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A program of professional accreditation of hospital wards by the Italian Society of Internal Medicine (SIMI): self- versus peer-evaluation

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Abstract

The Italian Society of Internal Medicine has developed a voluntary program of professional accreditation of the medical units run by its constituency. Participation in the program, which is meant to foster staff involvement in clinical governance, includes all the medical personnel and nurses. Accreditation is awarded provided the candidate unit is able to adhere to a pre-established set of quality standards, meet a number of clinical and organizational requirements and monitor specific indicators. Self-evaluation is the first step in the program, followed by a site visit by a team of peer internists experienced in quality auditing. The program, which has involved so far 19 units, has considered a number of clinical requirements related to the three most frequent diseases in Italian internal medicine wards: chronic heart failure (CHF), exacerbation of chronic obstructive pulmonary disease (COPD) and hepatic cirrhosis with ascites (HCA). The comparison between self- and peer-evaluation witnessed less discrepancies for disease-related than for organizational requirements, the latter being met to a smaller degree by most units. In particular, concordance was higher for requirements and indicators pertaining to CHF and HCA than to COPD. This program of professional accreditation developed by the Italian Society of Internal Medicine has the potential to describe, monitor and improve clinical and organizational performances in internal medicine. It should also be seen as a contribution to implement the strategy of professional governance in hospitals.

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Acknowledgments

The authors are indebted to Professor Pier Mannuccio Mannucci who devised and launched this program when he was President of the Italian Society of Internal Medicine. Professor Giuseppe Licata continued to support enthusiastically this program during his term of office. Professor Francesco Violi, current President, is actively engaged in the implementation of the program.

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Authors and Affiliations

  1. Internal Medicine Unit, Azienda Ospedaliera della Provincia di Lecco, Ospedale di Merate, Largo Mandic 1, 23807, Merate (LC), Italy

    Massimo Vanoli

  2. Internal Medicine Unit, Hospital of Pescara, Pescara, Italy

    Giancarlo Traisci

  3. Necstep, Modena, Italy

    Alberto Franchini

  4. Internal Medicine Unit, Melegnano (MI), Italy

    Gianpiero Benetti

  5. Internal Medicine Unit III, University Sapienza, Rome, Italy

    Pietro Serra

  6. Department of Internal Medicine, IRCCS Ca’ Granda Policlinico, Milan, Italy

    Maria Alice Monti

Authors
  1. Massimo Vanoli
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  2. Giancarlo Traisci
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  3. Alberto Franchini
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  4. Gianpiero Benetti
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  5. Pietro Serra
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  6. Maria Alice Monti
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Corresponding author

Correspondence to Massimo Vanoli.

Appendices

Appendix 1: Internal medicine wards participating to the program of professional accreditation of the Italian Society of Internal Medicine

  • Medicina A, ASL Asti, Ospedale “C. Massaia”, Asti, Chief: Walter Saracco, M.D.

  • Medicina Interna, AO S. Croce e Carle, Ospedale S.Croce, Cuneo, Chief: Luigi Fenoglio, M.D.

  • S.C. Medicina, ASL Torino 4, Ospedale di Ciriè, Chief:Roberto Quadri, M.D.

  • Medicina Generale ad indirizzo geriatrico, IRCCS Istituto Auxologico Italiano, Ospedale S.Luca, Milano, Chief: Daniela Mari, M.D.

  • Medicina Interna 2–3, IRCCS Fondazione Ca’ Granda Policlinico, Milano, Chief: Pier Mannuccio Mannucci, M.D.

  • Medicina III, AO L.Sacco, Milano, Chief: Michele Cortellaro, M.D.

  • Medicina Generale, AO Provinciale Pavia, Osp.Carlo Mira, Casorate Primo, Chief: Esio Ronchi, M.D.

  • Medicina Interna A, Ospedale Maggiore “C.A. Pizzardi”, Azienda USL di Bologna, Chief: Vincenzo Arienti, M.D.

  • Medicina Interna 1, AO San Camillo Forlanini, Ospedale San Camillo, Roma,Chief: Laura Gasbarrone, M.D.

  • Medicina Interna II, Università Cattolica, Policlinico Gemelli, Roma, Chief: Raffaele Landolfi, M.D.

  • Medicina e Rep. Breve Osservazione—PS, Ospedale “S.Giovanni Calibita” FBF Isola Tiberina di Roma, Chief: Filippo Alegiani, M.D.

  • Medicina Interna per l’Urgenza, AO S.Giovanni Addolorata-Britannico, Roma, Chief: Giannantonio Cerqua, M.D.

  • Medicina Interna e Clinica Medica, ASL 106 Teramo, Ospedale G. Mazzini, Chief: Dario Di Michele, M.D.

  • Medicina Interna/Lungodegenza, ASL/BR Brindisi, PO Francavilla Fontana—Ceglie, Chief: Carmelo Sconosciuto, M.D.

  • Medicina, AO “Cardinale Panico”, Tricase, Chief: Maria Grazia Serra, M.D.

  • Medicina Interna, ASP di Cosenza, P.O. “Giannelli” di Cetraro, Chief: Giuseppe Musca, M.D.

  • Medicina Interna, ASP VV/Calabria, Presidio “I. Toraldo”, Tropea, Chief: Cesare Bianco, M.D.

  • Medicina Interna e Cardioangiologia, AOU Policlinico “P.Giaccone”, Palermo, Chief: Giuseppe Licata, M.D.

  • Medicina, Ospedale S. Elia, Caltanisetta, Chief: Federico Vancheri, M.D.

Appendix 2: Peer internists involved in the evaluation process in the frame of the program of professional accreditation of the Italian Society of Internal medicine

  • Abbita Giuseppe, M.D., Ospedale di Pantelleria Erice

  • Bianchi Giovanni Battista, M.D., Ospedale SS. Capitanio e Gerosa, Lovere

  • De Feudis Lucrezia, M.D., PO di Pescara

  • Fenoglio Luigi, M.D., ASO S. Croce e Carle, Cuneo

  • Fugazza Luciano, M.D., Ospedale Civico Codogno

  • Liberato Nicola Lucio, M.D., Ospedale Carlo Mira, Casorate Primo

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Vanoli, M., Traisci, G., Franchini, A. et al. A program of professional accreditation of hospital wards by the Italian Society of Internal Medicine (SIMI): self- versus peer-evaluation. Intern Emerg Med 7, 27–32 (2012). https://doi.org/10.1007/s11739-011-0684-6

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  • DOI: https://doi.org/10.1007/s11739-011-0684-6

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