🏥 Amyaz Award for Healthcare Excellence
Health Centers & Polyclinics Criteria - Eastern Region | Ministry of Health - Saudi Arabia
🏛️ Governance & Leadership
Weight: 20%1 A strategeic / operational plan with valid date , implemented and addresses the poly clinic vision and mission, objectives, analytic tools , show associated traceable measures to the strategic plan; activities to achieve the objectives performance are being accomplished.
Strategy complies with ministry of health stratigic goals. Strategy generally involves setting goals and priorities, determining actions to achieve the goals, and mobilizing resources to execute the actions. Shaping the strategy with the future. Whether the developers and implementers are making decisions consistent with the current national policies.
2 Context of the poly clinic Objectives Include patient safety, poly clinic's risk and quality goals. Appropriate progress and success performance measures have been established against the strategic plan and improvement efforts.
Strategic planning is a process and thus has inputs, activities, outputs and outcomes. Sitting objectives should include patient safety. Analytical tools (PESTLE, SWOT analysis, Growth-share matrix, Balanced scorecards or strategy maps). If there is no clear evidence of the criterion, the entire criterion = zero.
3 Structured leadership Walkrounds/ meetings program addressing patient safety improvement / initiatives.
CEO senior leaders perform patient safety measures walk rounds / meetings, as leaders establish open and transparent communication with front line staff, fostering an environment where safety concerns are identified, discussed, and acted upon collaboratively. If there is no clear evidence of the criterion, the entire criterion = zero.
4 Board of Directors meetings /excutive committee meetings.( addressing patient safety efforts and Focused Improvement projects patient safety).
Board meetings reporting to /chaired by Chief Executive Officer (CEO) are documenting patient safety discussions during periodic meeting agenda or minutes. Board members also review performance data, patient satisfaction scores, and incident reports to identify trends and opportunities for improvement. If there is no clear evidence of the criterion, the entire criterion = zero.
5 Continuous comprehensive quality indicator system that reports the progress of strategic plans according to the time frame.
Data is collected at the Polyclinic level, The presence of systematic, data-guided activities designed to bring about the progress of the plan according to the proposed schedule. If there is no clear evidence of the criterion, the entire criterion = zero.
6 Manpower: Periotizing citizen staffing requirements and specific qualifications.
The poly clinic must have documented evidence that indicates Periotizing citizen staffing requirements and specific qualifications. Saudization rate in the private sector. This indicator measures the number of Saudis working in the private sector. (Number of Saudis working in the private sector / Total employees in the private sector) * 100 A staffing policy is a strategic framework that guides how a poly clinic hires, manages and places its employees Attach (التوطين) certificate from Human Resources and Social Development.
7 Formulate an associated Saudi staffing recruitment and retention plan .
The percentage of employees who left the poly clinic over the last 12 month.
8 Safe Staffing Levels (SSL); Nursing ratio requirement. The poly clinic complies with the minimum nurse staffing standards in all clinical areas at all times according to Saudi healthcare system
Safe staffing for nurses in an outpatient polyclinic involves ensuring an appropriate number of nurses with the correct skills and experience are available to meet the needs of the patient population, considering the volume of patients and the complexity of their conditions. This ensures safe, effective, and efficient healthcare delivery. In primary care settings, nurse-to-patient ratios can range from 1:10 to 1:20, depending on patient volume and needs. If there is no clear evidence of the criterion, the entire criterion = zero.
9 Nurse Participation in clinical A?air
Clinical decision-making, from patient assessment and implementing care plans( health education sessions, nurses participate in developing policies, advocating for patients, and collaborating with other healthcare professionals to ensure optimal outcomes. Presence of different nursing committee's)
10 Nursing competency policy : Documented evidence of presence of competency for all nurses
A core competency of nursing is "the ability to practice nursing that meets the needs of clients cared for using logical thinking and accurate nursing skills".
👥 Customer/Beneficiary Services
Weight: 30%11 Patient Experience Measurement Program. Presence of focused improvement project, initiated from the program
The poly clinic implements mechanisms to gather, review, and utilize patient and family opinion about the health services provided. Patient experience is a process that reflects the interpersonal aspects of quality of care received. Attach clear and complete detailed proof (e.g. patient regular survey)and evidence =2 attach an example of a project =2
12 Report Closure of 937 complaints within 48 hours Index Percentage of closure within the recommended time 48 hours
Percentage of complaints resolved within 48 hours from time it was filed/submitted by patient family or others resolution was communicated to the patient/ family/other Numerator: Number of Complaints resolved within 48 hours from filing/submission to communication of resolution over total number of complaints Denominator : Total number of complaints received
13 937 Report Closure Satisfaction Index Overall Satisfaction with complaint resolution
Not only the closure of 937 notification, it is the decision for improvement . Numerator: Complaints who received a (satisfied, very satisfied) scoring on its resolution/ outcome by the patient/family/others Denominator : Total number of complaints received
14 937 Reports of abuse Reports of Customer abuse against Polyclinic employee over the last 12 months.
Any report or complaint that includes verbal or physical abuse or expulsion of the beneficiary. Ministry of health indicator for the number of reports of abuse is calculated monthly (in the monitoring mechanism, one number per month).
15 Care of Persons with Disabilities: Mowaamah certificate from Ministry of Human Resource and Social Development
Developing work environment standards for people with disabilities and making them available electronically through an automated program (platform) called "Mowaamah." These standards allow establishments wishing to develop their work environment to be accessible to people with disabilities to evaluate themselves based on these standards.
16 Number of institutional violations (from the committee in the branch of MOH) according to Private Health Institutions Law.
Improper conduct, Negligence or Default issued against health instution . (The committee, mentioned is meant to look into Violations, negligence, or dereliction against Polyclinic. These include professional violations committed by medical staff, with penalties imposed by the Health Administration Violations Review Committee). Violations committed by medical and administrative staff are punished by the Polyclinic to which they belong or even will be raised to higher health authority. Attach clear and complete proof and evidence
17 Number of healthcare providers violation against any staff member of the polyclinic.
Improper conduct, Negligence or Default issued against healthcare profession. (The committee, mentioned is meant to look into violations of the healthcare professions practice. Professional violations committed by the medical staff, the penalty will be imposed by the Committee for Reviewing Violations of the Health Administrative violations committed by the medical and administrative staff, the penalty will be imposed by the Polyclinic to which it belongs. Improper conduct, Negligence or Default issued against health cae workers Attach clear and complete proof and evidence
18 Number of improvement projects or processes implemented based on beneficiary feedback
Number of improvement projects or processes that have been implemented and are based on beneficiary feedback. (Monitoring mechanism: number of projects affecting the patient experience survey element, divided by the total number of projects for every 6months) Attach clear and complete design/ details of the projects.
📊 Performance & Sustainability
Weight: 20%19 Recognition, Licensing and accreditation .Accreditations obtained by the poly clinic
An accredited poly clinic demonstrates that it has met departmental standards. If there is no clear evidence of the criterion, the entire criterion = zero (Attach the valid accreditations granted to the Polyclinic)
20 Recognition, Licensing and accreditation: Number of training courses conducted by the poly clinic over 12 months for the current year.
If there is no clear evidence of attendance at all training courses with names, the full criterion = zero. (Attatch training course schedules, accreditation numbers, and evidence of submitting and attending training programs)
21 Recognition, Licensing and accreditation: Employees trained by the Polyclinic on quality and patient safety/ tasks and skills.
(attach the number and names of employees trained and the quality/ patient safety training programs are clear and evidence of providing and attending the training programs)
22 Recognition, Licensing and accreditation: Percentage of administrators trained in safety .programs
If there is no clear evidence of attendance at all training courses with names, the full criterion = zero.
23 Active agreements with non-profit societies or organizations for sick and needy patients (Attach a copy of each agreement)
Non-profit organizations and societies play a crucial role in providing support for sick and needy individuals, often through active agreements and collaborations. Active agreement with community charities to help the sick and needy people is of value in community support ( If there is no clear evidence , the full criterion = zero).
24 Number of national initiatives, events, and campaigns in which the Polyclinic has participated (Attach a copy of the participation certificates.)
1 per quarter, equivalent to 4 contributions over 12 months during the specified year. If there is no clear evidence of the criterion, the entire criterion = zero.
25 Electronic Medical Records
Ducoment of digital version of the medical charts in the clinician's office
26 Integrated Health System
All services provided in a single system. (Attach the name of the system/program and the activation date.
27 Active Cybersecurity Protection Program
It must have specific policies and processes that demonstrate its compliance with current and future health information and cybersecurity regulatory requirements. It must establish a secure arrangement for sharing data between third parties, including the patient. If there is no clear evidence , the full criterion = zero.
28 Medical staff members have current delineated clinical privileges, Documented evidence of implementing best practice
If there is no clear evidence, the full criterion = zero.
29 The Polyclinic has an employee wellbeing program
How poly clinic can improve the well-being of their workers, according to the World Health Organization recommendations for the vital role healthcare workers, to give an example done during 2024
30 The Polyclinic has a policy for an employee safe complaint reporting program
The program should ensure that employees can report safety concerns without fear of retaliation or negative consequence, it should be accessible method for employees to voice their concerns and for the organization to address potential issues.
🛡️ Patient Safety
Weight: 30%31 Clinical warning system policy: A written policy outlines the management of clinical alarms, including setting alarm parameters and alarm escalation procedures.
Clinical alarm life cycle includes the pathway for alarms of abnormal results in vital signs, lab or X ray results, which include: alarm generation, transmission, identification and response; thereby enhancing patient safety
32 Clinical warning system policy: Evidence of reviewing and monitoring compliance with the clinical alarm system policy at least monthly, with a corrective action plan.
This involves tracking performance indicators, conducting audits, and documenting any non-compliance or areas needing improvement.
33 Clinical warning system policy: Example of flow charts for following and for measuring vital sign each visit
Evidence of measuring vital signs for adult patients
34 Polyclinic KPIs for Monitoring Internal Processes: Ratio of ( sentinel events ) over the total number of OVR,s reported in the facility.
Error Rate: This rate measures the number of mistakes( wrong patient identification, BP measurement , vital signs, made by staff in poly clinic when treating a patient that was reported appropriately reflecting the presence of JUST culture.
35 Polyclinic KPIs for Monitoring Internal Processes: Cancellation Rate (%) = (Number of Missed Appointments ( no show) / Total Number of Appointments) * 100
Cancellation Rate: This is a KPI for outpatient clinics . If a patient misses a scheduled appointment, or schaduled procedure. Measure this value over time so you can address the issues and improve the attendance via a designed system/ proceedure .
36 Patient education materials and audiovisual health education
Documents of different examples( pdf, and screens in waiting areas.
37 Medical Waste Management: There is a valid medical waste management contract.
Committee Formation Order and Terms of reference of the infection prevention and control committee, and minutes of at least 6 meetings
38 Medical Waste Management: An assigned infection control officer with clear job description and tasks.
Assigment order and approved Job description.
39 Medical Waste Management: Membership of (the infection conrtol officer and/or a staff trained nurse) in the committee of infection prevention and control committee.
Committee Formation Order.
40 Infection Control: ratio of Employees that have been trained on the infection control system.
To ensure a safe and healthy environment by equipping its workforce with the knowledge and skills to prevent and control infections. This training likely covers various aspects of infection control, such as hand hygiene, personal protective equipment, and proper cleaning and disinfection procedures. If there is no clear evidence, the full criterion = zero.
41 Infection Control: There is a central sterilization room, separate from other clinics and compliant with resources.
presence of separate room or area for sterilization
42 Infection Control: Percentage of employee with BICSL certificate.
Number of health care employee with Bicsll certificate / total number of healthcare employee *100
43 Infection Control: Clear policy for Infection Prevention and Control.
Policies and procedures are based on MOH guidelines.
44 Never events in medical clinic standards: Sentinel Events and Root Cause Analysis Policy
Adverse events that occur with medical treatment can include medication side effects, injury, psychological harm or trauma, or death. Adverse events can be either preventable or unpreventable and are often associated with medication errors. The list of reportable adverse events include: Surgical events - wrong patient, wrong site, wrong procedure, retained foreign body. Product/device related - contaminated products, air embolism. Patient protection events - patient elopement, suicide. Care management issues - medication errors, mismatched blood transfusion. Environmental factors - burn, electric shock, wrong gas. Criminal events - sexual assault, impersonation, physical assault
45 Never events in medical clinic standards: Documented Just Culture Training: personnel are comfortable disclosing errors, including their own
Adverse events that occur with medical treatment can include medication side effects, injury, psychological harm or trauma, or death. Adverse events can be either preventable or unpreventable and are often associated with medication errors. The list of reportable adverse events include: Surgical events - wrong patient, wrong site, wrong procedure, retained foreign body. Product/device related - contaminated products, air embolism. Patient protection events - patient elopement, suicide. Care management issues - medication errors, mismatched blood transfusion. Environmental factors - burn, electric shock, wrong gas. Criminal events - sexual assault, impersonation, physical assault