157-963 / Applying benchmarking to improve patient safety in the Galician Health Service

GOP Information
Organisation sharing the GOP
Related practices from PaSQ database
Galician Health Service


Quality indicators
Patient safety system
Implementation of Patient Safety initiatives / Activities
Patient safety culture / Patient safety climate
GOP Description
Implementation level
Clinical settings
All hospitals of the Galician Health Service
Improve patient safety by applying benchmarking and thus establishing process and results comparison systematics in our health organizations. Identify and share good practices which have led to best results.
All hospital directors, management and quality and patient safety managers of the Galician Health Service.
Since 2010, the Galician Health Service uses the benchmarking strategy as a tool for continuous improvement. A total of 51 indicators dealing with Patient Safety projects were defined, in order to compare quality and safety in centers in a systematized manner and constitute an integrated indicator information system. The results obtained from health care centers are included in a results report which is divulged to all Hospital Directors, management, and quality and safety managers of the Galician Health Service, in a semi-anonymous manner (each organization knows which code is theirs but does not know the codes of the rest of organizations). The results are presented in an annual meeting headed by the Galician Health Minister and the Director of the Galician Health Service. In addition to presenting the results of each project, improvement measures are also proposed as well as goals to be met in the following year.
Timeframe implementation
In order to begin the Project, indicators must be agreed upon and a measurement system must be set up. This means approximately three months of work. To evaluate the implementation, a minimum of two years is required in order to carry out temporary comparison of results.
Implementation tools available
Panel of indicators which have been evaluated and compared.
Example of graphs and charts dealing with comparing results.
Implementation cost
Not have information on direct costs, but we can approach the cost of a year’s work of three technicians of the General Sub-Directorate for Patient Care and Quality
Method used to measure the results
The General Sub-Directorate for Patient Care and Quality takes on the compilation and analysis of data from all centers, which is evaluated uniformly. Sources are diverse (computerized medical record, internal audits in centers, external audits, documentation sent from centers or other organisms). A final report on results is elaborated, comparing centers with one another and the global annual average, since this process was begun in 2010. For each project, new goals to be reached as well as improvement recommendations are incorporated. Before the official results presentation, all data is confirmed by the centers’ quality and safety managers.
For the time period which was evaluated, we present some of the most relevant results:
a four percent increase as to incident reporting involving patient safety; we have exceeded 95% in patient identification; number of patients with pain evaluation as fifth vital sign, was doubled; the use of potassium chloride solutions has been brought into general use; almost 50% of incidence of some adverse events such as pressure ulcers due to hospital stay, central venous catheter infections and ventilator-associated pneumonias have decreased.
Analysis of the results
By means of the benchmarking program, we can objectify that between 2010 and 2012, the results of 88% of safety indicators which were evaluated (41 of 51 indicators) improved. Year after year, the centers receive information of their results and how they compare with the other organizations and the global averages of the region and the levels of achievement improve constantly. Rankings have also been established where those organizations with the best results and those who are still up for much improvement, stand out. Best practices have also been identified.
Implementation barriers
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Please describe implementation barriers
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Describe the strategies used to overcome the barriers (If needed)
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Other information
Other information about the GOP that you would like to add (Link or attached document)
Having included benchmarking in health quality and risk management for patient safety in the Galician Health Service has been useful in terms of:
1.Improving the results of our patient safety indicators.
2.Identifying best practices in the different processes developed in our organizations and encouraging the transfer of these to the other organizations.
3.Detecting strong and weak points in the whole organization.
4.Proposing improvement recommendations.
5.Encouraging transparency and learning for continuous improvement.