Quality Management


The main aim of the implementation of "Quality and Safety" in the hospital is to prevent patients being hurt and, by doing so, reduce the negative consequences of any treatment that has been carried out in an unsafe way.
The World Health Organization (WHO) said that patient safety had been increasingly recognized as an issue of global importance over the last 10 years but added that there was still a lot to be done.

Concern with the quality of care and the safety of the patient in health services has been a high priority issue.

At the same time, managing risks and improving the quality and care have led to joint efforts being made within health organizations throughout the world, to obtain patient safety by setting goals.

These goals are adopted by institutions throughout the world as a means of offering a service that is increasingly better and suitable.

 Correct Identification of the Patient – The patients are identified by two means: complete name and date of birth.

  Effective Communication – The complete prescription or the result of an exam, provided verbally or by phone, is noted entirely by whoever receives this information and occurs in specific situations in which the doctor, although present, finds it impossible to carry out the medical prescription in situations of urgency or emergency.

  Safe Use of Medicine – To improve the safety of high vigilance medication through the identification of the place, label and storage of the high vigilance drugs. This control work has been carried out by the process of pharmaceutical assistance, in partnership with all the processes involved.

  Safe Surgery – Ensuring safe surgery with the correct intervention site, correct procedure and correct patient, through a process of identification of the site of the surgical intervention and involving the patient in the process of marking the site on the body. The process involves verifying the documents and equipment that are necessary and whether these are the correct ones and are working. The check list is carried out by the nurse and registered in the patient´s medical record.

  Preventing the Risk of Infections – Reducing the risk of infections associated with health care, educating professionals on the correct technique of hand hygiene and constantly striving to reduce infections associated with health care.

  Preventing the Risk of the Patient Falling – Reducing the risk of injuries to patients through falls by carrying out a daily evaluation of the patient, identifying the risk and taking the measures needed to prevent a fall and reduce the injuries caused by it.

Based on these guidelines, the Clínica São Vicente has been developing actions and strategies, with the focus on the quality and safety of the patient. These are regarded as being of fundamental importance in the provisions of the hospital´s services and the constant pursuit of excellent results. The Clínica São Vicente maintains its commitment through the constant pursuit of improvements in the quality of attendance to all patients/clients and in the 
positioning in institutional safety.

To do so, it makes investments in technology, training and improving its human resources and creates protocols and policies based on best practices that give priority to the quality of the care provided to the patient.

The Hospital Accreditation process that led the Clínica São Vicente to win ONA II Certification also spread the culture of safety and continuous quality in patient care. The Patient Safety Indicators are tracking tools that use administrative data to identify potential complications in the care and have been increasingly more used as ways of measuring hospital safety.

We present below information and indicators of four of these goals, used in the Clínica São Vicente.

Prevention of the Risk of the Patient Falling

Falls are events that can cause injuries in patients who are hospitalized. Their occurrence in a hospital environment varies according to the type of patient being treated. The elderly, people with problems in walking or maintaining their balance, and those with a lower level of awareness and using certain drugs are more liable to fall.

As a safety measure, the health institutions should identify the risk of their patients falling and act to prevent this kind of event and injuries caused by it.

The Clínica São Vicente´s program to prevent falls includes identifying patients with the highest risk – due to their medical conditions, the drugs prescribed and treatments – and the adoption of preventive measures, according to this risk.

The risk assessment is carried out on a daily basis, from the admission, based on the medical conditions of the patient. The risk for patients who are being treated in the diagnosis, outpatient and first aid center is established according to the procedure to be undertaken.

All patients are given guidance about the risks and prevention measures. Moreover, the Clínica São Vicente´s physical environment has been designed to reduce the risk of falls related to the physical structure and furniture, which includes the patient´s room and bathroom.

The result of this program is monitored through the Density Indicator of the Incidence of Falls, with injury to inpatients. What do we measure?

In this indicator, we consider the number of falls by inpatients which led to injury.




​The goal established by the Clínica São Vicente is 0% for inpatients. This index considers the length of the stay as a determining factor in the risk of the patient and/or what could occur to develop this risk.

If you have any questions, ask the health professionals who are looking after you. This can avoid mistakes. Take part in this process.

Safe Surgery

The concept of safe surgery involves measures adopted to reduce the risk of adverse events that could occur before, during and after surgery. Adverse surgery events are incidents that result in the patient being harmed.

The World Health Organization (WHO) has established a program to ensure safety in surgery which consists in checking essential items in the surgical process. The aim is to ensure that the procedure is carried out as planned and meets five correct points: patient, procedure, lateral position (side to be operated on), positioning and equipment.

The Clínica São Vicente uses this model and works with well-defined protocols that depend on the involvement of the whole multi-professional team. The results of this program are monitored through an Adhesion to the Safe Surgery Protocol Indicator.

What do we measure?

In this indicator, we consider the number of patients who arrive at the surgery center with the correct application of the safe surgery protocol completed and continue with the protocol when the patient is admitted to the surgery center.

We also check the safety, surgery check list or time out, a combination of actions carried out in the various phases that involve a surgical procedure from the scheduling to the post-operation period.

These actions include:

Correct identification of the patient and presence of the entire surgical team;

     Confirmation of the procedure to be undertaken and planning respiratory access and  the need for blood transfusion;

     Correct positioning of the patient on the operating table;

     Confirmation of the side to be operated on;

     Availability of the equipment and materials needed for the surgery

     Sending materials for diagnostic exams.



The goal was established by the Clínica São Vicente at 90%, rising to 100%. The development of the results can be seen in the graph.

If you have any questions, ask the health professionals who are looking after you. This can avoid mistakes. Take part in this process

Correct Identification of the Patient

What is this?

The correct identification of the patient is very important to ensure the safety of the assistance process. This action is the starting point for the correct undertaking of the various safety stages in our institution.

This ensures that the right person is given the right attendance, even in those situations in which the patient cannot respond for himself or herself.

The patient identification process must be able to identify the individual correctly as being the person to whom the service is directed (drugs, blood or hemoderivatives, exams, surgery and treatment).

The result of this program is monitored through a triple checking indicator that consists of confirming through an electric bar code reader, the correct drug, according to the doctor´s prescription, the correct patient, according to the identification, and the identification of the professional who is carrying out the treatment. The triple check process is not only used for the drugs but can also be used to control the materials and other procedures.

Our patient identification process includes two separate pieces of information: the full name and the medical record number, inserted in the bar code format used to identify the patient, before each act of assistance. This ensures that the care goes to the right individual.

The identification occurs at the moment of admission through a wristband and all the safety processes include advance confirmation of the information contained in it.

What do we measure?

We use this indicator to consider the rate of undertaking the triple check, before administering drugs, in situations that do not involve urgent and emergency attendance.

As a result of these different situations, our goal for the indicator was fixed at 80%. The development of the results can be seen in the following graph.

What can you do to improve this process?

It is important to always wear the wristband to ensure safety. The patient/relative should check that the information is correct. Make sure the assistance team checks your identification before any treatment/procedure.


No graph is available.

​ If you have any questions, ask the health professionals who are looking after you. This can avoid mistakes. Take part in this process

Prevention of the Risk of Infection

Health care associated infections (HAI) are those acquired as a result of the procedures needed for the monitoring and treatment of inpatients, outpatients, diagnostic centers or even home care.

Even when all the measures known to prevent and control HAI are taken, certain groups have a greater risk of developing an infection. These include people who are very young and very old, diabetics,  immunosuppressed illnesses, with  extensive skin injuries, patients submitted to major surgery or transplants, the obese and smokers.

The monitoring of HAI allows the care processes to be improved and the risks of these infections being reduced. In this situation, hand hygiene is an essential procedure. Our process is based on the recommendations of the World Health Organization (WHO) which states that all professionals need to keep their hands disinfected at five different times, including before and after any contact with the patient.

A hospital infection is one that is acquired in the hospital and was not present or in incubation when the patient was admitted. It can appear during the stay or even after the patient has been discharged.

To ensure that our professionals, patients, those accompanying them and visitors disinfect their hands, the Hospital Infection Control Committee (local acronym CCIH) coordinates actions and educational campaigns on hand hygiene to raise awareness of the importance of this act.

Who is most exposed to the risk of hospital infection?

New-born babies, older people, diabetics and people with cancer and organ transplants have the greatest risk as their defense system against microorganisms may have been altered.

What can you do to improve this process?

Ask the doctor or nurse why you have to use the catheter and for how long. Ask them about the measures that will be taken to prevent infection. Check that the professionals disinfect their hands with water and soap or alcohol gel before and after every treatment. If the bandage is dirty or wet, inform the doctor or nurse immediately.

Also advise them if pain occurs and the skin becomes red. Do not allow your relatives, friends and other visitors to touch the catheter. Everyone should disinfect their hands when they enter and leave the room.




When we began to monitor the adhesion to disinfecting hands and set the goal of  70% in April, the staff who were part of the clean hands group in the Clínica São Vicente made an effort and we reached a large number. This figure dropped off in the two following months but initiatives were taken and we managed to raise the index.

If you have any questions, ask the health professionals who are looking after you. This can avoid mistakes. Take part in this process.


The Clínica São Vicente won Level II certification, granted by the National Accreditation Organization (ONA), a non-governmental body that aims to promote the process of quality certification in all organizations and health service providers in the country.  The Level II certification (Full Accreditation) confirms that the institution not only complies with the requirements of Level I (Safety Level) but also has a planning and organization system focused on integrated management.

It also prepares the institution to pursue the greatest efficiency and effectiveness in attending patients, the rationalization and suitability of the resources, in the use of the benchmarks in terms of excellent health treatment and the reduction in the risk to the patients, professionals and employees. The main benefit to the patients and doctors of this certification is the guarantee of the safety policy. The following values are taken into consideration in the evaluation: credibility, legitimacy, quality, ethics and result.