Quality and Patient Safety

At the Cerdanya Hospital we are committed to provide our patients high quality services within the safest possible environment. To achieve this goal, we follow all the mandatory quality and safety regulations and we implement as well our own policies and strategies, which involve the entire organization

Our main instruments for improving quality and safety are:

  • The Quality Plan, based on the EFQM model developed by the European Foundation for Quality Management.
  • 15 internal working groups, spearheaded by the Patient Safety and Quality Committee .
  • Accreditation processes and certifications
    • Accreditation by the Department of Health of the Catalan government
    • ISO 9001 :2015 Certification (Laboratory)
    • Validation of the environmental quality and biosafety of the surgical area
    • Regular control of radiation levels (diagnostic imaging area)
    • Legalization and regular controls of the electrical systems
    • Regular detection, notification and management of adverse events
  • Benchmarking and communication of results to:
  • Results Centre of the public health system in Catalonia. NOTE: only the activity in relation to patients with Catalan public health coverage (CatSalut) is published on this platform.
  • Dashboard of safety and quality indicators of the public health system of Catalonia
  • Satisfaction surveys by CatSalut (PLAENSA)
  • Continuous training on quality and safety both for medical and non-medical personnel.

Quality and Patient Safety Report

Our hospital monitors regularly more than 200 key indicators on Quality and Patient Safety . In the latest edition of the center 's activity report (2020), the following summary was published :

Indicator

% 2020

Risk assessment of pressure sores 

98,81%

Nosocomial pressure sores grade I

0,08%

Nosocomial pressure sores grade II

0,47%

Nosocomial pressure sores grades III and IV

0%

Fall risk assessment

98,81%

Falls of hospitalized patients

3,84 %

Falls with injury

0,89 %

Falls with minor injury

19,23%

Falls with major injury

3,85%

Degree of implementation of the "safe surgery" chek-list (SSC /CIRSEG)

98,485

Evaluation of the application of all the items included in the safe surgery checklist

100%

Erroneous transfusion due to improper patient identification

0%

Use of alcohol -based preparations for hand hygiene (Hospitalization ward)

84,99%

Degree of compliance with the protocol for the unequivocal identification of patients

98%

Degree of compliance with the protocol for the unequivocal identification of at-risk patients 

82,64%