Introduction of quality improvement unit
Shams Medical Group Hospital Quality Improvement Unit
Head of Unit: Dr. Behzad Ashrafi Anesthesiologist
Experts: Rabab Admission Expert in Health Management – Zohreh Rezaei Expert in Health Management
Unit introduction:
The quality improvement unit of the hospital started working with the announcement of the hospital accreditation program by the relevant ministry in 1991. In addition to establishing and implementing quality improvement measures, this unit is also responsible for coordinating all accreditation activities in the hospital.
Description of duties and responsibilities:
- Develop and review the strategic plan of the hospital
- Coordinate with senior hospital managers regarding the development of policies and executive instructions and strategic goals
- Coordinating the organization’s statements, including visions, missions and values
- Guidance and coordination between units in the implementation of strategic goals and operational plans
- Participate in developing a program to improve the quality and safety of patients
- Having a pivotal role and team building to improve the quality of the hospital
- Determining patient safety and continuous quality improvement as strategic priorities of the hospital and monitoring its implementation in the form of an operational plan throughout the hospital
- Supervise the implementation of an appropriate action plan throughout the hospital to improve patient quality and safety and achieve the strategic goals of the hospital
- Supervise the determination and analysis of key indicators and perform corrective actions based on them in all wards and units of the hospital
- Supervise the performance of expert and executive affairs in evaluating the performance of existing organizational units in order to improve the systems, methods and processes used by them in accordance with the objectives, missions and tasks assigned
- Follow up to implement hospital affairs according to accreditation standards
- Regular managerial visits to promote patient safety culture, identify risks in the system and intervene to improve opportunities
- Identify, compile and document hospital processes
- Holding regular and at least monthly meetings of the executive management team and following up on its approvals