Accreditation and quality improvement

Quality improvement and accreditation Office

This unit has started working on the sixth floor, west side, under the direct supervision of the hospital directorate.

In this unit, two parts of hospital accreditation and clinical governance work in order to improve the quality of providing clinical services and patient safety in line with the goals of the Ministry of Health.

Description of duties of quality improvement unit:

• Developing the hospital’s strategic plan under the guidance of the hospital’s executive management team.
• Determining and publishing the mission statement of the hospital at the level of different hospital units.
• Formulation of comprehensive hospital quality improvement program in clinical and non-clinical matters (management, financial affairs, medical services, nursing services, general and support services, paraclinical services).
• Coordination and integration of quality improvement activities in the hospital.
• Continuous monitoring of the quality improvement program, data, actions and management interventions through the analysis of indicators.
• Compilation of hospital systems and processes designed according to the principles of quality improvement.
• Compilation of specific, measurable, attainable and timely performance indicators for various hospital processes.
• Preparation of the annual report of the hospital’s quality improvement program.
• Developing an annual operational plan, promoting, coordinating and integrating quality improvement programs, promoting patient safety in line with the accreditation model.
• Approving and communicating policies and procedures received from different hospital units.
• Monitoring the process and implementation of the policy for dealing with suggestions, criticisms and complaints in the hospital.
• Coordinating the holding of hospital committees and monitoring the implementation of approvals.
• Communication and coordination in the implementation of clinical medicine guidelines at the level of different hospital units.
• Monitoring the patient care process from the moment of entering the hospital until the moment of discharge and following up on “patient satisfaction” from the hospital services.