Quality Improvement in Healthcare InstitutionsIn the Kingdom of Saudi Arabia, A Private Hospital’s Perspective

By Dr. M. F. Siddiqui, FRCS, FICSChief of Surgery and Quality Management Director

C B A H I : A F r a m e w o r k f o r Q u a l I t y I m p r o v e m e n t i n H e a l t h c a r e

The process touched every aspect of medicine and healthcare in Mohammad Dossary Hospital based in Al-Khobar, as confirmed by statistics.

This presentation highlights the impact of this process on the quality improvement of local hospitals and subsequently better care provided to clients. We will recommend the same model to less developed

Sep. 11, 2008 Jul. 7, 2008Nov. 4, 2007

Aug. 21, 2007Jul. 11, 2008

Jul. 24, 2008

Sep. 22, 2007

Jan. 8, 2009

countries in order to improve the quality of their healthcare institutions. The cost of implementing these changes could be kept at a minimum, as in our hospital, by assigning the role of Director ofQuality Management to the senior most consultant of the hospital.

Introduction

Preliminary Assessment

Results of Quality Intervention

Message for Others

Effects – A Private Hospital’s Experience

Surveyed Passed Surveyed Passed2004-2005 2005-2006

34

11

23

8

14

2

12

48

1

7

0

Quality Program in Western Region of KSA

Jeddah Mecca Taif

2007

2006

2004

93.28%

93.05%

76.88%

6.72%

6.95%

23.12%

Accounts Receivable

Rejected Collected

The Ministry of Health (MOH) conducted situational analysis of various hospitals to identify problems and opportunities at the current hospital setting.

In the past year serious medical errors were reported on a daily basis by the local press. This has greatly undermined the confidence of the public in the quality of medical care provided by both private and government run institutions in the Kingdom of Saudi Arabia (KSA).

Jan. 6, 2009

Aug. 19, 2007

Aug. 22, 2007

7 Teams

Leadership &

TQM

Nursing

Infection Control

Pharmacy

Laboratory

Safety

Medical

Oct. 28, 2008

10 visits each

4 visits each

22 Chapters881

Standards

Improved revenue base due to lower rejections by insurance companies of the invoices.

Low number of reported incidents and problems.

Upward trend in patient census.

2004 2005 2006 2007 2008 -

50,000

100,000

150,000

200,000

250,000

Admissions ER Visits Clinic Visits

No.

of

Pat

ient

s

2004 2005 2006 2007 2008

384 459 668 787 1,173

2,723

3,608 4,019

4,506 4,830

Deliveries Surgeries

MOH setup the Central Board of Accreditation for Healthcare Institutions (CBAHI) and formulated the National Hospital Standards, at par with JCAHO (Joint Commission on Accreditation of Hospital Organizations), in order to improve healthcare quality in all hospitals within KSA. A key factor in the success of implementing this process was to appoint Consultants to visit the hospitals.

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2008 Quality Indicators

Nosocomial Infection Needle PrickPharmacy Error

No.

of I

ncid

ents

Jul. 24, 2008