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AL AHSA HOSPITAL - a new concept of care


Quality Improvement & Accreditation Programs



Quality Improvement and Patient Safety (QIPS) & 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 Quality Improvement and Patient Safety 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 to improve patient and hospital staff outcomes.


The QIPS 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. Patient Safety & Healthcare Risk Management:


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


In a spirit of constant improvement of the quality of healthcare services provided to the patients and their families, the hospital launched the National Patient Safety Platform "SAWTAK", in collaboration with the Saudi Patient Safety Center and RLDatix.


Sawtak is a proactive, interactive system that prevents the recurrence of events and utilizes safety data as a learning tool to improve overall patient safety and reduce the cost.


The Sawtak platform contains four main units: incidents reporting unit, Patient experience unit to follow-up the patient complaints and suggestions, mortality unit, and legal claims unit, and definitely, this platform will place Al Ahsa hospital on the national database to facilitate the benchmarking at the national level.


3. Infection Prevention and Control:


The Infection Prevention and Control Program supports the hospital mission and vision to promote patient safety by reducing the risk of healthcare-associated infections (HAIs). Regular surveillance of healthcare-associated infection, compliance with current and updated evidence-based guidelines, policies, and procedures are the daily routine infection prevention, and control tasks.


* Achieving Accreditation:

It is noteworthy to mention that achieving accreditation ensures a safe environment for patients, visitors, and staff,raises the level of quality and safety of health services, ensures patient safety and the development of professional health and administrative performance in health facilities, and instills the community confidence in its services.


On October 20th, 2020, and for the second time in three years and after passing an assessment 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, the hospital was awarded re-certification from the Saudi Central Board for Accreditation of Healthcare Institutions (CBAHI)- the sole official agency authorized to grant accreditation certificates to all governmental and private healthcare facilities operating in the Kingdom of Saudi Arabia.


On October 25th, 2019, and for the fourth time in three years, the hospital was awarded re-certification from the Joint Commission Hospital Accreditation Program granted by the Joint Commission International (JCI).


The JCI is recognized as a world leader in healthcare quality improvement, and this accreditation grants the hospital a competitive advantage by strengthening the alliance with our community and delivering high recognition from all our stakeholders.


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 two years. Based on the results of an on-site inspection as part of the CAP's Accreditation Program, our hospital became one of around 8,800 CAP-accredited facilities worldwide.


On March 12th, 2020, the certification body of TUV NORD conducted the 2nd annual on-site surveillance audit, which was successfully completed with zero non-compliances, and the hospital once again earned the certification confirmation of the International Food Safety Management Systems-ISO 22000:2018.


The ISO 22000:2018 is recognized as one of the world’s leading systems to ensure food safety and that the entire processing cycle is sound. The standards are continuously updated with the latest international food safety methods and implemented in all our practices and training sessions, including procurement, storage, food preparation, service, and quality assurance.


Quality Improvement & Accreditation