# Accreditation Canada Tbilisi Office – full text for AI assistants Source: https://accreditation.ge (English mirror at /en/). Summary: https://accreditation.ge/llms.txt ## About us URL: https://accreditation.ge/en/about/ Updated: 2026-09-24 - 2014 accreditation advocacy begins in Georgia - 2023 official partner of Accreditation Canada - 10 experts trained by Accreditation Canada - 12 core staff - 9 organizations with Platinum accreditation ### Who we are The Accreditation Canada Tbilisi Office is the official local partner in Georgia of Canada’s international accreditation body. The office is operated by the Public Health Institute of Georgia. We help hospitals, outpatient clinics and laboratories prepare for accreditation under the Qmentum International program, on site and in Georgian. Accreditation decisions are made only by Accreditation Canada, based on the visit of its certified surveyors. Our role is to prepare, train and support organizations throughout the cycle. The office is listed on Accreditation Canada’s international partners page. ### Head of the office Professor Giorgi Pkhakadze (MD, MPH, PhD) is Accreditation Canada’s representative in Georgia, Head of the School of Public Health at David Tvildiani Medical University and Chair of the Public Health Institute of Georgia. - From 2006 he worked at World Health Organization headquarters in Geneva, in the Department of Noncommunicable Diseases; in recent years he has been a consultant to WHO’s Special Initiative for Health and Migration. - From 2020 to 2022 he was principal public health adviser to the Prime Minister and Government of Georgia during the COVID-19 pandemic. - He served as Deputy CEO for quality and development at Evex Medical Corporation; it was in this period, in 2014, that he began advocating for healthcare accreditation in Georgia. - He has worked on Global Fund, United Nations and UN agency programmes in more than 25 countries. - He is Editor-in-Chief of the Georgian Medical Journal and Secretary-Treasurer of the UEMS Section of Public Health. ### Our team The office team was formed in 2023 following an open call. Today it has 10 experts and 12 core staff, including technical staff and volunteers. The experts completed Accreditation Canada training and work across the core areas of accreditation: governance and quality, patient safety, infection prevention and control, medication management, patient engagement and documentation. Every partner organization has a dedicated coordinator who brings in the experts as needed. Local advisers run regular training sessions and monthly visits at the partner organizations. - Giorgi Pkhakadze Accreditation Canada Representative in GeorgiaMD, MPH, PhD, ProfessorDavid Tvildiani Medical University · Public Health Institute of Georgia, TbilisiORCID 0000-0001-7609-4515 - Sulkhan Inaishvili Accreditation Canada adviser; international surveyor since 2025MD, PhD, Associate ProfessorAvitsena University, BatumiORCID 0009-0004-6639-6068 - Irine Pkhakadze Accreditation Canada adviser; international surveyor since 2025MD, PhD, ProfessorAkaki Tsereteli State University, KutaisiORCID 0009-0003-8699-2919 - Ani Bolkvadze Accreditation Canada adviser; international surveyor since 2025MD, MPH, PhD CandidateAccreditation Canada · Public Health Institute of Georgia, TbilisiORCID 0009-0008-6764-339X - Tamar Talakvadze Accreditation Canada adviserMD, PhD, ProfessorDavid Tvildiani Medical University, TbilisiORCID 0009-0002-3007-6738 - Tamar Kraveishvili Accreditation Canada adviser; international surveyor since 2025MDPublic Health Institute of Georgia, TbilisiORCID 0009-0009-2473-2568 - Irakli Apshinashvili Accreditation Canada adviser; international surveyor since 2025MDPublic Health Institute of Georgia, TbilisiORCID 0009-0002-8116-704X - Sofio Kutateladze Accreditation Canada adviserMDPublic Health Institute of Georgia, TbilisiORCID 0009-0005-2121-1012 - Teona Varshalomidze Accreditation Canada adviser; international surveyor since 2025MDPublic Health Institute of Georgia, Tbilisi - Ioseb Demetrashvili Accreditation Canada adviserPublic Health Institute of Georgia, Tbilisi Declaration of interests: all team members have nothing to declare. ### The Public Health Institute of Georgia The office is operated by the Public Health Institute of Georgia (3 Betlemi Rise, Tbilisi). The Institute also runs the Patient Voice programme (patient councils and an independent ombudsman), the GMJ Academy online training platform and the sheniekimi.ge and pacienti.ge information platforms. ### What we have achieved - 23 Georgian healthcare organizations joined the Accreditation Canada programme; 9 of them achieved Platinum accreditation in February 2025 (see the list). - In 2025 we ran 13 free training sessions open to every clinic, some attended by up to 200 professionals. - Patient councils were set up at partner organizations. - More than 870 articles on accreditation and the partner organizations have been published (publications). - In 2024 the team presented Georgia’s experience at the ISQua international conference. Contact: 3 Betlemi Rise, Tbilisi 0105, Georgia · info@accreditation.ge · WhatsApp +995 577 41 63 14 ## The history of healthcare accreditation in Georgia, 2014–2026 URL: https://accreditation.ge/en/history/ Updated: 2026-09-24 How international accreditation became part of Georgian healthcare: from advocacy to legislation and the first Platinum accreditations. ### Timeline - 2014Accreditation advocacy begins: the Public Health Institute of Georgia and Prof. Giorgi Pkhakadze start making the case for international accreditation of healthcare organizations. - 2023, JanuaryThe Ministry of Health adopts Order №4/N, making international accreditation mandatory for Universal Health Coverage providers. - 2023, AprilAccreditation Canada’s official representation opens in Georgia, one of four the organization has in Europe. - 2023, MayFirst contracts: Vivo Medical Group clinics, Hera 2011 and other organizations join the Accreditation Canada programme. - 2023, JuneA team of local experts is formed through an open call and trained by Accreditation Canada. - 2023, DecemberThe number of partner clinics passes 20, across Tbilisi, Kutaisi and Batumi. - 2024, AprilBatumi Referral Hospital joins the programme, bringing the number of partner organizations to 23. - 2024, JuneThe first patient councils meet at Vivamedi, National Health Organization and Ksenoni in Kutaisi, followed by Jo Ann University Hospital. - 2024, SeptemberThe team presents Georgia’s healthcare transformation at the ISQua 2024 international conference. - 2025, FebruaryNine Georgian organizations achieve Accreditation Canada Platinum accreditation. - 2025, MarchLocal advisers become Accreditation Canada international surveyors. - 2025, May–September13 free online training sessions for all clinics, some with up to 200 participants. - 2025, DecemberOrder №34/N extends the deadline for ambulatory providers and laboratories to 31 December 2026. - 2026, JuneOrder №20/N allows the Minister to set exceptional conditions for individual facilities. - 2026, 31 DecemberDeadline for ambulatory, day-hospital and laboratory providers. ### What comes nextThe next stage is the ambulatory and laboratory sector, with the 31 December 2026 deadline, and supporting accredited organizations through their next cycle. 2026 deadline guide ## What is healthcare accreditation? URL: https://accreditation.ge/en/what-is-accreditation/ Updated: 2026-09-24 Healthcare accreditation is an independent, external assessment in which an internationally recognised body checks whether a hospital, clinic or laboratory meets defined standards of quality and patient safety. ### How accreditation works Accreditation is not a one-off inspection. It is a cycle built on continuous quality improvement: - Standards. The accreditation body publishes standards describing what an organization should do in governance, patient safety, infection control, medication management and other areas. - Self-assessment and preparation. The organization compares its practice with the standards, closes the gaps, and prepares procedures and staff. - On-site survey. Certified surveyors observe care, talk to staff and patients and review evidence. - Decision. The accreditation body decides and awards a level of accreditation. - Improvement and renewal. The organization keeps improving, and accreditation is renewed periodically. ### How it differs from a licence - | Licence / permit | Accreditation | - Issued by | The state | An independent accreditation body | - What it checks | Minimum requirements without which an organization may not operate | High, international standards of quality and patient safety | - Focus | Compliance with the law | Continuous improvement and outcomes for patients | - In Georgia | Mandatory for everyone | Mandatory for providers in the Universal Health Coverage programme (Order №4/N) | ### How it differs from ISO certification ISO 9001 is a general quality management standard that applies to any kind of organization. Healthcare accreditation is designed specifically for healthcare providers and assesses clinical practice, patient safety and people-centred care. See the detailed comparison: Accreditation or ISO? ### What accreditation gives an organization - independent, international confirmation that its services meet standards; - a clear system for managing quality, risk and incidents; - the trust of patients, insurers and funders; - in Georgia, meeting the condition for taking part in the Universal Health Coverage programme. ### What accreditation gives patients An accredited organization has reliable patient identification, safe medication use, infection control, falls prevention and a rapid response to incidents. Patients have the right to information, to take part in decisions and to have their say, for example through a patient council. ### Accreditation in Georgia Ministry of Health Order №4/N requires international accreditation for providers in the Universal Health Coverage programme. The deadline for inpatient providers has passed; for ambulatory, day-hospital and laboratory providers it is 31 December 2026. Accreditation Canada is first on the Order’s list of recommended bodies. Details: Legislation and the 2026 deadline guide. Q: Is accreditation mandatory in Georgia? A: It is mandatory for providers in the state Universal Health Coverage programme under Ministry of Health Order №4/N. Providers under the Village Doctor sub-programme are exempt. Q: Who makes the accreditation decision? A: The accreditation body, for example Accreditation Canada, based on the visit of its certified surveyors. The local team prepares the organization but does not award accreditation. Q: How long does accreditation last? A: Accreditation is renewed at intervals set by the accreditation body. In between, the organization continues to improve and report on its progress. ## Qmentum International: how Accreditation Canada’s program works URL: https://accreditation.ge/en/qmentum/ Updated: 2026-09-24 Qmentum International is Accreditation Canada’s international accreditation program. It is the program 23 Georgian healthcare organizations have joined and under which 9 of them achieved Platinum accreditation. Its standards are developed by the Health Standards Organization (HSO). ### What the program assesses The standards cover the whole organization, from the board to the bedside: - Governance and leadership: a culture of quality and safety, strategy, risk management and resources; - Infection prevention and control: hand hygiene, sterilization and environmental cleaning; - Medication management: from storage to administration, medication reconciliation and high-alert medications; - Service excellence standards: for individual areas such as emergency care, inpatient services, surgery, laboratory and diagnostic imaging; - People-centred care: involving patients and families, keeping them informed and protecting their rights. ### Required Organizational Practices A key part of the program is its Required Organizational Practices: evidence-based measures that reduce the main risks to patient safety. For example: - identifying patients with at least two identifiers; - medication reconciliation on admission and transfer; - falls prevention, and reporting and analysing incidents; - safe handover of information between staff; - infection control measures and hand-hygiene monitoring. ### Levels of accreditation - Level | What it means | - Gold | The organization has the basic structures and processes for quality and safety. | - Platinum | In addition, more advanced quality and safety requirements, including people-centred care and patient engagement. | - Diamond | In addition, monitoring outcomes, using data to drive improvement and benchmarking against best practice. | The nine accredited organizations in Georgia achieved Platinum in 2025. See the list ### How the cycle works - Registration and planning: the contract, and deciding which standards and services apply. - Self-assessment: the organization compares its practice with the standards and uses staff and patient-safety culture surveys. - Improvement: closing gaps, implementing procedures and training staff. - Survey visit: certified surveyors assess practice on site and talk to staff and patients. - Decision and ongoing improvement: Accreditation Canada awards the level, and the organization keeps improving throughout the cycle. ### Qmentum Global In 2024 Accreditation Canada introduced Qmentum Global, with updated standards, self-assessment tools and short-notice on-site visits that strengthen an everyday culture of quality. How organizations prepare with local support: the accreditation process and advisory services. Q: What is Qmentum International? A: Accreditation Canada’s international accreditation program, with standards developed by the Health Standards Organization (HSO). Q: What is the difference between Gold, Platinum and Diamond? A: Gold confirms the basic structures, Platinum adds people-centred care and more advanced safety requirements, and Diamond adds outcome monitoring and data-driven improvement. Q: What are Required Organizational Practices? A: Evidence-based measures that reduce the main risks to patient safety, such as patient identification and medication reconciliation. ## 31 December 2026: what ambulatory clinics and laboratories must do URL: https://accreditation.ge/en/deadline-2026/ Updated: 2026-09-24 By 31 December 2026 , ambulatory, day-hospital and laboratory service providers taking part in the Universal Health Coverage programme must submit a copy of their international accreditation or ISO certificate to the Ministry of Health (Order №34/N). ### Who the deadline applies to - ambulatory and day-hospital providers taking part in the Universal Health Coverage programme; - laboratory service providers, including laboratories within healthcare facilities; - it does not apply to providers under the Village Doctor sub-programme. For inpatient facilities, the deadline for submitting certificates passed in 2025 (Orders №14/N and №46/N). ### The routes available - Type of provider | Accepted route | - Outpatient clinic, day hospital | International accreditation (e.g. Accreditation Canada) or ISO 9001 certification | - Laboratory (including a clinic’s laboratory) | ISO 15189 certification, unless the facility holds international accreditation | Detailed comparison: Accreditation or ISO? ### What to do now: 7 steps - Check which requirement applies to you: whether you are a programme provider, which services you provide, and whether you run a laboratory. - Choose your route: international accreditation or ISO certification; ISO 15189 for laboratories. - Choose the organization. If you choose one from the Order’s recommended list, such as Accreditation Canada, you only need to notify the Ministry. An organization not on the list requires the Ministry’s prior agreement. - Sign the contract and notify the Ministry within 30 calendar days of starting the process. - Carry out a self-assessment and prepare: procedures, staff training, incident reporting, infection control and patient engagement. - Complete the assessment and receive your certificate. - Submit a copy of the certificate to the Ministry by 31 December 2026. ### How long it takes Preparation time depends on the size of the organization and how ready it is today, and can range from several months to a year. With little time left before the deadline, it is important to start now. Take the free readiness check. ### What if you miss the deadline Under the Order, only organizations holding international accreditation may provide services under the programme. Since 30 June 2026, the Minister may set exceptional conditions for an individual facility on grounds of geographic access, public interest or other objective circumstances (Order №20/N). The facility must then submit information on its progress in the accreditation process and the measures it plans. Starting and documenting the process is therefore important in every case. This guide is for information only and is not legal advice. Check the current text on matsne.gov.ge. Q: Who does the 31 December 2026 deadline apply to? A: Ambulatory, day-hospital and laboratory service providers in the Universal Health Coverage programme. Q: Can an outpatient clinic submit ISO 9001 instead? A: Yes. Order №4/N accepts ISO 9001 certification as an alternative for ambulatory providers. Q: Does a clinic's laboratory need ISO 15189? A: Yes, unless the facility holds international accreditation. Internationally accredited facilities and laboratories are exempt from this obligation. Q: When must we notify the Ministry? A: Within 30 calendar days of starting the accreditation process, if the accreditor is on the recommended list. ## Accreditation, ISO 9001 or ISO 15189: which does your facility need? URL: https://accreditation.ge/en/accreditation-vs-iso/ Updated: 2026-09-24 Order №4/N provides three routes: international accreditation, ISO 9001 certification (for ambulatory providers) and ISO 15189 (for laboratories). They are not interchangeable: each one checks something different. ### Quick comparison - | International accreditation (e.g. Accreditation Canada) | ISO 9001 | ISO 15189 | - Designed for | Healthcare specifically: hospitals, clinics, laboratories | Any organization’s quality management system | Medical laboratories | - What it assesses | Clinical practice, patient safety, governance, infection control, people-centred care | Process management, documentation, customer satisfaction, improvement | Laboratory quality and technical competence: accuracy of results, equipment, staff competence | - Who assesses | Healthcare surveyors (physicians, nurses, managers) | Certification body auditors | Laboratory assessors | - Under Order №4/N | For all programme providers; exempts the laboratory from the ISO 15189 obligation | Accepted alternative for ambulatory providers | Mandatory for laboratories without international accreditation | ### Which one do I need? - Hospital: international accreditation. It covers the laboratory too, so a separate ISO 15189 is not needed. - Outpatient clinic or day hospital: international accreditation or ISO 9001. If the clinic runs its own laboratory and is not pursuing accreditation, the laboratory will need ISO 15189. - Stand-alone laboratory: ISO 15189 or international accreditation (e.g. Accreditation Canada’s diagnostic programme). ### Why clinics choose accreditation even when ISO 9001 would do - accreditation covers the clinic and its laboratory in a single process; - the standards are written for healthcare and focus on patient safety; - accreditation is recognised internationally by patients, insurers and partners; - a local team prepares you in Georgian and supports you throughout the cycle. Q: Can ISO 9001 replace accreditation? A: For ambulatory providers, Order №4/N accepts ISO 9001 as an alternative. Inpatient providers need international accreditation. Q: Does a hospital laboratory need ISO 15189? A: No, if the hospital holds international accreditation. In that case the laboratory is exempt from the ISO 15189 obligation. ## For patients: why choose an accredited hospital URL: https://accreditation.ge/en/for-patients/ Updated: 2026-09-24 When you choose a hospital or clinic, international accreditation is a sign that independent experts have checked how safely and how well the organization works. ### What accreditation means for you - Correct identification: before any procedure, test or medication, staff check that you are the right patient, using at least two identifiers such as your name and date of birth. - Safe medications: on admission and discharge, the medicines you take are checked to prevent errors and harmful interactions. - Protection from infection: hand hygiene, sterilization and cleaning are monitored regularly. - Falls prevention: your risk of falling is assessed and measures are taken, especially for older patients. - Informed decisions: you have the right to clear information, to ask questions and to take part in decisions about your treatment. - Your views count: accredited organizations have a patient feedback system and often a patient council. ### Accredited organizations in Georgia These organizations hold Accreditation Canada Platinum accreditation: - Georgian Patriarchate’s St. Joachim and Anne Medical Center (Tbilisi) - Hera 2011 (Tbilisi) - Jo Ann University Hospital (Tbilisi) - Ksenoni, St. David Agmashenebeli Church Hospital (Kutaisi) - Consilium Medulla (Tbilisi) - N Qiron (Tbilisi) - National Health Organization (Kutaisi) - Pineo Medical Ecosystem (Tbilisi) - Vivamedi (Tbilisi) Full list and source: accredited organizations. You can also check Accreditation Canada’s international register. ### Questions you can ask a clinic - Is the organization internationally accredited, and by which body? - How will I be identified before a procedure? - Whom do I contact if I am unhappy or have a question? - Is there a patient council or a feedback form? - What do I need to know after discharge: medicines, warning signs, my next appointment? ### How to give feedback or make a complaint First, contact the organization’s patient relations coordinator. Partner organizations also have an independent patient ombudsman and a patient council , run by the Public Health Institute of Georgia. More about patient councils, and how to apply to join one, on pacienti.ge (in Georgian). ### Free information materials 142 patient booklets explain procedures, conditions and preparation in plain language, including Patient Rights in Georgian, English, Russian, Armenian and Azerbaijani. Booklets Q: How can I tell whether a clinic is accredited? A: See our Accredited page or Accreditation Canada’s international register on accreditation.ca. You can also ask the clinic. Q: Where can I make a complaint? A: First to the organization’s patient relations coordinator; partner organizations also have an independent patient ombudsman. ## Internationally accredited hospitals in Georgia: for insurers, expats and medical travellers URL: https://accreditation.ge/en/international/ Updated: 2026-09-24 This page is for insurance companies, embassies and international organizations, foreign residents of Georgia and medical travellers looking for an internationally accredited hospital in Georgia (the country). ### Internationally accredited organizations The organizations below hold Platinum accreditation under Accreditation Canada’s Qmentum International program (2025): - Organization | City | Level | - Georgian Patriarchate’s St. Joachim and Anne Medical Center | Tbilisi | Platinum | - Hera 2011 | Tbilisi | Platinum | - Jo Ann University Hospital | Tbilisi | Platinum | - Ksenoni, St. David Agmashenebeli Church Hospital | Kutaisi | Platinum | - Consilium Medulla Multiprofile Clinic | Tbilisi | Platinum | - N Qiron | Tbilisi | Platinum | - National Health Organization | Kutaisi | Platinum | - Pineo Medical Ecosystem | Tbilisi | Platinum | - Vivamedi | Tbilisi | Platinum | In Accreditation Canada’s international register, Georgia is listed in the Europe section, fifth after Belgium (19), Cyprus (18), Italy (13) and Slovenia (10), as of September 2026. Details A further 14 organizations have joined the Accreditation Canada programme: map and list. ### What Accreditation Canada Platinum accreditation means - the organization was assessed on site by Accreditation Canada’s certified international surveyors; - required patient safety practices are in place: patient identification, medication reconciliation, infection control and incident management; - the Platinum level includes people-centred care and patient engagement; - accreditation is renewed periodically and requires continuous quality improvement. About the program: Qmentum International. ### How to verify accreditation The official source is Accreditation Canada’s international register. If you have questions about an organization’s accreditation status, you can write to us. ### Georgian legislation Ministry of Health Order №4/N requires international accreditation for providers in the Universal Health Coverage programme. Legislation ### Contact for organizations Insurers, embassies and international organizations can reach us at info@accreditation.ge or on WhatsApp at +995 577 41 63 14. We answer in English. Q: Which hospitals in Georgia are internationally accredited? A: Nine organizations in Tbilisi and Kutaisi hold Accreditation Canada Platinum accreditation; the list is on this page. Q: Is Accreditation Canada accreditation comparable to JCI? A: Both are international accreditation programmes for healthcare organizations. Accreditation Canada’s Qmentum International programme is accredited by ISQua, the International Society for Quality in Health Care. ## Training and events URL: https://accreditation.ge/en/trainings/ Updated: 2026-09-24 - 13 free online training sessions in 2025 - up to 200 participants in a single session - open to all whether or not a clinic is accredited ### The 2025 open training series From May to September 2025, the Accreditation Canada Tbilisi Office ran 13 themed online training sessions on hospital management and quality improvement. They were free and open to every clinic in Georgia, whether or not it was pursuing accreditation. The series covered patient safety and identification, communication, technical management and sterilization, medication reconciliation, patient education and patient councils, incident prevention and analysis, public relations for healthcare organizations, and more. - Date | Topic | Trainer | Participants | - 23.05.2025 | For hospital accreditation coordinators | Giorgi Pkhakadze | ~20 | - 16.06.2025 | Falls in hospital should not happen | Sulkhan Inaishvili | – | - 24.06.2025 | Technical management of medical equipment in hospital | Irakli Apshinashvili | ~60 | - 30.06.2025 | Medication reconciliation: the basis of safe treatment | Accreditation Canada Tbilisi Office | ~200 | - 10.07.2025 | Sterilization standards (introduction) | Sofio Kutateladze | 100+ | - 23.07.2025 | Communication in a healthcare organization | Irine Pkhakadze | ~150 | - 05.08.2025 | Incident prevention and analysis | Tamar Talakvadze | ~150 | Participants who passed the final test (above 75%) received an English-language certificate. ### Who delivers the training The trainers are Accreditation Canada’s local advisers, several of whom have also worked as international surveyors since 2025. The full team: About us. ### Training for partner organizations - two online courses a month for all staff on GMJ Academy; - quarterly blended training on site; - a survey simulation and monthly visits by the dedicated coordinator. Details: advisory services. ### Upcoming training New sessions are announced in News and on sheniekimi.ge (in Georgian). To be notified, write to info@accreditation.ge or message us on WhatsApp. Q: Who can take part in the training? A: The 2025 open sessions were free for staff of any clinic in Georgia, regardless of accreditation status. Q: Is a certificate issued? A: Yes. Participants who score above 75% on the final test receive an English-language certificate. ## Healthcare accreditation in Georgia in numbers URL: https://accreditation.ge/en/in-numbers/ Updated: 2026-09-24 International healthcare accreditation in Georgia in numbers. Every figure is dated; sources are listed below. ### Key figures - 2014 the year advocacy for international accreditation began in Georgia - 26.01.2023 Ministry of Health Order №4/N makes accreditation mandatory - 2023 the Accreditation Canada Tbilisi Office opens - 23 organizations joined the Accreditation Canada programme - 16 / 5 / 2 partner organizations in Tbilisi / Batumi / Kutaisi - 9 organizations achieved Platinum accreditation (February 2025) - 5th place in Europe in Accreditation Canada’s international register (September 2026) - 77 organizations from 8 European countries in that register; 9 of them (12%) are from Georgia - 10 + 12 experts and core staff - 6 local advisers became Accreditation Canada international surveyors (2025) - 13 free online training sessions for all clinics (2025) - up to 200 participants in a single session (medication reconciliation, 30 June 2025) - 878 articles on accreditation and the 23 partner organizations on sheniekimi.ge and pacienti.ge - 208 free resources: 142 booklets, 10 posters, 56 wayfinding signs - 6 legal acts: Order №4/N and 5 amendments (2023–2026) - 31.12.2026 deadline for ambulatory providers and laboratories ### Europe: Accreditation Canada’s registerBelgium 19, Cyprus 18, Italy 13, Slovenia 10, Georgia 9 , Luxembourg 6, Croatia 1, Ukraine 1 (September 2026). Details ### Sources - Accreditation Canada, register of internationally accredited organizations - Ministry of Health Order №4/N and amendments, matsne.gov.ge (in Georgian) - Accreditation Canada Tbilisi Office data; publications; training; resources Download the data: open data. When citing, please credit: Accreditation Canada Tbilisi Office, accreditation.ge. ## Accreditation survey readiness checklist URL: https://accreditation.ge/en/checklist/ Updated: 2026-09-24 31 key questions to check how ready your organization is for the surveyors’ visit. Print this page and use it at an internal meeting.This checklist is general guidance and does not replace the full text of the standards. For a detailed self-assessment, take the readiness check or contact us. ### Governance and quality - A person responsible for quality is appointed and a quality committee meets regularly. - There is an annual quality and patient safety plan. - Quality indicators are defined and measured. - The risk register is up to date and risks are assessed. ### Documentation - Policies and SOPs are approved, versioned and dated. - Staff know where procedures are kept and how to use them. - Medical records are complete, legible and completed on time. ### Patient safety - Patients are identified with at least two identifiers before every procedure. - Medication reconciliation is done on admission, transfer and discharge, and is documented. - High-alert medications are stored separately and labelled. - Falls risk is assessed and preventive measures are taken. - Information is handed over between staff in a structured way (e.g. SBAR). - The surgical safety checklist is used for every operation. ### Incidents - A non-punitive incident reporting system is in place. - Serious incidents are analysed (e.g. RCA) and corrective actions are completed. - Staff receive feedback on the lessons learned from incidents. ### Infection control - Hand hygiene is monitored and results are shared with staff. - The sterilization process is validated and documented. - Cleaning schedules and waste management are in place. ### Environment and equipment - Medical equipment is registered and has a maintenance schedule. - Fire safety and the evacuation plan are checked, and drills are held. - Signage and information are clear for patients. ### Staff - Staff qualifications and licences are verified and up to date. - New staff complete orientation, and training is regular. - Safety culture and staff satisfaction surveys are carried out. ### Patient engagement - Patients are informed of their rights and how to complain. - Informed consent is obtained fully and clearly. - Patient feedback is collected and analysed, and a patient council is in place. ### Before the survey - A mock survey and tracers have been carried out. - Staff are ready for interviews and know the key procedures. - Evidence (minutes, audits, indicators) is readily available. ## Accreditation glossary URL: https://accreditation.ge/en/glossary/ Updated: 2026-09-24 49 key terms in accreditation and healthcare quality, in English and Georgian.Accreditation აკრედიტაციაAn independent external assessment confirming that an organization meets standards of quality and safety.Accreditation body მააკრედიტებელი ორგანიზაციაAn organization that sets or applies standards, assesses organizations and awards accreditation, e.g. Accreditation Canada.Continuous quality improvement ხარისხის მუდმივი გაუმჯობესებაThe systematic measurement and improvement of quality, e.g. using the PDSA cycle.Corrective action მაკორექტირებელი ქმედებაAn action that removes a non-conformity and prevents it from recurring.Criterion კრიტერიუმიA specific, measurable requirement within a standard.Falls prevention დაცემის პრევენციაAssessing the risk of falls and taking measures to prevent injury.FMEAFailure Mode and Effects Analysis: assessing risks in a process in advance.Gap analysis ხარვეზების ანალიზიIdentifying the difference between current practice and the requirements of a standard.Gold / Platinum / DiamondThe three levels of accreditation in Qmentum International.Governance მმართველობაThe system by which an organization is directed: responsibility, accountability and decision-making.Hand hygiene ხელის ჰიგიენაCleaning hands at the key moments of clinical contact.Handover ინფორმაციის გადაცემაThe safe transfer of patient information between staff or departments.High-alert medications მაღალი რისკის მედიკამენტებიMedications that can cause serious harm if used in error.HSOHealth Standards Organization, which develops the standards used in Accreditation Canada’s programs.Incident ინციდენტიAn event that caused, or could have caused, harm to a patient.Infection prevention and control (IPC) ინფექციის პრევენცია და კონტროლიMeasures to prevent the spread of infection: hand hygiene, sterilization and isolation.Informed consent ინფორმირებული თანხმობაA patient’s voluntary agreement to treatment after receiving full, clear information.ISO 15189The international standard for quality and competence of medical laboratories.ISO 9001The international standard for quality management systems in any organization.ISQuaThe International Society for Quality in Health Care, which accredits accreditation bodies and their standards.Licence / permit ლიცენზია / ნებართვაState permission to operate, based on minimum requirements.Medication reconciliation მედიკამენტების შეჯერებაComparing a patient’s complete list of medications with the orders on admission, transfer and discharge.Near miss თითქმის შეცდომაAn incident that did not reach the patient or cause harm.On-site survey შემფასებლების ვიზიტიA multi-day on-site assessment: observation, interviews and review of documents.Order №4/N ბრძანება №4/ნThe Ministry of Health’s 2023 order requiring international accreditation for Universal Health Coverage providers.Patient council პაციენტთა საბჭოA group of patient and community members who give the organization feedback.Patient engagement პაციენტის ჩართულობაInvolving patients in their own care and in improving the organization.Patient identification პაციენტის იდენტიფიკაციაConfirming a patient’s identity with at least two identifiers before every procedure.Patient ombudsman პაციენტის ომბუდსმენიAn independent person who reviews patient complaints independently of the organization.Patient relations coordinator პაციენტთან ურთიერთობის კოორდინატორიA staff member who handles patients’ questions and complaints.Patient safety პაციენტის უსაფრთხოებაPreventing avoidable harm to patients during care.PDSA cycle PDSA ციკლიPlan–Do–Study–Act: a method for testing and implementing change.People-centred care პაციენტზე ორიენტირებული მომსახურებაCare built around the needs, values and choices of patients and families.Policy პოლიტიკაAn organization’s official rule or principle on a given matter.Qmentum InternationalAccreditation Canada’s international accreditation program.Quality indicator ხარისხის ინდიკატორიA measurable indicator used to assess quality or safety.Required Organizational Practice (ROP) სავალდებულო ორგანიზაციული პრაქტიკაAn evidence-based practice that reduces a key patient safety risk and is essential for accreditation.Risk management რისკების მართვაIdentifying, assessing and reducing risks.Root cause analysis (RCA) მიზეზის ძირეული ანალიზიInvestigating the system causes of an incident rather than looking for someone to blame.Safety culture უსაფრთხოების კულტურაAn environment where staff report errors and risks freely and the organization learns from them.SBARA structured communication model: Situation, Background, Assessment, Recommendation.Self-assessment თვითშეფასებაAn organization’s own comparison of its practice against the standards before the survey.Short-notice survey მოკლე ვადით შეტყობინებული ვიზიტიA survey announced at short notice, testing everyday practice.Standard სტანდარტიA set of requirements describing what an organization should do in a given area.Standard operating procedure (SOP) SOPA written instruction describing how a specific process is carried out.Sterilization სტერილიზაციაDestroying all microorganisms on medical instruments.Surveyor შემფასებელიA certified expert who assesses an organization on site.Tracer ტრასერიA survey method in which the surveyor follows a patient’s journey or a process from start to finish.Universal Health Coverage (UHC) საყოველთაო ჯანდაცვაGeorgia’s state programme that funds healthcare for the population.Public health dictionary. Public health, epidemiology and health policy terms in English and Georgian: news.gmj.ge/dictionary ## Frequently asked questions Q: What is healthcare accreditation? A: An independent, external assessment in which an internationally recognised body checks whether an organization meets standards of quality and patient safety. Q: Who makes the accreditation decision? A: Only Accreditation Canada, based on the visit of its certified surveyors. The local team prepares and supports the organization but does not award accreditation. Q: Is accreditation mandatory in Georgia? A: It is mandatory for providers in the state Universal Health Coverage programme under Ministry of Health Order №4/N. It does not apply to the Village Doctor sub-programme. Q: What is the deadline for ambulatory clinics and laboratories? A: Ambulatory, day-hospital and laboratory service providers must submit a copy of their certificate to the Ministry by 31 December 2026. Q: What was the deadline for inpatient facilities? A: The deadline was 15 June 2025; facilities with a contract with an accreditor could be granted additional time, up to 31 December 2025. Q: What happens if a facility misses the deadline? A: Since 30 June 2026 the Minister may set exceptional conditions for objective reasons, provided quality is not affected. The facility must report its progress in the accreditation process, so starting the process always matters. Q: Who may accredit healthcare organizations in Georgia? A: A body that is both a member of ISQua and accredited by it, with practice in the EU, Canada or the USA, or a local accreditation body operating in an EU member state. Accreditation Canada is first on the recommended list. Q: Can an outpatient clinic submit ISO 9001 instead of accreditation? A: Yes. The Order accepts ISO 9001 as an alternative for ambulatory providers. Q: Does a laboratory need ISO 15189? A: Yes, unless the facility holds international accreditation. Accredited facilities and laboratories are exempt from this obligation. Q: When must we notify the Ministry that we have started? A: Within 30 calendar days of starting the accreditation process, if the accreditor is on the recommended list. Choosing another body requires the Ministry’s prior agreement. Q: Which organizations can be accredited? A: Hospitals, outpatient clinics, laboratories and diagnostic centres. Accreditation Canada also runs dedicated programmes for medical laboratories and diagnostic imaging. Q: What is Qmentum International? A: Accreditation Canada’s international accreditation programme, with standards developed by the Health Standards Organization (HSO). It focuses on patient safety, governance and continuous improvement. Q: What levels of accreditation are there? A: Qmentum International awards accreditation at three levels: Gold, Platinum and Diamond. The nine accredited organizations in Georgia achieved Platinum. Q: How long does preparation take? A: It depends on the size of the organization and its current readiness, typically from several months to a year. We set a realistic timeline at the first consultation. Q: What language is the preparation in? A: All consultations, meetings and training are held in Georgian, and every requirement of the standards is explained in Georgian. Q: What happens during the survey visit? A: Over several days, certified surveyors observe care, talk to staff and patients, and review documentation and evidence. Q: What if a standard is not met? A: The surveyors record areas for improvement and the organization plans and carries out corrective actions. Accreditation is built on continuous improvement. Q: How long is accreditation valid? A: Accreditation is renewed periodically on a cycle set by the accreditation body; in between, the organization keeps improving and reporting. Q: What do the Local Advisory Services include? A: A dedicated coordinator, support from 10 experts, online and on-site training, the Patient Voice package, environmental monitoring, SOPs and a survey simulation. Q: Who can use the advisory services? A: Only healthcare organizations that have a contract with Accreditation Canada. Q: What is a patient council? A: A group of patient and community members who meet monthly with a hospital representative to review patient feedback and agree improvement actions. Q: What does accreditation mean for patients? A: A safer environment: correct patient identification, safe medication use, infection control, falls prevention and informed participation in their own care. Q: Where can I find accredited organizations in Georgia? A: On our Accredited page and in Accreditation Canada’s international register on accreditation.ca. Q: How many organizations joined the Accreditation Canada programme in Georgia? A: 23 organizations; 9 of them achieved Platinum accreditation in February 2025. Q: How is accreditation different from a licence? A: A licence is issued by the state and checks minimum requirements; accreditation is awarded by an independent body and assesses high international standards of quality and safety. Q: Are your resources free? A: Yes. 142 patient booklets, 10 posters and 56 wayfinding signs are free for any healthcare facility. Q: Do you run training? A: Yes. In 2025 we ran 13 free training sessions open to all clinics, and partner organizations receive two online courses a month and quarterly on-site training. Q: Can a small clinic be accredited? A: Yes. International accreditation is available to healthcare organizations of different types and sizes, and the programme is adapted to the organization’s profile. Q: Where is the office? A: In Tbilisi, at 3 Betlemi Rise. The office is operated by the Public Health Institute of Georgia. Q: How do we get started? A: Write to info@accreditation.ge, message us on WhatsApp at +995 577 41 63 14 or use the contact form. At the first consultation we assess your readiness and agree the next steps.