ISMETT was the first hospital in southern Italy (in 2009) to earn accreditation from Joint Commission International (JCI), the recognized leader in international health care accreditation. JCI accreditation was reconfirmed in October 2015 in acknowledgment of ISMETT’s commitment to ongoing improvement of its clinical outcomes, nursing care, management, reception, patient focus, and training programs. At the end of 2018, ISMETT will undergo its fourth JCI survey.
In 2018, ISMETT will also renew its ISO 9001:2015 certification for quality management systems of its training and educational programs (certified since 2009), Pharmacy (first certified in 2016), and diagnostic and therapeutic services in Radiology, Endoscopy, Dialysis, Cath Lab, Pathology, and Microbiology and Clinical Pathology Laboratory.
Furthermore, ISMETT’s Environmental and Safety Management System was certified as compliant with the ISO 14001 and OHSAS 18001 standards.
ISMETT’s Quality & Safety System involves the entire organization and monitors:
- Clinical outcomes, using a thorough monitoring system that includes organ transplantation programs, cardiothoracic surgery, abdominal surgery, and anesthesia and critical care.
- Patient safety, reviewing incident reports, and monitoring preventable adverse events.
- Standards and regulations of various voluntary certification models, including JCI, ISO 9001:2015, 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, analysis of complaints, and claim assessment.
The tools used to promote clinical governance at ISMETT include the systematic evaluation of process and outcome indicators collected through IT systems, such as the electronic medical record, the drafting of evidence-based clinical protocols, continuing education, and improvement of the quality and management of the clinical risk program.
ISMETT’s Quality Improvement and Clinical Risk Management Program envisages:
- A dedicated and permanent risk management and patient safety role pursuant to regional legislative 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 with approximately 300 policies compliant with the JCI, ISO, and OHSAS standards. ISMETT policies are subject to regular updates and verifications approved by an internal Policy and Procedure Committee. Following approval, all policies are published on the company’s intranet, and compliance with the latter is constantly monitored.
- Training in quality and clinical risk. Training sessions are offered on a regular basis to clinical coordinators, area directors, and executives on quality improvement principles and methods, and Just Culture.
- Internal audits to verify compliance with the policies enforced to meet the standards of the accreditation bodies.
- Definition of diagnostic and therapeutic guidelines, development of order sets in the EMR, and monitoring of correct application.