63-579 / Quality Management System of SALUD Primary Healthcare Teams

GOP Information
Organisation sharing the GOP
Related practices from PaSQ database
Servicio Aragonés de Salud (SALUD)
Aragón Healthcare Service


Quality management system

GOP Description
Implementation level
Clinical settings
It has been institutionally implemented since 2010 in SALUD Primary Healthcare Teams (PHT). Initially with 9 teams and right now 36 have been certified and the goal is to get to 125.
To_sustain a quality_management_system which guarantees that PHT use proper procedures, provide right maintenance to the equipment, offer continuous training to healthcare workers and comply with the legal requirements, and thus play_their_role in the prevention of adverse_events and respond to the needs_and_expectations from their “clients”, mainly the population of their health_zone
General population (children/adults/aged people). In rural health zones mainly aged people.
ISO 9001 based Quality Management System, externally certified:
Process map development
Definition of objectives and indicators
Documentation of procedures and technical instructions
Continuous improvement (monitoring of indicators, detection of incidents, management of non-compliances, corrective and preventive actions)
Internal audits, system review and external audits
Timeframe implementation
Around 12 months
Implementation tools available
Work teams
Implementation cost
-Design and implementation phase (around 12 months): cost of external consulting
-Regular maintenance after implementation: self resources
-Cost of annual external audits by certification bodies
Method used to measure the results
Objectives and indicators follow-up
Annual system review
Annual internal audits
Annual external audits
7 minor non-compliances were identified in the last external audit.
The 36 PHT opened 167 non-compliances after the internal audit. The most frequent were associated with documentation and maintenance of equipment.
The number of incidents collected in the different processes was 729. The higher numbers are related to structure, equipment and net connection in rural areas.
Improvement areas detected: care of patients with diabetes, with tobacco addiction and with cardiovascular risk
Analysis of the results
Besides each PHT’s specific proposals, it has been agreed: to urge PHT to encourage Health Councils activity, to go on with the implementation of the verification and calibration of equipment, to use the detected incidents, complaints and non-compliances as a quality improvement tool and to introduce the analysis of objectives and indicators in a systematic way in the regular communication meetings.
Moreover, the SALUD Quality Unit is entrusted to create a work group to analyze new indicators for the Primary Healthcare Management Contract
Implementation barriers
Did you find implementation barriers?
Please describe implementation barriers
Professionals’ difficulty to assimilate ISO language
To achieve rigorous documentary registration
Describe the strategies used to overcome the barriers (If needed)
-Information and Training on ISO
-Simplification of Documentary System
-Quality Coordinators help
-Support to professionals
Other information
Other information about the GOP that you would like to add (Link or attached document)
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