GOP Information
Organisation sharing the GOP
Related practices from PaSQ database
Andalusian Agency for Healthcare Quality
Andalusian Regional Ministry of Health and Social Welfare


Patient safety culture / Patient safety climate
GOP Description
Implementation level
Clinical settings
Primary Healthcare, Specialized Healthcare, Emergency.
Public and private scope.
To give a public express recognition of the healthcare centres quality.
To drive continuous improvement processes in the Health System.
The accreditation is conceived as a tool. It is not the aim.
Primary healthcare units and centres.
Specialized healthcare units and centres.
Haemodialysis units.
Emergency centres.
Clinical laboratories.
Pharmacy offices.
Early child care centres.
Diagnostic Imaging centres.
Blood transfusion centres.
Orthopaedic aids shop.
Clinical Nutrition and Dietetics units.
Healthcare centres without admission
The self-assessment is very important in the accreditation model. The continuous improvement is based on people and organizations potential. In the self-assessment phase, professionals identify their current position, determine what they want to achieve and plan how to get it.
Self-assessment generates an agreement and shared improvement space where professionals, managers and citizens act. (1)
The accreditation model departs from standards with which health centres advance towards their citizen services improvement and the development of tools for the management of the quality improvement. Standards are distributed in the following quality dimensions: Person, Health System centre, Organization of activities focused on person (patient safety included), Professionals, Support Processes and Results.
From our view of the quality, standards constitute a system in continuous evolution. Citizen contributes with their needs and their expectations.
The accreditation is progressive. It has three levels: advanced, optimal and excellent and it is effective for five years.
Timeframe implementation
With the developed methodology and the assistance of ME_jora C, an application which support the process, accreditation manuals can be generated to test them in 12 months approximately.
Implementation tools available
12 Accreditation Manuals for Healthcare Centres and Units. (3)
ME_jora C, a web-based computer application where the accreditation process (Application, Self-Assessment, Assessment and Monitoring) is developed
Implementation cost
1 Standards Manual elaboration: 5.000 €.
ME_jora C application Licensed: 60.000 €
ME_jora C applicationTranslation: 65.000 €
4 Assessors Training: 40.000 €
Certification Process per unit: 4.500 €
Method used to measure the results
Descriptive analysis, validated satisfaction barometer, measurement of units’ performance.
More than 650 healthcare centres in the accreditation process, 556 processes finished. (4)
Units which have completed the accreditation process consider it adapted to the reality, flattering in the decision making and useful to plan the continuous improvement.
It is demonstrated in a statistically significant way that accredited centres reach better results than those centres which have not initiated their accreditation process.
Analysis of the results
According to the methodology, results confirm that the accreditation programme impulse the healthcare centre continuous improvement, obtaining better results once the accreditation process has begun.
Implementation barriers
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Other information
Other information about the GOP that you would like to add (Link or attached document)
This Accreditation Programme is based on the self-assesment as an environment of reflection about continuous improvement.
It is accredited by ENAC (National Entity of Accreditation) and their assessors training is accredited by ISQUA (International Society for Quality in Health Care).
ACSA Accreditation Model has been recognised by the Portuguese Ministry of Health as an official accreditation model in Portugal.More Information:1.    Almuedo-Paz A, Núnez-García D, Reyes-Alcázar V and Torres-Olivera A. The ACSA Accreditation Model: Self-Assessment as a Quality Improvement Tool. In: Mehmet Savsar editor. Quality Assurance and Management.InTech 2012. p. 289-314.
2.    http://www.juntadeandalucia.es/agenciadecalidadsanitaria/programas_de_acreditacion/centros/centro_y_unidades_fases/
3.    http://www.juntadeandalucia.es/agenciadecalidadsanitaria/programas_de_acreditacion/centros/programas_de_acreditacion/
4.    http://www.juntadeandalucia.es/agenciadecalidadsanitaria/resultados_de_acreditacion/centros_y_unidades_sanitarias/datos_de_actividad.html