42-275 / Accreditation of hospital units as national Reference Centres

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
Neurology and neurosurgery, ophthalmology, oncology, plastic surgery, cardiovascular surgery.
When the title is made shorter, the original title should be included in this part of the GOP.

“Accreditation of Reference centres: It is incumbent on the MSSSI the accreditation of hospital units as national reference centres. This means that patients can move to hospitals from different Health Regions to get assistance when a very qualified healthcare team is required to perform highly complex procedures”

50 hospitals that have applied for accreditation of reference units for those procedures (around 50) for which technical requirements have already been approved.
The MSSSI Unit for Accreditation and Audit has developed accreditation criteria and procedure manuals according to the Spanish legislative framework and the subsequently developed regulation for the appointment of reference centers, units and services.
Each year an evaluation plan is carried out, including the audit of those units that have applied to be appointed as national reference center for any of the procedures approved by the NHS Inter-territorial Board.
Once the centre has been audited, an Accreditation Report is prepared and presented to the Reference Centers, Services and Units Appointment Committee, made up by experts and representatives of the Health Regions.
Timeframe implementation
2 years
Implementation tools available
-MSSSI Unit for Accreditation and Audit
-Audit teams
-Assessment criteria and technical proceedings
-Appointment Committee
Implementation cost
No specific funds are available. 1000 € per audit are estimated, excluding human resources
Method used to measure the results
This only describes the authorities involved in measuring and decision making (methodology). What are the actual qualities what are measured and which indicators are used?
What are the outcomes and goals of the indicators?

Audit report and accreditation report are a summary of results if you think about an independent organization.

Common evaluation procedures: technical proceedings (Manual) and Audit/Accreditation report template are tools to complete the audit, so they are not actual results. If any development ideas for these documents were noticed, that could be considered as a result if the quality of the tools were also measured.

Analysis of the results
Description of the analysis?
Implementation barriers
Did you find implementation barriers?
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)
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