OUR DEFINITION OF QUALITY
Quality is care that is accessible, safe, effective, patient-centred, timely, efficient, equitable, appropriate and efficient
ROYAL HOSPITAL QUALITY MANAGEMENT POLICY
We, at the Royal Hospital shall provide quality care which is integrated with the Royal Hospital mission statement. We are committed to ensure care that is accessible, safe, effective, efficient, timely and appropriate. We strive to meet the needs and expectations of our patients, their families and others whom we serve. We consider that quality and safe care are our top priority and therefore we strive to eliminate unsafe practice by:
THE VISION
Our vision is to achieve excellence in everything we do; and thereafter , be recognised as the hospital that provides the best care in the region; the care that is the best to every patient that comes to the Royal Hospital, every time.
WHAT WE VALUE
We value our Patients first: We achieve this
Quality is care that is accessible, safe, effective, patient-centred, timely, efficient, equitable, appropriate and efficient
ROYAL HOSPITAL QUALITY MANAGEMENT POLICY
We, at the Royal Hospital shall provide quality care which is integrated with the Royal Hospital mission statement. We are committed to ensure care that is accessible, safe, effective, efficient, timely and appropriate. We strive to meet the needs and expectations of our patients, their families and others whom we serve. We consider that quality and safe care are our top priority and therefore we strive to eliminate unsafe practice by:
- Providing an environment that is clean;
- Conforming with safety regulations and legislation;
- Fostering professionalism;
- Ongoing Quality Improvement training program that empowers our staff, patients and their family;
- Involving outpatients and their families in decision making about their treatment in order to achieve care that is acceptable to our culture, with minimum cost possible, without compromising the quality of service we provide;
- Exercising a system of sharing knowledge and responsibilities with the key aim of continuously improving our system and processes based on measureable objectives.
THE VISION
Our vision is to achieve excellence in everything we do; and thereafter , be recognised as the hospital that provides the best care in the region; the care that is the best to every patient that comes to the Royal Hospital, every time.
WHAT WE VALUE
We value our Patients first: We achieve this
- By putting their health at the centre of everything we do and we achieve this by listening to their needs;
- By involving them in their treatment;
- By providing them with information they need regarding their conditions;
- By treating every patient as an individual with different needs and expectations;
- By respecting their privacy.
- Motivating and empowering them;
- Encouraging them to work in teams to achieve a common goal;
- Involving them in planning and improving care in their individual departments;
- We acknowledge the work when done when by our staff;
- We focus on their development.
Our beliefs: We believe we are all responsible for Quality.
OUR DEPARTMENT'S PURPOSE
The Quality Department has been established to provide a means of measuring and assessing specific processes of patient care, assisting departments/healthcare providers in the improvement of organizational performance and patient outcomes. In a planned and systematic way, it includes quality control, quality assessment, risk management and process redesign/review
OUR DEPARTMENT'S PURPOSE
The Quality Department has been established to provide a means of measuring and assessing specific processes of patient care, assisting departments/healthcare providers in the improvement of organizational performance and patient outcomes. In a planned and systematic way, it includes quality control, quality assessment, risk management and process redesign/review
Our Strategic Objective is to drive up quality by focusing on 4 Areas:
| Patient/Family Focus | Healthcare Professionals | Continuous Improvement and Learning | Focus on Results |
| We strive to meet their needs | We provide staff with Information | Support continuous Improvement | Use Performance measures |
| Understanding their preferences | Opportunity necessary to continue | System/Process Improvement | Focus on key hospital results |
| Meet their satisfaction | Strategic Goals |
QUALITY MANAGEMENT FUNCTION
We perform 4 main functions:
Risk Management
Performance Improvement
Clinical Auditing
Training and Development
Risk Management
Investigating and reporting incidence on a daily basis
Monitoring of adverse events including
Unusual occurrence
Sentinel events
Near miss
Root cause analysis
Corrective action
Performance Improvement
Feedback on patient and staff surveys
Management of patients complaints
Monitor key performance indicators
Drive and support implementation of quality improvements
Quality department also monitors and assesses the performance and produces data and report on performance, measuring against set indicators.
Liaison with other departments and staff throughout the hospital to ensure that the QA system is functioning properly. Where appropriate, the quality manager advises on changes and their implementation and provides training, tools and techniques to enable others to achieve quality
Coordinate Internal Clinical Audits
Clinical Audit Committee( Report to the Director General)
Morbidity and mortality audits
Quality Training and Education
All staff are given the opportunity to participate in QI Plan
To fully accomplish this, all staff are provided with QI education and training
This education includes a description of the QI Plan and how they fit into their particular job responsibilities.
It will also include education regarding the QI methodology.
POLICIES AND PROCEDURES
Performance Improvement
Clinical Auditing
Training and Development
Risk Management
Investigating and reporting incidence on a daily basis
Monitoring of adverse events including
Unusual occurrence
Sentinel events
Near miss
Root cause analysis
Corrective action
Performance Improvement
Feedback on patient and staff surveys
Management of patients complaints
Monitor key performance indicators
Drive and support implementation of quality improvements
Quality department also monitors and assesses the performance and produces data and report on performance, measuring against set indicators.
Liaison with other departments and staff throughout the hospital to ensure that the QA system is functioning properly. Where appropriate, the quality manager advises on changes and their implementation and provides training, tools and techniques to enable others to achieve quality
Coordinate Internal Clinical Audits
Clinical Audit Committee( Report to the Director General)
Morbidity and mortality audits
Quality Training and Education
All staff are given the opportunity to participate in QI Plan
To fully accomplish this, all staff are provided with QI education and training
This education includes a description of the QI Plan and how they fit into their particular job responsibilities.
It will also include education regarding the QI methodology.
POLICIES AND PROCEDURES
- Reporting of adverse events
- Reporting sentinel events
- Root Cause Analysis
- Quality Council
- Quality & Leadership Rounds
- Staff / Team of the year Guidelines
- Complaint guidelines
- Quality Improvement guidelines
- Morbidity and Mortality
- Clinical Audit
ABOUT US
Quality Council Committee
Chaired by the Director General of the Royal Hospital
The Quality Council is the main decision-making body and compromises of the Clinical Directors and certain heads of departments. The committee meets 3 times a year to monitor network progress, agree on service development and to set objectives.
Quality Management Department
The Department has 5 staff:
Head, Quality Department: Mrs. Leila Al Battashi
Risk Manager: Mrs. Zeyana Al Harthy
Clinical Auditor Coordinator: Mrs. Jihad Al Buriki
Health Information Supervisor: Mr. Bader Ali Saif Al Abri
Medical Coordinator: Ms. Abeer Said Humaid
The department reports to the Deputy Director General (Medical) and coordinator of Quality Council Activities. It:
Supports the Quality Council to achieve its strategic quality goals and objectives;
Supports existing professional quality improvement groups;
Ensures the Quality Improvement team leaders fulfil their obligations.
Quality Improvement Team Leaders
QITL is a clinical network which is formed across all disciplines to support quality improvement initiatives. It includes Clinicians, Nurses, Pharmacists, Laboratory staff, and staff from Radiology, IT and Medical records. The team leaders work closely with their respective heads of departments and sections.
