🏆 Amyaz Award for Healthcare Excellence
Hospital Criteria - Eastern Region | Ministry of Health - Saudi Arabia
🏛️ Governance & Leadership
Weight: 20%1 A strategic plan with valid date, implemented and addresses the health organization's 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 strategic 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 A strategic plan: Objectives (goals) Include patient safety, organization'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 and strategy maps). If there is no clear evidence of the criterion, the entire criterion = zero.
3 Structured leadership Walkrounds program addressing patient safety improvement / initiatives.
CEO senior leaders perform patient safety measures walk rounds, 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.
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 facility 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: Prioritizing citizen staffing requirements and specific qualifications.
The organization must have documented evidence that indicates Prioritizing citizen staffing requirements and specific qualifications. This indicator measures the number of Saudis working in the hospital. ((Number of Saudis working in the hospital / Total employees in the hospital) * 100 A staffing policy is a strategic framework that guides how an organization hires, manages and places its employees. Attach (شهادة التوطين) certificate from Human Resources and Social Development
7 Manpower: Formulate an associated Saudi staffing, recruitment and retention plan.
The percentage of Saudi employees who left the hospital over the last 12 month.
8 Safe Staffing Levels (SSL); Nursing ratio requirement. The hospital complies with the minimum nurse staffing standards in all clinical areas at all times according to Saudi healthcare system
Safe staffing is achieved when an appropriate number of health workers are always available across the continuum of care with the correct education, skills/competence, and experience to deliver safe patient care. The evidence is definitive. For example: 1:3 patients or fewer for (Emergency Room and for Cardiac Coronary Unit) / 1:2 patients for (Adult Intensive Care Unit/Cardiovascular Intensive Care Unit and for Pediatric Intensive Care Unit) / 1:6 patients Antenatal Ward: latent phase/induction area)
9 Nurse Participation in Hospital Affair
Attachment of different committees formation order
10 Nursing Recognition Program (Magnet, Nurse-Friendly Hospital)
Approved or certificate in the process of recognition
👥 Customer/Beneficiary Services
Weight: 30%11 Patient Experience Measurement Program: Presence of focused improvement project, initiated from the program
The organization 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.
12 Percentage of closure within the recommended time 48 hours
Percentage of 937 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 satisfaction about closure of customer complaints of different sources (937 & reception disk complaint, social media … etc) 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 Reported Customer abuse against the health facility or 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 Adherence to the guiding framework for dealing with reports: Compliance rate with the guiding framework for dealing with complaints.
Patients and their families have a great understanding of their needs and have their perspective on the expected level of health care provided in a healthcare facility. A proper complaint management system can assist in answering number questions related to safety and quality of care. There is clear policy and clear presentation of the standards (an office, phone number, on line, web site) for customers related to Ministry of Health complaint policy to Increase customer satisfaction with the service provided. Attach clear and complete proof and evidence
16 violations and convictions: Number of institutional violations according to Private Health Institutions Law.
Improper conduct, Negligence or Default issued against health institution. (The committee, mentioned is meant to look into Violations, negligence, or dereliction against a healthcare facility. 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 facility to which they belong or even will be raised to higher health authority.
17 violations and convictions: Number of hospital healthcare providers violation
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 facility to which it belongs. Improper conduct, Negligence or Default issued against health care workers Attach clear and complete proof and evidence
18 Number of improvement projects or processes implemented based on beneficiary feedback
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. Attach clear and complete design/ details of the projects.
📊 Performance & Sustainability
Weight: 20%19 Recognition, Licensing and accreditation: National / International accreditations obtained by the Hospital.
An accredited organization demonstrates that it has met departmental standards. If there is no clear evidence of the criterion, the entire criterion = zero. (Attach valid accreditations certificate obtained by the hospital)
20 Recognition, Licensing and accreditation: Accredited post graduate SCFHS training program; established and maintained.
If there is no clear evidence of the criterion, the entire criterion = zero.
21 Recognition, Licensing and accreditation: Accredited research protection program (IRP), Establish and maintain a facility-based Research Ethics Committee.
If there is no clear evidence of the criterion, the entire criterion = zero.
22 Recognition, Licensing and accreditation: Published scientific article, by the organization or one of its employees in the past 12 months.
Attach a copy of published articles / website of the Journal/ research. With clear evidence of the employee name.
23 Recognition, Licensing and accreditation: Number of training courses conducted by the organization over 12 months.
If there is no clear evidence of attendance at all training courses with names, the full criterion = zero. (Attach training course schedules, accreditation numbers, and evidence of submitting and attending training programs)
24 Recognition, Licensing and accreditation: Employees trained by the facility on quality and patient safety/infection control tasks and skills.
(Attach the number and names of employees trained and the quality training programs are clear and evidence of providing and attending the training programs)
25 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.
26 Active agreements with non-profit organizations. (Attach a copy of each agreement)
The hospital provide evidence of its leadership support and contributions for needy patients through Non-profit organizations. If there is no clear evidence, the full criterion = zero.
27 Number of national initiatives, events, and campaigns in which the facility has participated (Attach a copy of the participation certificates.)
one per quarter, equivalent to 4 contributions over 12 months during the current year. If there is no clear evidence of the criterion, the entire criterion = zero.
28 Amount of financial support provided to charitable organizations (Attach the name of the organization and the amount of support)
If there is no clear evidence, the full criterion = zero.
29 Medical staff members have current delineated clinical privileges, Documented evidence of implementing best practice.
If there is no clear evidence, the full criterion = zero.
30 The hospital has an employee wellbeing program
How hospitals can improve the well-being of their workers, according to the World Health Organization recommendations for the vital role healthcare workers
31 The hospital has Wellbeing Trigger (burnout) and mental health evaluation
Hospital support staff well-being formulated wellbeing committee
🛡️ Patient Safety
Weight: 30%32 Percent of drills completed from the total number of the (11) required drills.
Hospital drills, also known as emergency exercises, are supervised activities designed to test and improve a hospital's emergency response plans and procedures. The required information to be uploaded is Percentage of completed simulation exercises (Drill) done for each code during the year. Attach clear and complete proof and evidence
33 Sentinel Event Reporting and Management Policy Supporting safe reporting Closure rate of improvement plans for OVR
employee safety reporting of sentinel events under a just culture policy ensures a culture where errors are disclosed without fear of blame, focusing on continuous improvement and preventing future harm. There is evidence of implementation of approved CAPs in MOH Sentinel Events Platform. Exclusion of other improvement plans (approved from surveys or walkrounds) Attach clear and complete proof and evidence
34 Hospital Safety Index
The Hospital Safety Index is a tool that is used to assess hospitals' safety and vulnerabilities, make recommendations on necessary actions, and promote low-cost/high-impact measures for improving safety and strengthening emergency preparedness.
35 In-hospital Mortality Rate
Total number of deaths in the Emergency Department in the month, number of patients with disposition as LAMA or DAMA / total number of discharges in the Emergency Department in the month x 100
36 Hospital compliance rate with the highest-risk standards
An index that measures the extent to which hospitals adhere to risk assessment standards that aim to raise the level of patient safety and avoid the identified harms (safety, fairness in providing services, patient-centered services, efficient, effective, and timely services). Attach clear and complete proof and evidence