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INTRODUCTION
Hospitals play an important role in promoting health, preventing disease and
providing rehabilitation services. The health care requirements are rapidly
changing based on the following changes:
 The increasing prevalence of lifestyle-related health problems
 Chronic diseases require a more expanded scope and systematic provision
of activities such as therapeutic education, effective communication
strategies to enable patients to take an active role in chronic disease-
management or motivational counseling.
 Changing public expectations
 An increasing number of patients requiring continuous support
 Staff frequently being exposed to physical and emotional strains require
hospitals to incorporate a health promotion focus as a key service for
patients and staff.
 In addition, hospitals impact on health not only through the provision of
prevention, treatment and rehabilitation services of high quality, but also
through their impact on the local environment.
• Healthcare facilities standards are
statements that define the key functions,
activities, processes and structures and
systems required for organizations to be
in a position to provide quality services
and as they are determined by
professional and regulatory bodies,
health care professionals, staff, patients
and citizens.
• Hospitals these days strive to provide
preventive and promotive health care
strategies to achieve patient and staff
satisfaction.
• Using innovative measures to attain and
sustain positive outcome of the hospital
processes has become the key target.
• Hospitals started adopting the implementation
of evidence based practices to establish firm
foundation for work processes.
• Using of internal and external bench marking
for assessment of improvement has become a
trend.
MEASURING PERFORMANCE
THE KEY TO SUCESSFUL MEASURING OF
PERFORMANCE LIES IN THE EFFECTIVE
METHODS OF DATA COLLECTION,
ANALYSIS AND PROVIDING EVIDENCE
BASED CONCLUSIONS
Measures of quality
What are the Basic Seven Tools of
Quality?
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
0
20
40
60
80
100
120
Sepsis/septicemia/septicshock
Pneumonia
CKD/ARFwithcomplications
RTA
Headinjury
MI
Burns
Birthasphyxiawithcomplications
CLDwithcomplications
Postsurgerydeath
Fractures
AF/VF/SVT
Cardiacshock/arrest
HIV
Intestinalobstruction
respiratoryfailure
Nosheet
Gaucherdisease,activebleeding…
GullianBarreSyndrome
INFECTIVEENDOCARDITITIS
Metabolicdisorder
PatientnotfoundinMedicaplusand…
PeripartumDCMP
Rabis&viralencephalitis
UTI
Total
Cum percentage
80% marker
77
77
47
63
79
63
59
69
18
49
68
82
86
65
59
54 55
80
29
63
0
10
20
30
40
50
60
70
80
90
100
Moharrum Safar R. Awal R. Thany J. Awal J. Thany Rajab Shabaan Ramadan Shawwal
SURGICAL CANCELLATIONS 1436 & 1437
Cancellations 1436 Cancellations 1437
1436 cancellations percentage: 29.24%
1437 cancellations percentage: 32.56%
0
5
10
15
20
25
30
1 2 3 4 5 6 7 8 9 10 11 12
Chart Title
CLABSI Mean 1 sigma (- 1 sigma)
2 sigma (- 2 sigma) 3 sigma (- 3 Sigma)
Quality and patient safety intro
Quality and patient safety intro

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Quality and patient safety intro