Quality Label

In 2013, the Care Inspectorate implemented a renewed inspection model in Flemish hospitals. The new supervision model focuses on care pathways. The first pathway developed and inspected was that of surgical patients. The emphasis of the new inspection model is on elements that are critical to the quality of care, at the level of structures, processes and outcomes. Every Flemish hospital is expected to comply with these standards.

On 14 May 2013, the surgical patient's pathway in our hospital was reviewed by the Care Inspectorate. According to the report, no risks were found that need to be followed up in a subsequent inspection. In other words: the hospital has passed the inspection! The Care Inspectorate did formulate a number of findings for which the AZJP has defined concrete improvement actions. For example, a badge control reader was installed at the OR to prevent unauthorized access to the OR and tracing of packages within the OR was optimized. 

On 1 June 2015, the Care Inspectorate reviewed the care pathway of internal medicine patients. This involved inspecting the departments of internal medicine, the Internal Medicine day hospital, the emergency rooms and the intensive care unit. The inspectors found that the medical on-call system was guaranteed and the patient-nurse ratio in the ICU was in order. No risks were found that need to be followed up in a subsequent inspection. Another great result!

On 2 August 2018, a second unanticipated inspection was conducted by the Care Inspectorate of the above care pathways (surgical and internal medicine). In the process, a topic from these 2 pathways was revisited. The goal is to keep the focus on quality within both pathways and to increase the likelihood of effective implementation of quality through repeat compliance monitoring. This audit found no deficiencies at the hospital that warrant re-inspection or follow-up by the government. Medical and nursing on-call presence is guaranteed in the ER, pre-hospital unit and intensive care services.  As a point of improvement, the following was stated: Completeness of SOP IVs administered and syringe pumps. The hospital has started working on this and has made up uniformed labels that are applied on the IVs and syringe pumps.

After the requirement frameworks for the surgical and the internal medicine care pathway, the requirement framework for the cardiac care pathway was approved on 5 March 2018 whereby the cardiac pathology care programs would be checked in the hospitals. On 12 April 2019, there was an unannounced inspection visit by the Care Inspectorate for the cardiology care pathway. The following aspects were checked and found to be in order, among others: The composition of the medical team complied with the legal conditions throughout, all defibrillators, monitors and ECG equipment checked had been maintained on time, ... No shortages were found and we achieved a great result!

An inspection visit took place on 6 August 2021 regarding suicide prevention. During this inspection, the focus was on detection and treatment of suicidal behaviour in adults. The hospital has a suicide prevention policy in place, but follow-up care needs to be further recorded into written agreements. Notwithstanding this observation, the hospital achieved a great result for this inspection.

Providing excellent care to our patients is at the heart of our daily operations. Because we are convinced of our excellent operation and the quality thinking in our organisation, the management, the medical board and the governing body have committed to continue the accreditation process with Qualicor (formerly NIAZ) into the future. Thus, a bridging audit, with basic safety as its focus, is scheduled in October 2022. Then, through a sequential audit cycle, there will be regular reviews of daily operations, over a 5-year period. After each audit, improvement actions will be implemented that will constructively contribute to further raising the quality of our care.

The reports are publicly available and can be viewed via the following links: