Quality management system

Pau, Justícia i Institucions Sòlides

The Institut Guttmannhas a Transversal Quality Management System throughout the organization that is integrated into the Corporate Social Responsibility Management System and that promotes excellence from a process-focused perspective .

The Institut Guttmann has a Quality Management System which promotes excellence from a process-focused perspective. The dimensions of quality that are prioritised are Person-Centred Attention (PCA), Safety and Clinical Effectiveness, aimed at satisfying people’s needs and expectations, using strategies that favour the involvement of different professionals in the provision of quality services and continuous improvement, training, learning, and results-based improvement to guarantee safe and effective care.

During 2022, the mainstreaming of processes has continued to be promoted, providing methodological support and integrated tools to facilitate collaborative work, monitoring of activities, evaluation of results and, ultimately, continuous improvement in the organisation through committees and improvement groups that are involved in the Quality Plan.

The actions carried out include the design, development, piloting, validation and implementation of new initiatives led by the different committees and continuous improvement groups. Some examples to highlight:

  • The quality area has been reinforced with the incorporation of a professional staff member responsible for promoting safe practices and improving care processes, guaranteeing continuous improvement and standards of quality and excellence.
  • A synthetic quality scorecard (QCQS in Spanish) has been prepared to summarise relevant indicators in terms of quality and patient safety; it is monitored by the Management Committee.
  • Training in patient safety management and care and support for the second victim has been expanded.
  • An integrated, process-oriented tool has been designed that allows us to self-evaluate the standards of the Catalan Hospital Accreditation and of Joint Commission International, as well as a system for recording and managing non-conformity.

These strategies are promoted through the different committees, subcommittees and working groups and also with the leadership of the different clinical and non-clinical managers of all the different processes of the organisation. These committees and working groups meet regularly throughout the year and collaborate in the management and development of their field of knowledge.


Patient Safety Indicators

The Institut Guttmann provides data on the patient safety indicators that the hospital has committed to completing throughout the year to the Patient Safety Promotion Service of the Department of Health and within the established deadlines.

Regarding Patient Safety Indicators in specialised care, compatible with the Department of Health, 64 safety indicators were answered during 2022. Of these, 100% have been reported as established as applicable priorities (42).

  • 86% (36) met the standard established by the Department of Health.
  • 6 presented variances according to the following detail:

22 indicators representing 66% of the total optional indicators applicable to our centre have also been reported. Those that have not been reported are either not applicable to us or have not yet been prioritised. Of the total reported, 95% meet the requirements established by the Department of Health’s QCSP.

The joint evolution of the indicators is favourable in general, with global compliance of around 89%.

In addition, the hospital periodically reviews, evaluates and provides feedback to professionals and committees when sharing information with all professionals through its integrated management information system (SiiG). Monitoring and analysis allow us to identify points for improvement and design action plans for their implementation.