Quality Management

Date Issued Date of Renewal Effective From Valid Till

and Patient Safety
Department
QMS-P-QM-SS00 01 January 2018 22 March 2021 30 March 2021 25 March 2024

Policy Title Scope of Services DPP Rev. No. 1

1. STATEMENT OF PURPOSE

1.1 To provide a description of the Quality Management and Patient Safety scope of
service.

2. SCOPE

2.1 Applies to Quality Management and Patient Safety department staffs.

3. DEFINITIONS

3.1 Scope of Service: is a document which states the main services provided by an
individual or department. It clarifies the number, type and intensity or complexity
of services being provided.

4. POLICIES

4.1 It is a policy of the hospital to have a clearly defined Scope of Service for the
Quality Management and Patient Safety Department.

5. PROCEDURES

5.1 Functions, Activities and Service Provided

5.1.1 Develop and implement “Quality and Patient Safety Plan” within the
hospital.
5.1.2 Ensure consistency of hospital main set of documents such as
organizational structure, hospital-wide scope of services, committee’s term
of reference, etc.
5.1.3 Examining structure, process and outcomes in each department, identify
gaps and recommend actions to improve the system.
5.1.4 Consultation to departments on all aspects of Quality Management and
Patient Safety, continuous quality monitoring and improvement, risk
management, performance improvement and utilization management.
5.1.5 Consultation to departments in the development of departmental QI
programs.
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Policy and Procedures
 Quality Management
Date Issued Date of Renewal Effective From Valid Till
and Patient Safety
Department
QMS-P-QM-SS00 01 January 2018 22 March 2021 30 March 2021 25 March 2024

Policy Title Scope of Services DPP Rev. No. 1

5.1.6 Developing standards that aid department heads in monitoring,

evaluating and directing the development of hospital and
departmental policies, procedures and performance indicators.

5.1.3 Collating and monitoring hospital quality benchmarks.

5.1.4 Monitoring and evaluating employee incidents reports and
occurrence variance reports (OVR) and any other Clinical Adverse
Outcomes.
5.1.5 Coordinating monthly committee meetings and evaluating hospital
committees’ functions.
5.1.6 Maintains hospital archives for policies, procedures, committee
minutes, and information/data related to quality of care and risk
management activities.
5.1.7 Coordinate hospital-wide National and International Standards
compliance. Support Departments as needed in meeting standards
compliance.
5.1.8 Maintain performance measurement databases and generate
reports as requested.
5.1.9 Investigate and conduct focused studies as requested, and any
intensive reviews that may surface.
5.1.10 Monitoring high risk, high volume and problem prone procedures.
5.1.11 Provide educational activities for staff on quality principles.
5.1.12 Population Served
5.1.13 Internal Customers: All hospital staffs
5.1.14 External Customers: External auditors for healthcare quality

6. RESPONSIBILITIES

6.1 Director of Quality Management and Patient Safety is responsible for:

6.1.1 The effectiveness of implementation of this services.
6.2 Quality Management and Patient Safety Staff: To provide the mentioned services
to the hospital.

7. REFERENCES

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Policy and Procedures
 Quality Management
Date Issued Date of Renewal Effective From Valid Till
and Patient Safety
Department
QMS-P-QM-SS00 01 January 2018 22 March 2021 30 March 2021 25 March 2024

Policy Title Scope of Services DPP Rev. No. 1

7.1 ISO 9001 (1994). Quality systems - Model for quality assurance in design,
development, production, installation and servicing

7.2 Chartered Quality Institute, 2016, Total quality management (online), available:
[http://www.thecqi.org/Knowledge,Hub/Resources/Fact sheets/ Total-quality-
management/]

8. FORMS/MATERIALS AND EQUIPMENTS

9. REVISION

9.1 Will be reviewed every 3 years according to QMS-P-QM-DM13 and to be revised

as needed.

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Policy and Procedures
 Quality Management
Date Issued Date of Renewal Effective From Valid Till
and Patient Safety
Department
QMS-P-QM-SS00 01 January 2018 22 March 2021 30 March 2021 25 March 2024

Policy Title Scope of Services DPP Rev. No. 1

APPROVAL:
Prepared and reviewed by:

Acting Director of Quality, Risk

Management & Patient Safety
Signature Date

Reviewed by:
(Involved)

Medical Director

Signature Date

Director of Planning and Development

Signature Date

Approved by:
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Policy and Procedures
 Quality Management
Date Issued Date of Renewal Effective From Valid Till
and Patient Safety
Department
QMS-P-QM-SS00 01 January 2018 22 March 2021 30 March 2021 25 March 2024

Policy Title Scope of Services DPP Rev. No. 1

Chief Executive Officer

Signature Date

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Policy and Procedures