Espirales. Revista multidisciplinaria de investigación científica, Vol. 8, No. 48
January - March 2024. e-ISSN 2550-6862. pp 59-78
DOI https://doi.org/10.31876/er.v47i7.859
Mapping of quality standards of health services in a
Facility Management System for Colombian hospitals
Mapeo de estándares de calidad de servicios de salud en un Sistema de
Facility Management para hospitales colombianos
Manuel Madroñal-Ortiz*
Diego Cuartas-Ramírez**
Nelson Javier Escobar-Mora***
Marisol Osorio****
Received: October 19, 2023
Approved: November 12, 2023
Abstract
The health service quality standards for Colombian health
institutions entail obligations that must be aligned with the various
management systems, including for support activities in the
hospital environment. The authors of this work recognized the
need to determine the impact of the quality standards of health
services in the different phases of the continuous improvement
cycles of a Facility Management System. In this work, it was carried
out a documentary analysis and information treatment of national
and international accreditations related to the stages of the high-
level structure in a Facility Management System based on the ISO
41001 standard. The findings of this research have evidenced the
compatibility and impact of the groups of standards of regulatory
convergence in the different cycles of continuous improvement
(operational, tactical, strategic, and transformational) in a Facility
Management System for Colombian health institutions. Therefore,
the authors of this work deduce that the regulatory
correspondence in a Facility Management System can drive facility
management services to achieve continuous improvement of the
hospital infrastructure that guarantees the quality of health
services and integration with other management systems.
Keywords:
Standards, Management Systems, Facility
Management, Hospitals, ISO 41001, ISO 41001
Madroñal-Ortiz, M., Cuartas-Ramírez, D.,
Escobar-Mora, N., Osorio, M. (2024).
Mapping of quality standards of health
services in a Facility Management System for
Colombian hospitals. Espirales Revista
Multidisciplinaria de investigación científica,
8 (48), 59-78
* Doctor, Escuela de Ingenierías, Universidad Pontificia
Bolivariana, Medellín, Colombia,
manuel.madronal@upb.edu.co,
https://orcid.org/0000-0003-1599-969X
** Magister, Escuela de Ingenierías, Universidad
Pontificia Bolivariana, Medellín, Colombia,
diego.cuartas@upb.edu.co, https://orcid.org/0000-
0001-8585-1469
*** Magister, Escuela de Ingenierías, Universidad
Pontificia Bolivariana, Medellín, Colombia,
nelson.escobar@upb.edu.co
, https://orcid.org/0000-
0001-9681-3089
**** Doctor, Escuela de Ingenierías, Universidad
Pontificia Bolivariana, Medellín, Colombia,
marisol.osororio@upb.edu.co
Mapping of quality standards of health services in a Facility Management System for Colombian hospitals
Espirales. Revista multidisciplinaria de investigación científica, Vol. 8, No. 48
January - March 2024. e-ISSN 2550-6862. pp 59-78
60
Introduction
Many health institutions (HI) usually have some national or international accreditation
that guarantees dedication and excellence in the health service, giving a signal to
potential consumers of a comparable service (Smith, Martínez Álvarez & Chanda, 2011).
The authors of this work identified, through a questionnaire, that the most used
documents for ensuring the quality of the services of Colombian health institutions are
three: the Unique Habilitation System and the Unique Accreditation System in
Colombia, as well as The Joint Commission International worldwide. On the one hand,
the Single Habilitation System (SUH, acronym in Spanish) is mandatory for any
Colombian IS that wants to offer its services in the country, and, on the other hand, the
Single Accreditation System (SUA, acronym in Spanish) is voluntary for those who wish
to show their capacity. and quality in the provision of health services to stand out from
the rest of IS. At an international level, the recognized voluntary accreditation of The
Joint Commission International (JCI) has been identified, which ensures patient safety
and the quality of health care regarding the services of health professionals; this
accreditation is a prestigious international seal of hospital quality. Voluntary
accreditations (SUA & JCI) have the following characteristics: they are vital to confirm
the quality of care, they imply a high financial investment, a high demand for quality,
expensive technology and infrastructure, highly qualified human resources, complex
Resumen
Los estándares de calidad del servicio de salud para las instituciones
de salud colombianas conllevan obligaciones que deben estar
alineadas a los diversos sistemas de gestión, incluso para las
actividades de soporte del ámbito hospitalario. Los autores de este
trabajo reconocieron la necesidad de determinar el impacto de los
estándares de calidad de los servicios de salud en los diferentes
criterios de los ciclos de mejora continua de un Sistema de Facility
Management. En este trabajo se realizó un análisis documental y un
tratamiento de información de credenciales nacionales e
internacionales, que promueven la garantía de la calidad de los
servicios de salud, relacionado con los criterios de la estructura de
alto nivel en un Sistema de Facility Management basado en el
estándar ISO 41001. Los hallazgos de esta investigación han
evidenciado la compatibilidad y el impacto de los grupos de
estándares de la convergencia regulatoria en los diferentes ciclos de
mejora continua (operativo, táctico, estratégico y transformacional)
en un Sistema de Facility Management para las instituciones de salud
colombianas. Los autores de este trabajo deducen que la
correspondencia regulatoria en un Sistema de Facility Management
puede impulsar a los servicios de Facility Management a alcanzar una
mejora continua de la infraestructura hospitalaria que garantice la
calidad de los servicios de salud y la integración con otros sistemas
de gestión.
Palabras clave:
Estándares, Sistemas de Gestión, Facility
Management, Hospitales, ISO 41001
Manuel Madroñal-Ortiz, Diego Cuartas-Ramírez, Nelson Javier Escobar-Mora, Marisol Osorio
Espirales. Revista multidisciplinaria de investigación científica, Vol. 8, No. 48
January - March 2024. e-ISSN 2550-6862. pp 59-78
61
process design, and complicated relationships with stakeholders (González-Mendoza &
Fonseca-Vigoya, 2016).
These three accreditations (SUH, SUA and JCI) of health services are based on
compliance with standards that are made up of “requirements that define operational
expectations regarding structure, process and results that must be solidly in a adequate
place in the organization to achieve safety and quality in patient care” (Medina Ruiz,
Rosas Mosquera & Castro Bejarano, 2013). Therefore, the recognition and the objective
of these quality accreditations are vital factors to achieve world-class characteristics in
the evaluation of the quality of hospital care, considering the importance of health
tourism in Colombia (González-Mendoza & Fonseca-Vigoya, 2016). Furthermore, this
type of tourism has been part of government programs to promote new and emerging
sectors in order to project them internationally through the development of sectoral
business plans that promote economic growth and the strengthening of the national
productive apparatus.
The best way to understand each of the accreditation systems in Colombia is to define
them succinctly. The SUH establishes qualification standards as “the minimum and
essential scientific and technological conditions applicable to any provider regardless
of the service they offer” (Salazar Flórez, 2015; MinSalud, 2014; MinSalud, 2019).
Likewise, the SUA promoted by the Ministry of Social Protection and the Colombian
Institute of Technical Standards and Certification (ICONTEC) established a set of
processes, procedures, and tools for voluntary and periodic implementation by auditors
with the objective of continuous quality improvement. The HI that intends to be
accredited in the SUA, previously authorized in the SUH, must pass verification by an
accreditation body that carries out the analysis and makes the corresponding decisions
to achieve it (MinSalud, 2002; MinSalud, 2014a; MinSalud, 2018; MinSalud, 2019).
Finally, for this research, we considered exclusively the "management standards for
healthcare organizations" of the JCI (2017), which are linked to support activities (also
called non-core business) of the IS that appear in its accreditation manual. All the
standards considered from the SUH, SUA & JCI documents for this research that make
up the regulatory convergence are set out in table 1.
To comply with the requirements of regulatory convergence in an IPS, it is necessary to
have effective management of the processes that support the main health activity,
activities and support services is necessary. This is important to achieve better
performance of the needs of the IS and its users; this regulatory convergence falls within
the competencies of the Facility Management (FM) discipline. Several authors
(Chotipanich, 2004; Price, 2004) consider that the support activities controlled by the
FM of an organization are important since they imply a high impact for interested
parties. Especially in the health sector, FM activities are associated with high operational
risk of failure maintenance and high responsibility in financial management.
Mapping of quality standards of health services in a Facility Management System for Colombian hospitals
Espirales. Revista multidisciplinaria de investigación científica, Vol. 8, No. 48
January - March 2024. e-ISSN 2550-6862. pp 59-78
62
Table 1.
Regulatory convergence composed of the SUH, SUA & JCI standards groups
(Source: Authors)
Sistema Único de
Acreditación (SUA)
Health organization
management standards (JCI)
Leadership (LEA)
Quality Improvement and
Patient Safety (QPS)
Management (MAN)
Prevention and Control of
Infections (PCI)
Human Talent
Management (HTM)
Government Body,
Leadership and
Management (GLD)
Physical Environment
Management (PEM)
Facility Management and
Security (FM&S)
Technology
Management (TM)
Staff Qualification and
Education (SQE)
Information
Management (IM)
Management of
Information (MOI)
Quality Management
(QI)
--
The problem identified in this work was the lack of studies that relate the quality
standards of health services with the activities and support services that reach the
functions of the FM and, furthermore, with a standardized management system. For this
reason, the analysis of the establishment of a FM-oriented management system (MS) in
a Colombian IS has been considered relevant in this study, estimating the impact of the
SUH, SUA & JCI standards groups on each of the clause. of a Facility Management
System (FMS). Furthermore, it is appropriate to check the alignment of the FMS with a
process-based approach through continuous improvement cycles as set out in the ISO
9001 standard (UNE, 2015); this type of cycle of continuous improvement allows
problems to be solved in a structured way so that the organization benefits at all levels
from continuous learning. Furthermore, the authors trust that the use of the ISO 41001
standard for establishing the FMS in the IS will provide the advantages outlined by
Ballesty & Mitchell (2020): ensure that their FMS controls the risk, plan risk prevention,
reduce non-toxic effects. desired, identify who will be responsible, carry out internal and
external communication associated with risks, as well as consider opportunities for
continuous improvement of controls that respond to external events.
Furthermore, the authors of this study considered that the publication of the ISO 41001
standard (UNE, 2018) on an FMS will allow achieving the appropriate combination
between requirements, service levels, capabilities, constraints and costs of support
activities and services. Therefore, the objective of this work has been to map the
relationship of the different groups of regulatory convergence standards (SUH, SUA &
JCI), of mandatory or voluntary compliance, in the different clauses of the high-level
structure (HLS) of a FMS based on the ISO 41001 standard (Figure 1).
Manuel Madroñal-Ortiz, Diego Cuartas-Ramírez, Nelson Javier Escobar-Mora, Marisol Osorio
Espirales. Revista multidisciplinaria de investigación científica, Vol. 8, No. 48
January - March 2024. e-ISSN 2550-6862. pp 59-78
63
Figure 1.
Model for inclusion of accreditation standards associated with an FMS of a HI.
This mapping aims to show the impact of each group of quality standards of health
services at the different levels of management with a process-based approach for the
establishment of an FMS in Colombian IS and the achievement of the different national
and international accreditations of quality in the hospital environment.
According to the authors of this work, the HLS clauses of the FMS for HI are understood
as follows:
The Context of the organization (C) includes the understanding of the organization and
its context, the interpretation of the needs and expectations of the interested parties,
and the determination of the scope of the FMS and the different cycles of continuous
improvement or cycle PDCA (Plan, Do, Check and Act) in the organization.
Leadership (L) includes the demonstration of the commitment and leadership of top
management (TM) to the FMS; the establishment by the TM of an FMS policy; and the
assignment of roles, responsibilities, and authorities in the FMS by the TM.
Planning (P) integrates the purpose and requirements of FMS to address risks and
opportunities, the establishment of FMS objectives in accordance with the requirements
of interested parties, as well as the preservation of documented information on the
objectives and planning of the FMS.
Support (S) involves the determination of the resources and competencies of FMS
professionals, the identification of communication needs, policies, objectives, and
effectiveness of FMS, and additionally, the determination of the management of the
knowledge and information management of the FMS.
Operation (O) includes the planning, implementation, and control of the necessary
processes of the FMS, the coordination of the organization with the interest groups and
Mapping of quality standards of health services in a Facility Management System for Colombian hospitals
Espirales. Revista multidisciplinaria de investigación científica, Vol. 8, No. 48
January - March 2024. e-ISSN 2550-6862. pp 59-78
64
the definition of the relationship of the users with the interest groups, and the definition
of the integration of functions that guarantee the effectiveness and efficiency of the
FMS.
Performance Evaluation (E) integrates the monitoring, analysis and evaluation of
financial management services, the performance of planned internal audits of the FMS
in accordance with the ISO 41001 standard as other management systems and the
internal requirements of the FMS. Likewise, the review of the financial management
system by the TM, communicating the results and the measures to be adopted.
Improvement (I) involves taking measures to control non-conformities and keeping a
record of them, carrying out continuous improvement with the suitability, adequacy,
and effectiveness of FMS, and establishing processes to identify deficiencies in services,
performance, and evaluation of the FMS.
Materials and methods
The first step of this work was a systematic review of the selected literature using search
tools and methods in databases on the SUH, SUA, JCI and ISO 41001. The records
found underwent a documentary analysis and qualitative information treatment to
identify regulatory convergence (Table 1) and the link of those standards associated
with FM activities in the IH in an FMS, in this process an approach like another
documentary research was used (Dulzaides Iglesias & Molina Gómez, 2004; Hernández
& Tobón, 2016)
In a second step, related concepts of the three health quality accreditation documents
(SUH, SUA & JCI) with the FM are identified through the detailed study of each of the
190 requirements set out in the 16 groups of standards. In addition, a relationship of
each of the 190 requirements with each of the 7 clauses on the HLS in the FMS linked
to the different cycles of continuous improvement of this MS was identified.
In a third step, a matrix was developed to visualize the relationship of the standards with
the clauses on the HLS in the FMS. This relationship was assigned with an X within the
matrix and each group of standards obtained a sum of all assignments (X). The sums
with the two highest results (in bold) from each of the 16 groups of standards indicated
the greatest impact on each clause on the HLS in the FMS. Example: If the XXX
standards group had the greatest sum in L, S, E, say that the requirements of the XXX
standards group had the greatest relationship with the following clauses: Leadership,
Support and Evaluation of the FMS’s performance.
In a fourth step, a model was developed that is represented in a figure to conceptualize
the relationship of each of the most representative groups of standards in the 7 clauses
on the HLS in the FMS. This figure allowed us to visually represent the impact of the 16
groups of standards on the different levels of business management and the influence
of the requirements of health quality accreditations on the different PDCA cycles of the
FMS for Colombian IH.
Manuel Madroñal-Ortiz, Diego Cuartas-Ramírez, Nelson Javier Escobar-Mora, Marisol Osorio
Espirales. Revista multidisciplinaria de investigación científica, Vol. 8, No. 48
January - March 2024. e-ISSN 2550-6862. pp 59-78
65
Results
The document analysis and treatment (SUH, SUA, JCI and ISO 41001) allowed the
authors of this work to have a vision of the individual impact of the 190 standards linked
to FM activities of regulatory convergence (Figure 1) in each of the FMS clauses for
Colombian IH.
The individual impact of the 13 groups of SUA & JCI standards is identified by the
highest results of each sum, highlighted in bold, in the correlation matrices between the
requirements of each group of standards in each of the 7 clauses on the HLS in the FMS,
as can be seen in table 2 and table 3. In the case of table 2, it can be seen the impact
of the JCI standards groups on the FMS, through the summations (in bold of the blue
zones) of the individual assignments of the 6 groups of standards of this accreditation.
Table 2.
Impact of JCI standards on the HLS clauses of the FMS based on the ISO 41001
standard
(Source: Authors)
(JCI)
Clauses of the Facility Management System
QPS
C
L
P
S
O
E
I
No. 1
x
No. 2
x
x
No. 3
x
No. 4
x
x
No. 5
x
x
No. 6
x
No. 7
x
No. 8
x
No. 9
x
x
No. 10
x
No. 11
x
x
SUM
0
0
1
1
2
7
5
SQE
C
L
P
S
O
E
I
No. 1
x
x
No. 2
x
x
No. 3
x
No. 4
x
No. 5
x
Mapping of quality standards of health services in a Facility Management System for Colombian hospitals
Espirales. Revista multidisciplinaria de investigación científica, Vol. 8, No. 48
January - March 2024. e-ISSN 2550-6862. pp 59-78
66
No. 6
x
x
No. 7
x
No. 8
x
x
No. 9
x
x
No. 10
x
No. 11
x
x
No. 12
x
x
No. 13
x
x
No. 14
x
x
x
No. 15
x
x
No. 16
x
x
x
SUM
0
12
0
7
3
4
3
PCI
C
L
P
S
O
E
I
No. 1
x
x
x
No. 2
x
x
No. 3
x
x
x
No. 4
x
x
No. 5
x
x
x
No. 6
x
x
No. 7
x
x
x
No. 8
x
x
No. 9
x
No. 10
x
x
No. 11
x
x
SUM
0
3
6
4
7
3
2
FMS
C
L
P
S
O
E
I
No. 1
x
No. 2
x
x
No. 3
x
x
No. 4
x
x
x
x
No. 5
x
x
No. 6
x
x
Manuel Madroñal-Ortiz, Diego Cuartas-Ramírez, Nelson Javier Escobar-Mora, Marisol Osorio
Espirales. Revista multidisciplinaria de investigación científica, Vol. 8, No. 48
January - March 2024. e-ISSN 2550-6862. pp 59-78
67
No. 7
x
x
No. 8
x
x
x
x
No. 9
x
x
x
x
No. 10
x
x
x
x
No. 11
x
x
x
SUM
1
2
7
7
8
4
1
MOI
C
L
P
S
O
E
I
No. 1
x
x
No. 2
x
No. 3
x
No. 4
x
x
No. 5
x
No. 6
x
x
x
No. 7
x
x
No. 8
x
No. 9
x
x
x
No. 10
x
No. 11
x
No. 12
x
x
x
SUM
1
5
0
9
2
2
2
GLD
C
L
P
S
O
E
I
No. 1
x
x
No. 2
x
No. 3
x
x
No. 4
x
x
x
x
No. 5
x
x
x
x
No. 6
x
x
x
x
x
No. 7
x
x
x
x
No. 8
x
No. 9
x
No. 10
x
x
x
No. 11
x
x
x
x
Mapping of quality standards of health services in a Facility Management System for Colombian hospitals
Espirales. Revista multidisciplinaria de investigación científica, Vol. 8, No. 48
January - March 2024. e-ISSN 2550-6862. pp 59-78
68
No. 12
x
x
No. 13
x
x
x
No. 14
x
No. 15
x
No. 16
x
No. 17
x
No. 18
x
No. 19
x
SUM
6
14
1
6
5
5
5
On the other hand, in table 3 it can be seen the impact of the groups of standards of
the SUA on the FMS, through the sums (in bold green areas) of the individual
assignments of the 7 groups of standards of this accreditation.
Table 3.
Impact of the SUA standards on the HLS clauses of the FMS based on the ISO
41001 standard. (Source: Authors).
(SUA)
Criterios del Sistema Facility Management
LEA
C
L
P
S
O
E
I
No. 76
x
x
No. 77
x
x
x
No. 78
x
No. 79
x
x
x
x
No. 80
x
x
x
No. 81
x
x
No. 82
x
No. 83
x
No. 84
x
No. 85
x
No. 86
x
No. 87
x
No. 88
x
SUM
4
6
4
2
2
2
1
Manuel Madroñal-Ortiz, Diego Cuartas-Ramírez, Nelson Javier Escobar-Mora, Marisol Osorio
Espirales. Revista multidisciplinaria de investigación científica, Vol. 8, No. 48
January - March 2024. e-ISSN 2550-6862. pp 59-78
69
MAN
C
L
P
S
O
E
I
No. 89
x
No. 90
x
x
No. 91
x
x
No. 92
x
x
No. 93
x
x
No. 94
x
x
x
x
No. 95
x
No. 96
x
x
x
x
No. 97
x
x
No. 98
x
x
No. 99
x
No. 100
x
x
No. 101
x
x
x
No. 102
x
No. 103
x
SUM
1
9
7
4
3
4
2
HTM
C
L
P
S
O
E
I
No. 104
x
x
No. 105
x
No. 106
x
x
No. 107
x
x
No. 108
x
x
x
No. 109
x
x
No. 110
x
x
x
No. 111
x
No. 112
x
No. 113
x
x
x
No. 114
x
No. 115
x
Mapping of quality standards of health services in a Facility Management System for Colombian hospitals
Espirales. Revista multidisciplinaria de investigación científica, Vol. 8, No. 48
January - March 2024. e-ISSN 2550-6862. pp 59-78
70
No. 116
x
x
x
No. 117
x
x
x
No. 118
x
x
x
No. 119
x
No. 120
x
x
x
SUM
3
6
6
9
3
7
2
PEM
C
L
P
S
O
E
I
No. 121
x
x
x
No. 122
x
x
x
No. 123
x
x
No. 124
x
x
x
No. 125
x
x
x
No. 126
x
x
x
No. 127
x
x
x
No. 128
x
No. 129
x
x
x
No. 130
x
x
x
x
No. 131
x
SUM
2
3
4
5
5
6
4
TM
C
L
P
S
O
E
I
No. 132
x
x
No. 133
x
x
x
No. 134
x
x
No. 135
x
x
x
No. 136
x
x
x
No. 137
x
x
x
No. 138
x
x
x
x
x
No. 139
x
x
x
x
No. 140
x
x
No. 141
x
Manuel Madroñal-Ortiz, Diego Cuartas-Ramírez, Nelson Javier Escobar-Mora, Marisol Osorio
Espirales. Revista multidisciplinaria de investigación científica, Vol. 8, No. 48
January - March 2024. e-ISSN 2550-6862. pp 59-78
71
SUM
2
4
3
8
6
4
1
IM
C
L
P
S
O
E
I
No. 142
x
x
No. 143
x
No. 144
x
x
x
No. 145
x
No. 146
x
x
x
No. 147
x
x
x
No. 148
x
x
No. 149
x
x
x
No. 150
x
No. 151
x
x
x
No. 152
x
x
x
No. 153
x
x
x
No. 154
x
x
x
No. 155
x
SUM
1
0
4
10
10
5
2
QI
C
L
P
S
O
E
I
No. 156
x
x
x
No. 157
x
x
x
No. 158
x
x
x
No. 157
x
x
No. 159
x
x
RESUME
N
0
0
3
1
4
1
5
In the results of the previous tables, it can be seen the impact of each group of standards
on the HLS clauses of a FMS. This is understood as the linking of the individual
requirements of the standards to a criterion of different PDCA cycles. These results can
be explained with the following example from table 3: the SUA Leadership (LEA)
standards group impacts the following FMS clauses: Context of the organization,
Leadership and Planning; because they are the clauses with the highest score, displayed
in bold in the green area. This means that the requirements of the LEA standards group
Mapping of quality standards of health services in a Facility Management System for Colombian hospitals
Espirales. Revista multidisciplinaria de investigación científica, Vol. 8, No. 48
January - March 2024. e-ISSN 2550-6862. pp 59-78
72
of the SUA have more influence on these three clauses of different PDCA cycles of the
FMS, although to a lesser extent these requirements can influence the rest of the clauses
of this FMS.
Finally, the authors identified in the documentary analysis and documentation treatment
that the groups of standards in the SUH document have an impact only on the FMS
criterion called “Organizational Context” (Figure 4). This is because the stipulations of
this document, which are mandatory for Colombian IH, determine the minimum
requirements for any HI that intends to offer its services in the country. These
requirements are totally linked to the organizational environment with the most basic
processes, whether they are main or support activities or services. However, the groups
of standards in the SUH document may have a lesser impact on other FMS clauses
related to the economic, technological, or administrative capacity of the IH. This work
can be summarized in table 4 where the correlation of the 16 groups of standards in the
7 clauses on the HLS is observed in a FMS of the main quality accreditation systems of
health services for Colombian IH.
Table 4.
Evaluation matrix of the SUH, SUA & JCI standards groups on the HLS in a
FMS.
Accreditations
Standards Groups
Clauses of Facility Management System
C
L
P
S
O
E
I
THE JOINT COMMISSION INTERNATIONAL (JCI)
QPS
x
x
PCI
x
x
GLD
x
x
x
FMS
x
x
x
SQE
x
x
MOI
x
x
SISTEMA ÚNICO DE ACREDITACIÓN (SUA)
LEA
x
x
x
MAN
x
x
HTM
x
x
PEM
x
x
x
TM
x
x
IM
x
x
x
QI
x
x
Manuel Madroñal-Ortiz, Diego Cuartas-Ramírez, Nelson Javier Escobar-Mora, Marisol Osorio
Espirales. Revista multidisciplinaria de investigación científica, Vol. 8, No. 48
January - March 2024. e-ISSN 2550-6862. pp 59-78
73
SISTEMA ÚNICO DE HABILITACIÓN (SUH)
CTA
x
CPF
x
CTC
x
In the results presented, the authors were able to identify that the 16 groups of SUH,
SUA & JCI standards can be adequately integrated into the HLS and impact different
PDCA cycles of the FMS for Colombian IH (Figure 2). That is, the FM activities according
to the 16 groups of standards of regulatory convergence (Figure 1) are compatible in a
FMS based on the ISO 41001 standard. In addition, the authors interpreted that the
relationship of the 16 groups of standards within Regulatory convergence is distributed
almost uniformly in the 7 clauses on the HLS of the FMS for a Colombian IH (Figure 2).
Based on the analysis of the results, the authors observed that the SUH standards
groups have exclusively impacted the “Organization Context” clauses, since the SUH
document includes the conditions, requirements and minimum clauses requested to
provide health services in Colombia. However, the impact of the SUA and JCI standards
groups has been distributed in the different clauses of the HLS in the FMS in a more
homogeneous way.
Figure 2.
PDCA approach methodology based on the HLS of a FMS for Colombian HI.
Mapping of quality standards of health services in a Facility Management System for Colombian hospitals
Espirales. Revista multidisciplinaria de investigación científica, Vol. 8, No. 48
January - March 2024. e-ISSN 2550-6862. pp 59-78
74
According to Medina Ruiz et al. (2013), it can be indicated that these documents (SUA
& JCI) have aspects in common. Since the main objective of these accreditations is
continuous improvement and, therefore, they are usually associated with PDCA cycles
for both services and processes of the MS (García, Quispe & Ráez, 2003). Thus, the FMS
for a Colombian IH, in which the 16 groups of standards (SUH, SUA & JCI) are
integrated, is composed of different PDCA cycles at the following levels of business
management: transformational, strategic, tactical and operational (Figure 2).
Based on the ISO 41001 standard, the distribution of FMS, like a quality management
system (García, et al., 2003), provides the common clauses of a PDCA cycle. This allows
to develop and reformulate the necessary documents that support the main activity as
well as the supporting activities in an IH. Figure 2 shows four different PDCA cycles
established by a logical arrangement in an MS. At the operational level, short-term
support activities are linked to the following FMS clauses: “Planning”, “Operation”,
“Performance evaluation” and “Improvement”. At a tactical level, the PDCA cycle
grows, and the improvement reaches the “Support” clause of the HLS where
information and human talent management activities are developed. At a strategic
level, the PDCA cycle is extended, and the improvement reaches the “Leadership”
clause of the HLS, involving strategic management activities. Finally, the PDCA cycle is
expanded to a transformational level to achieve an improvement in the HLS
“Organizational Context” clause. This level of management includes the main work of
senior management related to policy development and business sophistication (Ford &
Trucker (2014).
The authors of this work deduce that the establishment of an FMS based on the ISO
41001 standard can favor the following objectives for any Colombian HI: demonstrate
the contribution of the efficiency and effectiveness of FM activities to organizational
objectives, be coherent in the definition of the requirements and needs of the parties
interested in the FM, being sustainable in a competitive environment, and organizing
FM activities according to the clauses of the HLS of a FMS. However, it has been noted
that the corresponding FM activities in each clause of the HLS and in each PDCA cycle
presented in Figure 2 will be different for each of the Colombian HI. This is because the
functions of the FM, their grouping and their distribution are not organized in the same
way in any IH.
The ISO 41001 standard as a basis for SFM, from the point of view of Escorcia et al.
(2018) for MS, encourages the use of adopted methods based on the PDCA approach
to develop a regulation integration model. This establishes clear guidelines and drives
objectives to promote and maintain continuous improvement in both core and
supporting organizational processes. Therefore, the authors of this work understand
that an FMS can: be integrated with the quality standards of health services to
strengthen its results, reduce time, reduce human effort, and optimize both its technical
and economic resources in HI, as proposed by López-Fresno (2010).
Manuel Madroñal-Ortiz, Diego Cuartas-Ramírez, Nelson Javier Escobar-Mora, Marisol Osorio
Espirales. Revista multidisciplinaria de investigación científica, Vol. 8, No. 48
January - March 2024. e-ISSN 2550-6862. pp 59-78
75
In any case, this work has been to show that the use of an FMS, based on the ISO 41001
standard, can be compatible with the achievement of the requirements linked to FM
activities and different accreditations (SUH, SUA & JCI). The choice to aspire to non-
mandatory accreditations for the quality of health services, whether national or
international, will depend on each HI and the adaptation of the accreditations to the
context and needs of each country. However, this work proposes a new line of research
on the integration of the groups of standards linked to the FM of the regulatory
convergence chosen through an FMS to take advantage of the advantages, mentioned
by Ballesty & Mitchell (2020).
Conclusions
The authors of this work have analyzed the correlation of the regulatory convergence
(Figure 1) of the three accreditations (SUH, SUA & JCI) for Colombian HI in each clause
of the HLS of the FMS based on the ISO 41001 standard, and its impact on the different
levels of business management (Figure 2), concluding the following findings:
- The requirements of the SUH standards groups aligned to FM activities mainly
impact the “Context of the Organization” criterion and can generate an
improvement at a transformational level for the HI.
- The requirements of the SUA standards groups aligned to FM activities impact
almost all FMS clauses and can generate improvements at the four management
levels presented but will be more significant at operational and tactical levels.
- The requirements of the JCI standards groups aligned to FM activities impact
almost all FM clauses and, analogously to the SUA, can generate improvements
in the four management levels presented, but will be more significant at tactical
and strategic levels.
This shows that the joint use of the three accreditations (SUH, SUA and JCI) covers the
entire spectrum of business management levels for a Colombian HI.
The benefits of this mapping, according to the authors of this work, are focused on the
identification of the impact of the regulatory convergence standards groups (SUH, SUA
& JCI), which are associated with FM activities, and this leads to relating these standards
with the PDCA approach (continuous improvement cycles) for the development of an
FMS in a Colombian HI. Furthermore, this study can lead to the development of a
hospital infrastructure management model, in which not only the MS according to ISO
are taken into consideration, but also the requirements of the health quality standards
of regulatory convergence are considered: the requirements of the ISO 41001 standard,
the macroprocesses of FM activities and the evidence of the FMS to form an integrated
FM system.
The usefulness of the findings of this work could be, on the one hand, to carry out future
consultations with experts on the detailed qualitative analysis of each of the standards
to validate it in a more objective way. On the other hand, the development of future
work focused on each of the continuous improvement cycles of the FMS with the groups
Mapping of quality standards of health services in a Facility Management System for Colombian hospitals
Espirales. Revista multidisciplinaria de investigación científica, Vol. 8, No. 48
January - March 2024. e-ISSN 2550-6862. pp 59-78
76
of standards corresponding to each accreditation. Finally, the determination of the
competencies between the different departments associated with the fulfillment of the
FM objectives and the requirements of the standards aligned with the organizational
objectives in the HI within the FMS.
..........................................................................................................
References
Ballesty S., & Mitchell S. (2020). Facilities
Management, Coronavirus and The Value of
ISO 41001. TC 267 News.
Chotipanich S. (2004). Positioning facility
management. Facilities. Vol. 22 No. 13/14:
364-72. 10.1108/02632770410563086
Dulzaides Iglesias, M. E., & Molina Gómez, A. M.
(2004). Análisis documental y de información:
dos componentes de un mismo
proceso. Acimed, 12(2), 1-1.
Escorcia Y.C., Valencia Ochoa G.E., & Acevedo
C.H. (2018). A systematic procedure to
combine the integral management systems in
a services sector company. Chemical
Engineering Transactions. Vol 67: 373-78.
10.3303/CET1867063
Ford, K., & Tucker, K. (2014). The Leadership
Triangle: The Three Options That Will Make
You a Stronger Leader. Morgan James
Publishing.
García M., Quispe C., & Ráez L. (2003). Mejora
continua de la calidad en los
procesos. Industrial data. 2003; 6(1): 89-94.
Avaible in:
https://www.redalyc.org/pdf/816/81606112.
pdf
Gonzalez-Mendoza, J. A., & Fonseca-Vigoya, M. D.
S. (2016). Cadena de Valor Turismo de Salud
del Área Metropolitana de Cúcuta.
Respuestas, 21(1), 28-44.
10.22463/0122820X.632
Manuel Madroñal-Ortiz, Diego Cuartas-Ramírez, Nelson Javier Escobar-Mora, Marisol Osorio
Espirales. Revista multidisciplinaria de investigación científica, Vol. 8, No. 48
January - March 2024. e-ISSN 2550-6862. pp 59-78
77
Hernández, H. & Tobón, S. (2016). Análisis
documental del proceso de inclusión en la
educación. Ra Ximhai, 12(6), 399-420.
Avaible in: https://goo.gl/82kGoW
JCI (2017) The Joint Commission International
Accreditation Standards for Hospitals, 6th
Edition, English version, PDF book. Oak
Brook: Joint Commission International.
López-Fresno P. (2010). Implementation of an
Integrated Management System in an Airline:
A Case Study. The TQM Journal. 22(6): 629–
47. 10.1108/17542731011085311
Medina Ruiz L.Z., Rosas Mosquera Y., & Castro
Bejarano J.A. (2013). Sistema obligatorio de
garantía de calidad de la atención de salud
(SOGCS) en su componente “Sistema Único
de Acreditación” en Colombia, comparación
con el modelo chileno. (Bachelor Thesis,
Universidad Nacional de Colombia).
MinSalud (2002). Sistema Obligatorio de Garantía
de Calidad de la Atención de Salud del
Sistema General de Seguridad Social en
Salud. Resolución 2309 de 2002 del
Ministerio de Salud de Colombia (17 octubre
2002)
MinSalud (2014). Sistema Único de Acreditación en
Salud. Resolución 903 de 2014 del Ministerio
de Salud y Protección Social de Colombia (13
mayo 2014)
MinSalud (2014a). Sistema Único de Acreditación
en Salud. Resolución 2082 de 2014 del
Ministerio de Salud y Protección Social de
Colombia (29 mayo 2014)
MinSalud (2016). Sistema Obligatorio de Garantía
de la Calidad en Salud. Decreto 780 de 2016
del Ministerio de Salud y Protección Social de
Colombia (6 mayo 2016).
MinSalud (2018). Manual de Acreditación en Salud
Ambulatorio y Hospitalario de Colombia
versión 3.1. Resolución 5095 de 2018 del
Mapping of quality standards of health services in a Facility Management System for Colombian hospitals
Espirales. Revista multidisciplinaria de investigación científica, Vol. 8, No. 48
January - March 2024. e-ISSN 2550-6862. pp 59-78
78
Ministerio de Salud y Protección Social de
Colombia (19 noviembre 2018)
MinSalud (2019). Manual de Inscripción de
Prestadores y Habilitación de Servicios de
Salud. Resolución 3100 de 2019 del
Ministerio de Salud y Protección Social de
Colombia (25 noviembre 2019)
Price I. (2003). Business critical FM. Facilities. Vol.
22 No. 13/14: 353-58.
10.1108/02632770410563068
Salazar Flórez, K.J. (2015). Contribución
metodológica para la evaluación de la
tecnología biomédica en la Clínica
Universitaria Bolivariana con fines de
Acreditación según los estándares de la Joint
Commission International. (Master Thesis,
Universidad Nacional de Colombia). Avaible
in:
https://repositorio.unal.edu.co/bitstream/ha
ndle/unal/56130/32298430.2015.pdf?seque
nce=1&isAllowed=y
Smith, R., Martínez Álvarez, M., & Chanda, R.
(2011). Medical tourism: A review of the
literature and analysis of a role for bilateral
trade. Health Policy, 103(2-3), 276–282.
10.1016/j.healthpol.2011.06.009
UNE (2015). UNE-EN ISO 9001:2015. Sistema de
gestión de la calidad - Requisitos. Madrid:
Asociación Española de Normalización
(UNE).
UNE (2018). UNE-EN ISO 41001:2018. Gestión de
Inmuebles y servicios de soporte – Sistemas
de Gestión – Requisitos con orientación para
uso. Madrid: Asociación Española de
Normalización (UNE).