Self-Assessment

Self-assessment is the hospital measuring its own compliance with the Health Quality Standards using its own team, without waiting for an external inspection. The aim is not to receive a score, but to see and correct shortcomings before an inspection does.

How it is carried out

1. Planning — The Quality Management Unit prepares the assessment calendar and announces it to the departments.
2. On-site assessment — The assessment team visits the department and reviews the SKS questions on site.
3. Reporting — Non-conformities identified are recorded in a written report.
4. Corrective action — A responsible person and a completion date are set for each non-conformity.
5. Follow-up — The next assessment checks whether the corrections have been made.

What happens with the result

The self-assessment report does not simply stay in a file. Every non-conformity identified is linked to a corrective action with a responsible person and a completion date. Recurring findings are brought to the agenda of the relevant committee and, where necessary, a new topic is added to the training plan.

This cycle prevents quality work from being squeezed into inspection periods: a shortcoming is seen where and when it occurs.