Hospital Mission
Kasra Hospital, as a private institution, relies on advanced medical scientific principles, competent human resources, and adherence to the regulations of the Ministry of Health. The hospital provides the highest level of safe therapeutic, diagnostic, rehabilitation, and healthcare services to all patients, ensuring the best treatment outcomes, promotion of public health, and the highest patient satisfaction.
Mission
Kasra Hospital as a private hospital relies on the advanced medical scientific principles and the rules and regulations of the Health Ministry, providing the highest level of the secure therapeutic, diagnostic, and rehabilitation services for all reputed patients are appreciated with the best health care services subject to the health care promotion and highest customer satisfaction.
Quality Improvement Unit Introduction
Quality Improvement Officer: Ms. Zeynab Dehghan, Senior Nursing Expert
According to the directive of the Ministry of Health regarding the establishment of an accreditation system in healthcare centers, Kasra Hospital’s Quality Improvement Unit has been operating under the supervision of Iran University of Medical Sciences since 2010. The Quality Improvement Office operates under the direct supervision of the hospital CEO.
Roles and Responsibilities of the Quality Improvement Unit
- Develop the hospital’s strategic plan under the guidance of the executive management team.
- Define and disseminate the hospital’s mission statement across different departments.
- Prepare the annual operational plan, advance, coordinate, and integrate quality improvement programs, and enhance patient safety in line with the accreditation model.
- Coordinate and integrate quality improvement activities throughout the hospital.
- Continuously monitor quality improvement programs, data, actions, and managerial interventions through performance indicator analysis.
- Develop hospital systems and processes aligned with quality improvement principles.
- Define specific, measurable, achievable, and time-bound key performance indicators (KPIs) for various hospital processes.
- Approve and communicate policies and procedures received from different hospital units.
- Supervise the implementation of hospital policies and procedures.
- Follow up and coordinate the implementation of accreditation standards in all hospital units.
- Establish a reporting system for medical and non-medical errors.
- Coordinate and integrate quality improvement activities hospital-wide.
- Continuously monitor the implementation of resolutions from other hospital committees.
- Participate in internal hospital audits to ensure compliance with various standards.
Patient Safety Unit Introduction
Patient Safety Officer:
Safety Coordination Expert:
Roles and Responsibilities:
- Field supervision of operational safety program progress.
- Coordinate with the executive management team regarding challenges and barriers in safety-related programs.
- Respond to all safety-related issues for patients, visitors, staff, and the hospital.
- Evaluate the effectiveness of actions taken to enhance patient safety.
- Monitor and assess the effectiveness of patient safety initiatives.
- Define, monitor, and measure patient safety indicators.
- Analyze safety indicators at regular intervals.
- Report safety indicator results at least quarterly.
- Supervise the implementation of corrective actions approved by the executive management team.
- Participate in regular managerial site visits.
- Conduct proactive assessments of medical errors.
- Identify infrastructural and process-related threats contributing to medical errors.
- Prepare and review lists, prioritize threats, and potential medical errors.
- Organize seminars/conferences on medical errors with a focus on the hospital’s Mortality Committee.
- Educate and inform staff about real hospital experiences and preventive evaluations of medical errors.
- Review and report unexpected deaths and hospital complications (RCA).
- Provide training and disseminate root cause analysis results.
- Participate in drafting procedures for “Anonymous Reporting of Medical Errors Without Fear of Blame or Punishment.”
- Plan for sharing medical error causes.
- Conduct field evaluations on patient safety and report findings to the executive management team.
Complaints Handling Unit Introduction
Complaints Officer:
Roles and Responsibilities:
- Receive written and verbal complaints from patients, visitors, and companions.
- Collect monthly complaints from hospital complaint boxes.
- Review complaints, investigate validity, and provide legal solutions to complainants.
- Investigate, review, and complete required information promptly with both complainant and respondent present.
- Participate in committees related to complaints.
- Seek opinions and recommendations from specialized units regarding complaints.
- Provide reports on complaints to relevant parties.
- Refer complaints that fall under other authorities and follow up on outcomes.
- Provide advice and recommendations to relevant units.
- Summarize complaints monthly and submit statistical reports to the Deputy of Treatment.
- Participate in meetings related to the complaints unit.
Complaint Submission Methods:
- In-person at the complaints unit
- By telephone
- Complaint boxes
- Follow-up with patients after discharge
Post-Discharge Patient Follow-Up Unit Introduction
Post-Discharge Follow-Up Officer:
Roles and Responsibilities:
- Contact patients/companions according to a scheduled plan.
- Collect information and data.
- Conduct regular meetings to analyze collected information.
- Develop corrective actions in cases of non-compliance.
- Follow up on non-compliance issues.