155-909 / Implementing a Patient Safety in Hospitals at Regional Level

GOP Information
Organisation sharing the GOP
Related practices from PaSQ database
Directorate-General of Ordination, and Health Regulation


Clinical risk management
Patient safety system

GOP Description
Implementation level
Clinical settings
All public hospitals in the Region (Autonomous Community: AC) are affiliated to the scheme (69 centers).
To implement a patient safety (PS) management model in hospitals in order to guarantee excellence in PS in particularly critical areas in hospitals in the AC.
A collaborative project was launched in 2012, with all hospitals in Catalonia public health care network invited to voluntarily take part. The Model is a methodological set of approaches, questionnaires, methods, etc., created and developed to meet the needs of each hospital, in order to produce conceptual and practical guidelines for the patient safety system. It is based on the EFQM Model and on Spanish and international PS standards. In each centre, the PS core staff is identified, comprising a PS key staff member and a responsible manager in each of the areas defined as critical and the composition of the Safety Committee is determined. This must include a representative of the centre’s management. The elements of the Model for each centre are: 1) a framework for managing the self-assessment of PS based on the EFQM Model; 2) an integrated PS management system which includes a tool for flagging incidents; 3) a scorecard for monitoring PS indicators; 4) key PS staff trained in accordance with the EFQM Model; 5) preparation and follow-up of the PS plan.
Timeframe implementation
(pilot study 2011)2012-2014/2015
Implementation tools available
Self Assessment Questionnaire (pre and post intervention)

Reporting system and incident / adverse events

Developing a Patient Safety Plan in each hospital aligned with the results of the first cut

PS Scorecard

Plan training in Patient Safety

Implementation cost
400.000€ (together with primary care project)
Method used to measure the results
Assessment Self Questionnaire
Assessment Reporting system and incident / adverse events
Assessment Developing a Patient Safety Plan in each hospital aligned with the results of the first cut
Assessment Plan training in Patient Safety
69 centres:
Based EFQM Model. The following results (out of 100) were obtained: Leadership 59; Strategy 43; People 50; Partnerships and Resources 53; Processes, Products and Services 66; Customer Results 54; People Results 55; Society Results 39; Business Results 59.
64 PS indicators were defined (31 of these appear in the PS scorecard).
100 staff forming the hospitals’ safety core received training in PS, management tools and the flagging system. Self-assessment workshops were also held for the PS key staff trained using the EFQM Model.
97% of centres to date have prepared a PS Plan and monitoring procedure.
Analysis of the results
Involvement of all hospitals in a high degree

Notifications increasing (1028 notifications to hospitals from September 2013 to the current date: February 2014)

Integration on Accreditation of Hospitals standards of patient safety

Suggestions for improvement and objectives in the short, medium and long term security

Detecting weaknesses to prioritize

Creating learning forums

Implementation barriers
Did you find implementation barriers?
Please describe implementation barriers
Resistance to change

Lack of safety culture

Economic crisis

Different levels of care

Describe the strategies used to overcome the barriers (If needed)
Common project: security is everyone’s business.
Safety Conference periodical patient (2-4 per year).
Plan training in Patient Safety.
Other information
Other information about the GOP that you would like to add (Link or attached document)

20140224035829413_843_GOP_113 UFSP hospitals_final (2)_EN.docx