Introduction of quality improvement unit

Shams Hospital > Introduction of quality improvement unit

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:

  1. Develop and review the strategic plan of the hospital
  2. Coordinate with senior hospital managers regarding the development of policies and executive instructions and strategic goals
  3. Coordinating the organization’s statements, including visions, missions and values
  4. Guidance and coordination between units in the implementation of strategic goals and operational plans
  5. Participate in developing a program to improve the quality and safety of patients
  6. Having a pivotal role and team building to improve the quality of the hospital
  7. 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
  8. 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
  9. Supervise the determination and analysis of key indicators and perform corrective actions based on them in all wards and units of the hospital
  10. 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
  11. Follow up to implement hospital affairs according to accreditation standards
  12. Regular managerial visits to promote patient safety culture, identify risks in the system and intervene to improve opportunities
  13. Identify, compile and document hospital processes
  14. Holding regular and at least monthly meetings of the executive management team and following up on its approvals