Definition of Quality:
Doing right things right, first time and every time.

Quality: is not what the supplier puts in, it is what the customer gets out, and is willing to pay for".

And in any setup, this can be accomplished by setting the standards, by implementing approved Policies and Procedures (departmental and hospital-wide), and all other applicable Protocols (and manuals). Continuous improvement is key to success.

"Good, Better, Best, Never let it Rest, Go for better until it is best"

TOTAL:
Applying Quality concepts covering everything within the organization (involving entire organization) i.e. 100% whatever we are managing within the organization and not less than that. Covering all the processes, procedures, internal and external customers i.e. entire system.

&

Management:
The system of managing with steps like Plan, Organize, Control, Policies/ Procedures, Lead, Staff, Teamwork, Communication.

Pillars/ Fundamentals of Quality:
	Customer Focused
	Total Involvement
	Measurement (i.e. no measurement, no improvement, thus no quality)
	Process Focus (i.e. 85% of the problems arise from the inadequate processes and not from the individual errors)
	Systems Approach (i.e. Unity of purpose)
	Continuous Improvement (i.e. like a spiral but not like a circle)

Ummal Qura General Hospital is committed to implement a Total Quality Management Program of Central Board of Accreditation for Healthcare Institutions (CBAHI), a Saudi National Accreditation Program.

The CBAHI is working to establish and pursue the application of the Quality Standards in all the health sectors all over the regions of the Kingdom to improve the health service provided & to meet the International Patient Safety Goals.

Top Management of Ummal Qura General Hospital is supporting its Quality Management Program by:

	Providing adequate resources to gain effective implementation.
	Following the objectives & plans for customer satisfaction and continuous improvement.
	Control of Occurrence Variance cases including the sentinel events and taking the suitable/ timely corrective actions to eliminate their root causes.

The hospital-wide Quality and Patient Safety program is established by the Hospital Executive Committee, the TQM Dept, with the support and approval from the Governing Body.

"The hospital has chosen Total Quality Management (TQM) as its management approach."

The hospital is managing its Total Quality systems through multi-disciplinary committees' members and in cooperation with all heads of departments/ units.

HOSPITAL-WIDE MULTI-DISCIPLINARY COMMITTEES' CHART

Our concept in TQM is that the quality is the responsibility of every personnel in the hospital and every one should take part and play his role in the quality system. Each department in the hospital is responsible for the implementation & management of the quality system.

We aim to minimize errors, prevent before their occurrences (pro-active approach), avoid their recurrences & conducting their root cause analysis. We have Quality Improvement (Q.I.) Teams undertaking & conducting different Q.I. projects from time to time for continuous improvements using FOCUS-PDCA Methodology and different Q.I. Tools.

The top management with the Quality Committee members is responsible for the overall TQM program implementation, supporting the departments in addition to monitoring, evaluation and improvement of the system.

Continuous monitoring is being carried out through regular data collection, analysis, trending and these periodic reports thus serve as the basis for decision making purposes, by the different Committees/ Leadership group, for further improvements.

DIFFERENT DATA ANALYSIS & TRENDING REPORTS/ CHARTS:

By involving everyone in our implementation phase of TQM and focusing upon the main stakeholders (i.e. internal and external customers) the hospital can be:

"A place where customers seek to receive the best services and employees feel proud to work".

Hospital Staff Levels according to their Responsibilities in the Implementation Process:
	The Governing Body (Board of Owners).
	The Hospital Executive Committee.
	The Medical Council.
	The Medical & Nursing Staff.
	TQM Team and different Q.I. Teams.
	Head of the Departments/Units.
	Departmental Quality Improvement Representatives/ Co-ordinators.
	Every Staff Member of the Hospital.

Standards are Implemented and Maintained in our Hospital through:
	Committees Meetings (Departmental, Hospital-wide and Ad-hoc on Regular Basis)
	Workshops/ Lectures (External & Internal)
	Rounds/ Visits (Observations, Interviews, Random Sampling of Medical Record & Personnel Files, Documents Review i.e. Manuals checking for their regular updation & implementation).
	Discussions/ Brainstorming (on different current issues).
	Periodic Competency Evaluations/ Assessments.
	Data Collection/ Analysis, Trending, Benchmarking etc. (Periodic Basis)
	Defining the Key Performance Indicators (KPIs), monitoring those areas in the light of those indicators, and thus making Decisions accordingly.

Educational Activities about Quality Concepts and Risk Management & Patient Safety Provided To Hospital Staff:
	Orientation Programs (Hospital wide General Orientation and Departmental Programs)
	Hospital-wide Approved Educational Program/ Schedule
	Departmental Education Programs
	Hospital-wide Intranet Access providing Easy Access to all the useful material (i.e. all the latest/ updated useful material like: Lectures, Videos, e-Books, Hospital-wide applicable Policies/ Procedures, Illustrations, Information, Plans, Programs, Duty Schedules, downloadable e-Forms, Hospital approved Drugs' Formulary, PFE Material incl. brochures & handouts, Employees' Work Regulation Manual etc. is readily available to all the staff with single mouse click). All this material is continously being updated.
	Participation of staff in External Educational Activities like BCLS, ACLS, ATLS, NALS, PALS, NRP, and in other relevant courses/ programs.
	Conduction of different In house Courses/ Seminars.
	Internet Access with DSL connection.
	Trainings/ Demonstrations.
	Continuous Evaluations and Competency Tests.

Our CBAHI-TQM Program is being implemented in all the hospital areas like:
	Leadership
	Medical Staff and Provision of Care
	Nursing
	Quality Management and Patient Safety
	Patient and Family Education and Rights
	Anesthesia
	Intensive Care Unit (Adult, NICU, CCU)
	Operating Room
	Labour and Delivery
	Emergency Room
	Radiology
	Psychiatry
	Specialized Areas (Dietary, Social, Rehab.)
	Ambulatory Care and Dental Services
	Management of Information and Medical Records
	Infection Control
	Pharmacy
	Laboratory
	Facility Management and Safety (FMS)

Our Quality Program and Plan is intended to serve as a reference for the hospital staff in their quest for achieving the hospital mission of quality and safety.

Quality & Patient Safety Goals
The primary goals of the Quality and Patient Safety Program are to continuously and systematically Plan, Design, Measure, Assess And Improve the performance and prioritizing by focusing on Structures, Processes And Outcomes in order to improve healthcare outcomes and reduce and prevent medical / health care errors.

Our focus is to Collect and analyze data, evaluate care processes in order to reduce risk and initiate preventive actions especially with regards to the following International Patient Safety Goals:

	Goal-1:	Identify Patients Correctly
	Goal-2:	Improve Effective Communication
	Goal-3:	Improve the Safety of High-alert Medications
	Goal-4:	Eliminate Wrong-site, Wrong-patient, Wrong-procedure Surgery
	Goal-5:	Reduce the Risk of Patient Harm Resulting from Falls
	Goal-6:	Reduce the Risk of Health Care–acquired Infections

Quality & Patient Safety Vision:
The Vision of the Patient Safety program is to establish Ummal Qura General Hospital as a benchmark for excellence in Quality and Safety outcomes and practices in Makkah Region.

INFECTION CONTROL PROGRAM