Improving Quality and Credit Validity



The emphasis on quality in today's global economy is the key to achieving excellence in operations and activities. Increasing quality leads to increased productivity and benefits associated with it. In today's high-quality environments, quality is a key point for hospitals giving priority to patient care because hospitals have realized that poor quality status will be very expensive. With this in mind, the most important goals of health centers are to provide satisfactory and affordable services, in accordance with scientific standards and in the most appropriate form and method, and in the shortest possible time, the necessity to balance the quality and cost of services is always mandatory. And should be taken into consideration.


 Responsible unit: Ms. Internal Polygons: 2060


A three-step approach to quality improvement includes:


- Identifying and determining the customer and their needs, designing services based on those needs, and finally designing processes for service generation (quality design)

- Performance appraisal to determine actual performance and compare it with goals (quality control).

- Establishing appropriate infrastructure and promotion teams for upgrading processes (quality improvement).


"Creating a culture of continuous quality improvement requires having a goal or accurate understanding of the organization's vision. »


1. Review the hospital's strategic plan for assessing credit

2- Conduct and implement accreditation standards for evaluation of credit

3. Explaining the goals of Laleh Hospital

  1. Improving the quality of health services
  2. Improve patient safety and risk management
  3. Improvement of infrastructure and resource development
  4. Improvement of patient and staff satisfaction

4- Development of an operational plan related to the strategic plan of the hospital

5- Development of a comprehensive hospital improvement plan

6- Development of an operational plan for the quality improvement program

7- Development of Patient Safety Program for Implementation of Patient-Friendly Hospital Standards

8. Developing and reviewing the policy and procedure for establishing national accreditation with the participation of the nursing office

9. Formation and revision of Laleh Hospital

10. Implementation and monitoring of hospital committees (drafting of sentences, minutes)

11. Participate in RCA meetings

Participation in Patient Safety Management Visits

13. Perform an internal audit based on national accreditation standards every 6 months

14. Perform an internal audit based on national accreditation standards

15. Analyzing the training needs of the units as a seasonal and collaborating with the nursing office and reporting to the nursing management

16- Analysis of performance evaluation performed in the department of nursing management as a seasonal and reporting report to nursing management

17. Implement individual PDP development plan on an annual basis for all personnel and upgrade their knowledge and skills related to their duties and personnel records on the basis of accreditation standards.

18. Participation in conducting an introductory period of entry; for new personnel based on accreditation standards;

19-Participate in the formulation of guidelines and guidelines with the treatment manager

20. Assist all departments of the hospital to establish national accreditation standards by providing specific training and counseling for each department.

21. Cooperation with the Vice-Chancellor of Health of Iran University of Medical Sciences

22- Carrying out affairs regarding the licensing department of the Ministry of Health and Medical Sciences of Iran as a legal representative of Laleh Hospital in the Ministry of Health

23- Implementation of the change of the main technical officer, and other sections, obtaining legal licenses

24. Participation in the management of risk management and disaster management programs

25-Participation in the execution of the description of the duties of the personnel (human resources)