Quality & Patient Safety

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We believe that quality and safety go hand in hand. We are dedicated to provide a healing environment that embraces quality care, promotes health and safety, and delivers the best possible patient experience. We take our commitment to patient safety seriously, by following proven best practices and processes that decrease harm to both our patients and team members.

Indeed, the Royal Hospital has established the leadership and organizational infrastructure to ensure the safety, efficiency and high standard patient care to be a core of everyday practice of all employees. This has created an organization-wide awareness and culture that supports the hospital’s goal towards quality and patients’ safety.


Quality & Patient Safety Sections

  1. Patient safety and Risk Management section
  2. Accreditation section
  3. Performance Improvement section
  4. Accreditation section

Quality & Safety Measures

Nothing is more important than making sure our patients get the right care at the right time in the right way-every time. Our dedicated doctors, nurses, and staff constantly review our processes for continual improvement, introducing new ideas and implementing best practices. To standardize the process we continuously track and monitor the quality of care we provide using a number of evidence-based patient safety measures or indicators.

Our Quality Priorities

  1. Healthcare Associated Infection
    1. Hand Hygiene Compliance Score by Healthcare workers
    2. Central Line-associated Bloodstream Infection in intensive care units (ICUs)
    3. Catheter-associated Urinary Tract Infections (CAUTI) in ICUs
    4. Ventilator Associated Pneumonia (VAP) in ICUs
  2. Surgical/ Procedure Related Complications
    1. Rate of complications after surgery
    2. Rate of complications after invasive procedures e.g endoscopy, cardiac catheterization …etc
  3. Mortality and morbidity Rates
  4. Other Complications
    1. Fall Rate
    2. Pressure Ulcer Rate
  1. Sepsis and Septic Shock
    1. Complains with Sepsis Bundles
    2. Time from sepsis recognition to antibiotics admistration
    3. Mortality rate in septic shock patients
  2. Monitor Operation Theater patient flow
  3. Monitor In-patients flow
  4. Track the Revisit to ERs and Readmission Rate to wards
  5. Monitor compliance with antibiotics stewardship
  1. Monitor the number of patient-safety incidents and near misses that are reported
  2. Monitor the rate of unreported patient-safety incidents using IHI screening tool
  3. Monitor the percentage of admitted patients risk assessed for venous thromboembolism (VTE)

The Royal Hospital patient experience vision is to aspire into providing an outstanding Patient Experience.

For that three aims and four strategic targets were set by the Royal Hospital Patient experience committee.

The aims for the PX committee are:

  1. Exploring what patients and their families want.
  2. Identifying the key-points that can improve the experience of patients and families.
  3. Empower patients to be actively involved in their treatment. Because of that,several types of surveys and tools were developed to collect the patients' feedback and assess the quality of services provided and areas of improvements from patients' perspective. These include but not limited to; anonymous surveys that assess the hospital as a whole and each and every specialty, meeting patients and their families in patients focused groups and listen to their feedback and stories, patient experience and leadership rounds, mapping the patient's journey and identifying the gaps and even calling patients after their discharge to get their feedback.

The patient experience committee since its formation in 2019 has kept four main strategic targets at sight.

  1. Develop both staff and patient's awareness and create culture of patient experience in Royal Hospital.
  2. Improving effective Communication skillsbetween health care service providers and patients and their families.
  3. Establish maintainable accessible and well-coordinated care. For which the PX committee is working closely with the performance improvement unit and quality department.
  4. To develop The Royal Hospital volunteering program (RHVP).It started by recruiting health care workers from The Royal Hospital to volunteer in helping to bridge the gap in communication between families and admitted COVID-19 patients during the pandemic.
  5. The patient experience opts for adding a strategic coproduction target which aims to include major non-profit societies and the community as partners in developing, planning and improving the services provided in Royal Hospital.

“SPEAK UP” for Safety

Every member of staff from the most senior clinician to the most junior are expected to speak up about patient safety concerns to help intercept errors and avoid adverse patient outcomes. By ‘speaking up,’ we mean raising concerns for the benefit of patient safety and quality of care upon recognizing or becoming aware of a risk or a potential risk.

Quality & Patient Safety Achievements

  1. Implementing the lean strategy and qualifying a number of employees as Lean champions
  2. Obtaining Accreditation Canadian International (ACI)
  3. Launching the leadership program in and training a number of staff
  4. Establishing Patient Experience Program Implementation
  5. Implementing the monitoring and follow-up policy for morbidity and mortality cases
  6. Applying the risk management strategy and forming a committee to deal with these matters
  7. Achieving ISO accreditation for the laboratory sections

Quality & Patient Safety Awards

  1. GCC Patient Experience Summit - Patient Experience Excellence Award (Government) - (2018)
  2. IHF/Dr Kwang Tae Kim Grand Award: Royal Hospital (Oman): Implementation of Lean in a Tertiary Care Public Hospital (2019)
  3. GCC Human Resource Excellence Award - Change Management (2019)
  4. IHF Beyond the Call of Duty for COVID-19 - Royal Hospital recognition (2020)