Velasco Gimeno Cristina, Cuerda Compés Cristina, Alonso Puerta Alba, Frías Soriano Laura, Camblor Álvarez Miguel, Bretón Lesmes Irene, Plá Mestre Rosa, Izquierdo Membrilla Isabel, García-Peris Pilar
Unidad de Nutrición Clínica y Dietética. Hospital General Universitario Gregorio Marañón. Instituto de Investigación Sanitaria Gregorio Marañón, Madrid..
Servicio de Medicina Preventiva y Gestión de la Calidad. Hospital General Universitario Gregorio Marañón, Madrid. España..
Nutr Hosp. 2015 Sep 1;32(3):1386-92. doi: 10.3305/nh.2015.32.3.9403.
the implementation of quality management systems (QMS) in the health sector has made great progress in recent years, remains a key tool for the management and improvement of services provides to patients.
to describe the process of implementing a quality management system (QMS) according to the standard ISO 9001:2008 in a Nutrition Unit.
the implementation began in October 2012. Nutrition Unit was supported by Hospital Preventive Medicine and Quality Management Service (PMQM). Initially training sessions on QMS and ISO standards for staff were held. Quality Committee (QC) was established with representation of the medical and nursing staff. Every week, meeting took place among members of the QC and PMQM to define processes, procedures and quality indicators. We carry on a 2 months follow-up of these documents after their validation.
a total of 4 processes were identified and documented (Nutritional status assessment, Nutritional treatment, Monitoring of nutritional treatment and Planning and control of oral feeding) and 13 operating procedures in which all the activity of the Unit were described. The interactions among them were defined in the processes map. Each process has associated specific quality indicators for measuring the state of the QMS, and identifying opportunities for improvement. All the documents associated with requirements of ISO 9001:2008 were developed: quality policy, quality objectives, quality manual, documents and records control, internal audit, nonconformities and corrective and preventive actions. The unit was certified by AENOR in April 2013.
the implementation of a QMS causes a reorganization of the activities of the Unit in order to meet customer's expectations. Documenting these activities ensures a better understanding of the organization, defines the responsibilities of all staff and brings a better management of time and resources. QMS also improves the internal communication and is a motivational element. Explore the satisfaction and expectations of patients can include their view in the design of care processes.
近年来，质量管理体系（QMS）在卫生部门的实施取得了巨大进展，仍然是管理和改善为患者提供服务的关键工具。
描述在一个营养科按照ISO 9001:2008标准实施质量管理体系（QMS）的过程。
实施工作于2012年10月开始。营养科得到医院预防医学与质量管理服务部门（PMQM）的支持。最初为工作人员举办了关于质量管理体系和ISO标准的培训课程。成立了质量委员会（QC），成员包括医护人员。每周，质量委员会成员和PMQM人员开会确定流程、程序和质量指标。这些文件经验证后，我们对其进行了为期2个月的跟踪。
共确定并记录了4个流程（营养状况评估、营养治疗、营养治疗监测以及经口喂养的规划与控制）和13个操作程序，其中描述了该科室的所有活动。在流程图中定义了它们之间的相互作用。每个流程都有相关的特定质量指标，用于衡量质量管理体系的状态并识别改进机会。制定了所有与ISO 9001:2008要求相关的文件：质量方针、质量目标、质量手册、文件和记录控制、内部审核、不符合项以及纠正和预防措施。该科室于2013年4月获得AENOR认证。
质量管理体系的实施促使科室活动进行重组，以满足客户期望。记录这些活动有助于更好地理解组织，明确所有员工的职责，并实现对时间和资源的更好管理。质量管理体系还改善了内部沟通，是一个激励因素。探索患者的满意度和期望可以将他们的观点纳入护理流程设计中。
