Quality Department

Quality Department




Since Established ALJ Hospital has been firmly committed to providing quality care. The Quality and outcomes measures are applied for monitoring patient’s progress, program evaluation and improvement of services.

Quality in Rehabilitation is differs from other health sectors:

  • Not directed at arresting pathology but on improvement in function and quality of daily living.
  • Usually involves a waiting period for admission and process of selection based on various criteria.
  • Average length of stay longer.
  • Does not end with discharge but can last for a lifetime.



To guide all components of the organization towards obtaining clients outcomes of the highest quality and providing excellent rehabilitation services that meet or exceed the expectations of our clients.


To be the leader in advocating high quality medical rehabilitation services in Saudi Arabia through compliance with legislative regulations and accreditation standards.



Safety: Committed to community and providing high standard safe and effective rehabilitative services.

Customer Focus: Committed to understanding and responding to the needs and expectations of our clients.

Team work: Seeks to achieve consistency of purpose, participation and effort to everyone across the units and disciplines through the organization.

Outcomes: Improvement in performance in all aspects of service.


Our concept is to enhance and maintain optimal patient care delivery through objective assessment of important aspects of patient care and the correction of identified problems.
Patients deserve nothing less than the best quality humanly possible, good just is not enough.


Accreditation is a “seal of approval” given by a private, independent group such as the JCI (Joint Commission International), CARF (Commission on Accreditation for Rehabilitation Facilities). Health care organizations must meet national standards of patient care-including clinical performance measures-to be accredited.

In order to improve Quality, ALJ Hospital for medical rehabilitation has initiated an accreditation process with CBAHI (Central Board for accreditation of Health Care Institutions). CBAHI Standards is derived form JCI, has a mission to apply the quality standards in all health care institutions in the kingdom.

ALJ Hospital for medical rehabilitation will be the first rehabilitation hospital to be accredited with CBAHI in the kingdom.


Clinical indicators are increasingly being used to assess and improve the quality of health care. It is increasingly acknowledged on an international level that the development and use of clinical indicators can positively influence clinical practice.


A clinical indicator is defined as a measure of the clinical management and / or outcome of care.

Indicators are best seen as measures that screen for a particular event.

A well-designed indicator should ‘screen’, ‘flag’ or ‘draw attention’ to a specific clinical issue. Usually rate based, indicators identify the rate of occurrence of an event. Indicators do not provide definitive answers; rather they are designed to indicate potential problems that might need addressing, usually demonstrated by statistical outliers or variations within data results. They are used to assess, compare and determine the potential to improve care. Indicators can therefore be used as a tool to assist in assessing whether or not a standard in patient care is being met.


Accessing regular and current information on processes and outcomes of health care. * Trending data over time and benchmarking with peers.
Utilizing comparative reports in conjunction with a quality improvement program to provide evidence of how an Organization is monitoring and evaluating patient care.
Accessing documented evidence of improved management and examples of improved patient outcomes, and Utilizing indicators to support change and improvement.
The quality improvement program includes monitoring the performance with regards to the patients outcomes and include but is not limited to :

  • All direct patient care services and indirect services affecting patient health and safety.
  • Functional Gain Achieved
  • Medication error
  • Utilization review
  • Nosocomial infection
  • Policy Development
  • Patient/Staff satisfaction surveys
  • Patient complaints
  • Professional staffing credentialing & privileging
  • Medical Record Review (include active and close record review)
  • Risk management activities
  • Morbidity review
  • JCI international safety goals
  • Injury rate
  • Fall Rate
  • Occurrence variance reporting
  • Patient &Family education
  • Staff education


The Quality Improvement Model used in ALJ Hospital is FOCUS –PDSA Cycle, This model was selected because it is simple and can be understood by the multicultural staff that will be using it. It is effective and incorporates the continuous cycle of improvement to which the organization is committed.

FOCUS- PDSA (Plan- Do- Study- Act)

F: Find – an opportunity for improvement
O: Organize – a team
C: Clarify – the current process
U: Understand – the sources of the problem and the process variation
S: Select – the improvement (a change)
P: Plan – the improvement
D: Do – the improvement
Study – the results (is the change an improvement)?
A: Act -to hold the gain

The Measures/Indicators of any quality improvement activity should reflect improvement in one or more of the following Dimensions of Quality:

  • Efficacy
  • Appropriateness
  • Availability
  • Timeliness
  • Effectiveness
  • Continuity
  • Safety
  • Efficiency
  • Respect + Caring (rights)


Falls are a serious health risk for all patients in hospital. They are significant source of disability and death in older persons as well as a serious threat to their psychological and physical health.

Falls happen because of a complex interaction of intrinsic and/or extrinsic factors. Interventions also require a multi-faceted approach.

A comprehensive falls prevention program will include an assessment of many factors by a team of professional, with interventions that address a variety of approaches that will help most patients as well as tailored for individual patient needs. A falls program should be oriented to both reducing falls and reducing injuries.

In ALJ Hospital Fall Prevention is a high priority area for improvement, we believe that the Interdisciplinary falls teams are a key success factor in falls prevention programs. Hospital Falls are reported, rates are measured and monitored.

Fall rates ensure measuring outcomes in a standardized manner, so the organization can monitor internal performance over time and compare with external organizations in order to improve.

Mrs. Enas Al Absi
Quality Coordinator