ﺑﺮﻧﺎﻣﺞ ﺗﺤﺴﻴﻦ ﺟﻮﺩﺓ ﺍﻻﺩﺍﺀ ﺑﻤﺴﺘﺸﻔﻴﺎﺕ ﺟﺎﻣﻌﺔ ﻋﻴﻦ

ﺑﺮﻧﺎﻣﺞ ﺗﺤﺴﻴﻦ ﺟﻮﺩﺓ ﺍﻻﺩﺍﺀ ﺑﻤﺴﺘﺸﻔﻴﺎﺕ ﺟﺎﻣﻌﺔ ﻋﻴﻦ ﺷﻤﺲ Performance Improvement Program At Ain Shams University Hospitals By Prof. Mahi Al-Tehewy

Justification • Quality of service delivery has become an important focus of attention for every one employed in health care. • The national health reform policies in Egypt elaborated the pressing need and demand for a highly recognized quality improvement. • This has led Ain Shams University leaders to adopt a program to improve service delivery at Ain shams University hospitals.

• Accordingly, we reviewed the local quality initiatives and experiences and studied different quality approaches available to learn lessons. • Then we conducted situational analysis to formulate the basis for selecting strategic directions and Q policies

Background • ASUHs are consisted of 4 hospitals of totally 2780 beds. • The oldest hospital had been established in 1931 and has been exposed to several trials of renovation. • There about half million patients attending the outpatients clinics annually. • About 85 thousands patients admitted annually, most of them are very poor people. • 30 thousands surgical interference are done annually • In addition, there are three specialized centers, the first for mental health, the second for oncology and the third for clinical toxicology.

Objectives of situational analysis • Determine QI strategies & policies at ASUHs • Identify requirements for QI implementation.

Method • SWOT analysis was used as a simple tool for situational analysis of the internal and external environment of ASUHs. • Three-day workshop was done and attended by representatives of all stakeholders of healthcare (provided at ASUHs) • The workshop was facilitated by national quality experts.

Results of Situational Analysis I- Strengths • Strong Leadership commitment • High technology • Manpower

Situational Analysis I- Strengths • Manpower – Highly qualified and competent staff – Increasing interest in quality improvement among hospital leaders and some members of the medical staff – Presence of qualified persons capable of leading quality improvement programs

Situational Analysis II- Weakness • Manpower – Poor culture of quality – Some health leaders underestimate the value of quality and are skeptical about feasibility and effectiveness of its approaches in improving health services – Poor spirit of team work – High resistance to change – Few qualified human resources in quality

Situational Analysis II- Weakness • Undergraduate and postgraduate medical studies are lacking components about healthcare quality concepts and approaches • Training needs in healthcare quality are not clearly identified

Situational Analysis II- Weakness (cont. ) • Organization – Deeply rooted bureaucratic administrative approaches – Poor inter and intra-sectoral coordination – Dual role: being educational and service institutions (unclear organization) – Lack of managerial skills at all levels – Job descriptions are not available for all members of health teams. Moreover, what are available are not properly communicated between health team

Situational Analysis II- Weakness (cont. ) • Supply and Finance • Rules and regulation of incentives do not support quality improvement activities. • Bureaucracy of financing and methods of dispensing • Poor salaries of physicians and other members of health team • Preparing budget is not depending on real needs • Mal distribution of some resources • Scanty fund posts for quality

Situational Analysis II- Weakness (cont. ) • • • Poor maintenance Poor monitoring system Poor information system Poor infrastructure The problem of sustainability of activities

Situational Analysis III Opportunities • Political commitment • National standards for general hospitals are available now • Establishment of HSQ unit at Faculty of Medicine in 1999 • Starting establishment of the Center of Educational Quality and Accreditation at Ain Shams University

Situational Analysis III Opportunities (cont. ) • Many parties are interested in quality (national and international) • Availability of evidence based practice guidelines at no cost • Availability of quality measures and quality improvement projects at no cost

Situational Analysis IV Threats • Global Layer • Unstable exchange rate foreign currency • Globalization of the health sector by January 2005 will develop free market of healthcare, new competitive providers, firms or organizations for accreditation, unstudied rush of local facilities to be accredited by international organization

• TRIPS (Trade related aspects of intellectual property rights) will affect, drug market and medical supplies • The current legislations, or policies are unsufficient to protect the local healthcare market. • Vision of the authorities regarding how to face current and future threats is poorly communicated.

Situational Analysis IV Threats (cont. ) • Lack of quality culture • Lack of data culture • Low expectation of clients is considered as a threat to achieve optimum level of quality

Situational Analysis IV Threats (cont. ) Adjacent Layer - Powerful highly skilled professional international competitors are starting invading healthcare market in Egypt - Potential competitors are expected from everywhere for the big Egyptian market - Monopoly in the field of medical supplies and drugs especially after application of TRIPS

Strategic Goals • Ensure quality of healthcare delivered in ASUHs • Building up capacities for quality at all levels • Create and communicate culture of quality in ASUHs • Satisfy the needs and expectations of healthcare providers and consumers • Intra-sectoral coordination between different departments

Strategic Direction • Intensive strategies – Service development – Market development • Defensive strategies – Joining with others – Right sizing and down sizing • Decentralization • Diversification (low cost providers)

ﺳﻴﺎﺳﺔ ﺍﻟﺠﻮﺩﺓ ﺑﻤﺴﺘﺸﻔﻴﺎﺕ ﺟﺎﻣﻌﺔ ﻋﻴﻦ ﺷﻤﺲ ﺍﻟﺘﺄﺴﻴﺲ ﺍﻟﻬﻴﻜﻠﻰ ﻟﻠﺠﻮﺩﺓ Institutionalization of quality • • ﺗﻤﻜﻴﻦ ﻟﺠﺎﻥ ﺍﻟﺠﻮﺩﺓ ﻣﻦ ﺗﻨﻔﻴﺬ ﺧﻄﻄﻬﺎ ﻭﺃﻨﺸﻄﺘﻬﺎ ﻭﺩﻋﻤﻬﺎ ﺑﻜﺎﻓﺔ ﺍﻟﺼﻼﺣﻴﺎﺕ ﻟﻠﻮﺻﻮﻝ ﺇﻟﻰ ﺃﻬﺪﺍﻓﻬﺎ • ﺑﻨﺎﺀ ﺍﻟﻜﻮﺍﺩﺭ ﺍﻟﺒﺸﺮﻳﺔ ﻓﻰ ﻣﺠﺎﻝ ﺇﺩﺍﺭﺓ ﺍﻟﺠﻮﺩﺓ • ﺩﻋﻢ ﺍﻟﻤﺴﺘﺸﻔﻴﺎﺕ ﻟﻠﺘﻄﺎﺑﻖ ﻣﻊ ﺍﻟﻤﻌﺎﻳﻴﺮ • ﻧﺸﺮ ﺛﻘﺎﻓﺔ ﺍﻟﺠﻮﺩﺓ ﻭﺧﻠﻖ ﺇﺣﺘﻴﺎﺝ ﻟﺘﺤﺴﺴﻴﻦ ﺍﻟﺠﻮﺩﺓ ﺑﻴﻦ ﻣﻘﺪﻣﻰ ﻭﻣﺴﺘﺨﺪﻣﻰ ﺍﻟﺨﺪﻣﺔ

ﺳﻴﺎﺳﺔ ﺍﻟﺠﻮﺩﺓ ﺑﻤﺴﺘﺸﻔﻴﺎﺕ ﺟﺎﻣﻌﺔ ﻋﻴﻦ ﺷﻤﺲ • • • ﺍﻟﺘﻨﺴﻴﻖ ﺑﻴﻦ ﺍﻟﻘﻄﺎﻋﺎﺕ ﺩﺍﺧﻞ ﺍﻷﺪﺍﺭﺓ ﺍﻟﻤﺮﻛﺰﻳﺔ ﻟﻠﻤﺴﺘﺸﻔﻴﺎﺕ ﺍﻻﺗﺠﺎﻩ ﺍﻟﺘﺪﺭﻳﻴﺠﻰ ﺍﻟﻤﺪﺭﻭﺱ ﻧﺤﻮ ﺍﻟﻼﻣﺮﻛﺰﻳﺔ ﻓﻰ ﺍﻷﺪﺍﺭﺓ ﺗﻀﻤﻴﻴﻦ ﺍﻟﻤﻨﺎﻫﺞ ﺍﻟﺪﺭﺍﺳﻴﺔ ﺑﻜﻠﻴﺔ ﺍﻟﻄﺐ ﻭﺍﻟﺘﻤﺮﻳﺾ ﻟﻤﻔﺎﻫﻴﻢ ﺍﻟﺠﻮﺩﺓ ﺗﻘﻮﻳﺔ ﻭﺗﺪﻋﻴﻢ ﻧﻈﺎﻡ ﻗﻴﺎﺱ ﺃﻮﻣﺘﺎﺑﻌﺔ ﺫﺍﺗﻴﺔ ﻭﺧﺎﺭﺟﻴﺔ ﻣﺴﺘﻤﺮ ﻣﻜﺎﻓﺎﺀﺓ ﻭﺗﺤﻔﻴﺰ ﺍﻷﺪﺍﺀ ﺍﻟﻤﺘﻤﻴﺰ

Come to the challenge End of The First and Easy part

ﻋﺮﺽ ﻣﻠﺨﺺ ﻟﺘﺠﺮﺑﺔ ﻣﺴﺘﺸﻔﻰ ﺍﻟﺪﻣﺮﺩﺍﺵ

Performance Improvement Program • Goal Improving performance and quality of service delivery at ASUHs

Objectives: • 1 - Developing a sustainable system for managing quality • 2 - Improving effectiveness and efficiency of the service • 3 - Containment of Resources • 4 - Satisfaction of internal and external customers

Methodology: • 1 - Building up structure for quality – Higher Quality Council – Hospital Quality Committee – Quality Coordinator – Relevant Committees Starting date: Jan. 2004

Structure of quality Higher QC Central Q Manager Q Committee Hospital Q coordinator Relevant Committees

Methodology (cont. ) • 2 - Setting Standards – Task Force Group A group of experts (headed by the head of technical office) in different hospital functions formulated to review available national and international standards to adopt, adapt, clarify, and end up with welldefined quality standards for all functions of the hospital.

Methodology (cont. ) • 3 - Training of QC of Al. Demerdash and Maternity Hospitals (28 th Feb. -2 nd March)

Methodology (cont. ) • 3 - Communicate standards • 4 Awareness employees of all

• 5 Quality awareness among high and middlelevel leaders (Sonesta Hotel, 15 th March)

Methodology (cont. ) • 6 - Pilot study Implementation of QM at one hospital – Comprehensive Initial Assessment (guided by the settled standards) (20 -24 th March)

ﺍﻟﻤﻜﺎﻥ ﺍﻟﺪﻟﻴﻞ ﺍﻟﻤﻮﺿﻮﻋﻲ ﺭﻗﻢ ﺍﻟﻤﻌﻴﺎﺭ CSS. D Observation And interview D 2. 2. 15 Biological test results are not available CSS. D Observation and interview D 2. 2. 4 The pressure of A. C is not negative D 2. 2. 8 Date of sterilization not motioned. D 2. 2. 4 Workers in CSSD not wear proper protection devices There is no sufficient antiseptic, nor known proper % of dilution CSS. D Observation and interview D 2. 2. 10 Observation and interview D 2. 1. 12 & 13 D 2. 1. 14 CSS. D ﺗﻔﺎﺻﻴﻞ ﺣﺎﻟﺔ ﻋﺪﻡ ﺍﻟﻤﻄﺎﺑﻘﺔ Staff not trained on all items of I. C and so these is no a lost of training courses No Infection control policies

Methodology (cont. ) – Q I Plan • Priority assessment • Establish the projects for improvement • Diagnose the cause • Remedy the cause • Hold the gain (monitoring system) - Plan of action

ﻣﻠﺨﺺ ﺗﻘﺮﻳﺮ ﻣﻨﺴﻖ ﺍﻟﺠﻮﺩﺓ ﻣﺎﻳﻮ 4002

ﺍﻟﺘﻄﺒﻴﻖ ﺍﻟﻌﻤﻠﻰ ﻟﻠﺠﻮﺩﺓ ﺩﺍﺧﻞ ﺍﻟﻤﺴﺘﺸﻔﻰ • ﻣﺮﺣﻠﺔ ﻣﺎ ﺑﻌﺪ ﺍﻟﺪﻭﺭﺓ ﺍﻟﺘﺪﺭﻳﺒﻴﺔ – ﺍﺟﺘﻤﺎﻉ ﻟﺠﻨﺔ ﺍﻟﺠﻮﺩﺓ – ﺗﻮﻋﻴﺔ ﺍﻟﻌﺎﻣﻠﻴﻦ ﺑﺄﻬﻤﻴﺔ ﺍﻟﺠﻮﺩﺓ ﻭﻣﻔﻬﻮﻡ ﺍﻟﺠﻮﺩﺓ – ﺍﺟﺘﻤﺎﻋﺎﺕ ﻣﻊ ﺟﻤﻴﻊ ﺭﻭﺅﺴﺎﺀ ﺍﻷﺪﺍﺭﺍﺕ ﻟﻤﻨﺎﻗﺸﺔ ﺍﻟﻤﻌﺎﻳﻴﺮ – ﻣﺤﺎﻭﻟﺔ ﺍﻟﺘﻄﺎﺑﻖ ﻣﻊ ﺑﻌﺾ ﺍﻟﻤﻌﺎﻳﻴﺮ – ﺗﺸﻜﻴﻞ ﺍﻟﻠﺠﺎﻥ

ﺍﻟﺘﻄﺒﻴﻖ ﺍﻟﻌﻤﻠﻰ ﻟﻠﺠﻮﺩﺓ ﺩﺍﺧﻞ ﺍﻟﻤﺴﺘﺸﻔﻰ )ﺗﺎﺑﻊ( • ﻣﺮﺣﻠﺔ ﺍﻟﺘﻘﻴﻴﻢ • ﻣﺮﺣﻠﺔ ﻣﺎ ﺑﻌﺪ ﺍﻟﺘﻘﻴﻴﻢ – ﺗﺤﺪﻳﺪ ﺍﻷﻮﻟﻮﻳﺎﺕ ﺑﻨﺎﺀ ﻋﻠﻰ ﺗﻘﺮﻳﺮ ﻋﺪﻡ ﺍﻟﺘﻄﺎﺑﻖ – ﺗﻔﻌﻴﻞ ﺍﻟﻠﺠﺎﻥ ﺣﺴﺐ ﺍﻷﻮﻟﻮﻳﺎﺕ – ﻣﺘﺎﺑﻌﺔ ﺗﻮﺻﻴﺎﺕ ﺍﻟﻠﺠﺎﻥ

ﺃﻨﺸﻄﺔ ﻟﺠﻨﺔ ﺍﻟﺠﻮﺩﺓ • • • )ﺣﺘﻰ ﺗﺎﺭﻳﺨﺔ( ﻣﺘﺎﺑﻌﺔ ﻭﺿﻊ ﺍﻟﺴﻴﺎﺳﺎﺕ ﻭ ﺍﻷﺠﺮﺍﺀﺍﺕ ﺑﺎﻷﻘﺴﺎﻡ ﺗﻌﺪﻳﻞ ﺳﻠﺴﻠﺔ ﺃﺠﺮﺍﺀﺍﺕ ﺩﺧﻮﻝ ﺍﻟﻤﺮﻳﺾ ﺟﺎﺭﻯ ﺗﻌﺪﻳﻞ ﻣﺴﺎﺭ ﺗﻮﺯﻳﻊ ﺍﻟﻮﺟﺒﺎﺕ ﻋﻠﻰ ﺍﻟﻤﺮﺿﻰ ﺃﺴﺘﺤﺪﺍﺙ ﻧﻈﺎﻡ ﺗﺴﻠﻴﻢ ﺍﻟﻔﻮﺍﺭﻍ ﺍﻟﻌﻤﻞ ﻋﻠﻰ ﺃﻨﺸﺎﺀ ﻭﺣﺪﺓ ﺟﺪﻳﺪﺓ ﻟﻠﺴﺠﻼﺕ ﺍﻟﻄﺒﻴﺔ

• ﺗﻘﺪﻳﻢ ﺃﻘﺘﺮﺍﺡ ﺑﻌﻤﻞ ﺍﻟﺘﺤﺎﻟﻴﻞ ﺍﻷﺴﺎﺳﻴﺔ ﻟﻠﻤﺮﺿﻰ ﺍﻟﺬﻳﻦ ﺳﻮﻑ ﻳﺘﻢ ﺣﺠﺰﻫﻢ ﺑﺎﻟﻤﺴﺘﺸﻔﻰ ﻣﻦ ﺧﻼﻝ ﺍﻟﻌﻴﺎﺩﺓ ﺍﻟﺨﺎﺭﺟﻴﺔ )ﻭﺫﻟﻚ ﻟﺘﺤﺴﻴﻦ ﺩﻭﺭﺓ ﺍﻷﺴﺮﺓ ﻭﺧﻔﺾ ﺗﻜﺎﻟﻴﻒ ﺍﻷﻘﺎﻣﺔ ﻭﺗﻘﻠﻴﻞ ﻣﻌﺪﻝ ﺍﻟﻌﺪﻭﻯ(. • ﺟﺎﺭﻯ ﻣﺮﺍﺟﻌﺔ ﻣﻌﺎﻳﻴﺮ ﺍﻟﺪﺧﻮﻝ Criteria for admission ﻭﻓﺘﺮﺓ ﺃﻘﺎﻣﺔ ﺍﻟﻤﺮﻳﺾ ) (LOS ﻻﺩﺭﺍﺟﻬﺎ ﺿﻤﻦ ﻧﺸﺎﻁ ﻣﺮﺍﺟﻌﺔ ﺍﻻﺳﺘﺨﺪﺍﻡ • ﺗﺼﻤﻴﻢ ﺃﺴﺘﺒﻴﺎﻥ ﻟﻘﻴﺎﺱ ﻣﺪﻯ ﺭﺿﺎﺀ ﺍﻟﻤﺮﺿﻰ ﻭﺍﻟﻌﺎﻣﻠﻴﻦ ﻋﻦ ﺍﻟﺨﺪﻣﺔ

ﺗﻔﻌﻴﻞ ﻟﺠﻨﺔ ﻣﺮﺍﺟﻌﺔ ﺍﻷﺴﺘﺨﺪﺍﻡ • ﻣﺮﺍﺟﻌﺔ ﺃﺴﺘﺨﺪﺍﻡ ﺍﻟﺸﺎﺵ ﻭﺍﻟﻘﻄﻦ )ﺗﻌﺪﻳﻞ ﺳﻠﺴﻠﺔ ﺃﺠﺮﺍﺀﺍﺕ ﺍﻟﺼﺮﻑ ﻭﺍﻟﺘﺠﻬﻴﺰ( • ﻣﺮﺍﺟﻌﺔ ﺍﺳﺘﺨﺪﺍﻡ ﺍﻟﻤﻨﻈﻔﺎﺕ • ﻣﺮﺍﺟﻌﺔ ﺃﺴﺘﺨﺪﺍﻡ ﻏﺮﻑ ﺍﻟﻌﻤﻠﻴﺎﺕ

ﺗﻔﻌﻴﻞ ﻟﺠﻨﺔ ﺍﻟﺪﻭﺍﺀ ﻭﻣﺮﺍﺟﻌﺔ ﺍﺳﺘﺨﺪﺍﻣﻪ • ﺗﺤﺪﻳﺪ ﻗﺎﺋﻤﺔ ﺍﻷﺪﻭﻳﺔ ﺍﻷﺴﺎﺳﻴﺔ ﻟﻜﻞ ﻣﻦ: – ﻗﺴﻢ ﺍﻟﻄﻮﺍﺭﺉ – ﺍﻟﻌﻨﺎﻳﺔ ﺍﻟﻤﺮﻛﺰﺓ – ﺍﻟﺘﺨﺪﻳﺮ • ﻭﺿﻊ ﺳﻴﺎﺳﺔ ﺍﺳﺘﺨﺪﺍﻡ ﺍﻟﻤﻀﺎﺩﺍﺕ ﺍﻟﺤﻴﻮﻳﺔ – ﻭﺿﻊ ﺑﺮﻭﺗﻜﻮﻝ ﺃﺴﺘﺨﺪﺍﻡ ﺍﻟﻤﻀﺎﺩﺍﺕ ﺍﻟﺤﻴﻮﻳﺔ – ﺗﻮﺻﻴﺔ ﺑﺸﺮﺍﺀ ﺩﻳﺴﻜﺎﺕ ﺍﻟﻤﺰﺍﺭﻉ ﺑﺎﻟﻤﻨﺎﻗﺼﺔ – آﻠﻴﻪ ﻟﻀﻤﺎﻥ ﺗﻮﻗﻴﻊ ﻃﺒﻴﺐ ﺍﻟﻤﻌﻤﻞ ﻋﻠﻰ ﻧﺘﻴﺠﺔ ﺍﻟﻤﺰﺍﺭﻉ

ﺗﻔﻌﻴﻞ ﻟﺠﻨﺔ ﻣﻜﺎﻓﺤﺔ ﺍﻟﻌﺪﻭﻱ • • • • ﻣﺴﺢ ﺗﻤﻬﻴﺪﻯ ﻟﻤﻜﺎﻓﺤﺔ ﺍﻟﻌﺪﻭﻯ ﺗﺪﺭﻳﺐ ﻋﻤﺎﻝ ﺍﻟﻨﻈﺎﻓﺔ ﻭﺗﺪﺭﻳﺐ ﺍﻟﺘﻤﺮﻳﺾ ﻭﺿﻊ ﺳﻴﺎﺳﺎﺕ ﻭﺇﺟﺮﺍﺀﺍﺕ ﻣﻜﺎﻓﺤﺔ ﺍﻟﻌﺪﻭﻱ ﺗﻮﻓﻴﺮ ﻗﻔﺎﺯﺍﺕ ﺳﻤﻴﻜﺔ ﻟﻠﻌﺎﻣﻠﻴﻦ ﺗﺨﺼﻴﺺ ﻏﺮﻑ ﻋﺰﻝ ﻭﺿﻊ ﺳﻴﺎﺳﺎﺕ ﺍﻟﻌﺰﻝ ﺍﺳﺘﺤﺪﺍﺙ ﻧﻤﻮﺫﺝ ﻟﻠﺘﺒﻠﻴﻎ ﻋﻦ ﻋﺪﻭﻯ ﺩﺍﺧﻞ ﺍﻟﻤﺴﺘﺸﻔﻰ ﻣﺸﺮﻭﻉ ﺗﻄﻌﻴﻢ ﺍﻟﻌﺎﻣﻠﻴﻦ ﺿﺪ ﺍﻷﻠﺘﻬﺎﺏ ﺍﻟﻜﺒﺪﻯ ﺍﻟﻮﺑﺎﺋﻰ ﺏ

ﺗﻔﻌﻴﻞ ﻟﺠﻨﺔ ﺍﻟﺴﺠﻼﺕ ﺍﻟﻄﺒﻴﺔ • • • ﺗﻌﺪﻳﻞ ﺗﺬﻛﺮﺓ ﺍﻟﻄﻮﺍﺭﺉ ﺗﻌﺪﻳﻞ ﺗﺬﻛﺮﺓ ﺍﻟﻌﻴﺎﺩﺓ ﺍﻟﺨﺎﺭﺟﻴﺔ ﺗﻌﺪﻳﻞ ﺗﺬﻛﺮﺓ ﺍﻟﻤﺮﻳﺾ ﺍﻟﺪﺍﺧﻠﻰ ) ﻧﻤﺎﺫﺝ ﻟﻠﻤﻌﻤﻞ – ﺍﻷﺸﻌﺔ – ﺍﻷﺴﺘﺸﺎﺭﺍﺕ ﺍﻟﻄﺒﻴﺔ- ﻛﺎﺭﺕ ﺍﻟﻤﺘﺎﺑﻌﺔ( ﺍﺳﺘﺤﺪﺍﺙ ﻧﻤﻮﺫﺝ ﻣﻠﺨﺺ ﺧﺮﻭﺝ ﺍﻟﻤﺮﻳﺾ ﺃﺴﺘﺤﺪﺍﺙ ﻧﻤﻮﺫﺝ ﺑﻴﺎﻧﺎﺕ ﺍﻟﻤﺮﺍﻓﻖ ﺍﺳﺘﺤﺪﺍﺙ ﻧﻤﻮﺫﺝ ﺣﺎﺩﺙ ) (Incident report

ﺗﻔﻌﻴﻞ ﻟﺠﻨﺔ ﺍﻟﺘﺪﺭﻳﺐ • ﺍﺳﺘﻄﻼﻉ ﺍﺣﺘﻴﺎﺟﺎﺕ ﺍﻷﻘﺴﺎﻡ ﺍﻟﺘﺪﺭﻳﺒﻴﺔ • ﺗﺤﺪﻳﺪ ﺍﻷﻮﻟﻮﻳﺎﺕ ﺍﻟﺘﺪﺭﻳﺒﻴﺔ. – ﻣﻜﺎﻓﺤﺔ ﺍﻟﻌﺪﻭﻯ – ﺗﺪﺭﻳﺐ ﺍﻟﻤﻬﻨﺪﺳﻴﻦ ﻋﻠﻰ ﺍﻟﺼﻴﺎﻧﺔ ﺍﻟﻮﻗﺎﺋﻴﺔ – ﺍﻟﺘﺪﺭﻳﺐ ﺍﻷﺴﺎﺳﻰ ﻓﻰ ﺍﻟﺘﻤﺮﻳﺾ ﺍﻟﺠﺮﺍﺣﻰ ﺑﺎﻟﺘﻌﺎﻭﻥ ﻣﻊ ﻛﻠﻴﺔ ﺍﻟﺘﻤﺮﻳﺾ. • ﺍﻟﻌﻤﻞ ﻋﻠﻰ ﺗﻔﻌﻴﻞ ﺑﺮﺍﻣﺞ ﺍﻟﺘﺪﺭﻳﺐ ﺍﻟﻤﺴﺘﻤﺮ ﻟﺠﻤﻴﻊ ﻓﺌﺎﺕ ﺍﻟﻌﺎﻣﻠﻴﻦ ﺑﻤﺎ ﻓﻴﻬﻢ ﺍﻷﻄﺒﺎﺀ ﺍﻟﻤﻘﻴﻤﻴﻴﻦ

ﺍﻟﺒﺪﺀ ﻓﻰ ﺗﻔﻌﻴﻞ ﻟﺠﻨﺔ ﺍﻟﺼﻴﺎﻧﺔ • ﺃﺴﺘﺤﺪﺍﺙ ﻧﻈﺎﻡ ﺍﻟﻤﺮﻭﺭ ﺍﻟﻴﻮﻣﻰ ﻣﻦ ﻗﺒﻞ ﺍﻟﻘﺴﻢ ﺍﻟﻬﻨﺪﺳﻰ • ﺗﻌﺪﻳﻞ ﻣﺴﺎﺭ ﺃﺠﺮﺍﺀﺍﺕ ﺍﻟﺼﻴﺎﻧﺔ ﺍﻟﺪﻭﺭﻳﺔ

ﺟﺎﺭﻯ ﺗﻔﻌﻴﻞ ﺍﻟﺠﺎﻥ ﺍﻻﺗﻴﺔ • ﻟﺠﻨﺔ ﺍﻟﺸﻜﺎﻭﻯ ﻭﺍﻟﻤﻘﺘﺮﺣﺎﺕ • ﻟﺠﻨﺔ ﺍﻟﻮﻗﺎﻳﺔ ﻣﻦ ﺍﻟﻤﺨﺎﻃﺮ ﻭﺻﺤﺔ ﺍﻟﻌﺎﻣﻠﻴﻦ • ﻟﺠﻨﺔ ﻣﺸﺎﺭﻛﺔ ﺍﻟﻤﺠﺘﻤﻊ • ﺍﻟﺘﻨﺴﻴﻖ ﻣﻊ ﻟﺠﻨﺔ ﺍﻟﻮﻓﻴﺎﺕ ﻭﺍﻟﻤﻀﺎﻋﻔﺎﺕ ﺍﻟﻤﺮﻛﺰﻳﺔ ﻭﺗﻔﻌﻴﻞ ﻟﺠﻨﺔ ﻟﻠﻤﺴﺘﺸﻔﻰ

ﺍﻟﻤﻌﻮﻗﺎﺕ • ﻣﻌﻮﻗﺎﺕ ﺇﺩﺍﺭﻳﺔ • ﻣﻌﻮﻗﺎﺕ ﻣﺎﻟﻴﺔ • ﻣﻌﻮﻗﺎﺕ ﺑﺸﺮﻳﺔ

• ﻳﻮﻧﻴﻮ 4002 ﻗﺎﻣﺖ ﻭﺣﺪﺓ ﺍﻟﺠﻮﺩﺓ ﺑﻤﺘﺎﺑﻌﺔ ﻣﺎﺗﻢ ﺇﻧﺠﺎﺯﺓ ﻓﻰ ﻧﻘﺎﻁ ﻋﺪﻡ ﺍﻟﺘﻄﺎﺑﻖ ﺑﺎﻟﺘﻌﺎﻭﻥ ﻣﻊ ﻟﺠﻨﺔ ﺍﻟﺠﻮﺩﺓ ﺑﺎﻟﻤﺴﺘﺸﻔﻰ • ﻟﻀﻤﺎﻥ ﺍﻷﺴﺘﻤﺮﺍﺭﻳﺔ ﺗﻢ ﺍﻷﺘﻔﺎﻕ ﻋﻠﻰ ﺃﻦ ﺗﻘﻮﻡ ﻟﺠﻨﺔ ﺍﻟﺠﻮﺩﺓ ﺑﺎﻟﻤﺴﺘﺸﻔﻰ ﺑﻌﻤﻞ ﻣﺘﺎﺑﻌﻪ ﻧﻘﺎﻁ ﻋﺪﻡ ﺍﻟﺘﻄﺎﺑﻖ ﻛﻞ ﺷﻬﺮ ﻭﺗﻘﻴﻴﻢ ﺩﺍﺧﻠﻰ ﻛﻞ 3 ﺃﺸﻬﺮ ﻭﺗﻘﺪﻳﻢ ﺗﻘﺮﻳﺮ ﻟﻠﺠﻨﺔ ﺍﻟﻌﻠﻴﺎ ﻟﻠﺠﻮﺩﺓ

• • ﻓﻰ ﻧﻘﺲ ﺍﻟﺸﻬﺮ )ﻳﻮﻧﻴﻮ 4002 ( ﺗﻢ ﺍﻟﺘﻘﻴﻴﻢ ﺍﻟﻤﺒﺪﺋﻰ ﻟﻤﺴﺘﺸﻔﻰ ﺍﻟﻨﺴﺎﺀ ﻭﺍﻟﺘﻮﻟﻴﺪ ﻓﻰ ﻳﻮﻟﻴﻮ 4002 ﺗﻢ ﺗﺪﺭﻳﺐ ﻟﺠﻨﺔ ﺍﻟﺠﻮﺩﺓ ﺑﻤﺴﺘﺸﻔﻰ ﻋﻴﻦ ﺷﻤﺲ ﺍﻟﺒﺎﻃﻨﻰ ﻓﻰ ﺩﻳﺴﻤﺒﺮ 4002 ﺗﻢ ﺍﻟﺘﻘﻴﻴﻢ ﺍﻟﻤﺒﺪﺋﻰ ﻟﻤﺴﺘﺸﻔﻰ ﻋﻴﻦ ﺷﻤﺲ ﺍﻟﺒﺎﻃﻨﻰ ﻧﻼﺣﻆ ﺃﻦ ﻫﺬﺍ ﺍﻟﺘﻮﺳﻊ ﻗﻰ ﺍﻟﺘﻄﺒﻴﻖ ﻟﻢ ﻳﺘﺢ ﺍﻟﻔﺮﺻﺔ ﻟﻤﺘﺎﺑﻌﺔ ﺗﺠﺮﺑﺔ ﺍﻟﺪﻣﺮﺩﺍﺵ ﻋﻦ ﻗﺮﺏ