Certifications and Quality

Certifications and Quality

Quality Program

IRCCS ISMETT was the first hospital in Southern Italy to receive accreditation from Joint Commission International (JCI), one of the most advanced accreditation systems for assessing the quality of health care organizations. First awarded in 2009, JCI accreditation was renewed for the sixth time in 2024, demonstrating IRCCS ISMETT’s ongoing commitment to continuous improvement of its clinical outcomes, nursing care, management activities, patient services, patient-centered care, and staff training and professional development programs.

IRCCS ISMETT has also renewed its certification under the UNI EN ISO 9001:2015 standard for the training quality management systems its Training Activities (certified since 2009), Pharmacy (first certified in 2016), and the diagnostic and therapeutic services provided by Radiology, Endoscopy, Dialysis, Cardiac Cath Lab, Pathology, and Microbiology and Clinical Pathology Laboratory, certified since 2012.

In addition, IRCCS ISMETT’s Occupational Health and Safety and Environmental Management System has been recognized as compliant with the UNI EN ISO 14001:2015 and UNI ISO 45001:2018 standards.

 

IRCCS ISMETT’s Quality, Environmental, and Safety Management System involves the entire organization and takes the following areas into consideration:

  • Clinical outcomes, through a robust outcome monitoring system of our organ transplant programs, cardiothoracic surgery, abdominal surgery, and anesthesia and intensive care.
  • Patient safety, reviewing and monitoring preventable adverse events reported by staff.
  • Standards and requirements of various voluntary certification frameworks, including JCI, ISO 9001:2015, and the integrated Occupational Health and Safety and Environmental Management System in accordance with UNI EN ISO 14001:2015 and UNI ISO 45001:2018.
  • Patient experience, monitoring patient satisfaction, analysis of complaints, and claim assessment.

The tools used to promote Clinical Governance at IRCCS ISMETT include the systematic evaluation of process and outcome indicators collected through information systems, such as the electronic medical record; the development of evidence-based clinical protocols; continuing education; and the Quality Improvement and Clinical Risk Management Program.

 

The Quality Improvement and Clinical Risk Management Program includes:

  • a permanent function dedicated to Clinical Risk Management and patient safety, pursuant to the Regional Health Department Decree of December 23, 2009.
  • Periodic external audits, including JCI and ISO surveys and other voluntary audits.
  • internal policies and procedures: IRCCS ISMETT has developed a manual containing approximately 300 policies that comply with JCI standards and ISO requirements. The policies are periodically reviewed, updated, and approved by the Corporate Policy Committee. Once approved, they are made available to all staff through the organization’s intranet, and compliance is monitored on an ongoing basis.
  • Training on quality and clinical risk: training sessions tailored to different roles are periodically provided to all clinical coordinators, managers, and leadership on the principles and methods of quality improvement and on the Culture of Safety (Just Culture). Internal audits are conducted to assess compliance with the policies adopted to meet the standards and requirements of certification bodies. The development of diagnostic and therapeutic guidelines and EMR order sets, and monitoring appropriate implementation.

Annual Quality Report

IRCCS ISMETT’s Annual Quality Improvement and Patient Safety Plan sets out the organization’s approach to continuous improvement. The Plan establishes the Total Quality and Patient Safety Council (TQPSC), a strategic committee that also performs the functions of Clinical Risk Management Committee and serves as liaison between the Board of Directors and the operational committees of the Quality and Safety System.

Quality report 2024

Clinical Risk Management Plan

Download file (PDF, 2.84 MB)

Gender Equality Plan (GEP)

IRCCS ISMETT has adopted a Gender Equality Plan (GEP).
The need to adopt a GEP arose from the initial goal of aligning with the measures and policies implemented by the European Commission to promote gender equality in research and innovation. At the same time, the Plan is part of a national framework that reflects similar priorities. Equality between women and men and achieving gender equality are among the highest priorities across national, European, and international policy agendas. In particular:

at a global level, the UN identified the achievement of gender equality and the empowerment of all women and girls as the fifth of the 17 Sustainable Development Goals Member States committed to achieving by 2030.

Italy’s National Recovery and Resilience Plan (PNNR) identifies “Inclusion and Cohesion” as the fifth of its missions and recognizes gender equality as a cross-cutting priority throughout the Plan.

This approach is fully consistent with IRCCS ISMETT’s commitment to Diversity & Inclusion identified as one of the priorities of its development strategy for 2021-2025.

More info on the GEP plan:

Visualizza il documento

Patient Care Experience Committee

IRCCS ISMETT and UPMC Italy have established a Joint Committee for Equal Opportunity to promote and ensure the implementation of the principles of equal opportunity and non-discrimination in the workplace, particularly with regard to access to employment and working conditions, professional training, and career development opportunities.

By bringing together different areas of expertise within a single body, this Committee promotes equal opportunity, employee well-being, and the prevention of discrimination. The Committee performs advisory, consultative, and monitoring functions and contributes to optimizing staff productivity. It helps improve organizational performance by fostering a working environment based on the principles of equal opportunity and organizational well-being. It also ensures the highest level of transparency in management decisions and works to prevent all forms of discrimination and any form of psychological or emotional abuse against staff.

The Committee has equal representation and consists of members appointed by each trade union and an equal number of representatives appointed by the administration.

Environment and Safety

IRCCS ISMETT, a leading center for transplantation and highly specialized therapies, is committed to providing its patient care of the highest quality while contributing to the development of tomorrow’s health system through clinical and managerial innovation, research, and a strong commitment to theoretical and practical training.

Within this context, IRCCS ISMETT has chosen to pursue voluntary accreditation by JCI with the aim of establishing mechanisms that support the continuous improvement of organizational and professional quality, in compliance with applicable legislation, as well as the quality of care delivered and perceived by patients.

IRCCS ISMETT’s commitment, however, is not limited to patient treatment and care. We consider environmental protection and occupational health and safety to be fundamental and essential components of our work. Accordingly, we seek to ensure all tasks of everybody working for or on behalf of IRCCS ISMETT are conducted in full compliance with applicable laws and regulations.

In keeping with these principles and with a view to continuously improving performance, we have made the strategic decision to maintain the Integrated Environmental and Occupational Health and Safety Management System, certified since 2014 and compliant with the UNI EN ISO 14001:2015 and UNI ISO 45001:2018 standards.

 
 
In line with the approach described above, we are committed to:

  • Operating at all times
      ensuring full satisfaction of our shareholders and stakeholders.
    1. Ensuring effectiveness, efficiency, and reliability by providing all the resources necessary to protect the environment and safeguard workers’ health and safety.
    2. Conducting our activities in compliance with applicable laws, standards, and regulations governing the health care sector, as well as any other voluntary requirements adopted by IRCCS ISMETT.
    3. Promoting the ongoing involvement of all staff working for or on behalf of IRCCS ISMETT and developing their skills through training designed to foster professional growth, awareness, and accountability.
    4. Selecting suppliers and contractors that pursue the continuous improvement of the quality of the products and services they provide, as well as their environmental and safety performance.
    5. Promoting a culture of sustainability, environmental responsibility, and occupational health and safety.
    6. Maintaining transparent and collaborative relationships with public authorities and the relevant environmental and safety regulatory and supervisory bodies.
    7. Preventing workplace accidents, occupational diseases, and harm to workers’ health, including the health of employees of third-party companies working on behalf of IRCCS ISMETT, while continuously improving health and safety in the workplace.
    8. Preventing all forms of environmental pollution affecting air, water, and soil.
    9. Periodically reviewing policy, objectives, targets, implementation programs, and management system.
    10. Ensuring appropriate internal and external visibility of the environmental and safety results and performance.

      11. IRCCS ISMETT is also committed to ensuring that:

    11. Environmental and occupational health and safety considerations are treated as essential elements when planning new activities or reviewing existing ones.
    12. All individuals working for or on behalf of IRCCS ISMETT receive appropriate training and information and are made aware of the environmental and safety impacts of their work, applicable requirements, and their respective responsibilities within the management system.
    13. The entire organization contributes, in accordance with each individual’s duties and responsibilities, to achieving the assigned objectives and targets, including those specifically related to environmental protection and occupational health and safety.

    • Daisy and Rose Awards

    At IRCCS ISMETT, we believe quality of care is measured not only by advanced technology and clinical effectiveness, but also by compassion, dedication, and respect for patient dignity. To recognize these values and thank the professionals who make a difference every day, IRCCS ISMETT participates in two prestigious international recognition programs: the DAISY Award and the ROSE Award. s

    DAISY Award: Celebrating Extraordinary Nurses

    The DAISY Award, whose name stands for Diseases Attacking the Immune System, is an international award established in the United States in memory of Patrick Barnes. His family, deeply moved by the exceptional compassion and expertise of the nurses who cared for him, created this award to thank healthcare’s “unsung heroes.”

    IRCCS ISMETT has adopted this program to recognize its nurses who not only provide clinical care, but also care for the whole person by demonstrating:

    • exceptional empathy and kindness
    • ability to listen to and support family members
    • clinical excellence combined with a profound sense of compassion

    ROSE Award: Recognizing Every Member of the Care Team

    The ROSE Award, whose name stands for Raising Our Standard of Excellence, complements the recognition of health care personnel by extending it to all non-nursing professionals. The award recognizes health care technicians, physical therapists, and other professionals working in patient care units, with a particular emphasis on:

    • Teamwork and professional collaboration.
    • Integrity and dedication in everyday practice.
    • The continuous improvement of standards of excellence in patient care.

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