Quality Management Department

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This page is a free sample showing what a hospital policy should look like. It can work at your place, you might need to modify it a little. The hospital here is HOSPITAL X. You might need to change that to your own institution name.



Code / Policy No:


Edition No:






Date reviewed:

Feb 2020

Approved date:

Feb 2020

Effective date:

Feb 2020

Due for review:

Feb 2022

Applies to:





Achieve and maintain the integrity and continuous improvement of the quality system and risk management in a “patient-centered approach" and to satisfy patient’s needs and expectations according to the region's health laws and accreditation bodies requirements.


"The Quality Management Department of HOSPITAL X seeks to ensure the disseminating of the quality, safety and customer services culture throughout the hospital, to promote, quality of care, ensure patient and staff safety and decrease potential risks as per national and international standards."



The Quality Management Department aims to establish a culture where the customer is always the focus of the operation and that quality is the responsibility and objective of all employees at all levels.

The external customers of Quality Management Department are as follows:
  1. 1
    Accrediting Bodies
  2. 2
    National Inspecting Bodies
  3. 3
    Big companies contracts and other companies.
  4. 4
    Quality Departments from sister hospitals
  5. 5
    Patient and their families
  6. 6
    Visiting organization (company, embassy representatives, etc.)
The internal customers are as follows:
  1. 1
    Hospital Board of Owners and executive board members
  2. 2
    Hospital Administration and hospital directors
  3. 3
    Heads of the Departments (Medical and non-medical)
  4. 4
    Departmental Ql Officers (Medical and non-medical)
  5. 5
    Medical, nursing, non-medical, allied health employees
  6. 6
    Hospital committees’ chairmen, members
  7. 7
    Support Services like Infection Prevention & Control Department and Safety, Loss & Prevention Department [SLPD) among others


  1. 1
    Patient Safety
Establish the patient safety system in the hospital by following the requirements of the accrediting bodies.
  1. 2
    Document Management
  • Policy and procedure development coordination.
  • Ensures the consistencies of all written dated policies and procedures reflect the current professional knowledge and principles of each service area, department and function.
  • Ensures that there is evidence of compliance with existing laws, regulations policies and procedures.
  1. 3
    Risk Management
  • Identifies risk and adverse events through occurrence variance reporting, sentinel event, patient complaints and other data sources.
  • Coordinates collection internal and external data on potential hospital risk and reports the analysis and investigated findings of the hospital's actual and potential risk to the Quality Management and Patient Safety Committee (QPS), medical staff, administration and the respective department.
  • Accountability and corrective measures for incidents most often involve educational functions of all the hospital about Risk Management (Occurrence Variance Report, and Sentinel Event evaluation, Root Cause Analysis and performance improvement).
  1. 4
    Monitoring Patient Satisfaction
Monitors corrective actions taken based on the patient satisfaction surveys (inpatient & outpatient) done by the social worker and PRO.
  1. 5
    Monitoring Staff Satisfaction
Facilitates staff satisfaction survey hospital-wide, endorses survey report and recommendation to hospital directors, heads of the departments and monitors the corrective actions taken based on the staff satisfaction surveys.
  1. 6
    Continuous Education Training
Enforces the Quality improvement and patient safety culture through design and deliver the proper continuous education/training by formulating a standard educational matrix applicable to different hospital staff categories.
  1. 7
    Accreditation Coordination
Facilitates the overall accreditation preparation of the hospital and coordinates activities of the accreditation task force teams who are working through the self-assessment process using the international  standards.
  1. 8
    Monitoring Committees Performance
  • Assigns a Quality Management staff representing the department in all hospital-wide regular monitoring committees as member (co-chairman, regular member, facilitator or secretary).
  • Receives the minutes of all approved committee meetings and facilitates provisional & final scheduling, agenda and activities per committee and facilitates annual function review per committee. QM staff will be responsible of the meeting minutes if assigned as facilitator or secretary of a certain committee.
  1. 9
    Clinical Audit Program
  1. Develops and monitors clinical and managerial indicators, KPl’s, International Library of Measures to support the quality improvement efforts.
  2. Clinical Record Review
    Some medical record of selected cases will be reviewed and find out the medical necessity for admissions, severity of illness and discharge criteria to assure the appropriate, cost-effective use of hospital resources, continued stays and services rendered. The Utilization Management addresses over utilization, underutilization, inefficient utilization of resources, in addition to some cases that can be referred to the focus review process.
  1. 10
    Credentialing and Privileging
  1. Ensures only qualified medical staff are hired by and is working in the hospital 
  2. Facilitates the activities of Credentialing and Privileging Committee
  1. 11
    Construct a Communication Chart
  1. Reports all Ql activities to the hospital directors and heads of the departments and QMPS Committee.
  2. Summarizes all performance indicators and analysis graphs and sheets in a quarterly report to the hospital directors and QMPS Committee.
  3. Prepares clinical audit monthly and quarter reports for analyzing and follow up of improvement action based on results.
  4. Reviews Occurrence Variance Report (OVR) from all departments.
  5. Reviews hospital wide Sentinel Events.
  6. Facilitates the display of storyboards, performance indicators and analysis graphs to respective areas/ units per monthly/ quarterly/ annually.
  7. Validates reports from the departments including from Infection Prevention and Control and Safety.
  1. 12
    Departmental Committees and Meetings
Coordinates and facilitates departmental meetings and other ad-hoc meetings as needed. QM department receives the minutes of all departmental meetings for referrals/ endorsement of departmental issues related to mortality & morbidity, quality management & patient safety, infection prevention & control, environment of care (EOC) among other concerns and for documentation purposes.
  1. 13
    Supporting Services
Works collaboratively with all relevant departments and considers itself an extension to all the hospital entities.


Quality Management Director, Manager and Supervisor, Quality Management Coordinators
for: Risk Management, Clinical Audit, Credentialing & Privileging, Committee & Training, and Manual & Indexing.
QM Department coordinates with the Departmental QI Officers including Nursing QI Coordinators with Nursing QI Unit Officers to convey the message to all departments.


Official working hours are from 08:00 AM to 04:00 PM every Saturdays to Thursdays, having Fridays off.