ISMETT is the first hospital in Southern Italy to have earned, in 2009, accreditation from Joint Commission International (JCI), one of the most advanced accreditation systems to assess the quality and safety of hospitals. JCI accreditation was reconfirmed for the fourth time in 2018, demonstrating ISMETT’s ongoing commitment to continuous improvement with regard to clinical outcomes, nursing care, management, customer service, patient-centered care, and staff skill development and training programs. The next JCI survey to confirm the accreditation is expected at the end of 2021.
In 2018, ISMETT also renewed its UNI EN ISO 9001: 2015 certification of quality management systems for Training (certified since 2009), Pharmacy (certified since 2016), and Diagnostic and Therapeutic services of Radiology, Endoscopy, Dialysis, Cath Lab, Pathology, and Clinical Pathology and Microbiology Laboratory (certified since 2012).
In addition, ISMETT’s Environmental and Safety Management System was certified as compliant with the UNI EN ISO 14001:2004 and BS OHSAS 18001:2007 standards.
ISMETT’s Quality & Safety System involves the entire organization and monitors:
- Clinical outcomes, using a thorough monitoring system that includes organ transplant programs, cardiothoracic surgery, abdominal surgery, and anesthesia and critical care.
- Patient safety, reviewing incident reports, and monitoring preventable adverse events highlighted by staff.
- Standards and regulations of various voluntary certification models, including Joint Commission International, ISO 9001:2015 standard, and the integrated Environmental and Safety Management System in compliance with UNI EN ISO 14001:2004 and BS OHSAS 18001:2007 standards.
- Patient experience, monitoring patient satisfaction and reviewing complaints and claims.
The tools used to promote clinical governance at ISMETT include a systematic evaluation of process and outcome indicators collected through IT systems, such as the electronic medical record (EMR), drafting evidence-based clinical protocols, continuing education, and the quality improvement and clinical risk management program.
ISMETT’s Quality Improvement and Clinical Risk Management Program envisages:
- A dedicated and ongoing risk management and patient safety role pursuant to Assessorato Decree 3181 of December 23, 2009.
- Periodic external audits, such as JCI and ISO surveys, and other voluntary audits.
- Internal policies and procedures: ISMETT has developed a manual of close to 300 policies compliant with JCI, ISO, and OHSAS standards. ISMETT’s policies are regularly reviewed and updated, and approved by an internal Policy and Procedure Committee. Following approval, all policies are published on the company’s intranet, and their compliance constantly monitored.
- Training in quality and clinical risk: training is offered on a regular basis to all clinical coordinators, area managers, and executives on quality improvement principles and methods, and Just Culture.
- Internal audits to verify compliance with the policies enforced and meet the standards of the accreditation bodies.
- Definition of diagnostic and therapeutic guidelines, developing order sets in the EMR, and monitoring their correct application.