Continuous Quality

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Continuous Quality

Continuous Quality

The Quality Improvement and Patient Safety Department is one of the fundamental pillars of the hospital. It operates through an integrated system based on continuous coordination and communication with all medical and administrative departments.

he department aims to ensure the delivery of safe, high-quality healthcare services, enhance patient experience, and improve operational efficiency by implementing structured programs for quality management and patient safety, performance monitoring, risk management, and standardization of practices in accordance with the latest national and international standards.

The department’s work is guided by a scientific approach based on performance measurement and data analysis, identification of gaps and improvement priorities, and implementation of sustainable improvement initiatives that support evidence-based decision-making and contribute to better clinical and operational outcomes.

Quality Department Mission

To continuously improve the quality and safety of healthcare services through a qualified and specialized team working in coordination with all hospital departments to oversee the implementation of quality systems, monitor performance, promote improvement opportunities, and sustain achieved results, ensuring patient satisfaction and exceeding their expectations.

Quality Department Vision

To be a leading reference at the national and regional levels in quality management and patient safety by adopting the latest global practices and applying best models and standards in healthcare.

Scope of the Quality Improvement Department

The Quality Improvement Department oversees a set of core functions that support institutional performance improvement and sustainable development, including:

1. Document Control and Management

Developing, managing, and updating policies, procedures, plans, and forms, and ensuring their preparation, review, and approval through a standardized system that promotes unified practices, compliance with standards, and operational efficiency.

2. Risk Management and Patient Safety

Implementing a comprehensive incident reporting, analysis, and follow-up system using Root Cause Analysis (RCA). This includes proactive identification and assessment of potential risks and the development of mitigation plans using Failure Mode and Effects Analysis (FMEA) to reduce risks, prevent recurrence, and promote a safe environment for patients and staff.

3. Performance Monitoring and Improvement Projects

Developing and monitoring clinical and administrative performance indicators aligned with quality priorities. Data are collected and analyzed regularly to identify trends and improvement opportunities. Improvement projects are implemented using structured methodologies such as FOCUS–PDCA, Lean, and Six Sigma, with ongoing monitoring to ensure effectiveness, sustainability, and data-driven decision-making.

4. Supporting the Quality of Medical and Nursing Services

Contributing to the development and improvement of medical and nursing policies and procedures, supporting staff training, and monitoring compliance with professional standards and quality indicators in collaboration with the Medical Directorate and Nursing Department.

5. Strengthening Governance through Hospital Committees

Ensuring committees conduct meetings in accordance with their Terms of Reference (TOR), overseeing proper documentation of activities, and following up on action plans and decisions to enhance committee effectiveness and support institutional governance.

6. Training and Promoting a Culture of Quality

Providing training and awareness programs in quality, patient safety, improvement tools, and risk management, in addition to supporting hospital readiness and maintaining continuous compliance with national and international accreditation requirements.

The hospital has obtained several accreditations and certifications that are regularly maintained and renewed, including:

  • International hospital accreditation from Joint Commission International (JCI).
  • National hospital accreditation from Health Care Accreditation Council (HCAC).
  • Institutional Excellence Award from King Abdullah II Center for Excellence.

Specialized accreditations:

  • Primary Stroke Center certification in collaboration with American Heart Association (AHA).
  • Breast Imaging Units accreditation from Health Care Accreditation Council (HCAC).
  • Baby-Friendly Hospital certification from Health Care Accreditation Council (HCAC).

Management system certifications according to International Organization for Standardization (ISO):

  • ISO 9001:2015 – Quality Management System.
  • ISO 14001 – Environmental Management System.
  • ISO 45001 – Occupational Health and Safety Management System.
  • ISO 22000 – Food Safety Management System.    
  

 

 

 

 



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