Quality management
Quality documents
| ID | Title | Department | Version | Owner | Expiry | Status |
|---|---|---|---|---|---|---|
| A-014 | Strategic Plan 2025-2028 | Administration | v3.0 | Sara Al-Mansour | 31 Jan 2028 | valid |
| A-022 | ICU Operational Plan 2026 | Intensive Care Unit | v1.2 | Dr. Faisal Al-Qahtani | 31 Dec 2026 | expiring |
| B-007 | Q3 Quality Council minutes | Quality | v1.0 | Sara Al-Mansour | 1 Oct 2027 | valid |
| B-011 | Indicator action log — Sep 2026 | Quality | v0.9 | Yousef Al-Malki | 30 Sept 2027 | pending |
| C-003 | Patient & family rights charter | Patient Affairs | v2.1 | Noura Al-Saud | 30 Nov 2026 | expiring |
| D-018 | Morse Fall Scale procedure | Nursing | v4.0 | Ns. Hessa Al-Qurashi | 15 May 2027 | valid |
| D-021 | Falls prevention bundle checklist | Nursing | v1.0 | Ns. Hessa Al-Qurashi | 2 Nov 2028 | pending |
| D-027 | Sepsis early recognition protocol | Emergency Department | v2.3 | Dr. Mona Al-Harbi | 30 Sept 2026 | expired |
| E-003 | High-alert medication list | Pharmacy | v4.0 | Ph. Khalid Al-Otaibi | 1 Mar 2027 | valid |
| E-009 | Ward stock audit — Oct 2026 | Pharmacy | v1.0 | Ph. Khalid Al-Otaibi | 31 Oct 2027 | valid |
| F-012 | Hand hygiene audit — Oct 2026 | Infection Prevention & Control | v1.0 | Ns. Abeer Al-Zahrani | 31 Oct 2027 | valid |
| F-015 | IPC committee newsletter Q3 | Infection Prevention & Control | v1.0 | Ns. Abeer Al-Zahrani | 15 Oct 2027 | valid |
| G-002 | Staff orientation program | Human Resources | v5.1 | Ahmed Al-Juhani | 31 Aug 2026 | expired |
| H-005 | Fire drill report — Block B | Facility Management & Safety | v1.0 | Eng. Majed Al-Rashid | 12 Jun 2027 | valid |
| H-008 | Fire drill report — Block C | Facility Management & Safety | v1.0 | Eng. Majed Al-Rashid | 20 Jul 2027 | pending |
| I-004 | Medical records retention policy | Health Information | v3.0 | Rana Al-Fahad | 10 Dec 2026 | expiring |
| J-001 | Committee terms of reference | Quality | v2.0 | Sara Al-Mansour | 1 Feb 2027 | valid |
| K-002 | OVR policy QM-POL-011 | Quality | v3.2 | Sara Al-Mansour | 20 Apr 2027 | valid |
| K-004 | Corrective action tracker | Quality | v7.0 | Yousef Al-Malki | 5 Nov 2027 | valid |