41-275 / Accreditation of teaching hospitals: audit

GOP Information
Organisation sharing the GOP
Related practices from PaSQ database
Ministry of Health, Social Services and Equality (MSSSI)
Audit system

GOP Description
Implementation level
Clinical settings
Teaching hospitals
General_objective: to guarantee that hospitals participating in health sciences specialized education develop their teaching according to the regulation that frames this activity and as it is established in the teaching program from each speciality
1.Develop quality_management_systems in teaching_hospitals.
2.Guarantee a common_methodological_framework for teaching_hospitals_evaluation_and_accreditation.
3.Create a culture of hospital_evaluation
150 hospitals that are certified as teaching centres for specialized education in health sciences.
The MSSSI Unit for Accreditation and Audit, supported by evaluators from the Regions, has developed evaluation criteria and procedure manuals according to the Spanish legislative framework and the subsequently developed regulation for the specialized education in health sciences.
Each year an evaluation plan is carried out, including teaching hospitals audits and documentary assessment. Once the centre has been evaluated after documentary review or audit, a proposal for an improvement and accreditation plan is prepared and presented to the Accreditation Committee, made up by representatives of the different health sciences specialties National Boards, the members of which are expert clinicians.
Timeframe implementation
2 years
Implementation tools available
-MSSSI Unit for Accreditation and Audit
-Evaluation teams linked to the Regions.
-Evaluation criteria and technical proceedings.
-Teaching program
-Accreditation Committee
-Annual satisfaction survey for health sciences interns
Implementation cost
No specific funds are available. 1000 € per audit are estimated, excluding human resources.
Method used to measure the results
The National Committee for accreditation of teaching centres for specialized education in health sciences, identifies some key criteria (the noncompliance of which implies the suspension of the accreditation) and other specific criteria (the noncompliance of which limits the accreditation to 1 to 4 years).
The Audit Report describes, in a coloured graphic , the level of compliance according to the evaluated criteria. This report is sent to the National Committee to make a final decision about the reaccreditation and the timing for the next evaluation. The report is also sent to the healthcare centers for their information and feedback regarding the improvement plan for the next period.
These things are tools to complete the audits. The outcome measures used should be described here.
Analysis of the results
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Implementation barriers
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Other information
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