Pharmacy Department Strategy Plan: Goals Objective Indicators

Pharmacy Department Strategy Plan
Goals Objective Indicators

1. Provide safe and Apply national and • Acquire accreditation from
effective international pharmacy CBAHI and JCI.
pharmaceutical practice standards (e.g.,
care practices. MOH, SFDA, CBAHI, JCI,
etc.)
Establish well-structured • Regular review of policies and
policies and procedures for procedure.
all pharmacy services (e.g., • Annual review for guidelines
administrative, and protocols.
operational, and clinical) • Hospital departments’
satisfaction.
Collaborate and • Drug allergies rate.
communicate effectively • Drug contraindication rate.
with other healthcare • Number of medication errors
professionals to deliver reported.
optimum and safe • Number of adverse events
medication use services. reported.
• Proportion of TPN regimens
and intravenous preparations
that have been
monitored/optimised by a
pharmacist.
Establish Antimicrobial • Infection-related mortality.
stewardship and infection • Antibiotic-related readmission
control programs. cases.
• Antibiogram trend.
• Clostridium difficile rates.
• Clinical success/cure rates.
• Cost of antibiotics/1000
patients’ days.
• Consumption of restricted
antimicrobials/1000 patients’
days.
• Defined daily dose of restricted
antimicrobials.
• IV to Oral switching rate.
Participate in the decision- • Proportion of medicine charts
making processes within reviewed by clinical
the multidisciplinary team pharmacists within 24 hours of
through providing clinical admission.
pharmacy services. • Clinical interventions by a
pharmacist that were accepted
by the physician.
• Ward meetings attended by
the clinical pharmacist.
• Number of patients receiving
comprehensive direct patient
care by a clinical pharmacist.
• Number of medication errors
reported.
• Anticoagulation monitoring.
• Pharmacokinetic monitoring.
• Duration of therapy and length
of stay.
• Number of reviews for
guidelines and protocols.
Promote and provide • Number of medication
continuity of care for reconciliation done at
patients’ medication admissions, discharges, and
management. transfers.
• Number of counselling done by
pharmacist at discharge
• Patient satisfaction
• Pharmacy monthly inspection
at patient care areas.
Promote and support • Availability of training and
acquiring certified education certifications for
pharmacists in specialized each specialized pharmacist.
areas (e.g., clinical
pharmacy, chemotherapy,
IV & TPN, drug
information, quality and
medication safety, etc.)
2. Enhance patient Provide electronic services • System failure incidents.
care services through HIS- pharmacy • Paperless forms.
through module. • Medication error reports.
optimizing • Time to dispense.
technology and Implement electronic • Medication error electronic
innovation. reporting system for reporting.
various reports related to • Adverse drug related electronic
quality and patient safety. reporting.
• Healthcare professionals’
satisfaction
Implementation of • Time to dispense.
pharmaceutical • Patient satisfaction.
technologies and facilitate • Inventory management.
automation of pharmacy • Number or medication error
services reported.
Integration of pharmacy • Integration of drug interactions.
module and clinical • Integration of drug reference and
decision support system dose range.
• Integration of drug allergy.
• Integration of lab results.
• Integration of pregnancy
status and lactation.
3. Advocate for Provide continuous • healthcare professionals’
evidence-based pharmaceutical training satisfaction
practice through programs and sessions for • Number of Lectures provided by
continuous all healthcare the pharmacy department.
medication professionals. • Number of attendees.
education
Create and build up-to- • Patient satisfaction.
date digital and print • healthcare professionals’
educational resources for satisfaction.
patients and health care • Number of printed educational
professionals. materials.
Answer all drug • Number of drug information

information questions from enquiries that have been answered
all healthcare by a pharmacist.
professionals. • healthcare professionals’
satisfaction
Participate in public health • Medication counselling sessions
education, disease done by pharmacists.
prevention and healthy • Patient satisfaction
lifestyle promotion. • Number of health promotion
events provided by the pharmacy
department.
4. Establish growth
a. . • Numbers of courses attended by
opportunities and Provide continuous pharmacy staff.
safe workplace professional training in • Pharmacy staff satisfaction
culture for various pharmaceutical
pharmacists and areas to enhance
technicians. medication services.
Provide incentives and • Employee of the month
rewards to encourage • Monthly incentives
excellence and improve • Annual increments
morale.
5. Ensure patients’ Maintain the inventories • Rate of drug availability.

satisfaction through and coordinate with • Availability of Emergency
providing high quality corporate logistic Medications.
services and department to insure the • Availability of Narcotic and
products. availability of medicines as Controlled Medications.
per hospital requirement. • Availability of antidotes.
• Zero Stock Incidents.
• Inventory Turnover.
• Floor Stock Inspections.
• Rate of expired drugs returned
from wards.
• Number of expired and out-of-
date drugs and devices.
Promote and support • Staff Workload.
acquiring adequate • Number of medication errors.
number of well-trained • Average Prescriptions Filled per
pharmacy staff to increase Day.
quality of services. • Total number of consults provided
for patients new to therapy.
• Total number of consults provided
for patients who are maintaining
therapy.
Improve client’s experience • Patient satisfaction
and overall satisfaction
through maintaining high
Standards of ethical
conduct and providing
patient-centred care.
6. Improve sales and Provide all required • Zero stock incidents

maintain a steady medications and • Regularly updated drug formulary
financial growth. pharmaceutical products • Patients and clients’ satisfaction.
that are prescribed by
physicians.
Provide Prestigious • Clients’ satisfaction survey.
services and improve • Number of clients’ counselling per
patient overall journey in month
retail pharmacy
Provide medications and • Cost effectiveness analysis
pharmaceutical products • Purchasing deals
with high quality and high
profit margin.
Minimize non-moving • Quantity and cost of non-moving
items, nearly expired items items
and expired items • Quantity and cost of nearly expired
items.
• Quantity and cost of expired items
Physiotherapy Strategy Plan
PESTEL Factor Details Impact Comments
Saudization Saudization of physiotherapy jobs in accordance

Political
with the directives and vision of the Positive

government
Varity of Services Initiating variety of services can help to attract a

wider range of patients Positive
Simplifying insurance company approvals will
Economical
Insurance play a huge role in patients continuing physical Positive

therapy
Determining suitable prices for services in line
Services price with the market and compared to the quality of Positive
the service provided
Advertisement Awareness and advertisement of hospital Positive

services and facilities.
Sports and athletes A large trend of youth to sports, which may Positive
Social
increase the chances of various sports injuries

Staff Motherhood Can affect workflow due to long and sudden Negative
leaves
Technological
HIS referral process Clear and easy HIS referral process will help the Positive
staff to serve the patient better and faster
Staff Communication WhatsApp group, Bravo Positive
Hydrotherapy Spaces Hydrotherapy space is small Negative
In 1st floor, Elevators problems and crowding

Environmental
Department Location will affect patient arrive Negative

Great location will serve and attract a large
Hospital Location group of patients Positive
Cold temperature can harm OA patients and

Department Temperature uncovered patients during treatment Negative
External Factors Rain, crowded public streets will make it
difficult for patient to reach the hospital. Negative
Documentation
Completed within 24hours Positive
MOH Licensing.
Achieving all requirements Positive
Legal
CBAHI Standards. To obtain CBAHI standards Positive
Explaining and taking patients consent before

Consent starting any medical procedure. Positive
Administration/ Department: Rehabilitation Operational Plan
Goal: Expansion of Medical Support Services
Objective: Initiate and Expand Medical Rehabilitation Services
TIMELINE RESPONSIBLE
ACTION PLANS KPI’s
FROM TO DEPARTMENT(S)
Medical Rehabilitation department

1. Establishing Physiotherapy services and department Q1-2023 Q3-2023 The new organizational Chart
Quality Department
Policy initiation and implementation
2. Initiate Occupational therapy Specialty service. (based No. of services covered

on infrastructure, availability, space, and service Q1-2024 Q4-2024 Medical Rehabilitation Dep.
demand) Availability of Place and the Equipment Needed
Service statistics
No. of services covered

3. Initiate Hydrotherapy service. (based on infrastructure,
Q2-2023 Q4-2023 Medical Rehabilitation Dep.
availability, space, and service demand) Availability of Place and the Equipment Needed
Service statistics
No. of services covered

4. Initiate Speech therapy Clinic (based on infrastructure,
availability, space, and service demand) Availability of Place and the Equipment Needed
Service statistics
Policy implementation
5. Establishing education clinic (Pre-operation, Pre-natal,
Post-natal) Service statistics
Objective: Promote the Role of Speech & Language Unit

1. Support the unit with the need of manpower based on HR No. of newly hired
Beg. Q1 - 2024 End of Q4 2024
demand Medical Rehabilitation Dep. Service statistics
Medical Rehabilitation
department No. of educational sessions
2. Provide educational sessions to related specialties
Beg. Q1 - 2024 End. Q4 - 2024
regarding the clinic scope of service
Speech & Language Unit
supervisor
No. of trained staff
3. Train staff members. Beg. Q1 - 2024 End of Q4 -2024 department
Objective: Increase patient satisfaction

1. Increase Patient Satisfaction by improving treatment
Beg. Q4-2023 End. Q4-2024 Head of Rehabilitation department Patient Satisfaction Survey (Press Ganey)
Quality
Goal: Ensure Appropriate and Adequate Staffing is Available to Patient Care
Objective: Implement, Develop, and Monitor Man Power Plan in Alignment with Service Demand
TIMELINE
ACTION PLANS RESPONSIBLE DEPARTMENT(S) KPI’s
FROM TO
1. Recruitment Physical therapists, Occupational

Medical Rehabilitation department No. of new employees
therapists and speech & language disorder therapists.
Beg. Q1-2024 End of Q4-2024
(based on infrastructure, availability, space, and
Human Resource
service demand)
Objective: Promote Continuous Education, Training And Research
1. Initiate monthly in-service training program for Medical Rehabilitation department No. of trained staff
Beg. Q1-2024 End of Q4-2024
staff as continues education.
No. of trained staff

2. Establishing a program for internship students Beg. Q3-2024 End of Q4-2024 Medical Rehabilitation department
3. Initiate training Program for inpatient and

NO. of Trained Staff
Critical care Staff on Early Mobility program. Beg. Q4-2023 End of Q4-2024
4. Continue to train other medical departments staff Medical Rehabilitation department

on proper body mechanics, transferring and No. of employee trained
lifting technique, and role of rehabilitation Medical Services
Beg. Q1-2024 End of Q4-2024
department in patient care (target: 3 workshops No. of workshops
per year) Medical Support services
No. of employee trained

5. Provide internal training to all the staff members
from the Staff Who received external Training Beg. Q1-2023 End of Q4-2024
Medical Rehabilitation department No. of workshops
Objective: Promote Continuous Education in Infection Control

1. Initiate Infection Control program and assigning staff No. of employee trained
Q1-2024 Q4-2024
for it.
Infection Control Representative
Objective: Promote Continuous Education And Training, And Research
Objective: Promote Continuous Education in Quality Control

1. Initiate Quality Control program and assigning staff
Q1-2024 Q4-2024 No. of employee trained
for it.
Quality Control Representative
Goal: Seeking Accreditation

Objective: Maintain CBAHI & MOH Accreditation Program
department in collaboration with
1. Follow up implementation of the new MOH
Beg. Q1-2023 End of Q4-2023
respective departments
Compliance rate on a quarterly base
accreditation and CBAHI program standards
Quality Dep.
Goal: Enhance Community Quality of Life

Objective: Promote staff Participations in Community
ACTION PLANS TIMELINE KPI’s
Comprehensive services are available to an inpatient or outpatient
RESPONSIBLE
FROM TO
DEPARTMENT(S)
1. Collaborate with Saudi Arabian universities and NO. of collaborations
Beg. Q1-2024 End of Q4-2024 department
medical institutes.
Department
2. Engage community and public events to increase NO. of community participations
Beg. Q1-2024 End of Q4-2024
public health awareness (target: 2 per year)
Executive administration
Goal: Promote continuous education and training

Objective: Implement, develop, and monitor Educational plan in alignment with Hospital Educational plan
1. Provide courses with/without CME hours targeting Medical Rehabilitation
NO. of courses
internal audience (1 course per year) based on the Beg. Q1-2023 End of Q4-2024 department
approved Education plan
Specialty Service
Is the process of diagnosis, evaluation, treating and directing a rehabilitation plan that provides the best possible outcomes for
persons of all ages with physical or cognitive impairment and disability, collaborating skills and activities with many other affiliated
Physiatrist/Consultant physical therapist (0)
medical and surgical specialties, as well as with rehabilitation teams.
Is the treatment of individuals who require intervention for physical dysfunction secondary to disease, injury, or congenital anomaly.
Physical therapy (5) The goal of the treatment is to restore previously physical function or improve current physical function. These treatments may
include active and passive modalities based on biochemical and neurophysiologic principles to attain the highest level of previous
physical function in the shortest period of time.
Is the treatment neuro musculoskeletal and psychological dysfunction through the use of specific tasks or goal-directed activities
designed to improve the functional performance of an individual. It involves cognitive, perceptual, safety and judgment evaluations
Occupational Therapy (0) and training to improve neuro musculoskeletal functions and activity of daily living (ADL), beside job analysis, job development,
and placement services, including assistance with employment and job accommodations.
Is the treatment of communication impairment and swallowing disorders. Speech therapy services facilitate the development and
Speech Therapy (0) maintenance of human communication and swallowing through assessment, diagnosis, and rehabilitation.
Evaluation for and fitting of custom splints, braces and devices which enhance function in weakened or dystonic/spastic limbs of
Orthotics (0) spine.
Provides a comprehensive approach to prosthetic management through working with the client and family to meet both medical and
prosthetic needs. The clinic uses the latest advancements in technology and strives to attain the highest level of functional ability and
Prosthetics (0)
individual goals of the client.
Is exercise performed in water. Aquatic therapy provides an ideal environment for rehabilitation when it is difficult for patient to
exercise on the ground because of recent surgery, illness or injury. It is especially helpful if he/she is experiencing pain, weakness,
Aquatic Therapy (0) muscle spasms, limited range of motion, decreased strength and limited weight bearing. Aquatic therapy requires no swimming ability,
and it is usually done in groups.
Rehabilitation Workflow
Assisting patients in developing and attaining realistic vocational goals. Vocational rehabilitation services shall be provided, as
necessary to an individual to assess his/her eligibility for services, to specifically determine what services are necessary to attain
Work-Related Injuries/ Vocational Therapy (0)
his/her vocational objectives, and to help him/her achieve his/her vocational objectives.
Athletic training evaluates and treats a wide variety of injuries, from a simple ankle sprain to reconstructive knee surgery to a torn
rotator cuff. The evaluation consists of examining a patient’s muscle performance, joint mobility, flexibility, posture, and movement
Sports Medicine (0)
control.
To educate the staff, patients and the general public (including children, adults, the elderly and people with disabilities and chronic
illnesses) about the concept and health promotion strategies that allows for their participation in learning rehabilitative skills to foster
Patient and Family Education (0)
continued optimum levels of functioning inside and outside of the hospital environment.
Working Hours
• Departmental Process:
• The purpose of Rehabilitative medicine is to treat disease, injury and disability by assessment, examination, and use of rehabilitative procedures, including, but not limited to,
• Comprehensive examination; by Doctor of Physical therapy and Physiatrist, to determine potential for rehabilitation.
• All rehabilitation services for inpatient and outpatient will depend on physicians/departments referrals.
• Diagnosis and treatment planning;
1. Plan of patient care (PPC): Development of short-term, long-term goals.
2. A synopsis of the treatment plan: Equipment recommended for use; Frequency and duration of treatment planned; rehabilitation suggestions for further care.
• Patient Treatment Progress;
1. Monitor the patient’s progress toward goals and objectives outlined in the treatment plan; the patient is reassessed on an ongoing basis.
2. Treatment plans are revised as necessary
• Discharge planning processes;
is a fundamental component of rehabilitation services, and as such, is initiated as soon as practicable in the patient’s course of treatment. There is written criteria for which rehabilitation services
personnel can assess the patient’s progress and readiness to end rehabilitation services.
• Patient education;
an educational plan is formulated with the patient which allows for their participation in learning rehabilitative skills which will foster continued optimum levels of functioning outside of the hospital
environment.
Tests and Measurements: All assessments are performed by a physiatrist who is licensed to practice in the kingdom. Assessments are based on referral, patient diagnosis and clinical presentation.
Evaluations may include, but are not limited to:
1. Physical performance, including muscle strength, joint range of emotion, muscle excursion, balance, mobility, sensation, coordination, and motor control.
2. Functional performance including bed mobility, transition between positions, transfers, function in the upright position, and gait.
3. Nature, location, and factors impacting the patient’s pain/pain perception.
4. Occupational performance including ability to perform physical tasks of job, endurance, pain tolerance, and cardiovascular function.
5. Activities of daily living, self-care, and maintenance, and personal.
6. Uses of mobility devices such as gait assist devices and wheelchairs.
7. Need for technological devices (including prosthetics/ orthotics) management.
8. Sensor motor performance, including muscle strength, range of motion, coordination and joint mobility, balance, sensation and perception.
9. Cognitive performance, including memory, sequencing, problem solving, concentration, and attention.
10. Psychosocial performance, including behavior management, social skills and communication skills.
11. Human development.
12. Work readiness.
MMUR Radiology Department
strategic Goals , operational
goals and KPI
DRAFT
Sarah Y. Farhood
Radiology Manager
Organizational Vision
What we want to be
Level
Mission
Why we exist
Values
What is important to us
Strategy
Our game plan (strategic Direction )
Departmental
Level Strategy Map
Translate the strategy to action (strategic goals)
Dashboard-level Scorecard
Measure and focus (General operational KPI)
Granular-level Detail
Measure and focus (detailed operational KPI)
Reference:
Mediclinic Al Murjan Hospital- Clinical Services Strategy report
THE process…
1# MMUR 2# MMUR 3# MMUR 4# Radiology 5# Radiology

detailed
strategy strategic Radiology operational Granular-level
Perspective directions strategic goals goals (KPI)
Departmental Level
1# Strategic perspectives
Finance: How will we
maintain a positive
margin?
Stakeholders: How Operations: How will

will we satisfy we implement best
stakeholders?
Vision and practices?
strategy
Learning &
growth: what is the
organization capacity
in learning & growth?
Safety and quality
2# Strategic Directions
It has to be linked to each strategy perspective and to MMUR Mission Quality Safety
Human Information
Organizational strategic focus Capital Capital
Financial Learning &

Financial growth
Learning &
Growth
Internal
Stakeholder
Process
Operational
Referring
Resource
physicians Clinical
Staff utilization
and their Performance and
staff productivity
Patient Enhance
Patients experience innovation
3# Radiology strategic goals
Each departmental strategic goal comes from an organizational –level strategic direction
• Compliance with CBAHI, MOH , NRRC

• Partnership and collaboration • Policy formulation & adaption
• Social responsibility • Incident Reporting
• sustainability • Staff safety orientation & training
• Improve project management • Quality control for equipment
&service
Organization Safety &
infrastructure quality
Learning &
growth
Human Information
Capital Capital
• Licensing and certification • Improve Data integrity

• Education access and use • Technology adoption and development
• Application and transfer of knowledge • Minimize technical Downtime
• Employee retention programs
3# Radiology strategic goals (cont’d )
• Increase Intradepartmental • Equipment utilization

success rate • Equipment productivity
• Increase department-wide success • Equipment staffing
rate • Staff productivity (technical & clinical)
• Improvement of Communication
with referring physician Clinical
Resource
utilization and
Performance
productivity
Internal
Process
Patient Enhance
experience innovation
• Outpatient experience improvement • Strengthen brand /reputation

• Outpatient access improvement • Enhance community and staff
• Inpatient service improvement engagement
• Develop effective system for idea
implementation
3# Radiology strategic goals (cont’d)
• Increase staff satisfaction rate • Achieve the highest level of Referring

physicians’ satisfaction
Referring • Improving the mental image
Stakeholder physicians
Staff and their
staff
Patients
• Improve patient satisfaction rate

• Improving the mental image
Vision Our vision is to be the partner of choice that people of Jeddah trust for all their healthcare needs
In an age where malpractice endangers our community's lives, we strive to establish a safe
atmosphere by prioritizing precautions, safety, and the welfare of our patients. We accomplish this
Mission through reducing medical mistakes, lowering readmission rates, and educating our patients on how
to live a healthy lifestyle.
Trusting & Patient Safety Performance Team
Values Client Centered
respectful Focused Driven Orientated
F1 F2
Financial Increasing the efficiency and Maximize and sustain financial
effectiveness of the budget returns
C1 C2 C3
Stakeholder Achieve the highest level of Increase staff satisfaction rate Improve the mental image
stakeholder satisfaction
P1 P2 P3 P4
Internal Improve clinical Enhance innovation
Improve patients Resources utilization and
process performance experience productivity
LG1 LG2 LG3 LG4

Learning & Improve Organization Invest and develop the Excel in term of Quality and Improve the Information
growth infrastructure Human capital safety of services capital
4&5# Radiology operational goals & KPI
Learning &
growth
strategic goals specific (Tactical) goals

specific
weight code Name of startegic goal weight code name of specific (Tactical) goals (Tactical) Type and name of the Key performance indicator (KPI)
goal number
LG1 Improve Organization infrastructure 1.25% LG1-1 Partnership and collaboration 61 increase the number and improve outcome of partnership & collab
LG1 Improve Organization infrastructure 1.25% LG1-2 social responsibility 62 improve social responsibility
5.00%
LG1 Improve Organization infrastructure 1.25% LG1-3 Sustainability 63 adapt sutsinability program
LG1 Improve Organization infrastructure 1.25% LG1-4 Improve project management 64 improve project management tools
LG2 Invest and develop the Human capital 1.25% LG2-1 licenisng and certification 65 maintain staff certifiactes and lisence
LG2 Invest and develop the Human capital 1.25% LG2-2 Education access and use 66 develp access for eduction for staff
5.00%
LG2 Invest and develop the Human capital 1.25% LG2-3 Aplication and transfer knowledge 67 maintain knowldege transfer amon the team
LG2 Invest and develop the Human capital 1.25% LG2-4 Employee retention programs 68 develop and maintain retention programs
LG3 Excel in term of Quality and safety of services 1.25% LG3-1 compliance with regualtion 69 compliance with CBAHI , MOH and NRRC
LG3 Excel in term of Quality and safety of services 1.25% LG3-2 compliance with regualtion 70 Policy formulation & adaption
LG3 Excel in term of Quality and safety of services 1.25% LG3-3 improve quality and safety measures 71 incident reporting
LG3 Excel in term of Quality and safety of services 1.25% LG3-4 improve quality and safety measures 72 staff safety & quality orientation & training
6.25% LG3 Excel in term of Quality and safety of services 1.25% LG3-5 improve quality and safety measures 73 Quality control for equipment &services
LG4 Improve the Information capital 1.25% LG4-1 improve data integraty 74 completeness, accuracy, consistency, timeliness and compliance of
LG4 Improve the Information capital 1.25% LG4-2 minimize technical downtime 75 Mean Time to Repair (MTTR)
LG4 Improve the Information capital 1.25% LG4-3 minimize technical downtime 76 Overall Equipment Effectiveness (OEE) .
LG4 Improve the Information capital 1.25% LG4-4 minimize technical downtime 77 Mean Time Between Failures , or MTBF
LG4 Improve the Information capital 1.25% LG4-5 technology adoption and development 78 Average time spent using a product/feature
LG4 Improve the Information capital 1.25% LG4-6 technology adoption and development 79 Adoption rate
8.75% LG4 Improve the Information capital 1.25% LG4-7 technology adoption and development 80 Cost-Benefit Analysis
specific (Tactical) goals
specific
weight code name of specific (Tactical) goals (Tactical) Type and name of the Key performance indicator (KPI)
goal number
4&5# 0.68%
0.68%
0.68%
P1-1
P1-2
P1-3
Increase Intradepartmental division success rates
24
25
26
Peer review of image interpretation by staff
Correlation of radiologic findings with pathological findings
Complication rate
0.68% P1-4 Increase Department-wide success rates 27 False-positive rates
Radiology 0.68%
0.68%
0.68%
0.68%
P1-5
P1-6
P1-7
P1-8
Increase Department-wide success rates
Communication with referring physicians
28
29
30
31
False-negative rates
Peer review agreement rate
Percentage of examinations with unnecessary recommendations
Audits of e-mail alerts sent to physicians
operational 0.68%
0.68%
0.68%
0.68%
P1-9
P1-10
P2-1
P2-2
Imporvement of Outpatient patients experience
Imporvement of Outpatient patients experience
32
33
34
35
Rate of compliance with standardized protocols
Rate of compliance with report quality standards
Ease of appointment registration and scheduling
measurement of waiting time from patient arrival to beginning of examination,
goals & KPI

0.68% P2-3 Imporvement of Outpatient patients experience 36 measurement of appointment delay from scheduled examination time to beginning of examination
0.68% P2-4 Imporvement of Outpatient patients experience 37 Helpfulness of front desk staff
0.68% P2-5 Imporvement of Outpatient patients experience 38 Waiting area comfort
0.68% P2-6 Imporvement of Outpatient patients experience 39 Cleanliness
0.68% P2-7 Imporvement of Outpatient patients experience 40 Minimize outpatient report turnaround time
0.68% P2-8 Imporvement of Outpatient patients experience 41 Patients receiving preappointment examination information and education
Internal 0.68% P2-9 Improve outpatient access 42 Ease of appointment registration and scheduling
Process 0.68% P2-10 Improve outpatient access 43 Appointment availability
0.68% P2-11 Imporove Inpatient service 44 Inpatient report turnaround time
0.68% P2-12 Imporove Inpatient service 45 Inpatient imaging turnaround time
0.68% P3-1 Equipment utilization and productivity 46 Equipment idle time
0.68% P3-2 Equipment utilization and productivity 47 Equipment utilization
0.68% P3-3 equipment-staff utilization and productivity 48 Equipment staffing level
0.68% P3-4 staff productivity 49 professional staff productivity
0.68% P3-5 staff productivity 50 technical staff productivity
0.68% P4-1 Strengthen brand /reputation 51 patients and physicians feedback
0.68% P4-2 Strengthen brand /reputation 52 Customer Lifetime Value
0.68% P4-3 Strengthen brand /reputation 53 Referrals
0.68% P4-4 Enhance community and staff engagmnet 54 social media visitors and subscripers
0.68% P4-5 Enhance community and staff engagmnet 55 Absenteeism
0.68% P4-6 Enhance community and staff engagmnet 56 number of social activity inside and outside of hospital
0.68% P4-7 Enhance community and staff engagmnet 57 Turnover Rate
0.68% P4-8 Develop effective system for idea implementation 58 number of successful achieved idea
0.68% P4-9 Develop effective system for idea implementation 59 Planned Hours Vs. Time Spent on new idea implentation
0.68% P4-10 Develop effective system for idea implementation 60 Number Of Cancelled Projects
4&5 # Radiology operational goals & KPI
Stakeholder
strategic goals specific (Tactical) goals

specific
weight code Name of startegic goal weight code name of specific (Tactical) goals (Tactical) Type and name of the Key performance indicator (KPI)
goal number
C1 Achieve the highest level of stakeholder satisfaction 1.92% C1-1 Referring site satisfaction ( inside and outside) 11 answering referring physicians quastions
C1 Achieve the highest level of stakeholder satisfaction 1.92% C1-2 Referring site satisfaction ( inside and outside) 12 minimize response time
C1 Achieve the highest level of stakeholder satisfaction 1.92% C1-3 Referring site satisfaction ( inside and outside) 13 availability of technology and modalities (comprehensive service )
C1 Achieve the highest level of stakeholder satisfaction 1.92% C1-4 Achieve the highest level of partners satsifaction (MMUR) 14 Signing and activating contracts and agreements with SCFHS
15.38%
C1 Achieve the highest level of stakeholder satisfaction 1.92% C1-5 Achieve the highest level of partners satsifaction (MMUR) 15 expand the radiology services coverage
C1 Achieve the highest level of stakeholder satisfaction 1.92% C1-6 Achieve the highest level of partners satsifaction (MMUR) 16 Diversify Radiology dpearmtnet sources of income
C1 Achieve the highest level of stakeholder satisfaction 1.92% C1-7 Achieve the highest level of patients satsifaction 17 minimize report turnaround time
C1 Achieve the highest level of stakeholder satisfaction 1.92% C1-8 Achieve the highest level of patients satsifaction 18 numeric rating of overall patient satisfaction rate
C2 Increase staff satisfaction rate 1.92% C2-1 Achieve the highest level of staff satsifaction 19 numeric rating of overall staff satisfaction rate
3.85%
C2 Increase staff satisfaction rate 1.92% C2-2 Achieve the highest level of staff satsifaction 20 activiation of compensation prgram
C3 Improve the mental image 1.92% C3-1 Achieve the highest level positive image 21 Increase the level of professionalism
5.77% C3 Improve the mental image 1.92% C3-2 Achieve the highest level positive image 22 participating in an educational event
C3 Improve the mental image 1.92% C3-3 Achieve the highest level positive image 23 Implement department marketing plan
THANK YOU
Respiratory Care Department
STRATEGIC PLAN
1: Cardiopulmonary Rehabilitation Center
GOAL ACTIONS
1. To Be the first Cardiopulmonary rehabilitation Center In the 1. Provide an exercise with a rehabilitation session for those who
Western Region. has cardio or respiratory issue.
2. Medical tourism program in collaboration with ministry of
2. Arranging the schedule for OPD and internal candidate
tourism
3. To be a reference for all health care facilities
3. Design program for different cases in collaboration with
multidisciplinary team.
2: Education and Training
GOAL ACTIONS
1. Provide and education for the healthcare members. 1. prepare an education program for healthcare worker specially
2. Provide training and competency for RT and medical student. critical area including the periodical competency
3. Provide a lecture with CMEs 2. Implement the department policy and procedure and make sure
the RT and other related department applying it in quality and
good way
3. prepare training and education program for the students
and internship.
4. Weekly lectures schedule (Mechanical ventilators, ABG, PFT,

SL, NICU, PICU… Etc) with CME hours for each.
3: Enhancing Public Awareness and Home Care Services
GOAL ACTIONS
1. Increase knowledge and awareness about the respiratory 1. prepare program and materials to be used in any events
therapy diseases and how to prevent it and live with it.
2. Educate the patient at home on hoe to use the devices, tools 2. participate with the related department or companies in public
and aware them about the diseases. 3. educate the RTs on how to educate and aware the patient at
home including effective materials ( brochures, menus.. Etc )
4: Comprehensive Respiratory Services in one place
GOAL ACTIONS
4. provide all the respiratory services under one department and 1. covering all services in different areas with applying high
to be reference for other healthcare sectors. standard and creative ideas
2. Create a good team and manpower ( RTs) to supply the market

with full experience.
5: OPERATIONAL EXCELLENCE
GOAL ACTIONS
5. Build and sustain an operational infrastructure that operates 1. Review business processes to ensure flexibility, efficiency,
effectively and efficiently to meet the mission of the Kingdom. security, and transparency.
2. Explore and integrate best practices of other regulators in best

quality.
3. Develop awareness and practices of diversity and inclusion
with council, committees, staff, and membership.
Page|i
Hospital Name: Mediclinic Al Murjan

INFECTION PREVENTION & CONTROL STRATEGIC PLAN
DATE: 02/02/2023
VERSION: 1
Infection Control Strategic Plan

Facility Name: Page|2
Table of Contents
OVERVIEW / INTRODUCTION................................................................................................... 3
What is Infection Prevention and Control? .............................................................................. 3
VISION .................................................................................................................................... 4
MISSION.................................................................................................................................. 4
Framework.............................................................................................................................. 4
PURPOSE ................................................................................................................................. 5
Risk-Based Approach/ Infection Control Risk Assessment ........................................................ 5
Priority Areas .......................................................................................................................... 6
Operational Action Plan .......................................................................................................... 7
Infection Prevention & Control Strategic Plan

OVERVIEW / INTRODUCTION
Healthcare-associated infections (HCAIs) are defined as infections that occur in association with, or
related to, the provision of health care. HAIs are often associated with increased morbidity and mortality,
contributing to approximately one-third of unexpected in-hospital deaths. HAIs have a significant impact
on health care spending as a result of prolonged hospital stay, readmissions, and increasing
consumption of costly resources. It remains an important patient safety and quality issue, representing
a significant adverse outcome of health care. It is estimated that up to 70% of HAIs are preventable.
HAIs in hospitals could be prevented if the essential components required for PCI programs were
implemented. A properly resourced and effectively functioning PCI program is essential to improving
patients and healthcare workers safety.
Mediclinic Al Murjan Hospital is committed to provide a quality health care services to our patients in a
safe environment and also to protect our staffs and visitors from unnecessary exposure to any kind of
infections, to achieve this goal a comprehensive IPC program has been established throughout the
facility and it will be monitored periodically by setting surveillance activities & key performance
indicators, and further reinforced by training and competencies , allocation of resources, revision of
policies and procedures ,patient and family educations, as well as various awareness programs etc.
What is Infection Prevention and Control?

Infection prevention and control or IPC is a term used to describe activities intended to protect
individuals from infections. Every day, Mediclinic Al Murjan prevent and control infections by frequently
cleaning their hands, keeping their living and working environments clean and tidy, getting immunized
for vaccine preventable diseases and by staying home when sick. In healthcare settings, IPC measures
are enhanced to protect more vulnerable populations from acquiring healthcare-associated infections.
These types of infections can increase hospital lengths of stay, cause patient health complications and
may even result in death.
The IPC world continues to change. There are new and emerging infectious diseases and an increase
in antibiotic resistant organisms. Mediclinic Al Murjan Hospital need to make changes to improve how
we protect ourselves, our families, our communities, and future generations from infections we may not
be able to treat.

VISION
Quality and safe healthcare delivery across Mediclinic Al Murjan Hospital and beyond by promoting a
safety culture among patients, employees, contract workers, volunteers, and visitors, as well as adopting
evidence-based best practice guidelines.
MISSION
Identifying and eliminating or minimizing the risks of infection transmission among patients, employees,
healthcare practitioners, contract workers, volunteers, students, and visitors at Mediclinic Al Murjan and
throughout the community.
Framework
Mediclinic Al Murjan has introduced a framework that takes into account quality, people and sustainability
to develop strategies for success. This Infection Prevention and Control strategy is linked to these building
blocks and the hospital strategic objectives as detailed below:
▪ Quality
o Reduce avoidable harm from preventable healthcare associated infections (HCAIs)
o Provide a clean and safe environment to improve patients’ experiences of the
healthcare journey.
o Provide evidence-based care.
o Board assurance framework - Care Quality Commission (CQC) compliance for quality
o To ensure that all care is rated amongst the top in Saudi Arabia/ Western
Region for patient safety, clinical outcomes, and patient experience.
▪ People
o Education of all employees to ensure a competent workforce.
o To have a committed, skilled and highly engaged workforce who feel valued, supported and
developed and who work together to care for our patients.
▪ Sustainability
o Compliance with legislation and regulation
o Getting Accreditation (national and International)
o Liaison with procurement to promote financial viability without compromising quality.
o To work with our partners to consolidate and develop sustainable, high-quality care, and zero
patient harm as part of a thriving health economy for the future.

PURPOSE
HCAIs pose a serious risk to patients, staff, and visitors. Infection prevention and control consequently is
a top priority at Al Murjan Hospital. Infection control at Mediclinic Al Murjan used a Risk-Based Approach
to establish a hospital-wide infection prevention and control strategy with the goal of reducing the risk of
healthcare-associated infection among patients, staff, and visitors.
The IPC Department and Committee members aspire to design and maintain a comprehensive infection
prevention and control program in accordance with the National Standard, such as the Saudi Central
Board of Accreditation for Healthcare Institutions (CBAHI), and International Accreditations and
recommendations (e.g., JCI, WHO, CDC), as well as Saudi Ministry of Health guidelines (MOH).
Risk-Based Approach/ Infection Control Risk Assessment

Almurjan Mediclinic Hospital Infection Prevention and Control Risk Assessment (ICRA) is an assessment
of internal and external hazards, risks and conditions that have the potential of serious impact on patient
and staff safety, business operations, the facility and / or the environment. By identifying infection risks
assists in planning, processes, procedures, and program development to address, eliminate or counteract
the effects of these risks.
The risk assessment process also includes detecting the potential risks or negative outcomes of an activity
or situation, assessing the magnitude of those risks, and deciding whether to accept, minimize, or avoid
such risks.
Almurjan Mediclinic Hospital created and implemented an assessment tool based on the IPC program
and activities, which are supported by CBAHI standards and the National Patient Safety Goals
requirements.
A scoring tool developed for the Disaster and Emergency Preparedness Risk Assessment was amended
to accommodate the requirements of the IPC program.
The system enables Almurjan Mediclinic Hospital to objectively review and identify the high-risk areas
that require action by assessing risks, rates, and trends, evaluating the outcome of actions taken over
time.
Fifteen major risk categories were identified representing Almurjan Mediclinic Hospital - specific
circumstances and operations and include the following, each with further sub-categories:
❖ Global Considerations
❖ Geographic Location
❖ Community Considerations
❖ Clinical Services
❖ Special Patient Populations
❖ High Risk patients
❖ Workforce Risks
❖ Medical Procedures
❖ Equipment & Devices
❖ Environment of Care
❖ Emergency Preparedness
❖ Resource Limitations
❖ Surveillance Data Findings
❖ Education & Communication
❖ Supplies and Equipment
Priority Areas
The Main Five priority areas are identified:
Goal: To increase the Goal: Reduce the risk of Goal: To Improve Goal: Proper
healthcare-associated Goal: To maintain monitoring and reporting
capacity to manage and implementation of
infections throughout the Occupational Health and of Hand Hygiene
prevent outbreaks and year for all patients, staff, antibiotic stewardship
Safety throughout the compliance rate to be
influxes of patients with and visitors. program to prevent
year. with 70% to 75%
emerging infectious antibiotic resistance by the
. throughout the year.
diseases. fourth quarter of 2024.

Operational Action Plan

The following sections outline the key priorities, goals, objectives, strategies and performance measures
as guidance over the next three years. Performance measures will be analyzed on a continual basis to
monitor progress with each priority area.
Objectives Strategies Performance Measures

Objective 1.1 1.1.1. Implement a new outbreak policy and create an
Enhance the ability to detect the emergency preparedness program/plan.
occurrence of an outbreak in a 1.1.2. Conduct internal and external drills to evaluate the
facility or community and take
emergency preparedness program.
immediate corrective action.
1.1.3. Create a rapid-response outbreak control team with
specific responsibilities for each member.
1.2.1. Continually raise staff awareness about

Objective 1.2 infectious/communicable diseases and how to take
Improve compliance in early proper measures by ongoing education and report
infection detection and any suspicious cases immediately.
prevention through following 1.2.2. Submit monthly reports on HAI surveillance data to
active surveillance. the IPC committee and the quality & patient safety
department.
1.2.3. Utilize a dedicated portable X-ray machine for all
emergency department patients with respiratory
disease.
Rate of positive patients= (No. of
1.1.4. Increase the personal protective equipment PAR
New Cases of Positive cases/ No.
level by 25% to avoid shortages.
of Swaps) *100
Objective 1.3 1.3.1. Ensure that the MERS-CoV, COVID-19, & Monkey
Early detection and preventing pox policies and respiratory guidelines are strictly
the spread of respiratory followed and implemented.
infections diseases (e.g., MERS- 1.3.2. Conduct internal and external drills to assess staff
CoV, COVID-19, & Monkey pox) compliance with the concerned respiratory policies
throughout the year. & producers.
1.3.3. Ensure the strict implementation of isolation
measures for all suspected and confirmed cases.
1.2.4. Provide patients and patient family with
educational materials on MERS-CoV, COVID-19,
hand hygiene, cough etiquette, and PPE.
1.2.5. Ensure a safe environment for patients, prevent
cross-contamination by thorough environmental
cleaning and disinfection with the use of approved
hospital disinfectants, and ensure enough
resources.


Objective 2.1 2.1.1. Develop a surveillance policy for HAIs with up-to-
Maintain the overall HAI rate among date surveillance forms.
patients at or below 0.05 by: 2.1.2. To begin obtaining pan cultures for every patient
❖ Maintain the CAUTI rate at or who is admitted from another facility or who is
below 0.05. suspected to have sepsis.
❖ Maintain the VAE rate at or 2.1.3. Continuously monitor the rate of HAIs, and if there
below 0.05. is any variation, Root Cause Analysis (RCA) should
❖ Maintain the CLABSI rate at or be conducted to discover the underlying causes.
below 0.05. 2.1.4. Monitor the rate & compliance of the care bundle
❖ Maintain the SSI rate for CS at or including CLABSI, VAP, CAUTI, SSI, & MDRO’s.
below 0.05. 2.1.5. Enhance the rate of Hand Hygiene (HH) compliance
❖ Maintain the MDRO rate at or through intensive training and workshops with a
below 0.05. close monitoring.
2.1.6. Identify and trace high-risk and high-volume
procedures that may lead to HAIs (e.g. CS,
endoscopy, orthopedic, etc.). ▪ Indicator to measure HCAIs= (# of
2.1.7. Organize an educational plan targeting staff, HCAI's/ # of Patient Days) * 100
patients, families, visitors, and trainees to improve Patients Days.
infection prevention and control behaviors such as
HH, cough etiquette, the necessity of flu
vaccination, and the proper use of PPE to reduce ▪ CAUTI Indicator= (# of CAUTI/ of
the risk of hospital-acquired infections. Catheter Days) * 1000 Cath. Days
▪ VAP Indicator= (# of VAP/ # of VAP
2.2.1. Provide patients and their family with a pamphlet Days) * 1000 Ventilator Days.
Objective 2.2
Reduce the prevalence of HAIs detailing the basic IPC precaution measures. ▪ CALBSI Indicator= (# of CLABSI
2.2.2. Encourage caregivers to educate patients, family, cases in a month/# Central Line
among patients, their families,
and visitors on hand hygiene, personal protective Days) * Rate Per 1000 device Days
employees, and trainees.
equipment, cough etiquette, and isolation ▪ SSI Indicator= (# of SSI/ No. of
precautions. Surgeries) *100 Surgeries
2.2.3. Distribute IPC educational posters to all
▪ MDROs Indicator= (# of MDROs/ #
departments and waiting areas.
of Patient Days) * 100 Patients Days.
Objective 2.3 2.3.1. Create a new policy for the Central Sterilization Services
❖ Apply Spaulding classification for Department (CSSD) based on the most recent national
reprocessing equipment, and international standards.
devices and instruments.
2.3.2. Utilize physical, chemical, and biological indicators to
assess the quality of the cleaning, disinfection, and
❖ Utilize the key components of
sterilizing processes.
equipment, devices and
2.3.3. Maintain the PAR level for disinfectants and CSSD
instruments reprocessing supplies (e.g., chemical, biological indicators, and plastic
(cleaning, disinfection and peel pouches, etc.) to avoid any shortages.
sterilization). 2.3.4. Improve the performance of CSSD staff through
continuous education/ training and competency
❖ Provide safe, functional and evaluation.
sterile instrument, devices and
2.3.5. Maintain all sterilizer machines maintenance record log
medical equipment.
book/record.
2.3.6. Maintain tracking system record for sterilized devices/
instruments that will be utilized by patients.

Objective 2.4
2.4.1. Conduct environmental rounds in all clinical areas on a
Establish a plan for IPC rounds and regular basis to ensure a safe and clean environment.
interventions. 2.4.2. Utilize the MOH-Core Component Checklist on a regular
basis to audit the department or unit and report any
deficiencies to the relevant parties.
2.4.3. Discuss the HAIs rate results with the staff to raise
awareness of IPC indicators.
2.4.4. Auditing services by the IPC team when critical issues
have been detected to take remedial action immediately.
2.4.5. Monitor Organizational performance in relation to
Infection Prevention and Control procedures for hand Hygiene,
isolation precautions, appropriate use of PPE, and
reprocessing of medical devices, and instruments.
2.4.6. In-service training will be provided throughout the IPC
round to promote staff knowledge and improve their practices.

Objective 3.1
3.1.1. Create an Employee Health Program (EHP) based
❖ Maintain zero incidence of
on current national and international guidelines and
BBFE/NSI.
standards.
❖ Enhance the reporting of staff
3.1.2. Introduce new evidence based BBFE/needle stick
exposed to communicable
formats for incident investigation.
diseases during the course of
3.1.3. Ensure that all employees comply with the EHP
the year.
aspects.
❖ Provide a safe working
3.1.4. Emphasize the necessity of screening and
environment and practices for
immunization programs to all HCWs in order to promote
HCWs.
vaccine compliance and reduce the risk of infection Blood & Body Fluid Exposure/Needle
transmission. Stick Injury Indicator= (# of BBFE/#of
3.1.5. Create a new card for every hospital staff that Patients Days) *1000 Patient Days
includes the vaccination status and N95 mask fit test.
3.1.6. Ensure leadership support by allocating enough
resources to occupational health programs for screening,
vaccination, and other biological hazards.
3.1.7. Reduce the occurrence of BBFE by thorough
training, audiovisual teaching, competence, and
experience sharing among HCWs.
3.1.8. Provide safety/engineered equipment to staff and
ensure appropriate use to prevent BBFE incidents.

Facility Name: P a g e | 10
Objective 4.1 4.1.1. Initiate a hand hygiene program and strategy to

Increase HH compliance in all raise the staff's hand hygiene knowledge and
departments/units to meet the target compliance.
of hand hygiene practice. 4.1.2. Monitor the consumption of HH supplies (Soap &
alcohol) on quarterly basis.
4.1.3. Create a competition for hand hygiene to award the
department with the highest hand hygiene
compliance.
4.1.4. Ensuring the availability, accessibility, and Hand Hygiene Indicator = (Total No. of
functionality of HH resources and supplies (e.g. key moments that occurred/Total No. of
hand washing sink, soap, water, disposable hand opportunities taken) *100%
towels and alcohol dispensers).
4.1.5. Implement a new computerized system for data
collecting and compliance analysis on hand
hygiene.
4.1.6. Ensure that the antibiogram is published timely and accessible

Objective 5.1 to health care providers.
❖ Reduce the prescription of 4.1.7. Empower nurses to identify when a culture may not be needed
empirical antibiotics by the end of (e.g. does the patient have an infection?) and how to approach
4th quarter. the ordering provider to discuss their concerns.
4.1.8. Apply a notification system to alert the ASP Team Leader or
❖ Enhance the physician other appropriate team member (e.g., ID, clinical pharmacist) for
prescription of therapeutic any unusual resistance patterns or organisms that are noted
during surveillance.
antibiotics by the end of 4th
4.1.9. Ensure that all antimicrobials are prescribed based on the result
quarter. of C/S and is fully monitored by the clinical pharmacist, IPC
department and microbiologist. It will be decided by AMR
❖ Improve the administration of 4.1.10. De-escalation of antibiotics should be considered after receiving Committee Team.
prophylactic Pre, during and post- the culture and sensitivity report whenever possible.
surgery and therapeutic antibiotics 4.1.11. Implement a new indicator for MDROs to improve the ability for
at the right time by the end of 4th continuous monitoring.
quarter. 4.1.12. Ensure the implementation of basic preventive measures,
including standard, isolation precautions, and hand hygiene,
which can reduce the spread of MDRO’s and C- diff pathogen .
4.1.13. Intensify the infection control measures in the reduction of C-
diff cases and other MDROs to achieve the health care
improvement, efficiency, access to treatment and treatment to
patients.

Facility Name: P a g e | 11

Nutrition & Dietetics Department
Strategic Plan
Balsam Zahhar
Nutrition & Dietetics Department Supervisor
Content:
Vision ………………………………………………………………………….………….….2
Mission ………………………………………………………………………………….……2
Values ………………………………………………………………………….………….….2
PESTEL analysis ……………………………………………………………….….…………3
Strategic goals and KPIs ……………………………………….……………….……….……5
Nutrition & Dietetic Department Service Phasing According to MMUR Strategy Plan……..6
The Staffing plan according to MMUR phasing plan…………………………………………7
Working Hours…………………………………………………...……………………………7
1
1. Vision:
Toward Clinical Nutrition and food service excellence
2. Mission:
Exceed our stakeholder’s expectation regarding nutritional services through
providing therapeutic nutrition, specialized food service, continuous education,
and learning.
3. Values:
 Commitment to Quality Service

 Accountability and Integrity
 Resource Maximization
 Empowered Leadership and Management
2
4. PESTEL Analysis
Factor Detail Impact Recommendation

Politics
Changes in MOH regulations may positively or

MOH standards and Continuous monitoring of
negative affect the manpower and nutrition Unknown
regulations MOH updates
products supply
- Increase the number of

programs (preventive &
Coverage of nutrition clinic by the medical therapeutic) to be covered by
Clinic Price insurance can affect the patient turnaround to Negative the insurance
the clinic
- For uncovered service make
discount or first visit free
Economy
Catering Company The services and quality of food provided by

Unknown
contract catering company is unknown
Cost of meals provided
in restaurant The price of meals and snacks provided in the -feasible prices for staff and
Negative
staff restaurant can affect sales level provide offers
-Design training programs for

The presence of kitchen and different
Training Positive both clinical and general
specialties make the hospital a target for trainers
dietitians
Increase rate of Metabolic syndrome (includes
Metabolic syndrome rate obesity, hypertension, insulin resistance and
Positive
among citizens in KSA dyslipidemia) which will be a target for
nutrition clinic
Social
Staff with children may not be able to cover

Motherhood and shifts Negative
night or afternoon shift
The increased awareness among people
Sport & fitness especially the young generation toward the
Positive
awareness among youth fitness and sport will increase the target clients
in nutrition clinic
One elevator for
receiving raw material The use of the same service elevator will
Negative -Use of separate elevators
and delivering food to increase the chance of infection
patients
The use of HIS for

documentation and
Using the HIS will facilitate the workflow and -The use of paper forms in
obtaining patient Positive
Technological
save time case of system down

information and diet
plans
Cameras distributed all

over the kitchen and Continuous observation and supervision of food
Positive
connected to a screen in service area by supervisors
supervisors’ room
Formal communication between the staff will

Communication be via emails, and direct communication via Positive
WhatsApp group
3
The receiving area for raw food material is on
The location of Kitchen -Transfer the storage area for
the ground floor, which will increase the chance
in the hospital Negative raw food material to the
of cross contamination and insects transfer to
(mezzanine floor) ground floor
the kitchen area
Environmental
The rain and other

The staff may not be able to reach the hospital
weather factors in Negative
in raining
Jeddah
The kitchen and restaurant area have a nice -Expand the restaurant to
The view in the kitchen
view for food service staff, hospital staff and Positive visitors from outside the
and restaurant
visitors hospital
Saudi Food & Drug

Authority regulation and May affect the supply of nutrition supplement Unknown
guidelines
Legal
All healthcare providers must have valid

Valid Certification certificate form SCFHS and basic life support Positive
(BLS) certificate
4
5. Strategic Goals:
Strategic Goal 1: To increase the patients’ satisfaction toward food services provided by MMUR
hospital by 60% within 3 years.
Indicator Target Intervention/Actions Expected result
Percentage of patient 30% Provide palatable and safe food within -Positive patients’
complaints = Food the expected time and right temperature feedback regarding
complaints/ overall food food services and
surveys * 100 Supervision and corrective actions on the orders increases
whole food chain before meals reach the from patient’s
patient visitors
Continues process improvement projects -Patients receive safe

with the food services and right food order
Food Service
Number of menu 9 Continuous update on food menu,

improvements including:
• Adding new food option to satisfy

all age groups and preferences
(e.g., vegan, keto, high calorie
...etc.) and options
• Enhancement of current food
items taste
Strategic Goal 2: To increase the quality of services provided by the restaurant in MMUR hospital by
60 % within 3 years
Indicator Intervention/Actions Expected result
Number of new cuisine 6 -Increase in the
Analyze stakeholders needs and
and food options number of staff and
preferences and introduce new food
visitors to the
options and cuisines
restaurant
Strategic Goal 3: To increase the rate of referrals from healthcare providers to clinical dietitian for
inpatient and outpatient by 60% within 3 years
Indicator Target Intervention/Actions Expected result
Number of 9 -Increase the referral
Regular workshops will be made
workshops/lectures to clinical dietitian
targeting healthcare providers from
provided to healthcare from different
Clinical Nutrition
different specialties to increase

providers specialties in both
awareness regarding the importance of
Percentage of referrals = 30% inpatient and
nutrition
Number of departmental outpatient in clinics
referrals/ overall nutrition
assessments *100
Strategic Goal 4: To increase the patient turnout in nutrition clinic by 60 % within 3 years
Indicator Intervention/Actions Expected result
Percentage of patient 10% Continuous education for the clinical
turnout to nutrition clinic= dietitian on new therapeutic nutrition
Number of nutrition clinic services to be added to the clinics
5
clients/ Overall visitors to -Awareness for public will be made
OPD clinics* 100 through educational material (e.g.,
videos, messages, and public campaign)
-Packages and offers to nutrition clinic -Increase in the

Percentage of clients 30% patient number and
return to nutrition clinic = variation in nutrition
Increase the number of nutrition
number of patient coming clinic
clinic/day to cover all the time
back/ overall number of
appropriate for patients
clients in nutrition clinic
*100
Percentage of 20%
multidisciplinary programs
including nutrition
Develop multidisciplinary programs
services =
which will include clinical nutrition
multidisciplinary programs
services
including nutrition/ overall
numbers of programs *
100
6. Nutrition & Dietetic Department Service Phasing According to MMUR Strategy
Plan:
Phase 1 Phase 2 Phase 3

Clinical nutrition clinic 2 shifts/ *Addition of sport and * Addition of clinics depends on
Clinical Nutrition
day (morning and evening) 6 nutrition clinic patient turnout and specialty
days/week
* Homecare clinical nutrition
*Number of clinics is adjustable services
according to the patient turnout
All equipment for clinic, inpatient and formula room must be available
Inpatient Medical Nutrition Therapy (7 days/week)
Service will cover inpatient and *Extend the service of * Home delivered meals for
Service
their families, staff restaurant, and restaurant to visitors patients joining the weight
Food
pantries. management program

* Shop on site and vending
(3 main meals and snacks) machine across the hospital
6
7. The Staffing plan according to MMUR phasing plan:

Number of Beds 100 beds 200 beds 200 beds
Clinical 3 clinical dietitians 6 clinical dietitians *Increase according
Nutrition (Including the Clinical (Including the Clinical to the services
Nutrition Supervisor) Nutrition Supervisor) provided
Food Services 2 Diet Technician 4 Diet Technician *Increase according
to the services
MMUR Staff provided
8. Working hours:
Service No. of No. of Shift 1 Shift 2

hours/day days/week
Clinical nutrition for 9 6 7:30 am – 4:30
inpatient pm
Nutrition clinic 8 6 9 am – 1 pm 5 pm – 9 pm
Formula room As needed 7 7:30 am – 4:30
pm
Food services 18 7 6 am – 3 pm 1 pm – 10 pm
supervisors
7
By: Abdullah Kashgary MB BS FRCPC MMg
1. Introduction
The core purpose of the Mediclinic International group is to enhance the quality of life of its
patients through a clear focus on clinical excellence and patient safety. All three divisions (Southern
Africa, Switzerland, and the Middle East) have a solid clinical leadership structure in place to
maintain this focus, and stringent measurement against international clinical indicators and audit
processes is undertaken at every facility as part of this process.
The Internal Medicine Department of MMUR is committed to delivering the highest quality care through a
comprehensive clinical governance strategy. The following proposal seeks to outline our priorities in
establishing and implementing this strategy.
2. Definitions
• MOH: Ministry of Health
• CBAHI: Saudi Central Board for Accreditation of Healthcare Institution.
• CG: Clinical Governance
• EMB: Evidence Based Medicine
• IMD: Internal Medicine Department
3. Vision, Mission, and values of Internal Medicine Department at MMUR

➢ Vision:
The partner of choice that people trust for all their medical healthcare need.
➢ Mission:
Our Mission is to provide high quality specialized care for our patients to enhance
their quality of life and experience.
Client centric Trusting and respecting Patient safety focused Performance driven Team oriented
Determine client needs Treating other with curtesy Prioritizing patients’ safety Setting Objectives and Supporting colleagues
Involving clients decisions Embracing diversity Identifying and managing measuring progress Collaboration
Actively managing clients Providing and risks Honoring Decisions Encouraging team spirit
experiences. welcoming feedback Involving patients Addressing Challenges Creating opportunities to
Delivering on promises Respecting privacy Patients data confidentiality Accountable and decisive express opinions& ideas
➢
➢ Strategy to KPIs flow
The KPI will be formulated based on the following Diagram
All KPIs must serve the MMUR Vision
MMUR Vision/ Mission
➢ Strategic Objective
➢ Organizational Goals
▪ Department Goals
• Divisions Goals
o Team Goals
o Operational Goals
➢ Clinical Strategy Framework

We will adopt the Clinical Governance Strategy
framework
There are seven pillars for the framework as
shown in the diagram.
All our activities will serve these seven pillars
➢ Clinical Strategy Implementation Framework

This framework will serve as a guide to implement the
Strategy and prioritize the objectives.
Renal Care as an example

➢ Fundamentals
▪ Prevention and screening
▪ Nephrology Clinics
▪ Acute renal Care
▪ Hemodialysis
➢ Complex Care
▪ Population health
• CKD program
• Hemodialysis
o Fluid management
▪ Measure Effectiveness
• Mortality and Morbidity
▪ Quality of life measure
• PROM
• Surveys
➢ Strategic Objectives:
o To make sure the following is delivered
through well-established Clinical
Governance
▪ Enhance quality of life by safe and
evidence-based medicine
▪ Achieve demonstrable
improvements in patient outcomes
through high quality specialized
care.
▪ Increase the involvement of staff,
patients, and families in clinical
governance and quality improvements to enhance their experience.
▪ Build the patients and community trust in our services and quality of care
➢ Strategy Implementation Structure:
Leadership Internal Medicine Processes KPIs

department
•Excutive team •CG committee •Mechanism of •Quantative

•Medcial Director •Quality team review •Clnical outcome
•Head of •Policies & •Quality reports •each division
Departments Procedures •patients •Clinical Audit
•Education satisfaction •Qulaitative
committee •Provider •Annual
•Builidung performance Governance
managerial •Communication report
capacity channels
•Quality •Horizental
training •Vertical both
•Evidence ways
Based
Medicine
activities
➢ Strategy implementation plan
Stratgic Transitio Sub

Goal nal Goal Tasks Tasks
Establish KPIs
Quality team
P&P
Educational
team
Providing high Establish CG Quality training

quality care team Population
Health Team
EBM meetings
Foster a culture
of openess and
improvement
CPD
Monitor
adeherance
Transitional
Stratgic Transitional Stratgic Goal
Goal
Tasks
Tasks
Goal Goal
Hiring highly Compitatative
specialzed compensation
doctors
Establish KPIs
population health
programs
Providing highly Highly qualified
Patients Hiring doctors
experience specialized care supporting staff
PROM
Culture of
experiance
Equiping the
hospital with the Determian each
Patients right technology division needs
represtnative
committee
Stratgic Goal Transitional Goal Tasks
Best effective
EBM treatment
Preventative Care Health Promotion
Enhancing quality of Involving patients

life Health
Education in decesion making
Communication
Emmotional
Support
Information
Resources
4. Department overview
4.1. Department Facilities
Capacity Additional Remarks
Space
OPD General Clinics Six Clinic No
Cardiology 2 Clinics - 1 ECG Room
- 1 Stress ECG
Room
- 1 Echo Room
Units Cardiac Cath Lab One Shared with

Vascular and IR
2 Endoscopy Two Shared with
Unit Pulmonology
Dialysis Unit 10 Negative
2 Isolation
4 in ICU
CRRT in ICU
In-Patients 16 Beds
4
5. Scope of service
5.1. The service
The Internal medicine department will deliver care for patients in all subspecialities of medicine. The
department will serve patients in the outpatient and inpatient setting along with all the supportive care for each
subspeciality.
There will be three phases of implementation
➢ phase one will deal with Endocrinology, Gastroenterology, General Nephrology, Neurology,
Pulmonology, Cardiology, Hematology, and Infectious
➢ phase 2 will deal with Rheumatology, Immunology, Oncology, BMT, Psychiatry.
➢ Phase 3 will only deal with Transplant.
5.2. Internal Medicine service phasing
• General Internal • Oncology Expand Subspeciality

Medicine • BMT services
• Nephrology * • Immunology Nephrology
• Cardiology * • Expand Bed Capacity to Independent cardiology
•Interventional 200 Beds Full neurology service
•Non-Invasive Full pulmonology/sleep
• Pulmonology* medicine service
• Endocrinology Transplant
• Gastroenterology *
• Psychiatry
• Infectious Disease
• Hematology
• Rheumatology
• Dermatology
• Neurology
*Full capacity Services

6. MMUR Internal Medicine Recruitment
6.1. Overview
This section aims to provide principles which should be considered when reviewing staffing
models for internal medicine department.
Staffing levels are dependent on the scope of work and the minimum requirement for the MoH
for each division.
6.2. Principles of safe staffing

6.2.1. The Legal Requirement
6.2.1.1. The staffing must comply with the MOH requirements
6.2.2. The operational requirements
Specialty Clinic Sessions Physicians Nurses Allied Health (shared) Facility
Nephrology 5/ week 1 Consultant 1 HN 1 Dietitian Dialysis Unit
2 Specialists 5-6 RN 1 Pharmacist
1 Social Worker
Cardiology 24/ week 1 Consultant non- 3 nurses ? Echo tech* Cardiac Cath Lab
invasive
Stress test nurse Cardiac Physiology lab
2 Consultant
Interventional ECG nurse Cardiac imaging
2 Specialists *
GIM 10/week 2 Consultants
4 Specialists
Endocrinology 12/week * 2 Consultants
Gastroenterology 12/week 2 Consultants 4 nurses Endoscopy unit
Pulmonology 9/week 1 Consultants Pulmonary function

test/ Sleep lab
Neurology 6/week 0.5 Consultants EEG/EMG Lab tech * EEG/EMG lab
Rheumatology 3/week 0.25 Consultants
Infectious Diseases 3/week 0.25 Consultants
Dermatology 6/week 0.5 Consultants
Psychiatry 3/week 0.25 Consultants
Hematology 3/week 0.25 Consultants
*Not budgeted
Summary
The internal medicine department is the largest and busiest service in the hospital. The operational plan will be
conducted to serve the scope of work of the hospital and the department.
By implementing this clinical governance strategy, the Internal Medicine Department of MMUR can improve upon
its current standard of care and create a culture of excellence. We are confident that if implemented properly, this
strategy will set a new benchmark for quality in the healthcare landscape
The Provided facilities and resources will allow us to function as a general medical department with increasing
capabilities and resources as we move on from one phase to another.
Recruitment plan is based on legal and operational requirements and needs to be fulfilled as this will affect the
implementation of the strategy.
The SWOT analysis will be based on MMUR general SWOT assessment

Clinical Services
Anesthesia Department
v
Strategic Plan
Content
1. Introduction
2. Definitions
3. Vision , Mission and Values
5. Scope of service
6. Manpower
7. Department activities
8. 5 years Plan
v
Introduction :
We are committed to provide the highest Quality Medical Care Regional wide , and to be recognized as the
Leading Anesthetic Department in the Kingdom of Saudi Arabia in Medical Care , Educational Activities and
to be innovative Group to maximise patient Care while maintain cost effectiveness .
Definitions :
MOH : Ministry of health
MMUR : Mediclinic Almurjan Hospital
CEBAHI :
v
Vision , Value and Mission :
Vision :
Providing exceptional patient experience in a Holistic care, continuous improvement, innovative research,
Excellent educational settings and a positive work environment .
Mission :
shaping the future of perioperative patient care in Private Sector , delivering innovative research and
education, and providing Cost efficient clinical services.
Values :
v
Safe : Providing Safe perioperative Care
Team Work : We act as a dynamic, respectful care team
Resilience: Maintaing well-being in all team members
Innovative : we are committed to improve the field of anesthesia
Education : preparing the future anesthesiologists to help the community

Department Overview:
Location :
The department of anesthesia is located in the third floor , the offices are inside the Operating Rooms vicinity while the
Perioperative Clinics are located just outside the Operating Rooms Area .
Manpower :
The Anesthesia Service is Directed by the Head of Critical Care Department , who will oversee day to day
Activities with the Help of Anesthesia Service Lead .
The Department Members are Qualified Anesthesiologist , Technologist , Technicians and Admin assistant .
The workforce will be divided on Three different Phases ,

v
The first phase : which starts with the first day of Clinical Practice ,
4 Consultants , 12 Senior Registrars and 7 technician .
The Second Phase is a dynamic phase where Expanding the services will be met with expansion of the
manpower .
The third phase : This is where the full planned services are running .
7 consultants , 18 senior Registrars and 10 technologists .
At all phases , the plan is to keep 80% of the manpower for General anesthesia / 20% for Cardiac and
Pediatrics anesthesia .
Organogram :
Scope of Service :
Inside OR :
Providing anesthesia Care for various Specialties including but not excluding to GS , ENT , Peads , Neuro , Cardiac , Urology , Ortho
…
Outside OR :
Providing anestheisa care for radiology , endoscopy , cathlab , and all other area needs anesthetic care as well as being a part of
the CPR team
Acute pain Service :

Providing acute pain management in form of Regional anesthesia for surgical patients , Labor analgesia , PCA for surgical and no
surgical care .
v
Chronic Pain Service :

Managing chronic pain patients in outpatient settings and providing interventional management .
Department Activities :
Weekly Rounds :
a weekly Round to Discuss all Related Organizational Issues , Morbidities and Mortality Meetings ,
Continuous Education for the Staff Members in form of Lectures or workshops .
Staff Developments :
We will be providing a continous Developments Programs at all aspects including Career Progression Tracks
for our Team Members , in which will be reflected on patient care and Employee loyalty .
Business Plan Revision : v
In this activity we will be visiting our Department Goals and our Progression every Quarter , evaluation of
the current status and future plans from a business Scope .
5 years Plan :
1. Residency Program :
The Residency Program is part of our Goals and Values , we are planning to start the residency
Program 1 year after commissioning , During this time we will be working on educational and
training environment to fulfill the SCFHS Requirements .
2. Maximize Clinical Capacity :
3. Advances in peroperative medicine :
4. Financial :
v
v
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box anywhere on the page, just drag it.]
v
v
v
v
v
v
Clinical Services
Adult Intensive Care

v
Department Strategic Plan

v
Progress So Far April 17:

1. Quality
a. Forms: are complete, pending upload and reviewed with IT and Oasis team.
b. All policies updated with the new templates and index
2. Committees: CPR and Crash Carts committee establish, and first meeting will be after Eid.
3. Equipment: All Equipment agreed on and waiting installation
4. Staff all sign the contract, pending Iqama transfer by Al Murjan
5. Strategy and Manual in the process, will be ready with final product on May 14 as agreed with Quality and HOD.
Content
1. Introduction
2. Definitions
3. Vision, Mission and Values
5. Scope of service
6. Manpower
7. Department activities
8. 5 years Plan
v
Introduction :
Definitions :
MOH: Ministry of health
MMUR: Mediclinic AL Murjan Hospital
CEBAHI: Central Board For Accreditation Of Healthcare Institutions
v
Vision , Value and Mission :
Vision:
Providing exceptional patient experience in a Holistic care, continuous improvement, innovative research,
Excellent educational settings and a positive work environment.
Mission:
shaping the future of perioperative patient care in Private Sector, delivering innovative research and
education, and providing Cost efficient clinical services.
Values:
Safe : Providing Safe perioperative Care
v
Team Work : We act as a dynamic, respectful care team
Resilience: Maintaing well-being in all team members
Innovative : we are committed to improve the field of anesthesia
Education : preparing the future anesthesiologists to help the community

Department Overview:
Location:
Adult Intensive Care Unit is located in the third floor, the offices are inside the Unit, the unit divided into 3 parts, Medical ICU, CCU
and VIP ICU.
Manpower:
The Critical Care Service is Directed by an ICU lead consultant, who will oversee day to day Activities
reporting to Head of Critical Care Department and Medical Director.
The Department Members are Qualified Intensivist, Nurses, Clinical Dietitians, Clinical Pharmacists,
Physiotherapist and Admin assistant.
The workforce will be divided on Three different Phases,

v
The first phase: which starts with the first day of Clinical Practice,
1 Consultant, 1 Senior Registrars, 4 Registrars and 3 Physicians.
The Second Phase is a dynamic phase where expanding the services will be met with expansion of the
manpower.
The third phase: This is where the full planned services are running.
2 consultants or equivalent, 2 senior Registrars, 4 Registrars and 4 staff physicians.
Organogram :
Scope of Service :
• Adult Patients > 14 years old
• Minor Burn and Burn < 20%
Out of Scope of Service:

• Age older than < 14 years old
• Major Burns > 20% of body surface area
• Psychiatric patients
• Patients need ECMO services.
• Patients who have confirmed clinical and laboratory evidence of brain death (such patients can be
admitted if they are potential organ donors, but only for the purpose of life support before organ
donation);
• Competent patients who refuse life-support therapy. These patients would be admitted to the ICU only
under unusual circumstances, at the discretion of the ICU director, and they should be discharged if
necessary to make room for higher priority patients.
Inside ICU:
The ICU provides 24 hours nursing care all year round. The unit is staffed with nurse-to-patient ratio of 1:1-2. Many other
disciplines are involved in the care of the pt including but not limited to medical staff, respiratory therapy, pharmacy, radiology,
social worker, patient educator, Infection control and physical therapy.
Intensive care unit provides care to various types of patients including cardiac related illnesses and post operative surgeries, the
care includes but not inclusive to mechanical ventilation and continuous monitoring.
Outside ICU:
Providing continuation of care after discharge from ICU to the hospital’s wards for various Specialties including but not excluding
to GS, Ob, Neuro, Cardiac, Ortho …
Department Activities :
Monthly Departmental Meeting:

To Discuss all Related Organizational Issues, Morbidities and Mortality Meetings, review the Unit’s KPI and
follows the Lectures or workshops .
International recognition programs:

Focus on new international programs that evidence based driven to improve both the clinical outcome,
quality and insure patient journey and safety.
Define the model of care for the “ICU of the future” (e.g., what would be emerging care models or new
initiatives that would define future Critical Care services.
Bimonthly Education Session:

Will be conducted by Professional education/events (i.e., Education dinner), Multidisciplinary education
events, Staff driven education sessions, Lunch and Learns and conducting Journal Club in the western
region.
5 years Plan:
1. Residency Program:
Critical Care Residency Program is part of our Goals and Values, we are planning to be unit of training
first year after commissioning, then apply for full residency program in the year 3, During this time
we will be working on educational and training environment to fulfill the SCFHS Requirements.
2. Maximize Clinical Capacity:
Within the first year, plan is to gradually increase the number of beds utilize till reach full capacity.
And to start on Telemetry and Step-down Unit in the medical Ward.
3. Advances in Critical Care medicine:

Reintegration of Acute Services – Thoracic Surgery, ECMO, Novalung (iLA Membrane Ventilator),
returning of other programs, etc.
4. Financial:
To be a stand unit covering it expenses and generate income by integrate our services with Codes
and bills.
v
Patient Safety and Quality standards:

In conjunction with the MCME mission, vision, and values, the department of aims to give
collaborative direction to Quality and Patient Safety initiatives.
The main strategies are to:
• Involve all staff levels in quality improvement activities related to patient safety and care
delivery.
• Embed a Patient Safety and patient-centered culture within Services.
• Attain and maintain International Patient Safety standards.
• Ensure the delivery of safe and high-quality care by utilizing scientific and research
methods.
v
Progress So Far April 17:
6. Quality
a. Forms: are complete, pending upload and reviewed with IT and Oasis team.
b. All policies updated with the new templates and index
7. Committees: CPR and Crash Carts committee establish, and first meeting will be after Eid.
8. Equipment: All Equipment agreed on and waiting installation
9. Staff all sign the contract, pending Iqama transfer by Al Murjan
10. Strategy and Manual in the process, will be ready with final product on May 14 as agreed with Quality and HOD.
STRATIGIC PLAN
OBSTETRICS AND GYNECOLOGY & IVF
Abdulrahim Gari MD. FRCS (C)
April 2023
Obstetrics & Gynecology
Introduction:
Mediclinic AL Murjan is an icon of healthcare in Jeddah to elevate the provision of health care in
the area. A hospital where everyone is looking at and anticipated to provide top health care services
in the region and makes a difference by all means in the field health care.
In the department of Obstetrics and Gynecology – MMUR – Jeddah, we will focus on providing
an excellent and safe services in the field of women’s health with high quality and evidence based
medicine in all the Obstetrics and Gynecology subspecialties along with the supportive services
needed by women during different stages of her life starting with adolescent gynecology and
covering the reproductive age and pregnancy as well as postpartum period and continue the care
during perimenopausal and postmenopausal period.
Vision: Is to be the partner of choice that people of Jeddah and the surrounding areas trust for all
the maternity and women’s health needs.
Mission: Is to enhance the quality of life in women by providing high quality care in all the
subspecialties of Obstetrics and Gynecology with high standards
A. Stratigic Goals:
1) Providing high quality care and establish the standards of best OB/GYN practices to
pursue Zero Harm and improve the Quality of services provided.
2) Providing specialized health care by recrruting highly specialized medical staff with all
the subspecilities on the field of ObGyn.
3) Improve access to OB/GYN services through internal referrals (from other departments)
and external referrals from other hospitals as we will provide and lead tertiary level
OB/GYN services provision.
4) Practicing EBM (evidence based medicine) along with contiuing education of senior and
junior staff as well as the nursing team
1
5) Build the patients and community trust in our services and care.
6) Enhancing quality of life, includes health education & preventitave care through the
concept of healthy women clinic.
7) Increase the involvement of staff, patients, and families in clinical governance and quality
improvements to enhance their experience and satisfaction.
8) KPIs will be identified, and there will be an objective assessment of the clinical
outcomes in an annual basis.
9) Assign quality team in the department to work on and update the policies (P&P) and
to monitor the adherence. The Quality representative will continuously improve the
quality of healthcare; maintain a risk-free environment and to assure compliance with
regulatory standards.
B. Space allocation:
Total Phase 1 Phase 2 Other spaces

capacity
L&D 9 rooms 5 4
L&D OT 2 rooms 1 1
OPD 6 clinics 72 sessions Up to 96 Procedure room for
sessions colposcopy, hysteroscopy &
amniocentesis
IVF OPD 2 clinics 24 sessions 36 sessions
IVF OT 2 rooms 1 1
In Pts rooms 16 rooms 16
2
C. Scope of service:
The obstetrics and Gynecology department will deliver care for patients in all subspecialties in
the field of OBGYN. The department will serve patients in the outpatient and inpatient setting
along with all the supportive care for each subspecialty.
There will be three phases of implementation as follows:
Phase (I) will deal with:

 General Obstetrics and Gynecology
 Maternal-Fetal Medicine (MFM) & US
 Gynecologic Oncology
 Uro-Gynecology
 Reproductive Endocrinology and Infertility RIE (OPD only +/- full IVF service)
 Congenital female reproductive anomalies surgeries
Phase (II) will deal with:

 Cosmetic Gynecology
 Operate the IVF center (full function)
 Start the Ovarian Tissue Cryo (OTC) program (License permitting)
 Start the supportive maternity services
- Antenatal classes
- Maternal yoga
- Breast feeding consultations
Phase (III) will deal with:

 Expand the subspecialties and switching it into sections.
 Start the pre-implantation genetics testing service (PGT).
 Lead Maternity and GYN researches to enhance medical & health services and provide
highest level of care.
3
D. Staffing / Recruitment:
Staffing planning depends on the scope of service and the minimum requirement by
MOH per service / specialty.
Knowing that the ObGyn service is a 24/7 active specialty with one specialist should
cover only L&D throughout day/night (MOH requirement); it makes it a must to have
an in-house specialist & GP throughout the day/night.
The ObGyn staffing map will be explained here as approved and required:
Approved Required Remarks

FT Consultant 4 5 Including HOD
PT Consultant 6 Will assess 2 of each sub specialty
Specialist 4 6
GP/ Resident 4 6
IVF FT Consultant 1 MOH requirement
IVF Operation Manager(director) 1 MOH requirement
Embryologist- IVF Lab Tech 3 4 2 for the andrology lab , MOH req (2)
IVF Coordinator/Educator 1 2 1coordinator (MOH req) &1 educator
IVF PT consultant 2 4
OBS//IVF ultrasonographer 2 MOH requirement (1)
Genetics counselor 1
Psychologist 1
IVF nurse 2 MOH requirement (2)
Breast feeding consultant 1

ObGyn/Onc coordinator 1
Summary:
The strategic plan of ObGyn department is in line with vision, mission and values of MMUR, we
will maximize the likelihood of desired healthcare outcomes in a way that matches the planned
phases of MMUR. Will aspires to be a center of excellence in women’s health where care is safe,
timely, effective, efficient, and equitable and patient centered.
4
Emergency Medicine Department
Mediclinic Al Murjan Hospital
Strategic Plan 2023- 2028
OVER THIS PLANNING CYCLE, THE DEPARTMENT WILL FOCUS ITS
ATTENTION ON FINDING INNOVATIVE AND EFFECTIVE WAYS TO:
• Provide high-quality, integrated and streamlined care to ALL
PATIENTS AND POPULATIONS in the Emergency Department
• Equip faculty with the necessary tools, supports and programs to enable
PROFESSIONAL SUSTAINABILITY in the practice of Emergency
Medicine.
• Strengthen and build collaborative PARTNERSHIPS beyond our

department in order to advance clinical, educational and research
priorities
• Build our EDUCATION programs in Emergency Medicine with a focus on

fostering excellence in our learners and ourselves
• Build and grow our RESEARCH program, aligning research activity with
priority areas of clinical focus whenever possible
STRATEGIC PRIORITY:
• Provide high-quality, integrated and streamlined care to ALL PATIENTS
AND POPULATIONS in the Emergency Department
INTENDED GOALS:
• Create a “patient -friendly emergency department” by developing enhanced

care programs, pathways and protocols that address the unique needs of
our patients papulation .
• Develop innovative, multidisciplinary approaches for the care of patients
presenting to the emergency department with the common emergency
conditions , with a special focus on
• harm reduction, rapid access to multidisciplinary specialized resources, and
decreasing return ED visits.
ENABLING ACTIVITIES:
• Recruit new faculty with specialized training and expertise in the field of
Emergency Medicine
• Enhance departmental expertise on the care of vulnerable patients by
investing in targeted continuing professional development opportunities for faculty.
• Advocate for and empower trained non-physician caregivers to advance the
care of vulnerable populations within the Emergency Department
• Focus departmental quality improvement and patient safety initiatives on
enhancing care for vulnerable patient groups
• Identify and seek to collaboratively create partnerships and resources for
timely outpatient referral of patients with specialized care needs, as well as for
“upstream redirection” when possible, to support alternate access points to the
healthcare system
• Resource new clinical initiatives with the necessary project management,
administrative and operational support to enable effective, timely and coordinated
implementation of new projects and programs
STRATEGIC PRIORITY:
• Equip faculty with the necessary tools, supports and programs to enable
PROFESSIONAL SUSTAINABILITY in the practice of Emergency Medicine.
INTENDED GOALS:
Identify and pursue opportunities to enhance the clinical and academic department
in order to promote individual wellness, to sustain a collegial and supportive
culture, and to enable faculty, learners and staff to experience joy in their work.
• Actively promote the activities and successes of departmental faculty and

trainees, both internally and outside of the department
• Develop a regular program of faculty development activities that address the
clinical and non-clinical learning needs of the department’s physicians by engaging
internal and external subject matter experts
• Ensure the ED clinical schedule and scheduling practices support safe and
sustainable clinical practice, are responsive to patient care demands, and support a
healthy professional-personal life balance among physicians
• Embrace opportunities to increase the diversity of our faculty and staff, and to
promote an inclusive and supportive environment for all faculty members, staff and
trainees
STRATEGIC PRIORITY:
• Strengthen and build collaborative PARTNERSHIPS beyond our department

in order to advance clinical, educational and research priorities
INTENDED GOALS:
• Increase the participation and external visibility of the department and its
members within the hospital and community in order to share expertise,
increase collaborative partnerships, amplify our collective influence, and
build social capital.
• Grow relationships with regional health care partners in order to identify
opportunities for collaboration in clinical care, advocacy and education.
• Foster relationships with other community organizations, institutions and
individuals in order to promote shared interests, and enhance local
advocacy.
• Expand our engagement in the advancement of global emergency
medicine by supporting and contributing to international partnerships.
• Ensure departmental members are aware of, and supported to participate on

committees, working groups, and other collaborative activities within the community
and the Hospital.
• Create inter-departmental and inter-professional working groups to address key
clinical issues that would benefit from a collaborative approach
• Identify opportunities to enhance our community engagement through advocacy,
education and philanthropy
• Support the development of a residency program in emergency medicine by
supporting a faculty lead, encouraging visiting clinical faculty and contributing
educational expertise
STRATEGIC PRIORITY:
• Build our EDUCATION programs in Emergency Medicine with a focus on

fostering excellence in our learners and ourselves
INTENDED GOALS:
• Ensure that growth in clinical and academic specialization translates into

enhanced educational offerings for residents in domains of faculty
expertise.
• Grow the offering of training opportunities within the department that
attract learners from other centres and raise the national profile of the
department, as well as expand local opportunities for our own residents.
• Enable the continued success of the department’s education scholars,
maintaining our aim to be leaders and innovators in emergency medicine
education and training.
• Provide appropriate departmental support to training program leaders and
educators to enable engaged leadership and curricular innovation
• Review and revamp formal departmental rounds and teaching sessions, with an
emphasis on presenters, content and formats that optimize the educational yield for
both residents and faculty
• Encourage educational collaboration with other programs and departments
through joint rounds and teaching sessions, visiting speakers with interdisciplinary
appeal, and by leveraging departmental expertise teaching and other pedagogy
• Collaborate with other departments to establish a new, multidisciplinary
fellowship program in Point-of-Care Ultrasound
support and promote fellowship programs in Resuscitation and Global Emergency
Medicine
STRATEGIC PRIORITY:
• Build and grow our RESEARCH program, aligning research activity with
priority areas of clinical focus whenever possible
INTENDED GOALS:
• Build our clinical research studies enrolling patients in our centre led by
departmental investigators.
• Develop and support a program of research in emergency department

quality improvement and patient safety.
• enhance and Increase faculty participation in quality improvement projects and
program evaluations
• Pursue opportunities for collaborative research with partners in other clinical and
non- clinical departments.
• Increase opportunities for trainee engagement in both clinical and quality
improvement projects
Emergency Medicine Department
Mediclinic Al Murjan Hospital
Operational Plan
Introduction
The ED Facilities and Capacity
The Emergency Department (ED) ensures the provision of immediate care to patient arriving at
the hospital with a Triage Rooms, and 24 Bed Emergency Department organized as follows:
▪ 2 Resuscitation/ Trauma rooms
▪ 5 Pediatric rooms
▪ 1 Obstetrics and Gynecology room
▪ 4 Negative Pressure isolation room
▪ 11 General rooms (Beds)
▪ 1 Plaster / Procedure Room
▪ 2 urgent care ( Fast Tract ) Clinics
Mission Statement
▪ The Emergency Department at Mediclinic AlMurjan Hospital has been designed to
enhance in every aspect to offer a patient-centered care experience. The clinical area
features the latest technologies in health care to complement our world-class emergency
physicians, nurses, EMS and other health care providers.
▪ The Emergency department at Mediclinic AlMurjan Hospital is dedicated to provide a

holistic, compassionate, efficient. and high-quality care to our patients carried out
empowerment by a dedicated workforce that is committed to the best standards of
evidence-based medical practice and continuous quality improvement in a patient-
centered environment.
▪ pledge to provide excellent quality emergency medical care, safely, and efficiently, to all
patients presenting to The emergency department staff will strive to uphold the mission
statement of Mediclinic Al Murjan Hospital. They Mediclinic Al Murjan Hospital emergency
department.
▪ We are aiming to become a center for inspiration, education, and experience, for all those
interested in the field of emergency medicine. Participating in knowledge exchange,
education, promotion of self-learning and mastery of the craft, that is well known in the
region .
Goals of the Department

1. Promote the mental, emotional, and physical health of serving residents.
2. To emphasize the elevation of all we do to the a high level of excellence.
3. To reflect the Vision of Mediclinic AlMurjan Hospital to provide the highest quality of
emergency medical care, in the most effective and efficient manner possible, to all patients
presenting to the Emergency Department.
4. To present all with an opportunity for educational and practical-oriented experience for those
interested in the field of emergency medicine.
5. To pursue and implement the most modern, cutting edge, technological, pharmaceutical, and
medical advances, to raise the quality and safety of the medical care being offered.
6. Include our involvement in joint ventures and collaborative relationships with other
organizations.
7. Conduct community health education programs.
8. Continue to grow and evolve with the changing needs of the local communities
9. To strive to improve the quality of emergency care provided by reviewing practice and adopting
performance improvement projects as a vehicle for change.
Stages of Operation
▪ Start to Receive our first Patient 1st of July 2023
For the first six months the following will function:
o 2 respiratory Isolation rooms.
o 2 resuscitation/trauma beds.
o (total of 5 beds + 1 isolation room) Pediatric area that will accommodate adults and peds.
initially.
o The OBGYN room.
After the first six Months the ED bed Capacity will increase gradually till we reach our full
capacity.
▪ The Urgent Clinics (UC) will work 16 hours per day (from 08:00 till 02:00)
▪ The UC will be covered by 1 FM Specialist and 1 general physician in two 8-hour shifts.
▪ The UC staff will do 22 shifts per month.
For the urgent clinics:
4 x 30 = 120 Specialist shifts per month ➔ 6 FM Specialist + 1FM specialist to cover vacation
time and sick-leave. (Total of 7 FM specialist)
4 x 30 = 120 GP shifts per month ➔6 GPs + 1 GP to cover vacation time and sick-leave.
(Total of 7 GPs
The ED Full Staffing Requirements
During each shift (1) consultant , (1 )registrars/senior registrar, and (3) residents are required to
cover the ED beds per 12-hour shift.
Each staff is expected to do (16) 12-hour shifts per month. This would mean that the following is
needed to cover the ED beds 24/7:
60 Consultant shifts per month ➔4 consultants + 1 consultant to cover vacation time and sick-
leave. (total of 5 consultants) (including the HOD)
60 Registrar shift per month ➔4 registrars + 2 registrars to cover vacation time and sick leaves.
(Total of 6 registrars)
180 Resident Shifts Per month ➔ 12 Residents + 2 Residents to cover vacation and sick -leave.
(Total of 14 Resident)
Pediatric Emergency Medicine
Should recruitment of dedicated Pediatric emergency medicine consultant be done:
The increase in registrars will not be necessary and this is replaced by 1 PEM consultant per
shift.
Thus 60 PEM consultant shifts per month➔ 4 consultants + 1 consultant to cover vacation time
and sick-leave. (Total of 5 PEM consultant.
Item Position Required Number Available
Nos. Number
1. Consultant Adult EM 5 1
2. Specialist 6 0
3. General Practitioner 14 0
4. Consultant Paediatric 5 0
EM
5. Paramedics 10 0
6. EMTs 6 0
Part time Consultant Shift Coverage Contracts

Block vs per month coverage
3 month contracts 36 hours/month
Per-month coverage (i.e per shift – this is easier to implement)

375 SR per hour
4500 SR per 12 hours shift
Future Requirements of Emergency Satellite Clinics
▪ All emergency Units will be under direct supervision of the Emergency Medicine HOD with
clear clinical pathways for patient care and clear guidelines on how and when to transfer
patient from these units to the main ED . protocols of Direct Access to Critical care for
these units will be implemented.
▪ 24/7 Coverage of each units will need four (4) Senior Registrars / Registrars per unit per
month.
▪ A total of (20) Senior registrars for 5 satellite clinics
EMS Division
First stage:
▪ Interfacility Patient Transport.
▪ Transport of discharged patient (Home Transfer).
▪ Respond to all in-hospital emergency requests.
▪ Receiving Saudi Red Crescent Authority (SRCA) patients and patients in need of
assistance at the main ED entrance.
Future Plans:
▪ Respond to stable calls (to bring patient to their OPD appointments).
▪ Transferer patients from satellite clinics to our ED.
▪ Participate in covering events (Jeddah season).
▪ Be part of the future RRT team (responding to home calls).
▪ 3rd party EMS ?
EMS Division Manpower

▪ For the Main hospital
o 10 paramedics and 6 EMTs
▪ For each satellite clinics for 24/7 Coverage:
o 7 paramedics
ED Consultant Duties
▪ Manage the flow of patients in his her ED shifts.
▪ Supervise all ED medical staff in the shift.
▪ To be aware of all patients before discharge , service consultation , and imaging requests.
▪ On-line medical direction for the RRT team, and EMS teams
▪ Respond to the consultation from the emergency Units in the satellite clinics.
ED Plans
▪ To have consultant coverage in each ED shift.
▪ To have regular running research projects in the department .
▪ To have unified clinical practice guidelines in the main ED and the emergency units at the
satellite clinics .
▪ Implement the direct access to critical care policy for the referred patients from the
emergency units
▪ Establish Residency Training Program for the Emergency Medicine Saudi Board / Arab
Board certification.
▪ To have regular participation in all mass gathering events (eg. Jeddah Season, Formula
one etc. )

Pharmacy Department Strategy Plan: Goals Objective Indicators

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Pharmacy Department Strategy Plan: Goals Objective Indicators

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Pharmacy Department Strategy Plan

Goals Objective Indicators

Answer all drug • Number of drug information

5. Ensure patients’ Maintain the inventories • Rate of drug availability.

6. Improve sales and Provide all required • Zero stock incidents

PESTEL Factor Details Impact Comments

Saudization Saudization of physiotherapy jobs in accordance

with the directives and vision of the Positive

Varity of Services Initiating variety of services can help to attract a

Insurance play a huge role in patients continuing physical Positive

Advertisement Awareness and advertisement of hospital Positive

increase the chances of various sports injuries

Staff Communication WhatsApp group, Bravo Positive

Hydrotherapy Spaces Hydrotherapy space is small Negative

In 1st floor, Elevators problems and crowding

Department Location will affect patient arrive Negative

Cold temperature can harm OA patients and

CBAHI Standards. To obtain CBAHI standards Positive

Explaining and taking patients consent before

Medical Rehabilitation department

Policy initiation and implementation

2. Initiate Occupational therapy Specialty service. (based No. of services covered

Policy initiation and implementation

No. of services covered

Policy initiation and implementation

No. of services covered

Objective: Promote the Role of Speech & Language Unit

Objective: Increase patient satisfaction

1. Recruitment Physical therapists, Occupational

No. of trained staff

3. Initiate training Program for inpatient and

4. Continue to train other medical departments staff Medical Rehabilitation department

No. of employee trained

Medical Rehabilitation department

Objective: Promote Continuous Education And Training, And Research

Objective: Promote Continuous Education in Quality Control

Medical Rehabilitation department

Goal: Seeking Accreditation

Goal: Enhance Community Quality of Life

Goal: Promote continuous education and training

1# MMUR 2# MMUR 3# MMUR 4# Radiology 5# Radiology

Stakeholders: How Operations: How will

Financial Learning &

• Compliance with CBAHI, MOH , NRRC

• Licensing and certification • Improve Data integrity

• Increase Intradepartmental • Equipment utilization

• Outpatient experience improvement • Strengthen brand /reputation

• Increase staff satisfaction rate • Achieve the highest level of Referring

• Improve patient satisfaction rate

LG1 LG2 LG3 LG4

strategic goals specific (Tactical) goals

goals & KPI

strategic goals specific (Tactical) goals

2: Education and Training

4. Weekly lectures schedule (Mechanical ventilators, ABG, PFT,

3: Enhancing Public Awareness and Home Care Services

4: Comprehensive Respiratory Services in one place

2. Create a good team and manpower ( RTs) to supply the market

2. Explore and integrate best practices of other regulators in best

Hospital Name: Mediclinic Al Murjan

Infection Control Strategic Plan

Infection Prevention & Control Strategic Plan

What is Infection Prevention and Control?