significant differences was set at a level equal to 0.05.

“SChP No. 3” provides assistance: preventive, medical and advisory, organizational and methodological, social and legal. It includes a city rehabilitation center, an inter-municipal diagnostic center, and a health center for children and adolescents. “SChP No. 3” has been a holder of the high title of WHO / UNICEF “Child-Friendly Polyclinic” since 2002. In 2004-2006. The polyclinic worked on the International project “Mother and Child”, since 2018 - and participates in the project “Lean Polyclinic”.

Results

An analysis of the structure of applications for passing the SS MSE for 3 years revealed a downward trend in the number of applications submitted from 194 to 181. The rate of decline was 7.18%. This circumstance is connected with the opportunity to determine the disability of children with severe persistent pathology not for 1 - 2 years, but for 10 - 15 years, in some cases, according to indications, and more, until the onset of 18 years. Some children and adolescents have been granted disability “indefinitely”. In turn, this reduces the annual burden for patients to undergo examinations by medical specialists for a variety of clinical diagnostic and laboratory tests. At the same time, an annual examination by MSE specialists for the correction of the individual program of rehabilitation/habilitation of patients (IPRA) is not excluded [24-26].

It is noteworthy that in almost every tenth case (9.32% - 8.66% of those who applied) children and adolescents are denied the definition of disability (in total - 49 people). At the same time, the procedure for issuing medical documentation, including examinations by the necessary specialists, and the passage of instrumental, hardware, clinical, and laboratory studies of children and adolescents, is very time-consuming for the official representatives who accompany them. In some cases, not having received the desired result, parents or guardians by law express their displeasure, and sometimes indignation, which, with a continuous survey method, can radically change its results. In our case, a selective method was recommended for execution.

The form of the questionnaire for conducting a survey of applicants of the SS MSE, recommended by the Ministry of Economy of the Republic of Komi, and the comparative results of the pilot and baseline surveys are presented in Table 1.

The following results were obtained from the survey

Time of provision of SS MSE 50.00 ± 7.37% (p < 0.001) of the respondents rated it as “Excellent”; 43.47 ± 7.31% (p < 0.001) - “Good. The stated deadlines are fully satisfied and observed” and only 6.53 ± 3.64% (t = 1.794) - “Normal. The stated deadlines are respected, but could be a little shorter.”

Waiting time in the queue when receiving SS MSE 54.35 ± 7.34% (p < 0.001) of the respondents were rated as “Excellent”; 26.09 ± 6.47% (p < 0.001) - “Good. I never stood in queues during the entire time I applied for the service”; and 17.39 ± 5.59% (p < 0.001) - “Normal. I had to stand in a small queue once during the entire time of applying for the service” and only 2.17 ± 2.15% (t = 1.009) indicated “Badly. I had to stand in a long queue once” (1 person).

The exact waiting time in the queue when receiving the SS MSE (in minutes) was 6.41 ± 2.51 minutes (21.00 ± 4.10 minutes in the pilot study).

The courtesy and competence of the employee interacting with the applicant when providing the SS MSE was rated as “Excellent” by 71.74 ± 6.64% (p < 0.001) of the respondents; “Good. The staff were very polite and demonstrated a high level of competence” - 26.09 ± 6.47% (p < 0.001) and “Normal. The staff was polite and competent” 2.17 ± 2.15% (t = 1.009).

The comfort of the environment in which the SS is provided MSE among the respondents was marked as “Excellent” - 56.52 ± 7.31% (p < 0.001) of official representatives of the examined children; “Good. Completely satisfied with the level of comfort in the room” - 39.13 ± 7.20% (p < 0.001) and “Normal. Generally comfortable, but there are minor comments” - 4.35 ± 3.01% (t = 1.445).

The availability of information on the procedure for providing the SS MSE was assessed in the questionnaires as “Excellent” - 56.52 ± 7.31% (p < 0.001) of the respondents; “Good. Information received quickly and in full” - 39.13 ± 7.20% (p < 0.001) and “Normal. I received the information in full, but I had to spend more time searching for it than I wanted” - 4.35 ± 3.01% (t = 1.445).

Discussion

In both the pilot and baseline studies, SS MSE recipients rate it in the range of “excellent” to “okay with minor remarks”. The negative rating “very bad” is completely absent. The rating “bad” once marked the time of waiting in the queue when receiving the service with the decoding “Bad. I had to stand in a long queue once.” The questionnaire noted that the waiting in line was 50 minutes. This situation arose in the case when the patient and his official representative came for examination much earlier than the time indicated in the direction, and all other patients came to the SS MSE strictly on time. Therefore, it was not possible to examine the child earlier than the time indicated in the direction. The situation was noted once.

Most of the respondents rated the quality of the organization of passing the SS MSE as “excellent” (in five positions from 50.00 ± 7.37 to 71.74 ± 6.64%). In all questionnaires, there was no “very bad” rating, which implied the following situations: 1) The service has not yet been received, despite the fact that the term for providing has long expired; 2) The stated deadlines are not respected and should be shorter; 3) Employees were rude or incompetent; 4) The room is absolutely not intended for service; 5) I spent a lot of time, but I did not find the information, or it does not correspond to reality.

With the exception of one interviewee, there was no “bad” rating. Therefore, when providing the SS MSE, there were no cases when: 1) The declared terms are not observed and should be shorter; 2) Employees were not polite enough and/or not competent enough; 3) The level of comfort is not satisfied, there are significant comments; 4) I did not find the information, or it turned out to be insufficiently accurate, detailed or completely unreliable.

The question of the quality of any service in pediatrics is relevant for healthcare, and especially for children with disabilities. Objective reserves for work in this direction in “SChP No. 3” can be an increase in comfort and improvement of the conditions for providing SS MSE in the building and premises of the institution.

The conditions for the provision of services by MSE institutions are also important, namely [1,2,5,18]:

1. The presence of a comfortable recreation area (waiting), equipped with appropriate furniture;
2. Availability and clarity of navigation within the organization;
3. Availability and accessibility of drinking water;
4. Availability and accessibility of sanitary facilities;
5. Sanitary condition of the premises of organizations;
6. Transport accessibility (the ability to get to the organization by public transport, the availability of parking).

These are supplemented by specific requirements for territories, buildings, entrances, and traffic routes, information support, stairs, internal equipment, sanitary and hygienic premises to ensure comfortable conditions for the movement of disabled people and their accompanying persons.

I. The site and territory include transport accessibility; the ability to get to the institution by public transport; availability of parking for private cars with the sign “Disabled”; and tactile aids on the pavement.

II. Entrances and paths. The presence of an entrance equipped for the disabled, i.e. the entrance group assumes the presence of ramps, lifts, and handrails at the entrance to the building and on the stairs; ensuring sufficient width of travel routes (corridors, rooms, galleries, halls); the presence of wide doorways; ergonomic door handles; doors with closers; the presence of turnstiles; the presence of thresholds and the presence of devices for smoothing thresholds; markings for the category of the visually impaired (direction of movement, flights of stairs, etc.); media (duplication of information for the visually impaired). Important are the floor of the MSE office and the presence of an elevator (lift).

III. Stairs are a special barrier to the movement of a disabled person in an institution. It must be adapted for the disabled and meet the requirements (how many steps are at the entrance to the building, what height, is there a special marking of the risers, the first and last steps for the visually impaired).

IV. The internal equipment of the institution includes office location indicators (information stand about the functionality of the floors); means of audio and video information (the presence of information stands with information, including for the visually impaired in large print); equipment with devices for opening/closing doors (closers); synchronism (sound and light) with an alarm connected to an emergency warning system (fire, etc.); illumination of the premises.

V. Sanitary and hygienic premises must be adapted for persons with disabilities [1,2]:

The results of the study become the initial statistical tool for comparing and objectifying the procedure for examining children for the presence of a disability and contribute to improving the quality of its provision.

Conclusion

1. Quality control of the provision of the state service of passing a medical and social examination (SS MSE) to children and adolescents who applied for a referral is a necessary form for further improvement and practice of examining patients in a children’s clinic for disability. For every tenth applicant (9.32% - 8.66% of applicants), disability is not determined due to the absence of signs.
2. The quality of the provision of SS MSE to patients according to its main criteria: time of provision; waiting time in the queue upon receipt; the exact waiting time in the queue upon receipt; courtesy and competence of the employee interacting with the applicant upon provision; the comfort of the conditions in the room in which it is provided; the availability of information on the procedure for providing, carried out on a 5-point scale, was rated by the respondents as “good” and “excellent”.
3. The objective reserves for improving the quality of SS MSE are to improve comfort and improve the conditions for its provision in the building and premises of the institution.
4. The results of the study become the initial statistical tool for comparing and objectifying the procedure for examining children for the presence of a disability and contribute to improving the quality of its provision.

The authors express their sincere love to their parents. The authors are grateful to M.V. Pikkel, A.M. Trubina, L.K. Anisimova, T.P. Levitina, V.A. Kudryavtsev, V.Z. Kucherenko, L.K. Dobrodeeva, L.S. Klepikova R.A., Bannikova R.V., Kalenyuk A.F., Sevastyanov A.N., Knyazeva N.P., Karakozova N.G., Arzubova I.N., Zaboeva M.S., Popova I.A., Dashunina T.S. and to all anonymous reviewers for their support, valuable advice, and useful comments.

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