Page 12 - ICS Vall d'Hebron University Hospital 2011

• Safety training for residents services safety responsibles
and other interested professionals.
• Consolidation of the Balanced Scorecard for Safety for
monitoring the results of the Safety Plan.
• Preparation of basic recommendations for reporting inci-
dents related to patient safety (IRSP) after immediate
care is provided and any harm caused is assessed.
Hospital Certification
The results of the Ministry of Health’s 2008 acute care
hospital certification process reflected a high level of
achievement, with 85.66% of standards approved. The score
obtained resulted in certification until 2011 and the
preparation of an Improvement Plan for the 2009-2011
period. In 2011, the action provided for in the Improvement
Plan continued to be implemented. Of a total of 94
standards with improvement actions, the results showed 82
completed improvement actions, 10 in progress and two not
completed.
At the same time, the Ministry started reviewing the certi-
fication model with the participation of different hospitals,
including Vall d’Hebron University Hospital. To prepare this
new certification process, the look and feel and functions of
the hospital’s certification intranet were updated in 2011.
Operating Commissions, Sub-commissions and
Committees for Multidisciplinary Participation
Operating commissions, sub-commissions and committees
allow professionals to participate and form part of the hos-
pital’s Quality Plan. They assess management and ensure
that clinical practice is appropriate. In 2011, three new com-
missions and one operating committee were created:
• Clinical Nutrition Commission (April 2011)
• Artificial Nutrition Sub-commission (April 2011)
• Environmental Management Commission (May 2011)
• Cardiac Arrest Operating Committee (December 2011)
The commissions, sub-commissions and committees worked
intensely. In 2011, a total of 316 professionals took part and 83
meetings were held with a mean participation of 73%. The
high level of involvement and professional qualifications of
the participants, as well as their enthusiasm, work ethic,
consensus and cross-cutting vision, were largely responsible
for the achievement of most of the objectives proposed
(more than 90%were achieved or started). Some of the high
points include the preparation, review and assessment of
guides, manuals, recommendations and action protocols, the
assessment of new technologies and new diagnostic and
therapeutic procedures, and providing professionals and
patients with training and information.
Also held in 2011 were the third Plenary Meeting of Com-
missions and Sub-commissions, the first open call to cover
places on the commissions and the second satisfaction sur-
vey on commissions. The survey was answered by 59% of
people and 72% of the members said they were quite satis-
fied or very satisfied with the dynamics and operation of
their commission.
Improvements in Communication and
Dissemination of Information to Professionals
In 2011, work continued on the improvement of internal and
external communication through the development of ses-
sions and plenary sessions, distribution of the Qualitat
Informa e-bulletin, updating of the intranet and participa-
tion in external conferences.
Different training actions were also implemented in quality
and safety, management by processes, ISO standards, basic
and advanced cardiopulmonary reanimation, waste mana-
gement and separation, and the prevention of drug errors.
Management by Processes
The progressive consolidation of the management by pro-
cesses approach continued to be one of the strategic lines
of hospital management in 2011. In different hospital areas,
an effort was made to improve the organizational proces-
ses of general care (surgery block, hospitalization, etc.),
specific services (Sound Unit, Physics Service, Radiation
Therapy Service, etc.) and clinical care (such as patients
with spinal cord injuries). The documentation of different
processes worked on was also standardized and made avai-
lable to hospital professionals on the intranet.
Healthcare Coordination and Continuity
in the Region
Within the structural framework of the coordination imple-
mented by the Barcelona Healthcare Consortium in the
Barcelona Nord Comprehensive Healthcare Area, agree-
ments were reached with different institutions in the
region to improve healthcare coordination and continuity.
Moreover, hospital representatives continued to sit on
healthcare boards in the area of influence (Nou Barris,
Horta-Guinardó and Sant Andreu).
12 ICS · Vall d’Hebron University Hospital 2011