Creation of the Quality Improvement Unit
This unit has been operating in the hospital since the end of June 89, according to the order of Mashhad University of Medical Sciences, and is currently located on the second floor of the second stage, under the direct supervision of the hospital director.
All the efforts of the Razavi Hospital in obtaining the highest degree of national accreditation are due to the assignment of this medical center to the Razavi Hospital, and the focus of the efforts of officials and workers in this hospital in achieving this noble goal of improving the level of services provided to patients and customers. During this planning, key measures were planned and implemented in line with the vision, mission and goals. The approach and focus on patient safety is continuous quality improvement and health promotion.
At present, national accreditation standards are being implemented in this unit to improve the quality of services and patient safety in line with the objectives of the Ministry of Health. Also other quality standards
• Integrated Management Standard – IMS (ISO9001, ISO18001, ISO14000
• ISO10015 training standard
• ISO50001 energy management standard
• ISO27000 information security management standard
• ISO22000 and HACCP health and food safety standards
• International accreditation standards
carried out to improve the quality of the organization.
The main activities of this unit are:
• Develop a strategic plan for the hospital under the guidance of the executive management team
• Developing operational plans for the hospital in line with the strategic plan and the overall objectives of the institution, with a focus on continuous improvement of quality and increasing patient safety.
• Define and disseminate the hospital mission statement at the hospital level
• Develop quality improvement programs with a focus on continuous quality improvement and increased patient safety
• Continuous monitoring of operational program progress and quality improvement
• Participate in the preparation of the hospital’s budget according to the operational plans and quality improvement with the partners of the financial unit
• Monitor data, management measures and interventions through analysis of Balanced Scorecard indicators and other hospital indicators
• Analysis of indicators and operational plans
• Develop important, specific, measurable, achievable and timely performance indicators to improve various hospital operations
• Satisfaction analysis of patients, companions, staff and stakeholders
• Collect information related to the general needs of the organization and prepare relevant reports for the concerned officials and managers
• Review and develop cost reduction strategies
In fact, in this process, in order to eliminate the shortcomings and defects of the system, the performance of the organization is systematically reviewed and information related to the general needs of the organization, including cost-cutting strategies, analyzed, scientific and practical solutions are collected in the form of supplementary reports to officials and senior managers proposes.
Document control and process modification
• Coding all hospital documents in accordance with the document coding instructions, supervising the review and distribution of documents, and collecting obsolete and obsolete documents according to the executive method for controlling documents.
• Designing hospital operations in accordance with the principles of quality improvement, monitoring organizational processes and making suggestions to improve organizational activities
• Preparing operational policies and methods and work instructions in the wards and units of the hospital in cooperation with the concerned officials and managers
• Developing a system for reporting medical and non-medical errors in the hospital in cooperation with the Occupational Safety and Health Unit
• Cooperating with the administrative unit experts in the field of performance appraisal and preparing job descriptions
• In another step, the Quality Improvement Unit in the internal audit at Razavi Hospital monitors the accuracy and organization of the implementation of standards. Rated internal visits are planned by this unit and regular reports of internal visits and evaluations are developed and presented to the concerned managers in order to improve the points that can be improved. In other words, the following activities are carried out for internal audit;
• Plan regular inpatient visits to the hospital
• Participate in the internal audit of the hospital in accordance with the applicable standards
• Prepare audit reports and follow up on corrective actions
• Compile regular reports for internal visits and evaluation
• Overseeing all hospital accreditation matters through HIS expert visits and quality improvement
Use collective wisdom
The basic requirement for sound management is to have a comprehensive and scientific view of various issues and the basic requirement for success of a manager is that he does not take decisions alone and the decisions taken are based on collective wisdom. An excellent decision is also made on the basis of collective wisdom and consultation.
The presence of former and current presidents of Mashhad’s medical universities, as well as intellectuals from the country’s medical community, in the meetings of faculty members in this complex has led to an increase in its scientific wealth.
Management and leadership meetings of the Razavi Hospital complex were held in the presence of all managers and senior officials in the executive units on a continuous basis according to the meeting schedule and based on accreditation standards and job descriptions, during which collective decisions were made after discussion and exchange of information. Point of views.
• Organizing regular monthly meetings with the focal points to improve quality
• Continuous supervision of the formation and implementation of hospital committee approvals in collaboration with the hospital committee committee
• Coordination and integration of quality improvement activities in the hospital
• Follow up and coordinate the implementation of hospital accreditation standards
• Convening a regular quality control and evaluation committee and management and leadership team in order to improve quality
Implement senior management style and leadership in the hospital
Another strategic objective for this is to implement a management and leadership style