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


Implementation of Patient Safety initiatives / Activities
Education in Patient Safety
GOP Description
Implementation level
Clinical settings
Primary Healthcare, Specialized Healthcare, Emergency.
To recognize the achievements of professionals in their real and daily practice.
To promote professional development and continuous improvement. (
Healthcare professionals of 74 disciplines: doctors and nurses who work in Primary healthcare, specialized healthcare and emergencies, Physiotherapists, Occupational Therapists, Geneticists, Specialists in Clinical Tests, Microbiologists, Anatomopathologists, Pharmacists who work in Primary healthcare and specialized healthcare, Neurophysiologist and Nutritionists.
Based on a portfolio methodology, since 2005, ACSA has developed an accreditation model focused on the recognition of the achievements reached by professionals in their practice. The model pretends to contribute to the attention given to patients’ continuous improvement and it is an instrument for the continuous professional development.

It is voluntary, based on the self-assesment done by professionals in their real everyday practice and progressive with three accreditation levels: advanced, expert and excellent. It has been developed by scientific societies and Healthcare management representatives.

74 Professional skills accreditation manuals have been defined (2), one for each discipline. They are based on the following quality dimensions: User rights, Complete healthcare assistance (patient safety included), The Professional (teamwork, professional development, research and teaching), Efficient use of resources, Outcome orientation in the Professional Development Results.

Two assessors who belong to the same discipline and who have achieved the excellent level accreditation evaluate the professional.

The Accreditation is effective for five years.

Timeframe implementation
With the developed methodology and the assistance of ME_jora P, an application which support the process, accreditation maps can be generated to test them in 12 months approximately
Implementation tools available
78 Professional Skills Accreditation Manuals, one for each discipline. (3)
ME_jora P, a web-based computer application where the accreditation process (Application, Self-Assessment, Monitoring and Assessment) is developed.
Implementation cost
Elaboration of 1 Skills Manual: 5.000 €.
ME_jora P application Licensed: 100.000 €
ME_jora P application Translation: 80.000 €
4 Assessors Training: 40.000 €
Certification Process per professional: 700 €
Method used to measure the results
Descriptive analysis, validated satisfaction barometer, reliability and validity analysis, measurement of profesionals’ performance.
More than 20.000 professionals have initiated the accreditation process, 8.845 have finished it.

The perceived utility in the continuous professional development is demonstrated (“self-learning and reflection thanks to exercise”, “maintenance and improvement of competence”, “maintenance and improvement of result”).
Accreditation Programme reliability and validity is demonstrated.
It is demonstrated in a statistically significant way that professionals who have initiated their accreditation process reach better results than those professionals who have not initiated their accreditation process.

It is demonstrated in a statistically significant way that accredited professionals reach better results than non-accredited professionals.

Analysis of the results
According to portfolio methodology, results confirm that the programme is useful for continuous professional development and it promotes continuous improvement in their work reaching better achievements when they initiate the accreditation process.
Implementation barriers
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Other information
Other information about the GOP that you would like to add (Link or attached document)
This Professional Skills Accreditation Programme is based on the self-assesment as an environment of reflection about continuous improvement.
Peer review contributes to the remarkable acceptance of the accreditation model by professionals and it promotes continuous professional development as the Accreditation Council for Continuing Medical Education indicates. (4)
This programme has obtained three national prizes given by important media and specialized consultant.1.    http://www.juntadeandalucia.es/agenciadecalidadsanitaria/system/galleries/download/acsa/Programas_Acreditacion/pcp_es.pdf
2.    http://www.juntadeandalucia.es/agenciadecalidadsanitaria/programas_de_acreditacion/profesionales/herr_apoyo_comp_prof/competencias_profesionales_herr_apoyo.html
3.    http://www.juntadeandalucia.es/agenciadecalidadsanitaria/resultados_de_acreditacion/competencias_profesionales/situacion_actual.html
4.    Bellande B, Winicur Z, Cox K. Urgently Needed: A safe place for self-assesment on the path to maintaining competence and improving performance. Adacemic Med. 2010; 85: 16-8.