Introduction:

The Institute of Hematology and Immunology (IHI) had begun training all its personnel in the Quality Management System since 2002 and it gradually progressed in the required documentation until achieving a policy and a Quality Assurance Program, based on national regulations, complying with the annex "Program of continuous improvement of the quality of hospital services".

Objective:

To carry out a preliminary evaluation of quality standards in the IHI, applying the latest version of the Accreditation Manual, in order to request hospital accreditation.

Methods:

A partial evaluation was carried out through internal audits to 90% of the areas and activities were developed to comply with the requirements of the National Health Accreditation Board. Various methods were used, such as: application of checklists, training and improvement courses, on-site observation of objective evidence, interviews, surveys and document review.

Results:

Of the 18 audited services, compliance with 77% of the elements to be evaluated was obtained from the Standard centered on Patient Care and Safety; 88% of the Standard related to Teaching and Research was fullfilled and the Hospital Management and Safety Standard achieved 87% of the audited elements.

Conclusion:

The preliminary application of the quality standards in the IHI has generated more than 60 documents. It indicates the progressive development of this activity and at the same time allows for the training of the staff on quality issues and gives us the possibility of knowing the satisfaction status of patients and service providers.

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