ISMETT is the first hospital in southern Italy to receive Joint Commission International (JCI) accreditation, considered one of the most advanced accreditation systems to assess the quality and safety of hospital facilities. The JCI accreditation was reconfirmed in October 2015 and reflects ISMETT’s commitment to continual improvement of clinical outcomes, nursing care, management, reception, humanization, and training programs. And in 2015, the ISO 9001:2008 certification was renewed. The standard certifies the quality of diagnostic and therapeutic services, such as radiology, endoscopy, dialysis, the cath lab, pathology, and the microbiology and clinical pathology laboratory. Furthermore, the Education Department received the ISO certification, and the Quality, Environmental and Safety Management System was also recognized with the ISO 14001 and OHSAS 18001 certifications.
ISMETT Quality & Safety System involves the whole organization and covers:
- Clinical outcomes through a robust monitoring system, which includes the organ transplant program, cardiothoracic surgery, abdominal surgery, and anesthesia and critical care.
- Patient safety through the analysis of incident reports and the monitoring of preventable adverse events.
- The standards of different voluntary certification models, including Joint Commission International, ISO 9001:2008 standard and the Quality, Environmental and Safety Management System in compliance with the UNI EN ISO 14001:2004 and BS OHSAS 18001:2007 standards.
- The patient experience through the monitoring of patient satisfaction, analysis of complaints, and assessment of claims.
The tools used to promote clinical governance at ISMETT include the system evaluation of process and outcome indicators collected through IT systems, such as the electronic medical record, the preparation of evidence-based clinical protocols, continuing education, and improvement of the quality and management of the clinical risk program.
The Quality Improvement and Clinical Risk Management Program envisages:
- The establishment of the permanent risk management and patient safety function pursuant to regional legislative decree 3181 of December 23, 2009.
- Periodic external audits, like the ISO or JCI surveys, and other voluntary audits.
- The definition and use of internal policies and procedures: ISMETT has developed a manual with approximately 300 corporate policies compliant with the JCI, ISO and OHSAS standards, which undergoes regular updates and verifications approved by the Policy and Procedure Committee. After they are approved, policies are published on the company intranet and compliance with the policies is constantly monitored.
- Training in quality, and clinical risk: training sessions are offered on a regular basis to clinical coordinators, area managers, and executives on quality improvement principles and methods. In October 2015, clinical management participated in a Just Culture training course.
- Internal audits to verify compliance with the policies and standards. Quality assurance group.
- The definition of diagnostic and therapeutic guidelines and the development of order sets in the electronic medical record, and the monitoring of their correct application.