Accreditation and International Certification Unit

The mission is to oversee matters related to regional and national accreditation regulations, as well as to promote all activities related to excellence certifications awarded to the IRCCS. In particular, the Unit is responsible for handling the procedures regarding the design and implementation of processes related to the authorization and institutional accreditation of healthcare activities at the IRCCS. 

The activities include: 

- Monitoring accreditation requirements (institutional and excellence), in collaboration with the Hospital Medical Directorate (for organizational and hygiene-health aspects), 

  the Technical and Asset Management Unit (for structural aspects), the Prevention and Protection Service (for safety and protection of workers and users), and Clinical Engineering (for technological requirements) 

- Providing technical support to the Strategic Corporate Management, especially in the case of new regulations, organizational changes, and the launch of new activities 

- Uploading accreditation applications to the regional portal during expansions or transformations of activities, after verifying the completeness of the supporting documentation for each requirement 

- Planning, systematizing, and monitoring the collection of healthcare activity data to ensure accurate reporting to institutional bodies 

- Interacting directly with the Management Control and Information System units, which are responsible for ensuring system functionality and technical conditions for data acquisition, including within the SISS project 

- Supporting inspections by ATS control units or Excellence Certification Commissions during their visits to the IRCCS, interacting with them to improve the appropriateness of the activities carried out, including service reporting 

- Analyzing the services provided at the IRCCS as a means to focus on both outcomes and the effectiveness of the activities, critically reviewing indicators monitored by Regione Lombardia and AGENAS in constructive collaboration with operational units 

- Engaging with international accreditation entities and applying innovative models at the local level.