Al Mouwasat Medical Services - Operational and Support Functions

Al-Mouwasat has developed an efficient operational and support functional structure with ten departments that manage the Company's operations and provide support to the Company's hospitals, dispensaries and pharmacies. The management of each department consists of a team of experienced and capable professionals, who report either to the Vice-Chairman, Managing Director or Deputy Managing Director.

Finance and administration, Medical affairs, Performance improvement, and Internal audit departments report to the Vice-Chairman. The purchasing, human resources and pharmaceutical departments report to the Managing Director whereas the marketing and promotion, information technology, support services, and engineering and safety departments report to the Deputy Managing Director.

Medical Affairs and Performance Management Department

Medical Affairs Division

The main objectives of Medical Affairs division are to ensure that patients receive medical care and utilizing available resources with achievable goals. The main responsibilities of the Medical Affairs division are as follows:

Identify internal and external customers of individual departments;
Identify, evaluates and implements the scope of service, practice and governance of the individual departments;
Identify key functions and processes of each department;
Develop and implement department plans to establish standards by which performance can be evaluated to provide a sense of direction for each department by assigning responsibility and accountability for structure, process and outcomes.
- Develop and implement targets for each of the standards.
- Collect data required by performance improvement division to allow quality control for performance improvement in each department.
- Develops and enhances department wide communication to avoid misunderstandings.
To support the performance improvement division in their data collection and/or other activities;
Help formulate introduce and review policies and procedures regarding performance improvement;
Monitor compliance with the performance improvement policies and procedures;
Ensure the current practice and international laws and regulations are taken into account when formulating and approving policies and procedures regarding performance improvement; and
Ensure educational programs are valid with regard to being current research based and comply with internal laws and regulations regarding safe practice.

| Back to top of page |

Performance Improvement Division

The main responsibilities of the Performance Improvement division are as follows:

To establish a comprehensive organization-wide improvement mechanism to maintain and improve the quality and safety of healthcare within the limitations of available resources and achievable goals;
To provide a structure for coordinating and integrating the quality and safety improvement responsibilities of all professional, managerial, technical and support staff in order to increase effectiveness, eliminate duplication of efforts and promote efficient utilization of staff and resources;
To promote the provision of a comparable level of care and safety throughout Al-Mouwasat hospitals and dispensaries;
To integrate, analyze, and direct actions, based on information derived from sources and functions within Al-Mouwasat hospitals and dispensaries, to improve the structure, system, and processes that affect patient care and safety, and service delivery throughout Al-Mouwasat hospitals and dispensaries;
To utilize external information sources representing "Best Practices" and "Standard of Care" in the design of system to improve service delivery outcomes. This includes incorporating the standard requirements of the Joint Commission International;
To direct and promote the implementation of Al-Mouwasat's performance improvement model, Plan Do Check Act (PDCA);
To assess and modify the performance improvement program, when necessary, to encourage better identification and resolution of challenges that significantly impact service delivery; and
To provide complete, pertinent, and timely information to the Performance Improvement Committee to assist in the fulfillment of their responsibilities for quality/safety improvement commitment, prioritization, management, and oversight.

The Performance Improvement division works with the purpose to track analyze, educate and develop activities and data for the performance improvement and patients safety concerns of the Al-Mouwasat hospitals and dispensaries.

| Back to top of page |

Facility Management and Safety Department

The main responsibilities of the Facility Management and Safety department are as follows:

To identify, assess, reduce and control environmental hazards and risks including planning, educating and monitoring;
To prevent and control of loss to the healthcare organization, its patients, visitors, volunteers, physicians, other healthcare professional and employees;
To maintain risk management statistics, and files in compliances with accreditation requirements of the Joint Commission and other agencies;
To develop/coordinate and administer facility wide system for risk identification, investigation, and reduction;
To perform risk surveys, inspect patient care areas, review facility and assess loss potential;
To design, implement and maintain a direct referral system for staff to report unexpected events, and potential claims against facility through input sources as medical record, nursing, medical staff and quality improvement;
To provide proactive analysis of patients' safety and medical errors process; and
To participate in root cause analysis and investigation and to report adverse drug events to the appropriate parties.

| Back to top of page |

Support Services Department

The Support Services department consists of three units; dietary, laundry and housekeeping units. The main responsibilities of each are as follows:

Dietary Unit

The main responsibilities of the Dietary unit are as follows:

To provide the best nutrition care to patients;
To educate and promote nutrition awareness;
To continuously improve the patient care process in a cost effective manner;
To educate, assess and reassess patients' needs;
To participate in the multidisciplinary activities (clinical rounds, discharge planning and case review); and
To plan menu and meal evaluation.

Laundry Unit

The main responsibilities of the Laundry unit are as follows:

To provide cleaning of hospital linens, staff uniforms, lab coats and tailoring services to meet the needs of the patients and staff;
To remove dirt or soiling matter from fabrics without damage;
To segregate the contaminated from non-contaminated linen;
To maintain the protection of laundry equipment;
To clean, handle, store and transport linen according to proper protocols to minimize contamination from surface contact or airborne deposition;
To ensure proper mixing and identification of cleaning solutions;
To render tailoring services for the linen, staff uniforms, curtains and furniture;
To ensure storage of cleaning solution and chemicals; and
To ensure disinfection of linens.

Housekeeping Unit

The main responsibilities of the Housekeeping unit are as follows:

To create a safe, and healthy environment surfaces which comprises walls, counters, and furniture table tops;
To use appropriate cleaning and disinfecting strategies for environmental surfaces in patient care areas;
To follow manufacturers' cleaning instructions and recommendations procedures;
To keep environmental surfaces (e.g. floors, walls, tables tops) visibly clean on a regular basis or as spills occur;
To use a one step process and water/detergent or an Environmental Protection Agency registered hospital grade disinfectant/detergent;
To clean and disinfect high-touch surfaces (e.g. doorknobs, bedrails, light switches, surfaces in and around toilets in patient room) on more frequent schedule;
To eliminate airborne transmission in operating and delivery rooms; and
To clean ambulance cars in and out as per standard guidelines.

| Back to top of page |

Pharmaceutical Department

The main responsibilities of the Pharmaceutical department are as follows:

To ensure that the inpatient pharmacy facilities are provided with the required services in the setting of the hospital's commitment to keep pharmacy standards up to the current quality requirements;
To utilize the department's staff professional judgment and extend their responsibilities to include participation in programs with the safe handling of medication throughout the hospital, while working with other member of the healthcare team;
To participate in medication use review and patient care audits;
To provide safe and effective use of medicines in the hospitals;
To ensure the department's staff legitimate role in each step of medication therapy in the hospital, which includes the promotion of rational therapeutics and improvement of patient care;
To implement clinical intervention program and redefine the role of pharmacists in minimizing preventable adverse drug events and applying cost-effectiveness drug therapy; and
To facilitate discharge planning by arranging meeting with patients' family to discuss patient's medical condition and home situation. This will help in reducing the risk of deterioration of patient's condition and the chance of readmission with same diagnosis.

| Back to top of page |

Purchasing Department

The main responsibilities of the Purchasing department are as follows:

To streamline the ordering process of supplies which will be used in the department (e.g., Nursing, Medical, Support Services departments);
To process of requesting new non-stock items by new, permanent or locum staff;
To control an efficient utilization of new materials requested by medical staff;
To assist the new consultants (locums and permanent) in all matters relating to in-house availability of all materials relating to their specialty;
To provide all units with the necessary materials to assure continuity of quality care;
To provide staff members with the supplies essential to perform their duties;
To establish procedure for obtaining required materials from the warehouse outside of normal working hours and on holidays and Fridays;
To assist in the procurement of all necessary materials to meet the operational needs of the hospital;
To purchase materials from any technically qualified vendor or manufacturer;
To receive ordered materials from the manufacturers and record them on the computerized inventory record system and store accordingly at optimal storage condition with regards to temperature and humidity;
To provide a process for inventory evaluation and control; and
To provide the units with an automated system for monitoring the expiry dates of the unit medical supplies, and the pre-packages supplies.

| Back to top of page |

Finance and Administration Department

The main responsibilities of the Finance and Administration department are as follows:

The department is responsible for all matters related to the financial liabilities of the Company;
To establish a comprehensive and well-defined accounting practices to ensure proper recording of all transactions of business;
To provide all the concerned stakeholders full and fair picture of the transactions entered into the company;
To administer the timely "state of affairs" for the concerned parties for all financial proceedings in the Company's business;
To align the financial discipline with the current and possible future market practices of Company;
To ensure the accounting transactions are performed in line with the Saudi Accounting standards;
To submit reports to the Company's management; and
To submit reports annually to identify indicators for management;

| Back to top of page |

Internal Audit Department

The Internal Audit department follows an independent internal audit practice. The department has spread its activity all over the Company's departments and units. The department functions autonomously and reports directly to the Vice Chairman.

The department plays a crucial role in many aspects of the business and aims to achieve the following:

Ensure that Company's policies and procedures have been put in operation with major focus on transactions having financial and administrative implications;
Ensure that each function of finance, primarily payroll, inventory management, revenue capturing and pricing applications, receivables and payables control and general ledger accounting process;
Ensure that financial books are closed on monthly basis at stipulated dates;
Liaison with external auditors at corporate level for completion of audit and ensure recommendations are taken into consideration all over the Company;
Prepare budgets at unit level and have alignment at corporate level and ensure the proper practice of the budget;
Report on monthly basis to the Vice-Chairman on significant areas of variances and importance from administrative and financial implication point of view as to ensure that financial results are in alliance with the projections; and
Participate in analysis of utilization of resources.

| Back to top of page |

Human Resources Department

The main responsibilities of the Human Resources department are as follows:

To employ qualified, well-trained, and experienced medical, nursing, paramedical and administrative staff;
To develop job description for all categories which are reviewed periodically;
To develop and maintain a decentralized staff scheduling system;
To establish a communication system based upon the organizational chart reporting relationship;
To ensure hospital information is disseminated to all new arrivals through an orientation program;
To conduct periodic performance evaluation through heads of department with main focus on strengths and weaknesses of employees;
To maintain a record and conduct 90-days probationary evaluation (performance appraisal);
To perform credentialing by way of contacting the individuals, authorities and institutions in order to be able to ensure the authenticity of the submitted certificates and testimonials;
To ensure that all the medical nursing staff are properly licensed to practice their duties;
To ensure compliance with Saudization requirements as stipulated by respective governmental bodies;
To maintain confidentiality of the employees personnel data using OASIS Personnel Module and Al-Mouwasat policy and procedure; and
Prepare and maintain salary tables.

| Back to top of page |

Information Technology Department

Responsibilities and Objectives

The Information Technology ("IT") Department of Al-Mouwasat is considered an integral part of the Company's operational efficiency. The main responsibilities of the IT Department is to develop and update the Company's management information plan, manage and upgrade the information systems, manage information in order to improve hospital performance in patient care, governance, and support management process by providing and designing information to be accurate, reliable, timely and above all easily accessible to produce high quality information.

The main objectives of the IT Department is to reduce medical errors and improve patient safety, reduce duplication and patient waiting time, adopt a paperless environment, accelerate the adoption of information technology, improve the human and technological infrastructure, assess the data captured and collected as well as to guarantee confidentiality and security of patient health information.

Information System Modules

Administrative & Personnel Modules
The administrative and personnel modules consist of system setup & security, personnel records, payroll system, staff scheduling and checklists modules.

Financial Modules
The financial modules consist of patient order processing (billing), patient contracts, stores/ inventory management, purchasing, patient account, accounts payables, cash book, general ledger, budget and fixed assets modules.

Patient Modules
The patient modules consist of patient master index, medical records, accident and emergency, clinics/outpatient department scheduling, in-patient management and planned admission modules. Doctor desktop and dietary modules implementation is currently in process.

Departmental Modules
Apart from the above modules, the departmental modules ensure independent modules for departments like radiology, pharmacy, operating room, delivery room, endoscopy, laboratory and biomedical maintenance modules.

Disaster Recovery Plan

Over time, IT services have become critical to performing the mission of Al-Mouwasat. As a result of this ever-increasing reliance on technology, IT services require a comprehensive disaster recovery plan to assure these services can be re-established quickly and completely in event of a disaster. The primary objective of the Company's disaster recovery plan is to help ensure Al-Mouwasat business continuity by providing the ability to successfully recover computer services in the event of a disaster.

The disaster recovery action plan is composed of a number of sections that document resources and procedures to be used in the event of a disaster affecting computing and networking services. Each supported computing platform has a section containing specific recovery procedures. Systems are regularly backed up on a seven days schedule Saturday thru Friday. Backups are a daily procedure and the backup data will be stored in a disaster proof location to recover in case a disaster happens.

Al-Mouwasat is currently using one of Oracle's most stable and advanced backup procedure called Recovery Manager (RMAN) as a primary backup and secondary backup system (export utility).

| Back to top of page |

Marketing and Promotion Department

The Company's marketing and Promotion department main responsibility is to identify and target a specific segment of the population. Efforts are initially concentrated to provide the best possible services in order to retain customers. Once an identified segment is captured, efforts are then focused on increasing the existing customer base as well as identifying new segments to achieve growth and to diversify customer base. The Company has successfully identified new locations, new specialties, and new target markets due to successful market analysis.

Marketing and promotion efforts of the Company include a pricing strategy. Since 1997, the Company has initiated a package deal for the most common surgical services and deliveries. These prices are approved by the management and are considered as general package deals. Currently Al-Mouwasat Hospital in Dammam has a general package deal prices for 50 of the most common procedures. New package deals are created based on demand and their prices reflect the cost of offering the relevant services.

| Back to top of page |