Page 11 - ICS Vall d'Hebron University Hospital 2011

Quality
ICS · Vall d’Hebron University Hospital 2011 11
2011-2012 Quality Improvement Plan
The Patient Safety Plan, which forms part of the Quality
Plan, was first implemented in 2009. It is designed to con-
solidate new working methods to improve patient safety
and provide a clear, coordinated and integrated list of all
activities. The main aim of the Patient Safety Plan is to pro-
mote the improvement of patient safety at the hospital as
a basic part of guaranteeing quality healthcare.
In 2011, the actions in the hospital’s Patient Safety Plan con-
tinued to be implemented and the following initiatives
were added:
• Safety projects promoted by the Ministry of Health
through the Alliance for Patient Safety in Catalonia.
• Programmes for monitoring, assessment and control of
nosocomial infections (EPINE, VINCat, ENVIN, detection
and control of outbreaks, prevention of environmental
nosocomial infections, etc.).
• Vall d’Hebron University Hospital Drug Error Prevention
Plan.
• Vall d’Hebron University Hospital Pharmacosurveillance
Programme.
• Vall d’Hebron University Hospital Transfusion Safety Pro-
gramme.
• Plan to Improve Hospitalization Care, with action in the
areas of pain prevention, falls, bed sores, catheter phle-
bitis, quality control of maintenance of cardiac arrest tre-
atment carts, etc.
• Other clinical safety projects and programmes in services
and units.
In terms of organization, other action was also taken:
• Consolidation of the system for reporting adverse events
(SiNASP), which was extended to the surgical area.
• Consolidation of the Patient Safety Functional Unit
(UFSP), which continued with the analysis of incidents
reported through the SiNASP (94 in 2011) by preparing
different proposals for improvement and monitoring.
Clinical Safety
Areas for Improvement
AM1. Management by processes
AM2. Clinical safety
AM3. Effectiveness of care
AM4. Patient satisfaction and participation
AM5. Alliances and cooperation with primary care and other
key patient providers
AM6. Consolidation and assessment of the clinical
management model
AM7. Sustainability, efficiency and suitable use of resources
Actions for Improvement
AcM1. Systematic assessment of results based on the
availability of the balanced scorecard
AcM2. Strategy review and strengthening
AcM3. Implementation and assessment of the
Communication Plan
AcM4. Implementation and assessment of the Plan for
Welcoming New Professionals
AcM5. Improvement of environmental management
The Quality Plan is the framework that proposes, coordina-
tes and promotes action plans aimed at improving the qua-
lity of the care received by patients, in accordance with
their needs and expectations, and encouraging the com-
mitment, training and participation of professionals in con-
tinuous improvement.
Vall d’Hebron University Hospital’s quality management
model is based on the European Foundation for Quality
Management (EFQM) model and is aligned with the quality
strategy of the Catalan Health Institute and the Catalan
Ministry of Health, which also uses the EFQMmodel as the
basis for its acute care hospital certification model.
In accordance with the EFQM model, the hospital carried
out self-assessments in 2004, 2006 and 2010. Based on the
results of the last self-assessment, the third Quality Impro-
vement Plan (2011-2012) was approved. It includes seven
areas for improvement (AM) and five actions for improve-
ment (AcM) that began being implemented in 2011.