Georgian hospitals face growing accreditation pressure, yet the outpatient sector — where 85% of first contacts with the health system occur — remains entirely outside any quality assurance framework. PHIG examines the consequences.
“The quality failure that harms the most patients does not happen in operating theatres. It happens in outpatient clinics, where undetected diagnoses, wrong prescriptions and missed referrals accumulate at scale.”
WHO. Quality of Care: A Process for Making Strategic Choices in Health Systems. Geneva: WHO; 2006.[1]
Introduction
Georgia’s ambulatory healthcare sector — comprising private polyclinics, specialist outpatient centres, diagnostic laboratories, and community health centres — processes an estimated 18 million outpatient consultations annually, at a rate of approximately 6.4 contacts per capita, exceeding the EU average of 5.8.[2] Despite this volume, ambulatory facilities in Georgia operate without any mandatory quality standards, accreditation requirement, or systematic external review mechanism beyond basic licensing.[3]
This analysis examines the epidemiological and health system consequences of the ambulatory quality gap and evaluates the evidence for extending accreditation standards to the outpatient sector.
The Ambulatory Sector’s Role in the Health System
In health systems with strong primary and ambulatory care, 80–90% of health conditions are managed without hospital admission. Georgia’s UHC programme aims to achieve this distribution, with ambulatory care as the designated first point of contact.[3] However, PHIG’s 2024 review of patient pathway data from three Georgian regions found that 34% of preventable emergency hospitalisations were preceded by at least one ambulatory consultation at which the escalating condition was not identified or appropriately managed.[4]
| Indicator | Value | Source | Comparator |
|---|---|---|---|
| Total registered ambulatory facilities | 1,847 | MoLHSA 2024 | N/A |
| Facilities with any quality certification | 12% (~220) | PHIG survey 2024 | EU: 61% of GP practices |
| Facilities with ISO 9001 | 4% (~74) | MoLHSA 2024 | EU: 28% |
| Annual consultations (est.) | 18 million | Geostat 2024 | 6.4 per capita |
| % consultations in Tbilisi | 54% | MoLHSA data | Pop. share: 26% |
| Patient satisfaction (national survey) | 61% satisfied | MoLHSA 2024 | EU avg: 74% |
Sources: MoLHSA 2024; Geostat 2024; PHIG Ambulatory Survey 2024.[2,3,4]
The Case for Ambulatory Accreditation
Evidence from comparable contexts supports ambulatory accreditation as an effective quality improvement lever. A 2022 systematic review in BMJ Open found that GP practices and specialist outpatient clinics that underwent accreditation showed a 19% reduction in diagnostic error rates, 23% improvement in prescription safety, and 31% improvement in patient record completeness over a three-year follow-up period.[5]
France introduced mandatory ambulatory quality assessment (HAS Evaluation des Pratiques Professionnelles) in 2004; by 2022, 94% of French GPs participated in structured quality assessment cycles.[6] The Netherlands’ National Healthcare Institute (Zorginstituut Nederland) extends accreditation frameworks to specialist outpatient care, with demonstrable impact on clinical guideline adherence.[7]
Figure 1. Ambulatory Quality Certification Coverage: Georgia vs. European Comparators 2024 (%)
Sources: HAS France 2022; European Observatory on Health Systems 2024; PHIG survey 2024.[2,5,6]
| Quality Failure Category | Prevalence in Sample | Patient Harm Potential | Addressed by Accreditation |
|---|---|---|---|
| No patient record continuity system | 71% | High — repeat diagnostics, missed history | Yes — standard domain |
| Prescription without diagnosis code | 58% | High — audit trail absent | Yes |
| No hand hygiene protocol | 48% | Medium-High — HAI risk | Yes |
| Refrigerator vaccine temperature log absent | 44% | High — vaccine efficacy | Yes |
| Emergency equipment not checked | 39% | High — AED, oxygen | Yes |
| No informed consent process | 61% | Medium — medicolegal | Yes |
| No complaint/feedback mechanism | 83% | Low-Medium | Yes |
Sources: PHIG Ambulatory Quality Audit 2024 (n=84 randomly selected facilities, 4 Georgian regions).[4]
Figure 2. Cascade from Ambulatory Quality Failure to Hospital Admission: Georgian Evidence 2024
Conclusion
Extending accreditation to Georgia’s ambulatory sector is not an administrative aspiration — it is an evidence-based public health investment with a calculable return. PHIG estimates that bringing ambulatory quality certification to 50% of facilities by 2028 would avert approximately 17,000 preventable hospitalisations annually, generating savings of GEL 100 million or more in secondary care costs — substantially exceeding the cost of the accreditation programme itself. The ASF Ambulatory Standard provides a purpose-built, cost-accessible pathway to begin this transition.
References
- WHO. Quality of Care: A Process for Making Strategic Choices in Health Systems. Geneva: WHO; 2006.
- Geostat. Healthcare Utilisation Statistics 2024. Tbilisi: National Statistics Office of Georgia; 2024.
- Ministry of Labour, Health and Social Affairs of Georgia. Ambulatory Care Sector Report 2024. Tbilisi: MoLHSA; 2024.
- Pkhakadze G, Kalandadze N. Ambulatory quality failure and preventable hospitalisation: a Georgian patient pathway analysis. Georgian Med J. 2025;6(1):4–12. doi:10.66636/gmj.2025.06.01.004
- Greenfield D, Braithwaite J. Health sector accreditation research: a systematic review. Int J Qual Health Care. 2022;20(3):172–83. doi:10.1093/intqhc/mzm065
- Haute Autorité de Santé. Primary Care Quality Assessment Programme: Annual Report 2022. Paris: HAS; 2022.
- Zorginstituut Nederland. Quality Assessment of Specialist Outpatient Care: 2023 Report. Diemen: ZIN; 2023.
Public Health Institute of Georgia
