Quality Improvement & Accreditation Programs



Quality Improvement & Accreditation



To provide hospital departments with continuous support in order to achieve hospital’s mission.



Seeking the integration of quality improvement, patient safety and risk management programs within the hospital quality culture, guided by evidence-based practice.


The Continuous Quality Improvement department provides the hospital with the framework to systematically measure and analyze performance, contribute essential information to management for decision-making and improve hospital functioning, structures and processes in order to improve outcomes for patients and hospital staff.


The department consists of the following sections:

1. Quality Improvement:

Data Collection on hospital-wide level, in-depth analysis by using sophisticated calculations to get information which will be used subsequently for further improvement. Moreover, close monitoring of hospital’s performance takes place as a proactive approach to prevent any deviation from hospital norms, and maintain good and sustained success based on national and international best practices.

A vast majority of statistical techniques have been utilized in analyzing data such as measurement of central tendency (mean, mode, and median)  as well as different charts in the data presentation (line graph, Pie Chart, Bar graph, scatter plot chart). Furthermore, we have developed our own electronic key performance indicators from the one hand as a commitment to continuous quality improvement, and on the other hand to keep development in the current era of rapid growth in information technology.


 2. Healthcare Risk Management:

Improving the quality and safety of healthcare services by identifying the circumstances and opportunities that put stakeholders at risk of harm, then acting to prevent or control those risks. By utilizing several methods in risk management such as Failure Mode and Effect Analysis (FMEA), Root Cause Analysis (RCA) and Risk Assessment.


Patient safety culture is our commitment, by utilizing an evidence-based approach to identify practices that are likely to improve patient safety with the involvement of leadership, staff, patients, and visitors in order to enhance the “speak up” practice.


 3. Prevention and Control of Infection:

The Prevention and Control of Infection Program support hospital mission and vision to promote patient safety by reducing the risk of healthcare associated infections (HAI).

Regular surveillance of healthcare associated infection, compliance with current and updated evidence-based guidelines, policies and procedures are the daily routine tasks of infection control.


4-Achieving Accreditation:

Accreditation is meant to ensure a safe environment for patients, health workers, outpatients and beneficiaries,get a high recognition from all stakeholders, as well as stress the commitment of health facilities to ongoing development, and to elevate its standard of care and instill confidence in the community it serves.


On November 10th, 2016, and for the third time in a row in three years, the hospital has earned the Re-certification of the Joint Commission hospital accreditation program granted by the Joint Commission International (JCI), who stands alone as a consistent beacon for patient Safety and Quality Improvement in the global community and recognized as the world’s pioneer in the Field of Health Facilities accreditation.


On June 7th, 2017, the hospital received accreditation from the Saudi Central Board for Accreditation of Healthcare institutions (CBAHI), who is the sole official agency authorized to grant accreditation certificates to all governmental and private healthcare facilities operating in the Kingdom of Saudi Arabia, after passing an assessment process that involved a comprehensive, rigorous, and transparent evaluation to determine the compliance of its systems, processes, and performance with the applicable predetermined and published national standards.


On March, 12th, 2018, and for the second time in a row, the hospital has once again earned the renewal of the International Food Safety Management Systems Certification - ISO 22000:2005 - for a new cycle of 3 years, which is recognized as one of the best systems in the world to ensure the food is safe and the entire processing cycle is sound.

On January 10th, 2019, and for the second time in a row, the accreditation committee of the College of American Pathologists (CAP), has awarded accreditation to the laboratory of Al Ahsa hospital, for a new cycle of 2 years, based on results of an on-site inspection, as part of the CAP's Accreditation Program.


Quality Improvement & Accreditation