Message from the Dean

By: Prof. Mahmoud S. Al-Ahwal Dean, Faculty of Medicine (P.3)

Message from Director of Quality

By: Mr. Hussam Al-baz ,Quality Director (P.4)

(1) Congratulations to the University Hospital

(2) Recognizing Quality Designees

By: Ahlam Alghanmi , Quality Improvement Consultant(P.5) and (P.27)

ACI Self-Assessment Teams’ Memberships

By: Fawziah Mashhour , Quality PR Of (p. 8) to (p. 24)

1) “Better Late Than Never”

2) Salute the Steerers

By: Iman J. Joaquin, Senior Assistant/Hospital Administration

Another 3 years had passed and what a challenging 3 years it was!

We have gone a long, long way. We have treaded a path that others might have refused but for us, we

did not buckle down. And, here we are.

To continuously maintain 9 years of international accreditation with Accreditation Canada International

is quite a feat. But, to sustain the level of Diamond Accreditation for two Survey cycles in a row and be

globally recognized is such a remarkable and extraordinary achievement. Indeed, this is a reflection of

the quality service that King Abdulaziz University Hospital (KAUH) provides.

I am so proud of everyone’s hard work and dedication shown during the preparation for the 3rd

ACI

Survey. I am really so honored to having a committed workforce standing behind my back.

I quote: “There is no one magic move or secret that creates victory, but lots of little items that when added

together can make you victorious.” – B. Toomey. Unquote.

To every individual staff member of our prestigious hospital, and to all the 18 Accreditation Teams

(Team Leaders and all its team members) who have unrelentlessly cooperated and committed to

finishing their assigned tasks, thank you so much!

To the highly-spirited Quality Team led by Mr. Hussam AlBaz and to all our devoted Hospital Leaders

led by Dr. Amro Al-Hibshi, who were the champions of this tedious endeavour, my salute!

May this honor we have received continue to inspire everyone in the years ahead.

Lastly, “All praises and thanks to the Almighty Creator who put us all together as ONE TEAM UNITED

to working towards a common mission, vision and goal”.

Once again, CONGRATULATIONS for a job well done!

Prof. Mahmoud S. Al-Ahwal

Dean, Faculty of Medicine

Come to think of it, it was not so long ago I asked myself, “Can we do it?”

The fact is for every survey cycle, an institution is given 3 years minimum to prepare .

Ours is an exception. I had just assumed the post of Director of Quality then, and we

had barely 14 months left before the ACI 3rd

Cycle Final Survey. The supposed work

for 3 years were all concentrated in just 1 year where we had to do everything literally –

from re-organization and preparation, reactivation and motivating all accreditation teams,

conducting meetings regularly, follow-ups, monitoring, auditing, documentations et al.

From October 2014 to December 2015, we re-begun the work. Seeing my team, the

Quality Team in strong collaboration with all the 18 Accreditation Teams was a great

blessing. The more it was proven that even with such magnitude of work, we

accomplished what needs to be accomplished because of an essential factor which is

'teamwork'.

My sincerest thanks and gratitude to every individual staff of KAUH. Bear in mind, no

matter how small and simple your contribution is, putting them all together made it

possible for us to sustain the Diamond Level of Accreditation from ACI.

To my wonderful and ever-supportive Quality team who have worked their way out -

patiently assisted the accreditation teams; provided education to those who required;

sacrificed time by staying late nights and coming during weekends to finish all work

needed, I am so proud and will remain indebted to you.

To the Hospital Leadership, whose trust was what motivated us from beginning to the end;

whose aim will always be to strive working to make the institution and its services more

better, thank you.

KAUH has once again proven it is one of the best hospital institutions in the region,

raising the bar of excellence in healthcare and will continue to do so for the coming

years.

CONGRATULATIONS to one and all!

Hussam O. Al-Baz

Director, Department of Quality

The Accreditation

Certificate was presented to

the University President by

the Director of

Accreditation Canada

International Mr. Martin

Ducharme.

For being accredited for the third

time and maintaining the Diamond

Level as the first in the Middle East.

The celebration ceremony was

conducted on Thursday 6th of

October 2016 , under the patronage

of his Excellency President of the

University Prof. Al-Youbi, the

University Vice Presidents, Faculty

Deans, KAUH Leadership, MOH

Hospital Directors, Quality Directors

in Jeddah, Hospital Staff, students

and visitors.

Prof. Abdulrahman O. Al-Youbi

President of King Abdulaziz

University

Message from the Quality

Department

To All KAUH Staff Thank You for

Your Efforts You Have Proven again

that Teamwork, Dedication and

Positive attitude Lead to our

continuous improvement and success

فريق خذماث العياداث الخارجيت

Ambulatory Care Services

DDrr.. LLeeeennaa AAnnbbaarr (Team Leader)

Ms. Nadia Aljedani Dr. Ferial Felimban

Ms. Nesreen Alqahtani Dr. Ohoud Shakroun

Ms. Nouf Aldossary Ms. Fabiola Rodrigues

Ms. Razaz Bajal Ms. Ghazala Perveen

Ms. Rowaydah Masoud Ms. Hanan Sarhan

Ms. Sara Althiebti Ms. Ibtisam Alhazmi

Ms. Susan Majano Ms. Karla Mendoza

Ms. Tahani Al-Sulami Ms. Laly James

Ms. Wafia Alghatani Ms. Leizel Monson

Ms.Yasmeen-Ashour

(Facilitator) Ms. Marissa Alvarez

فريق خدمات نقل الدم

BLOOD TRANSFUSION SERVICES

DDrr.. SSaallwwaa HHiinnddaawwii (Team Leader)

Dr. Maha Badawi

Mr. Edwin Raj

Mr. Fouad Sait

Ms. Khloud Gholam

Mr. Seraj Alwaiel

Ms. Sohila Ali

Ms. Biji P Thomas (Facilitator)

فريق خدمات المختبر للشؤون الفنية

BIOMEDICAL & LABORATORY

SERVICES

Mr. Raed Baeshen (Team Leader)

Ms. Mofida Tahlawi Mr. Abdulrahman Al Malki

Mr. Raed Baeshen Ms. Dolorosa Marissa Cudal

Ms . Rania Damanhouri Mr. Essam Qinaai Subhi

Ms. Reham Al-baz Mr. Hamad Al-Shegifi

Ms. Sahar Mumenah Mr. Hashim Sindi

Mr. Sami A. Khan Ms. Sara Al-Amoudi

Ms. Jaya Xavier

Mr. Hussam Omar Al-Baz (Facilitator)

Mrs. Intisar Zakaria Habeeb

فريق خدمات األشعة التشخيصية

DIAGNOSTIC IMAGING SERVICES

Mr. Jose Norwin M.

Catipay

Ms. Manal Ben Jalal

Ms. Merajen B. Rosalita

Mr. Rakan Al Mutairi

Mr. Riyhad Al Harbi

Ms. Rosario P. Amarille

Ms. Russell Gloriani

Ms. Vanessa Beriarmente

Usa

Dr. Lamia Jamjoom

(Team Leader)

Mr. Bander Almutairi

(Deputy Team Leader)

Dr. Khalid Al Safi

Dr. Khalid Khashoggi

Dr. Mohammad Wazzan

Mr. Ali Aljabri

Mr. Bonifacio

Gavilanggoso

Ms. Christine Mendoza

Ms. Dalal Hantul

Mr. Hamam Al Sulami

Mrs. Crescencia Javonillo

(Facilitator)

Ms. Ahlam Al Ghanmi

(Facilitator)

فريق خدمات الرعاية المنزلية

Home Care Services

Ms. Marites Macapagal

Ms. Rowaydah Masoud

(Team Leader)

Mr. Adolfo Olegario

Ms. Mary Rose Sanggalang Mr. Ali Bamarhool

Mr. Michael Rudica Ms. Angelli R.Velasquez

Mr. Miguel Villaflor Ms. Genika Maceda

Ms. Rania Damanhouri Ms. Hafsa Yassin

Ms. Salih Handa Abdula Mr. Hani Hamdi Elsayed

Mr. Vincent Paul Rabonza Ms. Linet Rodriques

Mr. Yousef Al Yahayowi Ms. Mariam Alnkhlani

Ms. Sana Aleidarous (Facilitator) Ms. Marilou Sta. Ana

فريق خدمات العناية المركزة

Critical Care Services

Ms. Jaya Xavier Dr. Adel Shabassy

Ms. Saadatu Abdullahi Dr. Haifa Algethamy

Ms. Shanthi Fernandes Dr. Haytham Mohammed

Noueldeen

Ms. Shehla Nuzhat Ms. Abrar Abushour

Ms. Sheryl Lugue Ms. Dolorosa Marissa Cudal

Ms. ManjuK Joseph (Facilitator)

Dr. AliAl-Faydhi (Team Leader)

Dr. Norah Al-Khathlan (Deputy Team Leader)

يق الخدمات الصيدالنيةفر

Medication Management Services

Dr. Suha Al-Hebshi Dr. Alaa Al-Ghamdi

Dr. Sultan Al-Dalbahi Dr. Haifa Algethamy

Ms. Emtenan Osseilan Dr. Hala Makki

Ms. Joselyn Punzalan Dr. Hind Fallatah

Ms. Laly James Dr. Nada Asaali

Ms. Shiney John Dr. Ohoud Shakroun

Ms. Sitti Fatima Umda Dr. Rahmah Al-Qarni

Dr. Rameen Zarban

Ms. Manju K Joseph

(Facilitator)

Dr. Bayan Darwesh (Team Leader)

فريق قسم الطوارئ

Emergency Department

Mr. Ahmad Lipae

Dr. Abdul Nasser S. Al

Khayat

Ms. Amani F. Abu

AlRob Dr. Abdul-Moneim A.

Mostafa

Ms. Anne Matthew

Dr. Ahmed S. Al

Rowayshed

Ms. Fawzya Higy Al-

Harbi Dr. Ebtisam Ashari

Ms. Gloria Daud Dr. Ghada Merdad

Ms. Jemma Yago Dr. Jameel Abualenain

Mr. Joey Soriano

Dr. Mohamed Diab AbdEl

Aaal

Ms. Maria Ricana Dr. Mohammed Khogeer

Ms. Marites

Macapagal Dr. Nader Abdullah

Alhuzali

Ms. Corazon Albino (Facilitator)

Ms. Michelle Basubas

Ms. Monica Manangan

Ms. Myrna Portos

Mr. Noel Thomas

Layosa

Ms. Sabitha John

Dr. Adnan Al-Bukhari (Team Leader)

Dr. Ismail Hassan Al-Mujtaba (Deputy Team

Leader)

Mr. Saeed Al-Shaikhy

Ms. Sanaa Shalaby

Ms. Sufana Naji Al

Maghrabi

Ms. Zoraida A. Isnani

الباطني الطب خذماث فريق

Medical Care Services

Ms. Intisar Zakaria Habeeb

Dr. Elaf Abudawood

(Team Leader)

Dr. Abeer Al-Najjar (Deputy Team

Leader)

Dr. Hind Fallatah

Ms. Rosalinda Huertazuela Dr. Ibtisam Jali

Ms. Sabeena Muhammed

Rasheed Ms. Anees Vincent

Ms. Sheena Lynn Labay Ms. Dolorosa Marissa Cudal

Ms. Corazon Albino

(Facilitator) Ms. Eman Banjar

Ms. Ghada Makki

راث الطبيتفريق خذماث المختب

Laboratory & Blood Services

(Team Leader) Dr. Rana Bokhary

Ms. Mofida Tahlawi

Mr. Abdulrahman Al Malki

Mr. Raed Baeshen Ms. Dolorosa Marissa Cudal

Ms. Rania Damanhouri Mr. Essam Qinaai Subhi

Ms. Reham Al-baz Mr. Hamad Al-Shegifi

Ms. Sahar Mumenah Mr. Hashim Sindi

Mr. Sami A. Khan Ms. Jaya Xavier

Ms. Sara Al-Amoudi

Mr. Hussam Omar Al-Baz (Facilitator)

Mrs. Intisar Zakaria Habeeb

فريق مكافحت العذوى

Infection Prevention & Control Services

) (Team Leader Prof. Tariq Madani

Dr. Nabeela Abdullah (Deputy Team Leader)

Ms. Meliza Sanogal Dr. Budoor Al-Dosari

Ms. Noor Al-Dossary Mr. Abdullah Al-Huraybi

Ms. Roba Damanhouri Ms. Ghazala Perveen

Ms. Senaida Hadji Sohail Ms. Manal Ahmad Hasan

Ms. Suseela Israve Moni Ms. Marites Macapagal

Ms. Manju K Joseph (Facilitator)

فريق خذماث التعقيم

Reprocessing & Sterilization of Usable

Medical Devices

Ms. Ghazala Perveen

Dr. Maha Mahmoud Alawi

(Team Leader)

Ms. Soby Jose (Deputy Team Leader)

Dr. Mohammed Hasan Bangash

Ms. Laureana Filipinas

Ricafrente Engr. Ahmed Hatem Abuzinadah

Ms. Manal Ahmad

Hasan Mr. Abdulrahman Fageeh

Ms. Marites Macapagal Mr. Anfal Basheer

Mr. Mohammadu Saddy

Amanolla Ms. Arlene Joy Dela Cruz

Mr. Nasser Al-Ghatani Mr. Bilal Hosain

Mr. Rodolfo Suarez Ms. Charity Ancajas

Mr. Sadek Mohmmad Mr. Fayez Al-Malki

Ms. Crescencia Javonillo (Facilitator)

فريق غرف العملياث

Operating Room

(Team Leader) Dr. Mohammed Hasan Bangash

Dr. Amre Sami Hamdi (Deputy Team Leader)

Dr. Maha Mahmoud Alawi

Mrs. Darlene Dacumos

Mr. Mokhles Said Baker Hassan

Ms. Rasha Basheer Al-Shawa

Mr. Wael Mohammed Mohammed

|Ms. Eva Marie Quilllao

Ms. Corazon Albino (Facilitator)

فريق خذماث النساء و حذيثي الوالدة

Obstetrics Services

(Team Leader) Dr. Saad Al Saeedi

Dr. Nisreen Anfinan (Deputy Team Leader

Ms. Mervat Ali Sayed Dr. Ettedal Al Jahdali

Ms. Radhika Mukundan Dr. Maha Bamehriz

Ms. Rahab Al Harbi Ms. Hala Zakaria

Ms. Randa Aynoosa Ms. Haleema Dabroom

Ms. Somaya Baeissa Ms. Laly James

Ms. Vesare Julit Ms. Layla Al-Thubaity

Ms. Biji Thomas (Facilitator)

فريق اإلستعذاد للكوارث و الطوارئ

Emergency & Disaster Preparedness

Ms. Marites Macapagal Dr. Abdulghani Mustafa

Mr. Misbahuddin Khan Dr. Abdulmunem Mustafa

Mr. Mohammed Abdullah Dr. Ahmed S. Al Rowayshed

Mr. Mohammed

Abdulmajeed Dr. Ebtisam Ashari

Mr. Mohammed Balobaid Dr. Ghada Merdad

Mr. Othman Al-Yahyawy Dr. Nabeela Abdullah

Mr. Saeed Al-Shaikhy Eng. Abdullah Al-Jefri

Mr. Saleh Alqarni Eng. Ahmed H. Abuzinadah

Mr. Hussam Al-Baz

(Facilitator)

Eng. Saeed A. Al-Amoudi

Eng. Samir Abduljawwad

Mr. Abdurrahman Alqarni

Mr. Ali Ahmed Gissi Eng. Samir Abduljawwad

Mr. Abdurrahman Alqarni

Mr. Ali Ahmed Gissi

Mr. Anis Al-Ansari

Mr. Bander S. Almutairi

Mr. Hamad Al-Shegifi

Mr. Hamza Jalal

Mr. Ismail Aljarda

Dr. Hassan Simbawa (Team Leader)

Mr. Khalid Al-Saiari (Deputy Team Leader)

فريق خذماث الجراحت

Surgical Services

(Team Leader) Radi-Dr. Osman Al

Dr. Wail Tashkandi (Deputy Team Leader)

Ms. Catherine S.

Manangan Prof. Taha Abo-Almagd

Ms. Daisy Thomas Dr. Abdullah Krimly

Mr. Edwin Velasco

Dr. Abdulrahman Rabie

Abdulhalim

Ms. Irshad George Dr. Hanaa Tashkandi

Mr. Joey Escandor Dr. Maram Al-Khatieb

Ms. Rasha Basheer Al-

Shawa Dr. Mazen Wakka

Ms. Crescencia Javonillo

(Facilitator)

Dr. Nisar Haider Zaidi

فريق الحوكمت والقيادة

Governance & Leadership

Dr. Laila Al Tabsh Dr. Saeed Al-Ghamdi

Engr. Abdullah Al-Jefri Dr. Shadi Al-Khayyat

Engr. Hani Qadi Mr. Hussam Al-Baz

(Facilitator)

Engr. Ahmed Abuzinadah Dr. Norah Al-Khathlan

Mr. Saeed Al-Shaikhy Mr. Khalid Al-Saiari

Ms. Taghreed Reshwan Mr. Hassan Al-Shaikh

Mr. Hamdi El-Sayed Dr. Abdullah Bataweel

Ms. Iman M. J. Joaquin

(Asst. Facilitator)

Mr. Mohammed

Abdulmajeed

Prof. Mahmoud Shaheen Al-Ahwal (Team Leader)

Dr. Amro Mohammad Al-Hibshi (Deputy Team Leader)

أعضاء اللجنت اإلشرافيت العليا

Higher Supervisory Committee

مذير جامعت الملك عبذالعزيز أ.د. عبذالرحمن عبيذ اليىبً

President, KAU Prof. Abdulrahman Obaid Al-

Youbi

وكيل جامعت الملك عبذالعزيز أ.د. عبذهللا مصطفى مهرجً

Vice-President, KAU Prof. Abdullah bin Mustafa

Mohorjy

وكيل الجامعت للمشاريع أ.د. عبذهللا بن عمر بافيل

Vice-President for Projects,

KAU Prof. Abdullah bin O. Bafail

عميذ كليت الطب أ.د. محمىد شاهين األحىل

Dean, Faculty of Medicine Prof. Mahmoud Shaheen Al-

Ahwal

في وكيل كليت الطب المذير للمستش

الجامعي د. عمرو دمحم الحبشً

Vice-Dean University

Hospital Director Dr. Amro Mohammad Al-

Hibshi

نائب مذير المستشفي د. سعيذ دمحم الغامذي

Deputy Hospital Director Dr. Saeed Al-Ghamdi

المذير الطبي د. شادي سالم الخياط

Medical Director Dr. Shadi Al-Khayyat

مذير إدارة الجودة أ. حسام عمر الباز

Director of Quality Mr. Hussam Omar Al-Baz

. . . . . for each individual Self-Assessment Teams for the Accreditation

Canada International celebrating with happiness and contentment the

success of being re-accredited for the 3rd time with “Diamond’ Level and the

recognition for every team member and every staff who had a part in the

great achievement of the Hospital

Behind every successful endeavor in the Department of Quality in the hospital are individuals who

gives their all --- efforts, time, sacrifices not known to many but only to a few; who always stood

ground working as a Team coupling their work with sincere prayers and utmost hope of attaining

nothing else but victory in every challenge faced.

The Captain and his crew …..

Quality Department Celebration

On Tuesday 27th of Sep 2016 , Quality Department celebrate with the Quality Designees for effort and for their commitment in 2016 and appreciated the top 3 designees for the first half of 2016 , congratulations and wishing the best for others.

Training

On 24 ,26 , 28 of July 2016 , Quality Department conducted a compressive training about Occurrence Variance Reporting to the Nursing staff , 2 sessions a day covering 170 Nurses.

Instructors from Quality Department :

*Ahlam Alghanmi

*Crescres javonillo

*Corazon Albino

*Sana Aleiderous

On 9th of August 2016 , Root Cause Analysis ( 5 Whys ) for Quality Designees ( Bilingual ).

Instructor from Quality Department : Ahlam Alghan