461881

Continuous Performance Improvement

  • 19057
  • (202) 25351500, Ext. 3066

Core Functions

  • Aims to ensure that all the services that the Children’s Cancer Hospital 57357 provide concentrate on boosting and improving patient safety results, and implementing effective safety measures in all aspects of care, through the following:
    • Spreading and activating the patient safety culture in the Hospital, which depends on safety and prevention of mistakes.
    • Concentrating on performance improvement instead of blaming the employees
    • Encouraging the employees to be knowledgeable about safety, risks and prevention of mistakes.
    • Encouraging the employees to report mistakes and risks that affect patient care safety.

  • Incident reporting system
    • The main purpose is to obtain information about the facts that lead to damages to learn from them and avoid them in the future.
    • Proactive reporting of these facts and analyzing them enhances safety plan in all stages of care.
    • The goal of analyzing events is to determine ways of healthcare improvement.
    • Using a preventive system to help employees report any incident through an electronic system or a hard copy.

  • Patient safety culture
    • Safety culture is known as an integrated pattern of individual and organizational behavior that aims to reduce the damages that patient may be exposed to as a result of healthcare provision.
    • The Hospital plans to establish, support, implement, monitor and improve safety culture in line with the Hospital’s vision, mission, quality standards and accreditation requirements.

  • Healthcare internal audit
    • Quality specialists in 57357 perform daily follow up on all kinds of services provided to patients in all the units according to best international practices and standards and Hospital’s policies, to identify procedures / processes at risk.
    • The internal audit is the proactive monitoring of these procedures or processes to spot any mistakes in the care procedure in an effective manner, it is designed to cover all aspects of patient safety, such as:
      • National and International patient safety standards.
      • Medication safety.
      • Environmental safety.
      • Medical documentation.
      • Evaluating awareness of policies and general procedures.
      • All the specified results are collected to be analyzed then presented to the head of the concerned department and the upper management for correction.
  • The risk management is known as the systematic process of identifying, evaluating and handling potential and actual risks.
  • Risk management is a proactive job involving the application of procedures to reduce the repetition and intensity of unexpected accidents.
  • Risk management is an approach to improve the provided healthcare quality and safety through concentrating on identifying the circumstances that would expose patient to risk, and working on preventing these risks or controlling them.
  • Performance improvement is one of the important pillars for improving and developing work operations.
  • The performance improvement unit directs, plans, supports and follows up the quality improvement projects in the Hospital.
    • PDCA.
    • FMEA.
    • 6 Sigma (DMAIC, DMADV, DOE).
    • Lean (Gemba Kaizen, 6-S, Value Stream Mapping).
    • Business Process Re-engineering (BPR).
    • Agile, Scrum.

The unit aligns quality processes with international guidelines, our strong research foundation depends on two pillars:

  • Testing and implementing different medical and nonmedical activities through an evidence-based research framework.
  • Employing evidence to serve application.

  • Electronic health records, IT accreditation, increased availability of electronic health data, and improving data analysis technology lead to improving healthcare services provision.
  • The goal of having informatics is to collect effective data about healthcare quality, analyzing these data, and applying the results towards quality improvement programs.
  • Clinical documentation improvement program is a process designed to obtain precise and comprehensive documentation for medical records.
  • Document management system is an electronic system used to receive, follow up and save documents in a consistent and uniform manner, and reduce paper use.
  • The data management unit performs the collection and validation of the Hospital’s performance data through performance indicators aligned with strategic objectives.
  • The informatics quality section uses the digital transformation to reach the highest degree of quality, for example (process mining, inspection automation, and dashboard).
  • Revealed information from analyzing the Hospital’s indicators helps taking the ideal decision on the medical, administrational, and strategic levels.
  • The large amount of healthcare data leads to the emergence of the idea of “big data” in the field of healthcare; with the collection of more data, the upgrading of tools required to support analysis and preparation of reports continues, which enables us to gain more wisdom in decision making.
  • Program of directing newly hired employees.
  • The department participates in presenting two lectures: the first is about the national and international standards of patient safety as a general direction to help employees improve patient safety and care quality and reduce risks of medical mistakes, and the second is about quality concepts in CCHE 57357.

  • The Hospital’s quality courses.
  • The quality department coordinates with the nursing continuous education department, for a 30 hours quality course, including improving patient safety, data management, accreditation (the Joint Commission International JCI and the national accreditation GAHAR), healthcare quality basic concepts, facility management safety, tracking, auditing and project improvement tools.

  • The department’s own quality training program.

  • On-the-job training on tracking activities.


  • The data management unit performs collection and validation of the Hospital’s performance data through performance indicators aligned with strategic objectives.
  • Document management system is an electronic system used to receive, follow up and save documents in a consistent and uniform manner, and reduce paper use
  • Electronic health records, IT accreditation, increased availability of electronic health data and improving data analysis technology lead to improving healthcare services provision
  • The goal of having informatics is to collect effective data about healthcare quality, analyzing these data and applying the results towards quality improvement programs
  • Clinical documentation improvement program, is a process designed to obtain precise and comprehensive documentation for medical records
  • The informatics quality uses the digital transformation to reach the highest degree of quality, for example (process mining, Auditing automation, dashboard)
  • Revealed information from analyzing the Hospital’s indicators helps taking the ideal decision on the medical, administrational and strategic levels
  • The large amount of healthcare data leads to the emergence of the idea of “big data” in the field of healthcare; with the collection of more data, the upgrading of tools required to support analysis and preparation of reports continues, which enables us to gain more wisdom in decision making
  1. Internal training
  • Program of directing newly hired employees
    • The department participates in presenting two lectures: the first is about the national and international standards of patient safety as a general direction to help employees improve patient safety and care quality and reduce risks of medical mistakes, and the second is about quality concepts in CCHE 57357
  • The Hospital’s quality courses
    • The quality department coordinates with the nursing continuous education department, for a 30 hours’ quality course, including improving patient safety, data management, accreditations (the Joint Commission International JCI and the national accreditation GAHAR), healthcare quality basic concepts, facility management safety, tracking, auditing and project improvement tools
  • The department’s own quality training program
  • On-the-job training on tracking activities