Quality management system


The Institut Guttmann has a Quality Management System that operates across the entire organisation that is integrated into the Corporate Social Responsibility Management System and which promotes excellence from a process-focused perspective.

Among the main dimensions defined in the institutional Corporate Social Responsibility Policy, it is worth highlighting the Person-Centred Attention model (PCA) as the central axis, aimed at satisfying the needs and expectations of people, strategies that favour the involvement of different professionals in the provision of quality services and continuous improvement, professionalism and the promotion of training, as well as the implementation of activities to improve patient safety and clinical effectiveness.

As the most relevant events within the activities carried out during 2020, it is necessary to highlight that some are continuing but are very relevant for the progressive development of the Quality Management System that is the basis of the model for the accreditation of acute hospital care centres in Catalonia, such as:

  • Participation in the working group led by the Department of Health , updating the new Manual of Hospital Evaluators, based on the Accreditation Model of acute hospital care centres in Catalonia, which follows the philosophy of the EFQM Excellence Model.
  • Design and development of Self-Assessment Instruments for Accreditation and Certification Standards that include equivalences between the different standards, in order to integrate common processes. This year, we would like to highlight:
    • The design of the Self-Assessment Instrument for the Catalan Hospital Accreditation (ACH).
    • The design and implementation of the Self-Assessment Instrument of Joint Commission International (JCI).
  • Design, integration and implementation of satisfaction surveys in the following areas: Hospital care, Post-Covid Programme and Guttmann Barcelona (pending implementation).
  • Design, implementation and dissemination of the Covid-19 symptom checklist upon arrival of the patient. Dissemination of the results report in the following areas: outpatient surgery, Guttmann Barcelona and outpatient care.
  • Promotion of the consolidation of patient safety strategies through new safety benchmarks for the different processes:
    • Implementation of the closed circuit in the patient with permanent bladder catheterisation for the prevention of hospital-acquired infections.
    • Implementation of the Home Safety Check List.
    • Inclusion of the identifier “date of birth” in the green pass verification programme to facilitate the active identification of patients.
    • Mainstreaming, review, approval and dissemination of the fall prevention protocol for inpatients, outpatients and the Specialist Neurorehabilitation Assessment and Support Team (EASE).
    • Review, approval and dissemination of the suicide risk prevention protocol and holding reminder sessions for the areas involved.

During 2020, a boost was given to the measurement of the Perception of User Satisfaction, both in-patients and outpatients, with the implementation of a new survey model and the assessment system with 83.7 % regarding the quality perceived by in-patients on the overall assessment of care, and 84.6% in the case of outpatients.

The development of improvement strategies in the organisation is effective in all identified processes and therefore affects all disciplines and professional fields with the aim of adding dynamism to the different management systems of the Institut Guttmann. These strategies are promoted through the 28 committees, subcommittees and working groups and also with the leadership of the different clinical and non-clinical managers of the different processes of the organisation. The committees meet regularly throughout the year and collaborate in the management and development of their field of knowledge.