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CRITERIA

The QH Accreditation Technical Office, in accordance with the criteria established by a group of experts and verified by the audit committee composed of: the Spanish Association for Quality (AEC), the General Alliance of Patients (AGP), the Spanish Society for Healthcare Directors (SEDISA), and the Institute for the Development and Integration of Health (IDIS), has established the following criteria regarding assessing certifications:

  • QH Accreditation shall periodically review the existing quality systems, in order to adapt the Synthetic Index to new certifications that may be created. The following are some of the more frequent certifications that healthcare organisations use:

International accreditation models

DIAS (DNV International Accreditation Standard)

JOINT COMISSION

ACCREDITATION CANADA

SEP (Excellent Private Healthcare)

FUNDIBEQ MENCION (Ibero-American Model of Excellence in Management)

EFQM 300+ / 3 Stars, 400+/4 Stars ó 500+/5 Stars

National and Regional Accreditations

Regional Accreditation

DISCERT ESPAÑA

Corporate social responsibility accreditations

EFR (Family-Responsible Company)

IQNet SR10 (Social Responsibility Management System)

SA 8000 (Social Responsibility)

SGE 21 (Ethics Management and Social Responsibility System)

Other accreditation

EMAS (Eco-Management and Audit Scheme)

HIMSS (Healthcare Information and Management Systems Society)

ISOs

- ISO 9001 (Quality Management System)

- ISO 14001 (Environmental Management System)

- ISO 14064 (Greenhouse Gases Management System)

- ISO 17001 (Conformity Assessment. Impartiality Principles and Requirements)

- ISO 18001 (OHSAS 18001:Occupational Health and Safety Management System)

- ISO 27001 (Information Security Management System)

- ISO 50001 (Energy Management System)

- ISO 170001 (Universal Accessibility Management System)

- ISO 179003 (Risk Management for Patient Safety)

- ISO 15189 (Clinical Laboratories. Particular requirements for quality and competence)

- ISO 166002 (Requirements for R&D+I Management System)

- ISO 179007 (Quality Management System for assisted reproduction laboratories)

  • In cases where a healthcare organisation holds a certification where the Technical Office has concerns about the suitability of including it, the Audit Committee shall be consulted.
  • QH Accreditation only takes into account the efforts made by hospitals and healthcare centres to manage their organisation, and does not assess the complexity of diagnostic methods or treatments applied.
  • To achieve the final mark, both the self-assessment completed by the centre and current official certifications are taken into account, weighted in accordance with the availability and scope of the same (the maturer the quality system, the better the mark awarded).
  • If an organisation has a scalable accreditation (e.g. EFQM 300+ and subsequently obtains an EFQM 400+), the start date shall be taken as the date on which the 300+ accreditation was awarded. Validity shall be assessed according to the date on the latest certification.
  • In the same way, if an organisation is certified for just one service and, over time, adds services or certifies the whole centre, the start date shall be taken as the date on which the first scope was certified.
  • Regardless of the period for which a certificate has been granted, the validity period shall be from the year in which QH Accreditation is requested (e.g. if the certificate is valid 2015-2018 and the QH request is created in 2017, the assessment shall be regarded as 2 years).
  • In the event that a hospital has subcontracted a service (e.g. catering) and changes contractor, the assessment shall only take into account the period from which the new contractor starts providing services, as it is the subcontracted service that is accredited, not the centre.
  • Prizes, decorations and awards are not assessed.
  • QH Accreditation shall be valid for two years, after which the centre shall have to submit a request for renewal. However, centres may submit their request annually if they believe that their system has developed and will be able to aim for a higher level of recognition.
  • Organisations that need to renew their accreditation shall have a grace period for renewal from the expiry date until the closure of the call for submissions for the current year.