King Fahd Hospital of the University Annual Report 2018

ANNUAL REPORT

2018 G 1439 H

KING FAHAD HOSPITAL OF THE UNIVERSITY

ANNUAL REPORT 2018 G - 1439 H

KING FAHAD HOSPITAL OF THE UNIVERSITY

KING FAHAD HOSPITAL OF THE UNIVERSITY

ANNUAL REPORT 2018 G - 1439 H

Custodian of the Two Holy Mosques

King Salman bin Abdul Aziz Al Saud

King of Saudi Arabia

His Royal Highness

Mohammad bin Salman Al Saud

Crown Prince of Saudi Arabia First Deputy Prime Minister of Saudi Arabia

His Royal Highness Saud bin Naif bin Abdulaziz Al Saud Governor of Eastern Province

His Royal Highness

Ahmed bin Fahd bin Salman bin Abdulaziz Al Saud

Deputy governor of the Eastern Province

His Excellency

Hamad M AlSheikh

Minister of Education

‫شهادة اعتماد الهيئة الدولية المشتركة لمستشفى الملك فهد الجامعي‬

‫‪ ‬‬

‫شهادة اعتماد من المركز السعودي العتماد المنشآت الصحية‬

Figures Figure 1: A total of (35812) patients were seen by the physicians during the period of 12 months ...................................................................45 Figure 2: Respiratory care procedures (238332) ....................................................................................................................................48 Figure 3: A total of 20,240 procedures for (187) patients were treated during the year 2018. ........................................................................54

Figure 4: A total of 128 patients were admitted to dental department in 2018G. ........................................................................................58 Figure 5: A total of 128 patients were admitted to dental department in 2018G .........................................................................................58 Figure 6: A total of (19557) patients were seen by the physicians during 2018. ...........................................................................................63 Figure 7: Number of admitted patients received (213) in an increase of 69% than the previous year. ...............................................................66 Figure 8: Number of admitted patients received (448) in an increase of 12.6% than the previous year. .............................................................66 Figure 9: Number of admitted patients received (225) in an increase of 0.8% than the previous year. ..............................................................67 Figure 10: Number of OPD for general surgery received (19557) in an increase of 0.8% than the previous year. .................................................68 Figure 11: Number of admitted patient of general surgery received (2256) .................................................................................................69 Figure 12: Urology OPD received (5572) in a decrease of 0.7% in comparison to the previous year. .................................................................71 Figure 13: Urology admitted patients received (549) in an increase of 47% in comparison to the previous year...................................................71 Figure 14: A total of (15768) out-patients were seen during the year 2018 ................................................................................................73 Figure 15: A total admission received (2784), in an increase of 17.7% than the previous year.........................................................................73 Figure 16: Number of admitted to oncology and hematology in pediatric dept. received (71). ........................................................................78 Figure 17: Admitted neonates for 2018 .............................................................................................................................................79 Figure 18: Number of admitted neonates received (802) for 2018G, in an increase of 23.8% than the previous year. .........................................80 Figure 19: Admission of the unit reached (113) for the year 2018 in an increase of 25.2% than the past year. ...................................................83 Figure 20: OPD received (6681) in an increase of 11.8% than the previous year...........................................................................................86 Figure 21: Admission reached (557) in an increase of 8.9% than the previous year.......................................................................................86 Figure 22: OPD in 2018= (16685) in increase of 7.6% than the last year. ...................................................................................................88 Figure 23: Admission in 2018= (795) in increase of 2.2% than the last year................................................................................................89 Figure 24: OPD received (24604) in an increase of 3.6% than the previous year...........................................................................................92 Figure 25: Admission reached (1244) in an increase of 100% than the previous year. ...................................................................................92 Figure 26: OPD received (13698) in an increase of 2.5% than the previous year...........................................................................................94 Figure 27: Admission reached (750) in an increase of 17.6% than the previous year. ....................................................................................94 Figure 28: OPD received (6874) in an increase of 4.5% than the previous year. ...........................................................................................97 Figure 29: Admission reached (736) in an increase of +100% than the previous year. ...................................................................................97 Figure 30: OPD received (13385) in an increase of 11.3% than the previous year. ........................................................................................99

Figure 31: OPD received (7693) in an increase of 3.2% than the previous year. ...........................................................................................101 Figure 32: Admission reached (261) in an increase of 10.1% than the previous year. ....................................................................................101 Figure 33: The number of emergency patients benefited from the unit in 2017 was 247331 in comparison to 234140 in 2016 which is an increase amounted of 5.6%................................................................................................................................................................. .......124

Figure 34: The number of patients benefited from this unit in 2017 reached 561 patients. ............................................................................125 Figure 35: A total of (9097) patients were seen in EHS during the year 2018. .............................................................................................128

Figure 36: A total of (17201) patients were seen 2018. Administration of oral polio vaccine, measles vaccine, MMR, Hepatitis B and H-Influenza B to children continued this year.......................................................................................................................................................... ....130

Figure 37: A total of 2,194 patients were seen at Royal clinic in 2018. ......................................................................................................131

Figure 38: The center admitted patients received 592 for the year of the report ..........................................................................................135 Figure39: Chart showing the services provided by human resources department for 2017 .............................................................................217 Figure 40: Number of examinees .......................................................................................................................................................275

Figure 41: PSI/AMP comparison to other professional fellowships .............................................................................................................276

Figure 42: DQS total employees ........................................................................................................................................................277 Figure 43: Percentage of updated forms ............................................................................................................................................283 Figure 44: Safety rounds..................................................................................................................................................................286 Figure 45: Department compliance to requirements of safety .................................................................................................................287 Figure 46: KFHU average of safety compliance .....................................................................................................................................288 Figure 48: Ratio of KPIs require an improvement ...................................................................................................................................290 Figure 49: OVR..............................................................................................................................................................................291 Figure 50: Breast Cancer/KFHU .........................................................................................................................................................307 Figure 51: Number of cases .............................................................................................................................................................308 Figure 52: Number of cases ............................................................................................................................................................309 Figure 53: Number of cases .............................................................................................................................................................310 Figure 54: Number of cases .............................................................................................................................................................311 Figure 55: Number of cases .............................................................................................................................................................312 Figure 56: Number of cases ............................................................................................................................................................313 Figure 57: patients referred centers of primary healthcare .....................................................................................................................314

Tables Table.1: Distribution of Beds according to the units ................................................................................................................................ 36 Table.2: Key Figures 2017 at KFHU ..................................................................................................................................................... 37 Table.3:KFHU major statistics 2017 ..................................................................................................................................................... 38 Table 4: Endoscopy Surgery ............................................................................................................................................................... 65 Table 5: A table shows surgical procedures according to specialties: ........................................................................................................... 67 Table 6: A table compares the number of current and previous OPD: ......................................................................................................... 69

Table7: showing the number of major surgeries performed .................................................................................................................... 111 Table 8: The Clinical Nursing Units .................................................................................................................................................... 141 Table 9: The Clinical Nursing Units .................................................................................................................................................... 142 Table 10: Medical Labs statistics /2017:.............................................................................................................................................. 149 Table 11: Statistic comparison: ........................................................................................................................................................ 156 Table 11: Pharmacy statistics/2017:................................................................................................................................................... 164 Table 12: Statistics of medical records: ............................................................................................................................................... 165 Table 13: Services provided by the unit: ............................................................................................................................................. 165 Table 14: Activities and achievements/2017: ....................................................................................................................................... 167 Table 15: Statistics of 2017: ............................................................................................................................................................ 176 Table 16: Activities and achievements / 2017: ..................................................................................................................................... 183 Table 17: Infection Control Section Activities & Tasks During the Year 2017: .............................................................................................. 185 Table 18: A Table shows Communications Admin. Activities & Tasks During the Year 2018........................................................................... 213 Table 19: Number of introduced services transactions according to each department. .................................................................................. 216 Table 20: In the previous year 51 physician completed SCHS requirements and now are fellows in the following programs. ................................. 227 Table 21: The following table presents these activities for the year 2018. .................................................................................................. 235 Table 22: External Training .............................................................................................................................................................. 237 Table 23: Interbal Training ............................................................................................................................................................... 240 Table 24: Life Support programs....................................................................................................................................................... 241 Table 25: Life Support programs....................................................................................................................................................... 242 Table 26: Saudi fellowship programs of health specialties. ..................................................................................................................... 242 Table 27: BACHELOR PROGRAM- 1ST SEMSTER / FEMALE ..................................................................................................................... 244 Table 28: BACHELOR PROGRAM- 2nd SEMSTER / FEMALE .................................................................................................................... 244 Table 29: BACHELOR PROGRAM- 1ST SEMSTER / MALE ........................................................................................................................ 244 Table 30: BACHELOR PROGRAM- 2nd SEMSTER / MALE ........................................................................................................................ 245 Table 31: BRIDGING PROGRAM – 1ST SEMSTER/ FEMALE ...................................................................................................................... 245 Table 32: BRIDGING PROGRAM – 2nd SEMSTER/ FEMALE ...................................................................................................................... 245

Table 33: BRIDGING PROGRAM – 1st SEMSTER/ MALE .......................................................................................................................... 246 Table 34: BRIDGING PROGRAM – 2nd SEMSTER/ MALE......................................................................................................................... 246 Table 35: MASTER PROGRAM – 1ST SEMSTER .................................................................................................................................... 246 Table 36: MASTER PROGRAM – 2nd SEMSTER ................................................................................................................................... 246 Table 37: Internship program........................................................................................................................................................... 247 Table 38: Training statistics for College of Medicine / internship: ............................................................................................................. 247

Table 39: Health Education Department ............................................................................................................................................. 259 Table 40: Computer Project ............................................................................................................................................................. 264 Table 41: Summarizes the number of policies that were changed after the CBAHI visit. ................................................................................ 281 Table 42: Number of newly developed Forms Available, Printed and Uploaded in the Intranet ....................................................................... 282 Table 43: Explains Statistics For Researches Support. ............................................................................................................................. 315

Content

INTRODUCTION TO KFHU H.E Message, IAU President and KFHU Supervisor General ......................................................................................................................32 KFHU Establishing & Development Stages ............................................................................................................................................34 Our Objectives ...............................................................................................................................................................................36 Our vision .....................................................................................................................................................................................36 Our mission ...................................................................................................................................................................................36 Our values .....................................................................................................................................................................................36 Organizational Structure ...................................................................................................................................................................37

Bed distribution ..............................................................................................................................................................................38 Bed distribution - Manpower - Statistics in Brief ....................................................................................................................................38 Manpower ....................................................................................................................................................................................39 Statistics in Brief ............................................................................................................................................................................39 KFHU Major Statistics.......................................................................................................................................................................40 KFHU major statistics .......................................................................................................................................................................40

CLINICAL DEPARTMENTS Internal Medicine ............................................................................................................................................................................44 Maxillofacial and Oral Health .............................................................................................................................................................59 General Surgery..............................................................................................................................................................................62 Urology ........................................................................................................................................................................................72 Obstetrics & Gynecology ..................................................................................................................................................................74 Pediatrics ......................................................................................................................................................................................77 Neurosurgery .................................................................................................................................................................................87 Orthopedics surgery outlines .............................................................................................................................................................90 Ophthalmology ..............................................................................................................................................................................93 ENT (Ear, Nose, and Throat) ..............................................................................................................................................................95 Neurology .....................................................................................................................................................................................97 Dermatology................................................................................................................................................................................ 100 Psychiatry .................................................................................................................................................................................... 102 Anesthesia .................................................................................................................................................................................. 104 Family and Community Medicine ..................................................................................................................................................... 106

SPECIAL SERVICES Intensive Care Unit (ICU) ................................................................................................................................................................ 110 Cardiac Intensive Care Unit ............................................................................................................................................................. 113 One-day Surgery Unit (short stay) ..................................................................................................................................................... 116 Radiology Department ................................................................................................................................................................... 118 Diagnosis and Treatment through Interventional Radiology and Vascular Catheterization .............................................................................. 123 Emergency Room Departments and Units........................................................................................................................................... 125

Wound Care Unit.......................................................................................................................................................................... 127

SPECIALIZED CLINICS Employees Health Service – EHS ....................................................................................................................................................... 130 Primary Healthcare Clinic ................................................................................................................................................................ 132 Private Clinic ................................................................................................................................................................................ 133 Private Center of Health Services ...................................................................................................................................................... 135

AUXILIARY DEPARTMENTS Department of Nursing Services ....................................................................................................................................................... 140 Medical Laboratories ..................................................................................................................................................................... 148 Blood Bank .................................................................................................................................................................................. 157 Services of Pharmacy Care .............................................................................................................................................................. 161 Health Information Department ....................................................................................................................................................... 166 Patient Affairs Department.............................................................................................................................................................. 169 Electronic Health Information Services & IT ......................................................................................................................................... 170 Patient Rights and Relations Department ........................................................................................................................................... 173 Rights of patients and limits of their responsibility in KFHU..................................................................................................................... 175 Central Sterilization & Supply Department ......................................................................................................................................... 176 Socio-medical Services Department .................................................................................................................................................. 178 Department tasks ......................................................................................................................................................................... 180 Dietary ....................................................................................................................................................................................... 184 2017 Accomplishments .................................................................................................................................................................. 185 Infection Control Department .......................................................................................................................................................... 187

SUPPORTIVE TECHNICAL ADMINISTRATIONS Maintenance, Operation and Projects ............................................................................................................................................... 190 Cleaning, Laundry and Medical Waste ............................................................................................................................................... 198 Security Department ...................................................................................................................................................................... 203 Bio-Medical Engineering Department ................................................................................................................................................ 208

Landscaping ............................................................................................................................................................................... 209 Telephone Exchange Department ..................................................................................................................................................... 210

ADMINISTRATIVE DIRECTORATES Transportation Directoratet ............................................................................................................................................................. 214 Administrative Communication Directorate ....................................................................................................................................... 215 Monitoring and Follow-Up Directorate .............................................................................................................................................. 216 Human Resource Directorate ......................................................................................................................................................... 217 Financial Affairs Directorate ........................................................................................................................................................... 220 Purchasing Directorate ................................................................................................................................................................. 221 Warehouses Directorate ............................................................................................................................................................... 222 Medical Supplies and Medical Equipment

........................................................................................................................................ 223

Housing Directorate .................................................................................................................................................................... 224

ACADEMIC AFFAIRS AND TRAINING 1. Continuous Professional Development Unit ..................................................................................................................................... 228 2. Post-Graduate studies Follow-up Unit ............................................................................................................................................ 228 3. External Training Unit ................................................................................................................................................................ 229 4. Internal Training ........................................................................................................................................................................ 230 5. Audio-visual Unit ...................................................................................................................................................................... 230 6. Medical Photography Unit .......................................................................................................................................................... 230

7. Designing Unit ......................................................................................................................................................................... 230

8. Life Support Center .................................................................................................................................................................. 231 10.EVIDENCE-BASED MEDICINE PROGRAM ........................................................................................................................................ 231

TRAINING/KFHU Introduction................................................................................................................................................................................. 234 Continuous Professional Development training courses ......................................................................................................................... 237 External Training Unit..................................................................................................................................................................... 239 Internal Training ........................................................................................................................................................................... 242 Nursing college training contributions ............................................................................................................................................... 245 Training projects implemented by Directorate of Quality & Safety ............................................................................................................ 250 Health Education Department ......................................................................................................................................................... 260

PROJECTS Projects ...................................................................................................................................................................................... 264 Futuristic projects .......................................................................................................................................................................... 266 Computer projects ........................................................................................................................................................................ 266

QUALITY AND SAFETY Vision ......................................................................................................................................................................................... 270 Mission....................................................................................................................................................................................... 270 Values ........................................................................................................................................................................................ 270 Introduction................................................................................................................................................................................. 273 Executive Summary ....................................................................................................................................................................... 273 Central Board for Accreditation of Healthcare Institutions (CBAHI) ........................................................................................................... 274 Certified Professional in Healthcare Quality (CPHQ) Training ................................................................................................................... 276 Summary of Units’ achievements (full report for each unit are enclosed) ................................................................................................... 280 Accreditation Unit ......................................................................................................................................................................... 280 Decision Support Unit .................................................................................................................................................................... 283

Documents Control Unit ................................................................................................................................................................. 283 Environmental Safety Unit............................................................................................................................................................... 286 Performance Measurement Unit ....................................................................................................................................................... 291 Risk Management Unit ................................................................................................................................................................... 293 Training Unit ................................................................................................................................................................................ 295 Significant Achievements & Activities for 2017 .................................................................................................................................... 295

Johns Hopkins Aramco Healthcare (JHAH) General Technical Survey ......................................................................................................... 296 PSI/Applied Measurement Professionals (PSI/AMP) ................................................................................................................................ 296

NCB Breast Cancer Chair Background ................................................................................................................................................................................. 304 Supervisor of NCB chair for breast cancer ........................................................................................................................................... 306 Chair professor............................................................................................................................................................................. 306 Introduction................................................................................................................................................................................. 307 About NCB chair of Breast Cancer .................................................................................................................................................... 307 Breast Unit Teamwork .................................................................................................................................................................... 308 Breast Clinic ................................................................................................................................................................................ 310

Breast Tumors Clinic ..................................................................................................................................................................... 311 One day surgery /2018 ................................................................................................................................................................... 312 Aid care procedures ...................................................................................................................................................................... 313 Admission .................................................................................................................................................................................. 314 Operating Room ( OR ) .................................................................................................................................................................. 315 Patients referred centers of primary healthcare .................................................................................................................................. 316 Researches .................................................................................................................................................................................. 317

1

INTRODUCTION TO KFHU ι H.E Message, IAU President and KFHU Supervisor General ι KFHU Establishing & Development Stages ι Objectives, Vision, Mission, Values ι Organizational Structure ι Bed distribution ι Manpower ι Statistics in Brief ι KFHU Major Statistics ι

1| INTRODUCTION

H.E Message, IAU President and KFHU Supervisor General

The performance development in our institutions mainly depends on close follow-up of our exerted efforts after improvements project gifted by scholars and thinkers via analysis of performance indicators after the careful implementation preceded by studied planning.

Hence, 2017G annual report issued distinctively by reviewing all KFHU various departments for exploring their current stances updates, futuristic visions, plans and programs that come together to achieve KFHU vision and convey its mission while maintain its values lined to the values and heritages of our dignified noble communities.

The report displays the strengths and opportunities of KFHU to enable the departments to improve their performance, and then to guard the international rank of KFHU, and to serve IAU goals by preparing of a unique environment for education and training, scientific research, health care provision and community service. These are all together will participate in boosting and achieving of KSA 2030 vision.

Here we do thank the Custodian of the two Holy Harams, King/Salman Bin Abdul-Aziz Al-Saud, may Allah save him. His Royal Highness, the Crown Prince / Muhammed Bin Salman Bin Abdul-Aziz Al-Saud, for what their good government keeps provide for care of education and health services H.E Message, IAU President and KFHU Supervisor General

30

generously toward serving the citizens of this fruitful home.

Thank is also due to H.R.H, Prince / Saud Bin Nayif Bin Abdul-Aziz Al Saud, for his great tremendous role he keeps perform in steering follow-up of KFHU by the dedicated sponsorship he prioritized the hospital to enable it convey its mission, to serve the community of the eastern Region, and to continue the approach, as we send our special thanks to Deputy of Eastern Region Prince, H.R.H, Prince/ Ahmed Bin Fahad Bin Salman Bin AbdulAziz Al-Saud.

Finally, I hope the readers of this report could make use of its valuable information relevant to educational and health services provided by our KFHU, as I hope it would benefit every department chair or director in updating the futuristic policies.

Thanks, and appreciation also extend to include everyone contributed in preparation and layout of 2017G report, departments chairs, directorate managers and all employees of KFHU. Dr. Abdullau Al-Rubaish The president of IAU & Supervisor General of KFHU

Annual Report | 2018 - 1439

31

1| INTRODUCTION

KFHU Establishing & Development Stages

KFHU has a good reputation extended for more than (35) years. We will review it here in brief lines 1. On 15th of Rajab 1401H, corresponding to May 19, 1981, it was firstly inaugurated

by Ex-Minister of Health, H.E. Dr. Hussein Al-Jazairy under the title " Khobar Teaching Hospital".

2. In 1404H/1984G, it was named King Fahad Hospital in Alkhobar.

3. Then King Fahad Hospital of the University under the management of King Faisal University in 1405H/1985G. 4. In 2010, It remains under University of Dammam Administration after the separation of its branch.

5. In 2016, when King Salman Bin Abdul-Aziz visited the Eastern Region, the university name was changed to Imam Abdulrahman Bin Faisal University and the hospital kept its name as KFHU.

KFHU Establishing & Development Stages

32

Annual Report | 2018 - 1439

33

1| INTRODUCTION

Our Objectives 1. Teaching and training 2. Healthcare 3. Scientific Research

Teaching and Training

The hospital is considered as on optimum environment works to prepare the future cadres of health specialties over their various levels of study.

It provides teaching for students of bachelor's in medicine, nursing, ML, and internship. In addition to training of postgraduate's students over KSA from HEIs as preparation for fellowship in their various sub-specialties.

Moreover, KFHU has an integrated administration for Academic Affairs and Training. We will review within the details of this report.

Health Care

The second chapter of this report will cover all the departments that consolidate this objective which aims to provide an integrated health care over all specialties that includes: • Internal Medicine • Cardio • Neurology • Neurosurgery • Nephrology • Gastro • Hepatology • Dermatology • Pediatrics • Obstetrics & Gynecology • Endocrinology • General Surgery & Endoscopic Surgery • Plastic surgery • Orthopedic surgery • Dental and Oral Medicine • Ophthalmology • Otolaryngology Our Objectives - Organizational Structure

34

Scientific Research

One of the prominent objectives of KFHU is the great care of scientific and applied researches in the different fields of health and medicine including; diagnostic, therapeutic, laboratory searches and family & community medical research by making use of a wide and various database provided by the hospital. Research is carried out only after being approved by the competent boards to make sure that it falls in line with the fundamentals and ethics of research. In this report there are chapters indicate to research support, projects and academic chairs.

Our vision

Leadership in the provision of healthcare and education, besides conducting scientific research in compliance with international and national standards.

Our mission

Quality in the provision of healthcare and education as well as support of scientific research.

Our values • • • • • •

Honesty Transparency Mutual respect Spirit of accountability Spirit of teamwork Commitment

Annual Report | 2018 - 1439

Organizational Structure

35

1| INTRODUCTION

Bed distribution Table.1: Distribution of Beds according to the units Units/Wards 1A 1A 1A 1B 1C 1D 2E 2A 2BN 2B 2C 2D 3A 3B 3C 3D 3E 4A 4B 4C 4D 4E 5A 5B Total Beds

MICU (Medical Intensive Care Unit) SICU (Surgical Intensive Care Unit) PICU (Pediatric Intensive Care Unit) Burn Unit Step Down Unit Female Surgical/Medical Word CCU (Coronary Care Unit) Delivery Room NICU (Neonatal Intensive Care Unit) WBN (Well Born Nursery) (OB/GYN Ward) (OB/GYN Ward) (Male ENT/ Neurosurgery/ Optha. Ward) ( Male Ortho Ward) (Male Medical Ward) (Male Medical Ward) (Male Surgical Ward) Male/ new ward (Pediatric Surgical Ward) (Pediatric Medical Ward) (Female Medical Ward) (Female Surgical Ward) (Female Surgical Ward) Female / new ward (Male Psychiatry Ward) (Female Psychiatry Ward) Total of Permanent beds Total of Temporary beds Recovery beds Other 630

Bed distribution - Manpower - Statistics in Brief

36

Patient services

No. of beds 18 10 13 12 6 20 10 10 20 40 21 21 20 20 21 21 19 24 20 24 21 21 19 24 18 18 491 84 18 37

Annual Report | 2018 - 1439

Manpower Attending Physician

337

Nurses

776

Resident

104

Other

941

Total of Employees

2,158

Statistics in Brief Table.2: Key Figures 2017 at KFHU Admissions

Out-Patients

Emergency patients

Deliveries

Radiology procedures

Pharmacy

Laboratory diagnostics

Surgical procedures

Dental procedures

Primary care services

Physiotherapy treatments

Respiratory therapy

EHS patients

ICU patients

CSSD services

19023 1633

1023840 13,056 10782

263802

142439 5817

58381 1776

247331

1954810 16730

238332 2845

37

1| INTRODUCTION

KFHU Major Statistics Table.3:KFHU major statistics 2017 Services

OPD ER Inpatients Dental EHS Physiotherapy Respiratory therapy Hemodialysis Lithotripsy OR FAMCO Day Surgery Deleveries Mortality Pharmacy Radiology Diagnostic Laboratories Cardiac Lab. Neurodignostic Lab Endoscopy Pedia Card Lab. Average length of stay Bed Occupancy Rate Total number of Beds

KFHU major statistics

38

Description

Patient Patient Patient Patient Patient Procedure Procedure Procedure Procedure Procedure Patient Operation Case Case Service Procedure Procedure Procedure Procedure Procedure Procedure Days average Percentage Bed

Total number 263802 247331 19023 10782 58381 238332 11685 20240 5817 4892 24830 16703 1633 505 1954810 142439 1023840 10000 2832 1776 2845 9.3 65% 630

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2

CLINICAL DEPARTMENTS ι ι ι ι ι ι ι ι ι ι ι ι ι ι ι

Internal Medicine Maxillofacial and Oral Health General Surgery Urology Obstetrics & Gynecology Pediatrics Neurosurgery Orthopedics Ophthalmology ENT Neurology

Dermatology Psychiatry Anesthesia Family & Community Medicine

2| CLINICAL DEPARTMENT

Internal Medicine Introduction

The Department of Internal Medicine is one of the leading departments of IAU’s College of Medicine.

It has more than 90 medical cadres, among faculty members (consultants, registrars, demonstrators).They all practise their professional activity in this essential field of KFHU. The department’s include the following subspecialties: 1. Cardiology 2. Gastroenterology 3. Pulmonary 4. Endocrinology 5. Hematology/Oncology 6. Nephrology 7. Infectious Diseases 8. Intensive Care.

9. Cardiovascular Care Unit Department Clinics: The department conducts more than 48 OPD clinics weekly – 10 for general and remaining for various sub-specialties of Internal Medicine.

Academic Contribution: • The Department of Internal Medicine is a major contributor to the continuing medical education programs in organized by the Directorate of Academic Affairs and Training in a continuous coordination.

• It establishes annual scientific meetings of the department where updates on topics in different specialties are presented.

• Besides, other activities, including awareness campaigns, are offered to the public by various subspecialty units from time to time.

• The department is actively involved in various research projects, not only intradepartmental, but also in association with other departments in the College of Medicine. Many publications have appeared in local as well as international journal Internal Medicine

42

Annual Report | 2018 - 1439

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2| CLINICAL DEPARTMENT

Goals 1. Provide excellent academic services in accordance with international higher education quality standards.

2. Provide comprehensive medical care that meets quality standards of service, technical competence, and ethics in all areas of the healthcare field including curative, rehabilitative, preventive, and promotive care.

3. Perform research health and medical studies.

4. Create opportunities in training for excellence in human resources.

5. Establish strategical partnerships with the community and other services providers.

6. Cooperate with peer departments locally, nationally, and internationally 7. Establish an academic, scientific, and safe professional environment.

8. Promote the concept of academic medicine as the principal health and medical care provider, and medical human resource developer in the region.

Additional Services 1.

2.

3.

4.

5.

A Fast-Track Clinic was opened to minimize the overstay of patients in the Emergency Room.

Diabetics center Insulin Pumb Clinc Adult Vaccination Clinic Periodical rounds by the Clinical Investigating Team are undertaken to discharge overstay patients in the medical wards.

6. A hotline mobile number has been created to relay critical lab values to the medical oncall team.

7. Routine monitoring of proper documentation in medical charts is conducted as per the requirements of JCI (Joint Commission International).

8. A Thyroid Awareness campaign was conducted.

9. A Liver Awareness Campaign was conducted.

10. An Internal Medicine page is brought out in the Friday editions of the Alyoum newspaper.

11. The official websited of the Department was recently launched.

12. The Objective Structured Clinical Examination (OSCE) was introduced in the 4th and 5th Year undergraduate courses.

13. Thrombosis Clinic.

Internal Medicine

44

Annual Report | 2018 - 1439

Internal Medicine Major Units 1. Adult Cardiac Lap

This unit kept – since its establishing in 1980- provides therapeutic and diagnostic services following the most updated technologies. It provides all of the services mentioned below:• ECG, • Echocardiography • Cardiac stress check • Bicycle stress Test • DES • Blood pressure for 24 hrs.

• DSE A total of (10000) tests were done during this year as well as (812) patients have been seen among OPD.

Total 4000

3,558

3,570

3,750

3,473

3500

3,033

3,372

3000

3,446

35,812

3,439

2,996

12 Months

2500

2,512

2000

2,226

1500 1000 437

500 0

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEP

OCT

NOV

DEC

Figure 1: A total of (35812) patients were seen by the physicians during the period of 12 months

45

2| CLINICAL DEPARTMENT

Cardio Patient

2. Cardiac Arrest Care Unit: It is a new unit for cardiac arrest patients and rapid surgical intervention via catheterization. It is the first unit in Eastern Region of KSA. In this unit a unified mechanism is followed for patients' date schedule by receiving the inbox referrals to the hospital which later will be sent to the designated department upon the case priority. A SMS would be sent to the patient's mobile. (2) beds were added to the unit under the supervision of surgery and ICU physicians.

Internal Medicine

46

Annual Report | 2018 - 1439

3. Respiratory Care Service Unit The Respiratory Care Services Unit provides comprehensive treatment for patients with deficiencies and abnormalities associated with the cardiopulmonary system. Respiratory care practitioners (RCP) exercise a considerable degree of independence in clinical judgments in patient care under direct or indirect supervision of the physician.

The scope of the services includes the application of technology and the use of protocols across all care sites including but not limited to the hospital. These responsibilities are supported by administration, education and research.

Respiratory specialist review results using a modern machine

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2| CLINICAL DEPARTMENT

• Diagnostic activities include: -

Obtaining analyzing and interpretation of physiological data, Arterial Blood Gases.

Pulmonary function studies, Perform Sleep disorder studies.

• Respiratory Therapy activity includes but not limited to The application and monitoring of medical gases, insertion and care of artificial airways, Broncho- pulmonary hygiene, hemodynamics cardiovascular support, mechanical ventilation support, pulmonary function studies, sleep apnea disorder.

The Respiratory Care Services in collaboration with college of Applied Medical Sciences plays a vital role in the education and training programs for students and interns.

22000

21407

21281 20650

21000

20203

20000

19000

19615

20322

19402

19869

19580 18992

18940

18000

18071

17000

16000

JAN

FEB

MAR

APR

MAY

Figure 2: Respiratory care procedures (238332)

Internal Medicine

48

JUN

JUL

AUG

SEP

OCT

NOV

DEC

Annual Report | 2018 - 1439

Beside the state-of-the-art Pulmonary Function Testing machine, the Respiratory Care Services has other top-quality instruments such as: 1. Dragger Evita XL ventilator 2. V-60 BIPAP Machine 3. Dragger Evita 4 Ventilator 4. SLE Nitric Oxide Delivery System 5. Servo I Ventilator 6. Dragger Baby log 8000 Infant Ventilator 7. Aeron ox Nitric Oxide 8. Puritan Bennett 840 Ventilator 9. Delivery system 10. T 5100 Globe Trotter Incubator Ventilator 11. G5 Vibram tic Machine

12. Cross vent C4 Transport Ventilator 13. Jaeger Computerized PFT 14. Para Pac Plus 310 & Baby Pac 100 Transport Ventilator 15. Sunstar Z4 Sleep System 16. SIPAP Machine 17. Easy one pro Lab. Pediatric 18. ResMed BIPAP machine System 19. Breas BIPAP machine 20. Cough Assist 21. High Frequency Ox Illation Ventilator 22. Chest Physiotherapy

The respiratory care performs a vital role in teaching and training students of College of Medicine, internship students in collaboration with College of Applied Medical Sciences. The unit procedures for 2018 received (238332).

49

2| CLINICAL DEPARTMENT

4. Cardiac Catheterization Unit

The cardiac catheterization laboratory is considered as one of the most important units of the hospital in general and for the cardiology department particularly.

It is supervised by a professional medical team of doctors and consultants, technicians and nurses.

The unit works seven days a week, with a special working team for emergency situations outside working hours. It is supported by the senior management of the hospital and is provided with all the medical supplies required to perform the cardiac catheterization procedures, including different types of balloons, BareMetal stents and drug eluting stents in order to provide better care for patients with cardiovascular diseases.

The total of what has been accomplished of cardiac catheterization procedures during 2018G has reached the number of (1355) cases, including various procedures. The unit has a new fully- equipped Cath-lab.

5. Endoscopy Unit 1. This unit works under the supervision of the Internal Medicine Department.

2. It includes several consultants of different specialties.

3. Different endoscopic procedures are done here for outpatients, inpatients and patients referred from other hospitals. The unit is equipped with advanced instruments for routine or special procedures.

Internal Medicine

50

Annual Report | 2018 - 1439

A patient under care in recovery room/ Cardio Catheterization Unit

Diagnosis Machine/Endoscopy Unit

51

2| CLINICAL DEPARTMENT

The photo shows a consultant during an endoscopic intervention

Endoscopy Unit Equipping

Internal Medicine

52

Annual Report | 2018 - 1439

6. Hemodialysis Unit -

It is the unit that provides services for patients with chronic and acute renal failure, including preparation for kidney transplant.

The unit is equipped with 12 dialysis machines and it is ready to receive patients 24 hours a day.

Kidney biopsies are done in the ultrasound room.

Acute dialysis for the critically ill-patients in ICU is also performed.

The unit is in constant contact and co-ordination with the Saudi Center for Organ Transplant (SCOT) regarding transplant evaluation and waiting list.

The Hemodialysis Unit was recently shifted to a new building that allows the accommodation of more machines in order to provide greater healthcare to patients with kidney failure or deficiency. A total of 20,240 procedures for (187) patients were treated during the year 2018.

Patients receive care in the unit of hemodyalisi

53

2| CLINICAL DEPARTMENT

35

31

30 25 20 15

17

18

Total

20

18

16

15

20,240 Procedures

12

10

11

10

10

9

5 0

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEP

OCT

NOV

DEC

Figure 3: A total of 20,240 procedures for (187) patients were treated during the year 2018.

Hemodialysis reception

Internal Medicine

54

Annual Report | 2018 - 1439

7. Peritoneal Dialysis Unit This unit was inaugurated in 2005 and affiliated to the Internal Medicine Department. It is supervised by nephrology consultants and supported with well-trained nurses. Here, all necessary medicines are given to the patient free of charge. Some patients are trained on how to use curative devices that suit their case.

A total of (1913) procedures were done during this year.

Pediatric hemodialysis

55

2| CLINICAL DEPARTMENT

8. Endocrinology & Diabetes Unit It is a separate unit concerns with diabetes where insulin plumbs are used for cure. It also deals with patients suffer from diseases relevant to endocrines.

9. Diabetes Center This center was established in 2016G with an initiative from internal medicine department and health education unit to guarantee a unified sustainable shared service interdepartmentally.

The center uses the modern electronic heath care system that focuses on patient case evaluation, beside his/ her involvement in the advance health care provided by the medical team which composed of consultants of; endocrinology and pediatrics, and registrars of health education, dietary, pharmacy and social services for the purpose of integrated care coordination.

The center works to follow-up the patients supported by insulin pump clinics, dietary clinics, obesity clinic and health education clinic.

The center vision: Work as a leading accredited center for care and cure of diabetics over KSA in a trial to be linked with international and regional organizations in order to shape a vital source for academic researches sand statistics.

The center goals: - Availability of continuous early care which contributes provision of knowledge and its role in marinating health education and abstaining side effects by making use of modern medical technologies that enables inventing the disease, keeping high level of health support, and avoiding side effects after health education sessions.

- Description of educational needs for the patient and the surrounding community by designing various training programs with provision of medical advice.

- Description the diets during the primary visit for making the urgent changes of the patient daily habits and life style as well as encouraging him/her to follow a healthy method.

- Communication with psychiatry in need for behavior evaluation.

- Running of regular training and educational courses for health providers in this field.

- Training of undergraduate and postgraduate students over all specialties.

Internal Medicine ูก Maxillofacial and Oral Health

56

Annual Report | 2018 - 1439

Maxillofacial and Oral Health An essential department provides the services of; health care for the citizens and employees of IAU an d KFHU, their families and internship students over the whole year.

It includes (4) clinics, a room for dental radiology, a lab for orthodontics. They are all equipped hi-tech medical equipment.

Scope of services The scope of services of the dental department is as follows: -

Providing high standard comprehensive dental services, including hospital dentistry, hygiene, orthodontic, and oral/maxillofacial surgery in order to satisfy the needs of our internal customers.

Offering limited dental care, mainly hospital dentistry and oral/maxillofacial surgery, [OMFS] to external customers with necessary follow-ups.

Making available 24 hrs on-call service especially for ER and trauma patients (e.g. Road Traffic Accidents [RTA]).

Conducting surgical/dental procedures under general anesthesia as part of the hospital plan and protocols.

57

2| CLINICAL DEPARTMENT

35

Total

30

‫إﺟﻤﺎﻟﻲ اﻟﻤﺮاﺟﻌﻴﻦ‬

25 20

128

20 16

15

12

11 11

10

10

9

7

5 0

14

13

15

JAN

FEB

MAR

APR

MAY

JUN

JUL

7

AUG

SEP

OCT

NOV

DEC

Figure 4: A total of 128 patients were admitted to dental department in 2018G.

A total of 128 patients were admitted to dental department in 2018G which is more than 73% in comparison to the previous year.

35 29

30 25

19 20 15

16 11 9

10

5 7

5 0

JAN

FEB

MAR

APR

MAY

JUN

2 JUL

0 AUG

4 SEP

OCT

Figure 5: A total of 128 patients were admitted to dental department in 2018G Maxillofacial and Oral Health

58

11

12

10

NOV

DEC

Annual Report | 2018 - 1439

Two dentists diagnose a patient tooth

Dental Surgery

59

2| CLINICAL DEPARTMENT

General Surgery Introduction

One of the first clinical department that was established in 1975G. it was including all surgical departments, in addition to anesthesia In 1984 the sections of anesthesia, orthopedic surgery, neurosurgery, ophthalmology surgery, urology surgery. E.N.T surgery were all departed from general surgery to be separate department

Operating Room

General Surgery

60

Annual Report | 2018 - 1439

Scope of services Our service is divided into 4 main domains: • • • •

Clinical Service Teaching Research Community service

Clinical Service: We serve our patients in 5 main sectors namely OPD, ER, wards, OR and consultations. The department comprises general surgery, pediatric surgery, vascular surgery, cardio-thoracic surgery, and plastic surgery divisions.

1. OPD: The department has 24 OPD sessions/week, (morning and afternoon sessions) supervised by a consultant as below; - General Surgery & Laparoscopic Clinic – 4 per week - Breast disorder and Breast Oncology Clinic – 3 per week - Wound Care & Diabetic Foot Clinic – 4 per week - Colorectal & Proctology Clinic – 2 per week - Hepatobiliary Clinic – 1 per week - Vascular Surgery Clinic – 2 per week - Pediatric Surgery Clinic – 3 per week - Plastic Surgery Clinic – 3 per week - Cardio-Thoracic Surgery Clinic – 2 per week

2. ER: Monthly on call Rota is covered daily by 1st on call (Junior Resident), 2nd on call (Specialist) and a 3rd on call (Consultant).

3. Admissions: Patients are admitted according to the hospital regulations either from OPD or ER. Patients are admitted under supervision of the consultant in charge. Elective admissions are investigated before admission to reduce the hospital stay.

4. OR: The department has nine major OR rooms and five minor OR rooms per week for elective cases which are under direct supervision of consultants. Emergency Operations are performed round the clock as and when required by all the units of the department.

5. Continuous assessment of medical services provided to our patient is done through monthly audit and case presentations.

61

2| CLINICAL DEPARTMENT

Teaching Services This is provided by the department throughout the year, and mainly done by consultants, but also by specialists and demonstrators who contribute to clinical teaching. Teaching is provided to the following: • • • • •

Undergraduate medical students Undergraduate dental students Undergraduate Nursing students Post graduate residents in Saudi Board grogram for General Surgery& Plastic Surgery Post graduate residents in Saudi Board program or its equivalent for Family & Community medicine, Urology, ENT, Orthopedics Neurosurgery etc. having their general surgery rotations.

General Surgery

62

Annual Report | 2018 - 1439

Research Service: •

Being a university hospital, research is one of the most important functions of our department, undertaken in order to help prevent, control, diagnose, and manage diseases.

Several clinical, experimental, and epidemiological studies (prospective, randomized, retrospective, cohort, and case control) have been done by the department.

Several books pertaining to general surgery have been published for undergraduates and postgraduates.

• •

The total of published articles and researches received (27).

Community service: The department provides and contributes in community services by making campaigns and programs for health education regularly.

- A total of (19557) patients were seen by the physicians during 2018. More than .0.8% from the previous year.

2500

2000

2027

1897

1849

1877

1907

Total Patients

1678 1751 1500

1784

1541

19,557

1475 1169

1000 602 500

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEP

OCT

NOV

DEC

Figure 6: A total of (19557) patients were seen by the physicians during 2018.

63

2| CLINICAL DEPARTMENT

General Surgery Units: 1. Open Heart Surgery

This unit was inaugurated in 2008 and affiliated to the General Surgery Department. All operations are conducted under the supervision of consultants of heart and chest surgy consultants. The unit is constantly equipped with advanced medical instruments.

2. Burn Unit It is a 12-bed unit in which four beds are allocated for critical cases. It falls under the direct supervision of plastic surgery consultants. The Unit receives patients referred from various hospitals in the Eastern Region.

A total of 134 patients were admitted to the Burn Care Unit this year.

Burn Unit admission wing

General Surgery

64

Annual Report | 2018 - 1439

3. Surgical Endoscopy (SEU) In this unit, various abdominal surgeries have been carried out using the endoscopy since 1994. The operations are conducted under the direct supervision of general surgery consultants specialized in this kind of surgeries. A total of 536 surgeries were carried out in the year under report. More details are found in the tables given below.

Table 4: Endoscopy Surgery Particulars

No. of surgeries

Hernia Endoscopic Procedure

31

Peritoneal Dialysis Catheterization

14

Appendectomy

115

Cholecystectomy

147

Gastric band removal

0

Peritoneal Dialysis Catheter

6

Front Amputation Surgery

11

Splenectomy

4

Gastrectomy

16

Dental Endoscopic Surgery

163

Semi-Colonoscopy

5

Diagnostic Endoscopic Surgery

24

Total

536

4. Pediatric surgery It was established in 1989 for maintaining a high-level of care for neonates and children of less than 12 years old. The unit also contributes in training on pediatric surgery.

65

2| CLINICAL DEPARTMENT

40

35

35 30

25

25

25

Total

24

20

20

10

12

11

16

16

12

5 0

213 Patients

13

15

4 JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEP

OCT

NOV

DEC

Figure 7: Number of admitted patients received (213) in an increase of 69% than the previous year.

5. Plastic surgery It is unique unit in the Eastern Region of KSA. It was established in 1984 for treating all critical cases.

60 52 46

50

49

46

Total Patients

41 40

42

36

39

42

448

30

20 16 10

JAN

FEB

MAR

APR

MAY

20

19

JUN

JUL

AUG

SEP

OCT

NOV

DEC

Figure 8: Number of admitted patients received (448) in an increase of 12.6% than the previous year.

General Surgery

66

Annual Report | 2018 - 1439

6. Heart & Chest In this unit surgical interventions are done in collaboration with units of; cardio, respiratory of internal medicine as an integrated team work provide medical care in a high commitment of quality.

7. Thoracic surgery It is a modern unit established in 2014 under supervision of a long career consultants. The unit provides integrated medical services for outpatients and inpatients.

33

35

32

30 30

28

Total Patoents 25 24 21

20

15 14 10

JAN

15

15

16

225

15 12

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEP

OCT

NOV

DEC

Figure 9: Number of admitted patients received (225) in an increase of 0.8% than the previous year.

Table 5: A table shows surgical procedures according to specialties: Specialty

Number of procedures

General surgery

5463

Breast -

2887

Plastic -

2643

Pediatric -

1967

On-day surgery

1664

67

2| CLINICAL DEPARTMENT

Specialty

Number of procedures

Cardiovascular -

1040

Endocrine -

1037

Breast oncology -

707

Thoracic & cardio -

608

Colon -

574

Hepatobiliary -

399

Thoracic

376

Trauma -

170

Cardio -

16

Endoscopic -

6

Total

19557

2500

2000

1897

1849

1877 1678

1907

1751

1500

1784

19,557

1541

1475

1169

1000

500

0

OPD Patients

2027

602

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEP

OCT

NOV

DEC

Figure 10: Number of OPD for general surgery received (19557) in an increase of 0.8% than the previous year.

General Surgery

68

Annual Report | 2018 - 1439

Table 6: A table compares the number of current and previous OPD: OPD

NO.

New patients

12058

Previous patients

7499

Total

19557

General surgery admission; Number of admitted patient of general surgery received (2256) in an increase of 35.6% than the previous year.

300

Total Patients 242

231

250 200 200

200

192 207

194

195

2,256

182

150 133

100

140

140

50 0

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEP

OCT

NOV

DEC

Figure 11:Number of admitted patient of general surgery received (2256)

69

2| CLINICAL DEPARTMENT

Urology

Introduction: The urology department evolved significantly during the recent years with a continuous increase in the number of medical staff serving in it. It currently includes 10 Consultants, 2 Specialists and 4 Residents.

Department sub-specialties: 1.

2.

3.

4.

5.

6.

Pediatric urology Urologic oncology Minimally invasive surgery Voiding dysfunction/incontinence Erectile dysfunction Reconstruction

Number of out-patients clinics increased from 5 to 7 clinics after the addition of pediatric clinic and spina bifida.

Medical equipment: -

ESWL URODYNAMIC TEST ULTRASOUND URETHROSCOPE

• The department works on buying new modern medical equipment for lithotripsy.

Educational Services Activities: 1.

2.

3.

4.

5.

- Periodical meetings for critical cases discussion - Scientific symposia for reviewing updates in urology specialty - Basic and advance workshops - Lithotripsy seminar - World day of spina bifida

Urology

70

Annual Report | 2018 - 1439

Urology department units Lithotripsy Unit - The unit is functioning as a Day Care Unit under the direct supervision of the Department of Urology - It is well-equipped with advanced machines.

The total number of patients treated at this unit in the year under report reached 4641.

637

700 600

543 479

500

566

534

474

400

OPD Patients

559 554

395

5ŘŒ572

349

300 288 200

194

100 0

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEP

OCT

NOV

DEC

Figure 12: Urology OPD received (5572) in a decrease of 0.7% in comparison to the previous year.

70 60

61 57

Total

60

56

59

50

50 45

40

48

51

38 36

30

549

33

20 10 0

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEP

OCT

NOV

DEC

Figure 13: Urology admitted patients received (549) in an increase of 47% in comparison to the previous year.

71

2| CLINICAL DEPARTMENT

Obstetrics & Gynecology The Department of Obstetrics and Gynecology at KFHU was established in 1981. It includes many faculty members and researchers who are dedicated to doing everything possible to provide women and their families with the most advanced care available anywhere. It includes a separate delivery room equipped with the best of medical equipment, in addition to nursery unit. It also includes ultrasound machine and it has a section for emergency cases.

In the department there are 10 OPD general clinics, 2 clinics for sterility, 2 clinics for mother and fetal medicine and other 3 clinics for IAU and KFHU female employees. The department has a shared clinic with FAMCO. It also contributes in teaching of level 6 in College of Medicine of IAU, moreover the training of interns and residents of FAMCO. The department was also organized to deliver a special training for Saudi Commission for Health Specialties and Arab Board.

In addition to the daily round, the department runs some activities as morning report, weekly seminars and clinical discussion for births and mortality rates. It has a valued contribution in field of research. Faculty staff of this department published hundreds of academic papers on national and international journals. The department exert an appreciated effort for ensuring the updated medical equipment that share in providing the best of medical and care services and training for both nursing and medical staff.

Delivery wing

Obstetrics & Gynecology

72

Annual Report | 2018 - 1439

A total of (15768) out-patients were seen during the year 2018, estimated of 12.4% increase than the previous year.

2000

1600

1472

1400

1382 1363

1200

Total Pt. seen

1720

1638

1800

1241

1433

1416

1384

15،768

1097

1000

975

800 600

652

400 200 0

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEP

OCT

NOV

DEC

Figure 14: A total of (15768) out-patients were seen during the year 2018

300 255

234

250 200

240

225

256

252

274

222

205

201

Total deliveries

222

198

2,784

150 100 50 0

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEP

OCT

NOV

DEC

Figure 15: A total admission received (2784), in an increase of 17.7% than the previous year.

73

2| CLINICAL DEPARTMENT

Delivery rooms There are (10) rooms, (7) for labor and delivery, (2) are recovery rooms and (1) for cesarean section. All rooms are staffed with midwives and specially trained nurses.

- A total of (1633) deliveries were performed, (406) of them were cesarean.

Delivery Room preparation

Obstetrics & Gynecology ูก Pediatrics

74

Annual Report | 2018 - 1439

Pediatrics

Introduction The Pediatric Department is one of the major clinical departments at King Fahd Hospital of the University.

Since the department was established in 1981, it has been providing medical services and specialized and comprehensive medical care of high-quality for children from birth to the age of fourteen.

The Pediatric Department depends on highly-trained consultants, specialists, and residents who are working together with a group of qualified nurses and technicians.

75

2| CLINICAL DEPARTMENT

Pediatrician looks after a neonate

Pediatrics

76

Annual Report | 2018 - 1439

The Pediatric Department provides several services to Saudi society and includes: Medical care for patients through: 1. Inpatient Wards, 2. the Pediatric Intensive Care Unit and Neonatal Intensive Care Unit, 3. High Risk Pregnancy, Emergency Department, Outpatient Department and Pediatric Cardiology Unit.

4. Resident training program.

5. Teaching medical students at Imam Abdulrahman Bin Faisal University.

The department also contributes in: 1.

Training of residents' physician attached to multiple of fellowships.

2.

Training of postgraduates of nursing, respiratory and clinical pharmacy departments.

3.

IAU students from other relevant college.

Neonates ICU

77

2| CLINICAL DEPARTMENT

Units of the departments: 1. Inpatient Wards:

The Inpatient Ward contains (25) beds for the treatment of children suffering from various diseases. Clinical care is supervised by residents, specialists, and consultants in addition to a group of qualified nurses and technicians of respiratory and physiotherapy care.

Number of admitted to oncology and hematology in pediatric dept. received (71) in an increase of 65.1% than the previous year.

19

20

Total

18 16

13

14 12 10 8 6

4

4

3

6 2

2

MAR

APR

2

5

2

6

7

2 0

JAN

FEB

MAY

JUN

JUL

AUG

SEP

OCT

NOV

DEC

Figure 16: Number of admitted to oncology and hematology in pediatric dept. received (71).

Pediatrics

78

71

Annual Report | 2018 - 1439

250

232

225 194

200

200

185

Total

173

1,796 150 118

100

99

100

94

90

82

50

0

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEP

OCT

NOV

DEC

Figure 17: Admitted neonates for 2018

79

2| CLINICAL DEPARTMENT

2. Neonatal Intensive Care Unit (NICU): This unit started work in May 1981 and has been equipped with the latest devices and facilities, such as nursery, mechanical ventilation, and a central screen to monitor patients, in addition to being staffed with a qualified workforce.

A new unit was inaugurated under the sponsorship of the region prince and IAU president includes 17 beds, 3 of it for receiving babies from out KFHU their cases require an advance care or surgical interventions.

The medical staff consists of several consultants who are available 24 hours a day. Doctors supervise routine clinical care, caesarean sections, and cases of high-risk birth. Medical care in this unit includes care on surgical intervention which is carried out by a qualified and specialized surgical team in Pediatric Surgery.

This unit has gained a good reputation and has become a main referral center in the Eastern Region for specialized medical care. Hence, the number of newborns with medical or surgical problems that transferred to KFHU from other hospitals across the Eastern Region has increased.

There is close cooperation between this unit and the Obstetrics and Gynecology Department which are reflected in the regular monthly meetings to discuss morbidity in the pre-natal period. These activities have resulted in a continuous decline in mortality among newborns weighing less than 1000 grams, and plans are in place to reduce the morbidity rate deaths among low birth weight newborns.

147

160 140

119

115

108

120

Total neonates

107

100

802

87

80 60 40 20 0

39 19 JAN

14 FEB

MAR

APR

MAY

15

17

15 JUN

JUL

AUG

SEP

OCT

NOV

DEC

Figure 18: Number of admitted neonates received (802) for 2018G, in an increase of 23.8% than the

previous year.

Pediatrics

80

Annual Report | 2018 - 1439

3. Pediatric ICU It is a separate unit contains 9 beds for intensive care.It is staffed with a specialized ICU team works 24/7 It includes (3) isolation room receive urgent cases from other hospitals in coordination with the units of pediatric surgery department.

Pediatrics admission dept.

81

2| CLINICAL DEPARTMENT

4. Pediatric Emergency Department The provision of medical services for emergency cases is under the direct supervision of pediatric specialists.

The Emergency Department has a room for nurses to measure the vital signs of children. It also includes two rooms for clinical evaluation by pediatricians, and (8) beds for the treatment of cases that require observation and further assessment. The Emergency Department works harmoniously with the doctors working in the inpatient unit and the intensive care unit in order to provide complete care for patients as quickly as possible.

5. Outpatient Department (OPD) OPD provides medical care services through clinics throughout the week from Sunday to Thursday under the supervision of pediatric consultants.

Pediatrics outpatient clinics includes five general clinics (one clinic per day) in addition to subspecialty clinics including the following: - Three cardiology clinics, - Two endocrinology clinics, - One diabetic clinic, - One gastroenterology clinic, one nephrology clinic, - One pulmonary clinic, - One allergy clinic - One infectious disease clinic, - Two hematology clinics, - Two neurology clinics, - One high-risk clinic for the care of infants who require intensive care after birth. * The number of pediatric OPD received (6891) , in an increase of 0.2% than the previous year.

6. Pediatric Cardiology Unit This unit started work in 1982 under the supervision of a pediatric team consisting of a number of pediatric cardiologists and staff. This unit also includes a diagnostic laboratory for cardiac diseases and is equipped for echocardiography.

One of the objectives of this unit is to provide the clinical and laboratory services necessary to provide maximum diagnostic and therapeutic medical care for children who suffer from heart disease. Besides, it provides continuous medical care to all children admitted at the hospital or born in the hospital suffering from congenital heart disease or transferred from other clinics and primary health care centers in the Eastern Pediatrics

82

Annual Report | 2018 - 1439

Region. The total number of tests done the year under report was 2,737.

25

23 20

19

20

Total

20

113 15

12 13

10

5

0

JAN

0

3

0 FEB

MAR

APR

MAY

JUN

1

1

JUL

AUG

1 SEP

OCT

NOV

DEC

Figure 19: Admission of the unit reached (113) for the year 2018 in an increase of 25.2% than the past year.

Resident Training Program One of the most important objectives of the pediatric department is to train doctors in the specialty of pediatrics, in accordance with the Saudi Council of Medical Specialties requirements.

The training period is 4 years, during which the doctor can practice pediatrics in various sub-fields. The training program has gained a good reputation and now includes doctors on scholarships from neighboring Gulf countries.

Teaching medicine students at IAU

Pediatric Medicine is a mainstay of the medical curriculum. Teaching of 6th year students is provided by pediatric faculties. The educational process includes lectures and intensive clinical education for two months, concluding with a practical and written assessment.

Future of the Department The Pediatric Department seeks continuous development, evidenced by the continuing efforts through fellowships in all the pediatric specialties and subspecialties internally and externally. This helps the trainees

83

2| CLINICAL DEPARTMENT

acquire the exact specialties and fellowships in the peripheral fields of the pediatric department such as metabolic diseases, infectious diseases, kidney disease, and endocrinology.

One of the aims is to create a special unit for dialysis for children in order to be a main center for referral cases that require dialysis in the Eastern Region.

Pediatrics ูกNeurosurgery

84

Annual Report | 2018 - 1439

Neurosurgery Introduction

This department was opened officially in April 1981, gradually increasing its staff and its services in the education and medical care provided to citizens in the Eastern Region.

The department is the first academic department recognized in its field in Saudi Arabia. The section participates in the teaching and training of medical undergraduate and graduate students. This program has attracted some notable scientific and medical institutions in the Kingdom of Saudi Arabia to apply for collaboration.

It performs hundreds of surgeries per year that include treatment of brain tumors and cerebral bleeding under the arachnoid membrane and outer nerve injuries, as well as the treatment of birth defects in the nervous system of children.

85

2| CLINICAL DEPARTMENT

900 800 700

712

Total Pt. seen

765

713

649 655

600

6,681

441

557

500

668

668

400

306

369

300 200 178

100 0

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEP

OCT

NOV

DEC

Figure 20: OPD received (6681) in an increase of 11.8% than the previous year.

70

62

60

60

60

56

49

44

50 40

577

51

44

39

30

30

28

20 10 0

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEP

OCT

NOV

DEC

Figure 21: Admission reached (557) in an increase of 8.9% than the previous year.

Neurosurgery

86

Total Pt.seen

54

Annual Report | 2018 - 1439

The department features work in areas that are rare or unique among neurosurgical departments in Saudi Arabia, including: 1. The treatment of brain edema from the wings using a discharge cerebrospinal fluid from the ventricles of the brain to the amniotic fluid in the womb of the mother.

2. Treatment of head injuries moderate to severe.

3. The treatment of spinal injuries.

4. Follow-up on neurological cases by a team (ICU nerve).

5. A brain and nerve surgery using ultra-precision equipment such as binoculars, modern cerebrospinal surgical microscopes, surgical navigation devices inside the brain, and device control physiology.

6. Unit Vascular Surgery brain through catheter intervention.

7. Brain tumors surgery without anesthesia.

8. Establishing a specialized clinic for children with birth defects such as hydrocephalus and hematomas meningitides to maximize visibility early.

87

2| CLINICAL DEPARTMENT

Orthopedics surgery outlines Introduction

The Orthopedic Surgery Department began to work independently after having been a part of the Department of General Surgery since the opening of the hospital. There are several units to this section comprising 31 beds, 20 beds for men and 5 beds for women and 6 beds for children.

This section teaches medical students in the field of orthopedic surgery and trains resident doctors in the Departments of Orthopedic Surgery, General Surgery, family and community medicine, and emergency medicine. The orthopedic department is one of the most important clinical sections in the hospital and participates in scientific research locally and globally. Doctors Section participates actively in the activities of various researches.

The department keeps up with important research in the field relating to joint fabrication, osteoporosis, sports medicine, shoulder surgery and endoscopy, orthopedics and bone distortion in children. It conducts research and studies on complications of bone surgery for patients with sickle cell, hip fractures, paralysis of the spine, and spine fractures. Several of the department’s case reports have been published in journals and presented at both internal and external conferences and seminars.

2000 1665

1800 1600

1762

1697

1497

1380

1588

1527

1400 1200

1228

1000

1622

1117

16,685

1061

800 600 541

400 200 0

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEP

OCT

NOV

Figure 22: OPD in 2018= (16685) in increase of 7.6% than the last year.

Orthopedics

88

Total Pt. seen

DEC

Annual Report | 2018 - 1439

90 80 70

83

81 73

72 65

60

Total

73

64 62

66

62

50

48

46

40

795

30 20 10 0

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEP

OCT

NOV

DEC

Figure 23: Admission in 2018= (795) in increase of 2.2% than the last year.

Orthopedics department units 1. Unit joints industrial change Under the supervision of (4) consultants we have achieved training efficiency comparable with that offered in the best universities in the world. This section is associated in weekly specialized clinics reaches (20310) patient annually. operations number received (160) during the year.

2. Sports Trauma & Arthroscopy Clinic This clinic is supervised by an orthopedic consultant and is one of the first specialized units in the Eastern Region. The Unit is also associated with a specialized clinic weekly and treats patients at a rate of (2120) per year. The total anterior cruciate ligament repair operations from the beginning of this clinic in 2018 stands at about (62) cases. A consultant came back from the external mission joined the department in May,2018.

3. Shoulder Surgery and Upper Limb Clinic Under the supervision of a consultant. It one of the first specialized units established in the Eastern Region.

This section is associated with weekly specialized clinics. Operations performed in 2018 received (96).

4. Orthopedics unit for kids Under the supervision of (2) counselors. This section is associated in weekly specialized two clinics. The number of patients this year received (20253). More than (205) operations were performed.

89

2| CLINICAL DEPARTMENT

5. Spine surgery unit This unit functions under the supervision of (2) counselors. It conducts two specialized weekly clinics. The number of patients this year received (10962).

6. Weekly clinic specializing in surgery foot bones This unit was set up in 2014 and works under the supervision of a specialist orthopedic consultant.

7. Fractures and injuries clinic Four clinics a week are held. The number of patients this year received (3251).

Orthopedics ูก Ophthalmology

90

Annual Report | 2018 - 1439

Ophthalmology The department was created in 1981, its main activity being undergraduate teaching. It started admitting patients in 1982. Postgraduate teaching activity began in 1983.

Since then the department has gradually expanded. The department conducts clinical, teaching, and research activity. At present the department consists of 14 consultants, 7 demonstrators, 30 trainee residents, 4 optometrists, one female optician for children, 3 other opticians and 9 technicians.

The department consists of 8 clinics (six clinics for consultants and two clinics for refraction to help the consultants). The department is well equipped to perform all types of requirements like Laser, FFA, Minor OR, Visual Field/Ultra Sound and IOL Master/Topography. The Minor OR is equipped for minor surgeries in the OPD. All clinics are adequately equipped to provide for the care of patients. We have a small play area for the children to play in the female waiting area.

Eye Examination Equipment

91

2| CLINICAL DEPARTMENT

3000 2500

2385

2635

2504

2296

Total

2513

1930 2000

2146

2094

2187

24,604

1671

1500

1377 1000 866 500 0

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEP

OCT

NOV

DEC

Figure 24: OPD received (24604) in an increase of 3.6% than the previous year.

180

159

160

148

140 120

113

114

109

1,244 96

100

102

116

97

80

71

60

60

40

59

20 0

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEP

OCT

NOV

DEC

Figure 25: Admission reached (1244) in an increase of 100% than the previous year.

Ophthalmology ูก ENT

92

Total Pt.

Annual Report | 2018 - 1439

ENT (Ear, Nose, and Throat) Introduction

Department of ENT began work in 1981 with one consultant physician. Faculty members of this section now include many consultants and specialists, in addition to a group of audiologists with doctoral and master's degrees, and speech therapists with master's degrees.

The section operates in outpatient clinics daily in the mornings and afternoons. There are special rooms for audios and communication in outpatient clinics; the department works 5 full days in surgery rooms for major operations. A unit has been added for cochlear implants, considered to be the first in the region.

In addition to teaching students in their fifth year at the Faculty for Medicine and Dentistry, the section trains Saudi doctors enrolled in a graduate program in the ENT specialty. The section is actively and effectively involved in continuing medical education programs of the university through the organization of conferences, seminars, and workshops throughout the year. Members of the ENT department participate in research at local and international forums.

A Doctor during a check for a child

93

2| CLINICAL DEPARTMENT

1800 1600

1546

1524

Total

1437

1407

1373

1400 1360

1200 1161

1000 800

767

600 400

467

406

200 0

13,698

1311 939

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEP

OCT

NOV

DEC

Figure 26: OPD received (13698) in an increase of 2.5% than the previous year.

90 80

Total

70

67

70 60

83

78

71

69

59

63

750

51

50

58

48

40 30

33

20 10 0

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEP

OCT

NOV

DEC

Figure 27: Admission reached (750) in an increase of 17.6% than the previous year.

The Audiology Unit:

Number of out-patients were seen in this unit for the year 2018G received (3530).

ENT ูก Neurology

94

Annual Report | 2018 - 1439

Neurology The Department of Neurology was established in 1987 as the first academic department in this field over KSA. The department – since its establishment- keeps provide teaching and training services for undergraduates and postgraduates of IAU. In addition to its other academic commitments in clinical research. and community service by providing high-level clinics for inpatients and outpatients, beside referral cases from other health institutions in the Eastern Region.

Neuro. Diagnosis lab

Regarding research activities, the department has done great efforts in collaboration with KACST. In addition to many academic papers published on international peer-reviewed journals.

The department provides distinguished services in its field and specialized clinics as epilepsy clinic. Its OPD reached in 2018 (6874) pt.

95

2| CLINICAL DEPARTMENT

The department sponsors the Saudi Neuro Association which was established under a high decree. Its first meeting was concluded on 26th of May 2005.

The department is under ongoing developments. There are ambitious futuristic plans for establishing a distinguished regional center to provide health care and training this field cadres in KSA and GCC.

Neuro. Diagnosis

Units & Clinics: -

Neurology

96

Sclerosis clinics Memory clinic Electroencephalography unit Electromyography (EMG) unit Epilepsy Clinics Strokes unit

Annual Report | 2018 - 1439

ICU General nerves clinics Drugs re-prescription clinic Botox injection clinic for cure of headache and sclerosis Motor system diseases clinic Myasthenia gravis muscles diseases clinic

-

848

900 722

800 700 600

Total Pt.

739

697

580 614

500

621

499

513

411

6,874

487

400 300 200 143

100 0

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEP

OCT

NOV

DEC

Figure 28: OPD received (6874) in an increase of 4.5% than the previous year.

70

68 56

61

55

Total

67

61

60 50

76

73

80

66

54

50

736

49

40 30 20 10 0

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEP

OCT

NOV

DEC

Figure 29: Admission reached (736) in an increase of +100% than the previous year.

97

2| CLINICAL DEPARTMENT

Dermatology Introduction

The Department of Dermatology conducts 9 outpatient clinics a week at the hospital in addition to one outpatient clinic at the primary health care center. The section includes doctors, consultants, demonstrators, and resident doctors.

In addition to doing clinical work, they participate in academic activities such as teaching medical students, taking part in the Rapporteur Academy of Special Skin Diseases for three weeks, etc. The section started the IAU fellowship program in the dermatology for graduate students in January 1990.

A special medication for a patient - Dermatology department

Dermatology

98

Annual Report | 2018 - 1439

The department offers a training program for dermatology and genital medicine for the Saudi Commission for Health Specialties and the Arab Council for Health Specialties.

Among other activities undertaken by the department are providing scientific seminars, workshops, presentations, and clinical meetings for doctors and trainees. In sessions on “The case of the week and month,” resident doctors prepare cases, coordinate discussions of cases, organize histopathology sessions, and participate in research activities.

Some of the section’s work includes research projects on psoriasis, altitude sickness, leishmania, baldness, chemotherapy-related diseases, and fungal diseases of the skin. In addition to preparing clinical readiness studies and case reports, employees of the department actively participate in all dermatological seminars in the Kingdom of Saudi Arabia and attend several global conferences.

1800

1560

1600 1400

1228

1200 1000

1486

1233

1170

1140

13,385

1228

1193

1086

800

862

600 400

Total

782

417

200 0

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEP

OCT

NOV

DEC

Figure 30: OPD received (13385) in an increase of 11.3% than the previous year.

99

2| CLINICAL DEPARTMENT

Psychiatry

INTRODUCTION The Department of Psychiatry, with its own clinical departments, was established within the Faculty of Medicine in Dammam in 1975. Two members of the faculty were initially appointed from the Department of Internal Medicine in 1980. The department works in the areas of teaching students and providing services for outpatients. Students are taught psychiatry at both Bahrain and Al-Ahsa, and at Aramco Hospital in Dhahran.

In 1982 the Department of Psychiatry, on the directive of Presidency of the University Council began work as an independent unit with its own clinical departments. It also gained representation on the College Board on an equal footing with the other major clinical sections of the hospital. After working from out of rented premises until 1988, the new, independent psychiatric department was built, consisting of a ground floor for outpatient psychiatry, psychiatric clinics for children, and clinical psychology clinics. The first and second floors are marked for male and female patients, with 18 beds for each section, and additional space allocated for clinical and training activities.

The department teaches behavioral science and principles of psychiatry for students at the Faculty of Medicine. Similar courses are taught at other colleges of the university, such as at the College of Dentistry, the College of Nursing, and the College of Applied Medical Sciences.

The graduate studies section offers a psychiatry fellowship program for male and female doctors. Training in psychiatry concludes with graduates earning the Saudi Specialty Certificate in Psychiatry as well as the Arab Psychiatry fellowship. A master's program in clinical psychology was start a in the academic year 1435-1433 H. The section plans to introduce training programs in psychological counseling program (diploma), with a focus on the field of addiction. As it currently studies the promotion of clinical psychology program to Ph.D.

Psychiatry

100

Annual Report | 2018 - 1439

844

900

807

800

785

686

700

658 695

688

600

Total Pt. 712

612

7,639

500 400

460

459

300 200

233

100 0

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEP

OCT

NOV

DEC

Figure 31: OPD received (7693) in an increase of 3.2% than the previous year.

32

35 30

27

25 20

21 23

Total Pt.

28 25

261

20

21

18

15

18

15 13

10 5 0

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEP

OCT

NOV

DEC

Figure 32: Admission reached (261) in an increase of 10.1% than the previous year.

101

2| CLINICAL DEPARTMENT

Anesthesia Introduction

The anesthesia department at King Fahd University Hospital offers a variety of services to patients 24 hours a day. These services represent all major operations conducted in 10 operating rooms. Equipped with the latest equipment and anesthetics, our anesthetists are engaging in all types of surgeries, including those involving emergencies and accidents.

The section also contributes to the provision of medical care for all patients before, during, and after surgical operations. As part of the hospital’s medical team, the Anesthesia Department also assigns specialists in this field to provide therapeutic services and supervise surgical procedures in the intensive care unit and in the treatment of acute and chronic pain, as well as contribute to cases involving the treatment of critical birth.

The section also provides a variety of services to other sections using CT scan and MRI, binoculars digestive systems, the psychiatric department, and emergency department.

The section organizes several seminars and workshops with a select group of doctors and professors distinguished in this domain from local and international universities and hospitals. The section has made significant contributions in the field of scientific research and has published many scientific papers in local and international journals and specialized periodicals.

One of Anesthesia Team

Anesthesia

102

Annual Report | 2018 - 1439

As for other academic activities, the section gives lectures and practicals, and disseminates information about the specialty of anesthesia for fifth year students. The section also trains postgraduates for the fellowship program of the Saudi Board for Specialization in Anesthesia. This department has come to be regarded as one of the most important training centers in the Eastern Region of the Kingdom.

-

OPD received (1269) in an increase of 75.1% than the previous year.

Admission reached (61) in an increase of 2950% than the previous year.

A new Equipment for Anesthesia Department

103

2| CLINICAL DEPARTMENT

Family and Community Medicine This department is one of the major clinical departments in KFHU. It locates inside the eastern site of the hospital under supervision of consultants, registrars and nursing staff. It performs an essential role in training students of medicine and nursing in the level of undergraduate and postgraduate.

The department makes distinguished activities via seminars, symposia and workshops in participation of physicians and faculty staff from national and international universities and hospitals. It published many of academic papers.

It also contributes in conduction of various academic activities as educational lectures in and out KFHU. -

OPD received (17201) in an increase of +100% than the previous year.

Family and Community Medicine

104

Annual Report | 2018 - 1439

105

3

Special Services Intensive Care Unit Cardiac Intensive Care Unit Surgical Rooms One-day Surgery Unit Physiotherapy Radiology Interventional Radiotherapy & Vascular Catheterization Unit ι Outpatient Department ι Emergency Room ι Wound Care Unit ι ι ι ι ι ι ι

3| Special Services

ICU well-equipped room

Intensive Care Unit (ICU) Internal Medicine ICU

-This unit consists of 16 beds and 2 isolation beds, all fully equipped to provide 24-hour intensive medical care and services for critical cases transferred from various departments of KFHU or from other hospitals.

-It offers good training opportunities for physicians, nursing staff, and other specialists at the hospital. This unit is supplied with modern equipment to develop and provide better service and medical care.

-The number of patients admitted to this unit in 2017 was 256 in comparison to 246 in 2016, and the occupancy rate was 100%.

Intensive Care Unit (ICU)

108

Annual Report | 2018 - 1439

A discussion inside Neonates ICU

Surgical Intensive Care Unit

-The unit consists of 8 beds and 2 isolation beds, all of them are fully equipped. They provide 24-hour intensive medical services and care for critical cases transferred from the various departments of the hospital or from other hospitals.

-It also provides good training opportunities for the hospital’s young surgeons and nurses. This unit is supplied with modern equipment and machines to develop it and provide better medical care.

-The number of patients admitted to this unit in 2017 was 424 in comparison to 411 in 2016, and the occupancy rate was 100%.

Pediatric Intensive Care Unit

-It is a small unit, established with two beds and then expanded to become an independent unit containing 10 beds and 3 isolation beds.

-The unit provides medical care services to all critical pediatric cases, including post-operative cases such as ENT surgery, brain surgery, eye surgery, etc.

-This unit is staffed by medical specialists including consultants and specialists.

-The number of patients admitted to this unit in 2017 was 223 in comparison to 179 in 2016, and the occupancy rate was 100%.

109

3| Special Services

Intensive Care Unit (ICU) ูก Cardiac Intensive Care Unit

110

Annual Report | 2018 - 1439

Cardiac Intensive Care Unit -This unit delivers first class medical care, intensive nursing service, and continuous ECG monitoring. It consists of 10 beds and is a fully-prepared unit to receive and respond to all emergent cardiac cases such as catheter patients and others.

-There are also 4 remote patient monitoring units.

The number of patients admitted to this unit in 2017 was 809 in comparison to 757 in 2016, and the occupancy rate was 92%.

Main Surgical Room

-The surgical room complex consists of 10 fully equipped surgical rooms and a 10-bed recovery unit.

-The complex provides 24-hour service.

-The number of major surgeries undertaken in 2017 was 5832 in comparison to 6454 in 2016.

Table7: showing the number of major surgeries performed Types of Surgery

Number of patients

Thoracic Surgery

98

Pediatric Surgery

258

General Surgery

1065

Orthopedics Surgery

715

Gynecology Surgery

359

Plastic Surgery

235

Eye Surgery

1046

Neurosurgery

329

Otolaryngology

622

Vascular Surgery

109

Urologic Surgery

501

Oral and Maxillofacial Surgery

170

Breast surgery

165

Cesarean section

14

Total

5832

111

3| Special Services

OR

Cardiac Intensive Care Unit

112

Annual Report | 2018 - 1439

OR

113

3| Special Services

One-day Surgery Unit (short stay) -This unit consists of 10 beds in addition to a special treatment room that consists of the latest medical equipment.

-Its role is to prepare one-day-patients before and after the surgery.

-Besides, the unit is responsible for conducting blood transfusions for patients, giving intravenous fluids, chemotherapy and other one-day treatment procedures. This should be carried out in coordination with the relevant clinical and medical departments.

-in 2017 the unit run 5358 operations in comparison to 4629 in 2016.

Daily Surgery Unit (Micro surgeries) -This unit consists of two special surgery rooms under the direct supervision of the general surgery departments, urology, and other surgical departments.

-It performs therapeutic, diagnostic, chemotherapy, and micro-surgical procedures, and has the latest medical equipment.

-The number of patients who were referred to the unit in 2017 was 1582 in comparison to 1352 in 2016.

OR reception One-day Surgery Unit (short stay)

114

Annual Report | 2018 - 1439

Department of Physical Therapy -This department provides care for both outpatients and inpatients in various specialties and receives patients transferred from other hospitals. It provides services to male and female patients daily, with a group of senior officials appointed to follow up on these aspects under close supervision, as well as continuing efforts of children's physical therapy this year.

-The department witnessed an increase in the number of physiotherapy rooms to provide better health care.

The working staff in this department comprised 38 specialists and physiotherapists.

-The Department of Physical Therapy has participated in several research and educational activities. It has also presented several lectures to students of physical therapy and nursing and carried out educational awareness campaigns.

-Services provided by the department in 2017 was 58381 in comparison to 68683 in 2016.

Physiotherapy reception

115

3| Special Services

Radiology Department -The Department of Radiology, which has been in operation since 1981, provides diagnostic and therapeutic services (interventional radiology and catheterization) to inpatients, outpatients, and emergency patients.

In addition, the department serves the hospital's health centers and patients transferred by other hospitals and medical centers in the Eastern Province.

-The department also carries out academic and educational activities for students of the College of Medicine, and students, interns, and postgraduate students in the Saudi Board and Radiology Fellowship Program.

-The department carries out research locally and internationally, participates in the academic activities of continuing medical education programs, and teaches radiology courses for students in the College of Medicine, interns, and resident physicians from other programs around the Kingdom, as well as participate in international and local scientific conferences and symposia.

-The department provides all types of radiation services such as General Radiology, CT, Ultrasound, Magnetic Resonance Imaging, Nuclear Medicine, and diagnostic radiology services, such as Bone Density and Breast Imaging, in compliance with the quality and safety standards relevant to all tests

Units of the Radiology Department -MRI Unit

-This unit served a mere 22 cases when it was established in 1991, following which it developed and expanded.

-The unit now contains two devices updated with the latest international magnetic resonance imaging technology; one of them works with a magnetic field strength 1.5 tesla and the other is a 3-tesla device, used to conduct various diagnostic tests.

-The unit is supervised by radiologists specialized in different fields and staffed with trained radiologists. It receives inpatients, outpatients, and patients transferred from other hospitals.

-The number of cases that benefited from these unit in 2017 was 5446 in comparison to 2860 in 2016.

-CT scan unit

The work in this unit started in 1981 with 359 cases, and then developed and expanded into an integrated unit equipped with the latest devices. The unit consists of two machines, a 64 slices/ second scanner and a 128 slices/second scanner. Those two machines help in the constancy and accuracy of various tests, in particular HSG and CTCA, under the supervision of trained radiologists specialized in different fields. The unit receives inpatients, outpatients and patients transferred from other hospitals. The number of cases that benefited from these unit in 2017 was 13398 in comparison to 7577 in 2016.

Radiology Department

116

Annual Report | 2018 - 1439

Radiologists

117

3| Special Services

-Ultrasonic Unit

-The work in this unit started in 1983 with 1,200 cases, and later developed and expanded into an integrated unit equipped with the latest devices.

-The department has over the years developed and expanded into an integrated unit equipped with the latest global specialized devices under the supervision of trained radiologists specialized in different fields.

-The unit receives inpatients, outpatients and patients transferred from other hospitals. The number of cases that benefited from the unit in 2017 was 9441 in comparison to 7511 in 2016.

-Mammography Unit

It is a well-organized and modern unit. This unit is supervised by radiologists specialized in the field of breast imaging and have the professional experience that enables them to carry out the work effectively through the annual survey program for women who meet the requirements set out for the monitoring, diagnosing and treating breast diseases. These procedures are carried out in coordination with the hospital departments concerned in treatment.

The unit receives inpatients, outpatients, and patients transferred from other hospitals. The unit provides the following services:

-Breast Ultrasound

The unit has been providing this service since the establishment of the hospital, but the capacity of the service provided earlier was limited. Thereafter, it was developed and expanded into an integrated unit equipped with the latest devices under the supervision of trained female radiologists specialized in different fields. The number of cases benefited from the unit in 2017 was 1254 in comparison to 1238 in 2016.

-Mammogram Unit

The unit has been providing this service since the establishment of the hospital. The service was developed and expanded into an integrated unit equipped with the latest devices under the supervision of trained female radiologists specialized in different fields. The number of cases benefited from the unit in 2017 was 1187 in comparison to 923 in 2016.

-Special Procedures Room (Stereotactic)

In this room, a biopsy is taken from the breast using advanced breast equipment to be sent to the hospital’s tissue labs for examination and diagnosis. This operation is carried out by specialized female radiologists.

-Breast magnetic resonance imaging:

Magnetic resonance imaging is performed to obtain more accurate and detailed images of the tissues and different parts of the breast. These images are carried out by radiologists specialized in this field.

Radiology Department

118

-Bone Densitometry Unit

Annual Report | 2018 - 1439

The unit started working in 1983 with 1,200 cases. The department developed and expanded into an integrated unit equipped with the latest global specialized devices under the supervision of trained radiologists specialized in different fields. The unit receives inpatients, outpatients, and patients transferred from other hospitals. The number of cases benefited from the unit in 2017 was 1636 in comparison to 960 in 2016.

-Nuclear Medicine Unit (SPECT/CT):

The unit was established at the end of 2016. In terms of planning, building, and construction, this unit is well-prepared and equipped. To equip this unit, the hospital contracted with international companies specialized in manufacturing advanced equipment in the field of nuclear medicine. The necessary permits were obtained from the King Abdullah City for Atomic and Renewable Energy to practice work at the highest levels of safety, standards, and in accordance with the international radiation protection. The unit is supervised by qualified and experienced physicians and radiologists, specialized in the field of nuclear medicine. The unit works under the direct supervision of Radiation Protection Unit in Radiology Department.

The number of cases benefited from the unit in 2017 was 78 cases.

Radiologists

119

3| Special Services

Diagnosis and Treatment through Interventional Radiology and Vascular Catheterization

120

Annual Report | 2018 - 1439

Diagnosis and Treatment through Interventional Radiology and Vascular Catheterization This unit was established in 2010 to perform diagnosis and treatment through the latest technologies used in the field. The unit can treat cases such as: • Expansion of narrowed or blocked arteries.

• Uterine fibroids treatment.

• Treatment of some cases of liver tumors.

• Bleeding treatment through therapeutic catheterization.

• Varicose veins treatment using catheters or laser technology.

• This unit is also associated with a weekly clinic supervised by specialized consultants in these fields.

• The number of cases benefited from the unit in 2017 was 795 in comparison to 714 in 2016.

Quality Assurance Unit:

The Unit is responsible for the general supervision of all procedures and work policies in the Department of Radiology to ensure quality of work and the highest international standards in coordination with the Department of Quality and Safety in the hospital. The unit tasks are as follows: • Apply national and international standards to obtain various quality accreditations.

• Extract and analyze statistics to enhance and support the Radiology Department’s decisions.

• Develop, update, and upgrade the various policies, procedures and activities in the department.

• Establish, implement, and monitor performance indicators for the various activities of the department.

• Monitor and improve the performance of various activities through periodic surveys and through the Risk Management Unit report.

• Participate in the establishment of the department’s events, activities, and educational workshops.

• Train and follow-up on the performance of staff in the department through implementing the procedures and standards.

Radiation Protection Unit:

Previously, this unit used to examine radiology readers in coordination with one of the centers licensed by the King Abdullah City for Atomic and Renewable Energy. Its major task was conduct surveys to ensure that there is no radiation leakage from the radiation room. This unit was developed after the establishment of the Nuclear Medicine Unit and the use of radioactive materials in it. The university administration recruited specialized cadres in the field of nuclear medicine and nuclear physics. These cadres have the expertise and competence to work in the field of implementing and monitoring various standards, and instructions to maintain the prescribed levels of permissible exposure levels in this field. Moreover, these cadres are authorized by King Abdullah City for Atomic and Renewable Energy to work in this field and are responsible for the safe handling of all radiation in the hospital.

121

3| Special Services

Outpatients clinics: • Outpatient clinics work 5 days a week under the supervision of a team of consultant physicians and specialists in about 300 major and sub-specialties.

• According to the computerized registration, the number of outpatients in 2017 was 21667 in comparison to 194037 in 2016.

• The medical outpatient system is witnessing a steady development in terms of the general medical system development and the control of the number of visitors to each main clinic or subsidiary, in addition to sending messages to patients on their cellphones informing them about appointment schedules.

Emergency Section: The emergency department provides high quality emergency medical care to all citizens and residents. The department also provides educational and training opportunities for medical and nursing students, medical technicians, and emergency and resident physicians.

This department has witnessed remarkable development, in terms of manpower, equipment, buildings and facilities.

The department is staffed with a special, well-trained, and qualified medical team. It includes 6 consultants specialized in emergency and accident medicine, and who have fellowships in the various specialties of emergency medicine from the USA and Canada. The department also includes a group of specialist physicians with board certification or a master's degree in emergency medicine.

Recently, a number of Saudi physicians who graduated from the Saudi Board of Emergency Medicine have joined the department, as well as a number of other Saudi physicians who have completed their scholarship in the United States and Canada.

Diagnosis and Treatment through Interventional Radiology and Vascular Catheterization ١ Emergency Room Departments and Units

122

Annual Report | 2018 - 1439

Emergency Room Departments and Units The emergency room comprises the following departments: 1. Reception Department: All emergency patients are admitted and registered electronically. Patients in critical conditions complete their registration procedures at the treatment sites in the presence of their relatives.

2. Client assessment area: All emergency patients are initially assigned to the assessment area where patients are assessed and classified according to their cases and their severity using the internationallyrecognized standard, “The Canadian standard”.

3. The initial screening area: This is where patients with minor injuries are admitted in the primary examination area. This area is divided into two sections, one for examining males and the other to examining females. Each section contains a room for checking the patient’s vital signs before being examined by emergency physicians.

4. Critical care unit: It contains the necessary medical equipment and devices for the recovery and treatment of patients and injured people in severe and critical situations, including emergency cases.

5. Observation Unit: It consists of two separate areas, one for males comprising 13 beds, and the other for females comprising 8 beds. Middle-class surgical and medical patients are admitted to this unit.

6. Pediatric Care Unit: This unit is affiliated to the children’s department and operates 24-hours a day.

It includes two separate rooms for examining pediatric patients. It consists of 8 beds for the care of patients in critical and stable conditions.

7. Minor operating room: In this room simple surgeries such as suturing wounds are performed.

8. Orthopedic cast room: In this room casts are performed for simple fractures.

9. Psychiatric patients’ room: This room is used to receive emergency and unstable psychiatric patients.

10. Isolation room: Patients with infectious diseases are admitted to this room to protect the other patients.

11. Private clinic: This is a clinic equipped to check the urgent conditions of eye, ear, nose and throat diseases.

12. Wound dressings room: A special room, one for males and another for females, is allocated to take care of the dressing of wounds.

123

3| Special Services

ER OPD 25000 22598

23059 22093

22952

21093 20203

20000

19450

Dec

Nov

Oct

Sept

Aug

Jul

Apr

Mar

May

17024

15000 Feb

19524 18390

17914

Jan

23031

Total 247331 Figure 33: The number of emergency patients benefited from the unit in 2017 was 247331 in comparison to 234140 in 2016 which is an increase amounted of 5.6%.

Emergency Room Departments and Units ูก Wound Care Unit

124

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Wound Care Unit This unit was established in 2015. The unit is affiliated to the nursing department, administratively and technically. The tasks of this unit are to treat inpatients’ wounds in the hospital through monitoring and providing them with the necessary treatment.

2017

2015

2013

2011

2009

2007

2005

2003

2001

1999

1997

1995

1993

0

1991

50000

1989

100000

1987

150000

1983

200000

1981

250000

1920 33168 49467 66301 75153 72363 80408 90512 101985 123273 119005 130627 123087 128463 130271 135719 128283 155385 164315 196748 203449 212942 249960 239039 243267 235977 220965 233196 215010 192050 180630 194669 203374 186690 195062 234140 247331

ER Comparison for years 19812017-

Total 24331

Figure 34: The number of patients benefited from this unit in 2017 reached 561 patients.

125

4

SPECIALIZED CLINICS ι ι ι ι

Employees Health Service Primary Healthcare Clinic Private Clinic The private center of health services

Annual Report | 2018 - 1439

4| SPECIALIZE CLINICS

Employees Health Service – EHS Employee Health Services 2017 2000 1518

1500

1168 784

772

1089

724

680

475

Dec

Nov

293 Aug

Jul

May

Apr

Mar

Jan

0

325

Sept

490

Feb

500

779

Oct

1000

Total 12,546

Figure 35: A total of (9097) patients were seen in EHS during the year 2018.

This clinic provides comprehensive healthcare to employees of the hospital and undertakes medical examination procedures for students of IAU. It also carries out medical examination for new employees and students. Hepatitis vaccination and meningitis vaccination were also given.

Employees Health Service – EHS

128

Annual Report | 2018 - 1439

EHS Reception

129

4| SPECIALIZE CLINICS

Primary Healthcare Clinic Primary Healthcare Services 2414

2500

2000

1658

1860

1794

1691 1549

1500 1141

1596

1261

1000

Dec

Nov

Oct

Sept

Aug

Jul

May

Apr

692 Mar

Jan

500

791 Feb

754

Total 17201

Figure 36: A total of (17201) patients were seen 2018. Administration of oral polio vaccine, measles vaccine, MMR, Hepatitis B and H-Influenza B to children continued this year.

The Primary Care Clinic is developed by the department of FAMCO in collaboration with KFHU and MOH for providing training to Saudi medical graduates and undergraduates in Primary Health Care and Community Health Nursing.

The clinic has three major units, MCH, Adult Family Medicine and Health Promotion Unit providing curative, preventive and promote services.

Primary Healthcare Clinic ูก Private Clinic

130

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Private Clinic Royal Clinic 300 265 250

200

219 201

198 170

150

176

191

167

157

201

188

147

Dec

Nov

Oct

Sept

Aug

Jul

May

Apr

Mar

Feb

Jan

100

Total 2,194

Figure 37: A total of 2,194 patients were seen at Royal clinic in 2018.

This clinic treats employees working in the palace of Royal Prince of the Eastern Region. It is staffed by one doctor and one nurse. Patients who need more medical investigations are referred to the OPD of the hospital.

131

4| SPECIALIZE CLINICS

KFHU waiting hall

Private Clinic ูก Private Center of Health Services

132

Annual Report | 2018 - 1439

Private Room

Private Center of Health Services It is a new center established in 2016 to provide a private service to both Saudi nationals and residents. The center intends to make use of the state of the art equipment and infrastructure as well as the professional teams of the skillful cadres in providing services of a private type suit customers’ requirements.

Statistics indicate that the number of patients increases for the good fame acquired by the center in comparison to other healthcare centers.

KFHU is exerting best of its efforts to improve the center more and more to meet satisfaction of customers

133

4| SPECIALIZE CLINICS

A nursing station in the private center

in receiving care and medication in high quality and suitable rates.

The table below shows services provided by the center: 1.Eye care 2.E.N.T 3.Orthopedics surgery 4.Gastro 5.Urology 6.General surgery 7.Neuro 8.Neurosurgery 9.Other surgeries

10.Plastic surgery 11.Obesity 12.Radiology 13.Dental 14.Cardio Cath 15.Obstetrics & Gynecology 16.Endocrine & Diabetics 17.Health education 18.Dietary

Private Center of Health Services

134

Annual Report | 2018 - 1439

500

461

400 300 239 200 100

177

138

114

159

169

131

122

100

272

89

Dec

Nov

Oct

Sept

Aug

Jul

May

Apr

Mar

Feb

Jan

0

Figure 38: The center admitted patients received 592 for the year of the report

135

5

Auxiliary Departments ι ι ι ι

ι ι ι ι ι

Nursing Laboratory Medicine & Blood Bank Pharmacy Electronic Health service and information systems • Health information department • Information technology Patient Rights & Relations Central sterilization and supply Social medical service section Dietary Infection control

5| Auxiliary Departments

Department of Nursing Services The Department of Nursing Services is the largest department at King Fahd Hospital of the University, more than eight hundred (800) nurses in various capacities, working in a multinational and multicultural environment, that are available around the clock, twenty four hours a day, seven days per week, delivering optimum nursing services to patients and their families.

The Department of Nursing Services strives to provide its utmost contribution in primary, secondary and tertiary clinical patient-care services based on strong commitment to nursing practice, education, on the job training, research participation, innovation and collaboration with other services.

The Department Of Nursing Services operates under the leadership of the Directorate of Nursing Services that reports directly to the Hospital General Director of KFHU, which allow it to achieve its outlined purpose in its mission, vision and value statements.

Department of Nursing Services

138

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Mission

Our Mission is to provide the highest quality of Patient Centred Holistic Nursing care which is consistent with the high standards of excellence expected of Imam Abdulrahman Bin Faisal University and King Fahd Hospital of the University.

Vision

Our Vision is to further elevate our Nursing Standards of Excellence by continuously improving the quality of care provided to our patients and maintaining those high standards.

Values

Our Vision is to further elevate our Nursing Standards of Excellence by continuously improving the quality of care provided to our patients and maintaining those high standards.

139

5| Auxiliary Departments

Activities among NS

Location

The Department of Nursing Services is composed of: I. The Central Nursing Office: • The Central Nursing Office is located in the basement of KFHU central building (100) beside the Medical Director and the Administrator’s Office, and includes: - The Office of Nursing Director; - The Office of Associate Nursing Director; - The Office of the Assistant Nursing Directors; - The Office of Nursing Quality Management; - The Office of the Nursing Coordinators for: • Staff Competency and Skills Review • Environmental and Patient Safety • Materials, Equipment and Supply - The Nursing Education & Training Centre for Staff & Interns - The Office of Health Informatics and Research 2. The Clinical Nursing Units: • The Clinical Nursing Units include, but not limited to: Department of Nursing Services

140

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Table 8: The Clinical Nursing Units IN-PATIENT AND CRITICAL CARE SERVICES Coronary Care Unit Cardiac Catheterization Lab Medical Intensive Care Unit Pediatric Intensive Care Unit Surgical Intensive Care Unit Burns Unit Labor and Delivery Room Neonatal Intensive Care Unit Well-Born Nursery Obstetrics and Gynecology units Surgical Units – Adults Medical Units – Adults

Pediatric Surgical Unit Pediatric Medical Unit

141

5| Auxiliary Departments

Table 9: The Clinical Nursing Units AMBULATORY CARE AND PSYCHIATRY SERVICES Emergency Department Ambulance Services Out-Patient Department, Lithotripsy EHS clinic Hemodialysis Unit Peritoneal Dialysis Unit Operating Room and Recovery Room Endoscopy unit Day Surgery Short Stay Unit Satellite Clinics

Central Supplies & Sterilization Department Male Psychiatric Unit Female Psychiatric Unit

Department of Nursing Services

142

Annual Report | 2018 - 1439

Core Functions

The Department of Nursing Services is offered under the expert and supreme leadership of the Director of Nursing Services, who plans, oversees, supervises, evaluates and personally approves all departmental activities which are patient-focused care. The Associate Director of Nursing Services serves as co-leader of the Department of Nursing Services, and reports to and provides the utmost support to the Director of Nursing Services in the planning and decision-making process, and implementation of approved directives.

This encompasses the following steps to the ultimate goal of providing high-quality holistic patient care services and achieving patient satisfaction: • Early ‘drawing board’ stages of planning and designing innovative tools for the improvement of patient care and hospital-related services.

• Establishment of solid, evidence-based, policies and standards of nursing practice.

• Assurance of strong leadership and management of nursing personnel.

• Intensive training and education of nursing personnel on updated skills and techniques in holistic patient care • Supporting continuous education and research at all levels in the interest of producing outstanding healthcare professionals dedicated to patient care services, who will uphold the KFHU commitment to excellence.

• Ensuring provision of high-quality clinical nursing services and patient care services on patient care areas.

• Continuous assessment, evaluation and re-evaluation of all plans, innovative designs, patient and personnel management, delivery of patient care services and outcomes.

Nursing Management

The role of the nursing management is to work collaboratively with its members in evaluating the department’s achievement and outcomes in assuring safe patient care with measurable quality outcomes throughout two main Divisions: I. The Division of Planning and Development (Central Nursing Office) is the backbone of the Department of Nursing Services under the expert and supreme leadership, guidance, direction and direct supervision of the Directorate of Nursing Services the Division of Planning and Development facilitates the goal of providing high-quality holistic patient care services through its two complementary subdivisions, which are: - Nursing Quality Management Office Shall be responsible for the following functions: • Continuous assessment and analysis of current Nursing practices.

• Identification of problems that impact delivery of quality patient care and staff performance, including the analysis of incident reports .

• Innovation, recommendation, planning, developing, designing, coordinating, directing, modifying, establishing implementing and evaluating programs of quality improvement management.

• Continuous research, analysis and update of policies, procedures and job descriptions.

143

5| Auxiliary Departments

• Composition, preparation, review and revision of all written directives in the form of policies, procedures and job descriptions, as well as, all written material pertaining to quality initiatives and programs, in accordance with KFHU Vision and Mission.

• Management of electronic information systems within Nursing Services.

- Nursing Education, Training and Staff Development Office Shall be responsible for the following functions: • Coordination of all educational activities directed towards nursing personnel and based on the Planning and coordination of continuous educational programs for the theoretical and practical training and development of nursing personnel • Orientation of newly employed nursing personnel on the expectations of KFHU and the Department of Nursing Services, as well as, • Collaboration with the College of Nursing Education on the orientation of nursing students and interns to nursing and hospital policies and procedures 2. Division of (Clinical) Patient Care Services: - Assistant Directors of Nursing Services who represent the Division of Patient Care Service (InPatient Care Services and Ambulatory Care and Psychiatric Services) The Assistant Directors of Nursing Services shall perform the following functions to ensure the overall safe and effective delivery of patient-care services on clinical nursing units: • Direct supervision of the Unit Nursing Supervisor and Team in all matters concerning the clinical patient-care nursing unit – predominantly, in the areas of patient-care, nursing personnel and staffing.

• Ensure daily staffing requirements of clinical nursing units.

• Review monthly staffing schedules and vacation plans prior to submission to and final approval of the Associate Director of Nursing Services.

• Review and note all personal written requests of nursing personnel prior to final submission to the Directorate of Nursing Services.

• Conduct clinical rounds on respective patient-care areas to ensure and enforce compliance to established policies and procedures in all activities.

• Provide an intermediary link between the Unit Nursing Team and the Directorate of Nursing Services.

- The Nursing Coordinators works under the direction and direct supervision of the Directorate of Nursing Services and shall be responsible for guiding the nursing personnel on proper channels of communication and to the following: • Collecting necessary data needed to support clinical improvements • Investigate thoroughly incident reports; obtain clear information, statements and present summary reports to the nursing administration to identify the cause of the incidents.

• Prepare reports as instructed by the respective Associate DON to improve unit productivity.

• Facilitates direct access to the Central Nursing Office • Ensures that all activities are performed according to established nursing policies.

Department of Nursing Services

144

Annual Report | 2018 - 1439

- Off-Shift House Supervision: Outside of official business hours, the Central Nursing Office shall be represented by Off-Shift House Nursing Supervisors who shall report directly and continuously to the Directorate of Nursing Services and perform the following functions: • Immediate trouble-shooting of current problems which arise during assigned shift • Satisfaction of immediate staffing requirements during assigned shift hours • Reporting of sick leaves and absences to the Nursing Administrator on-call • Conduct clinical patient rounds of the ‘house’ during assigned shift hours • Facilitate coordination of patient care and enforce and ensure safe and effective delivery of patient care services as per established nursing policies and procedures in keeping with the philosophy, goals and objectives of the Department of Nursing Services during off-shift hours.

- The Unit Clinical Nursing Supervisor works under the direction and direct supervision of the respective Assistant Director of Nursing Services and shall be the leader of the Unit Nursing Team, shall be present at all times on the respective clinical patient-care nursing unit, and shall accept guidance from the clinical coordinator in regards of managerial and for the following: • Provides direct supervision and coordination of activities within the designated nursing unit including planning, organizing, leading and controlling these activities.

• Prepares the monthly duty schedule and vacation plan for nursing personnel in the designated unit • Conducts regular meetings with the unit staff to encourage and ensure professional staff development.

• Ensures and maintain the needs of the designated units.

- Unit Nursing Team which comprised of the following team members: • Unit Clinical Nursing Supervisor – Unit Leader .

• Head Nurse / Assistant Head Nurse.

- The Unit Head Nurse works under the direction and direct supervision of the respective Clinical Nursing Supervisor and for the following: • Assist and support the unit nursing supervisor in certain managerial activities as required.

• Ensures the effective delivery of patient-focus nursing care.

• Continuously monitor and evaluate the clinical performance of nursing staff.

• Plays an active role in teaching and job training of nursing personnel.

- All Staff Nurses.

- Nursing Assistants.

145

5| Auxiliary Departments

Medical Laboratories • The administration of medical laboratories which is accredited by CAP in 2015 provides diagnostic services around the hour for OPD, admission, other centers of ministry of health, private hospitals, center of primary health and EHS of IAU. • It performs more than 500 various tests in 11various lab. The total number of tests run in 2017 reached (3725699) in a daily average of (1207) test.

• The department also participates in the training of both under-graduate and post-graduate students with relevant medical specializations. It also supports the relevant approved research projects. The clinical laboratories avail training opportunities for medical interns in the field of histopathology and pathology.

• procedures development and documents of data saving are treated via electronic scanning in a hard desk for making use of storage area.

• Dolphin) software for blood donors is under process. It is one of the electronic software that cover blood bank needs in updating to modern technology.

medical laboratories

146

Annual Report | 2018 - 1439

147

5| Auxiliary Departments

medical laboratories

148

Annual Report | 2018 - 1439

Table 10: Medical Labs statistics /2017: Lab

Tests

Development remarks

Genetic cell

1149

Cell pathology

5496

Use of florescent in chromosome test Test

General chemistry

1899957

Fetal hemoglobin

Cytopathology

44061

Test

Pathology

369611

Immune

150743

Molecular Other

4328 536498

Microbiology

713856

Test

Test

Test Test

A side from KFHU ML

149

5| Auxiliary Departments

Immune. Lab

medical laboratories

150

Annual Report | 2018 - 1439

Blood. Lab

151

5| Auxiliary Departments

Pathology Lab

medical laboratories

152

Annual Report | 2018 - 1439

Microbiology Lab

153

5| Auxiliary Departments

Histology Lab medical laboratories ูก Blood Bank

154

Annual Report | 2018 - 1439

Blood Bank The Blood Bank was established in 1981 under supervision of ML of KFHU. It was including 2 rooms, one for blood group check and the other for storing blood and its components. The need for blood and its components increased, hence appeared the need for Blood Bank extension. IAU administration hired an external building of 4 rooms to achieve self-efficiency.

In 20027 a new building was established to contain all of Blood Bank units and now it presents many services for donors and patients.

The bank aims to guarantee the blood safety by using the best of technologies invented in the field of transfusion medicine as well as promoting of high quality to achieve national and international accreditations.

In addition to collaboration with counterparts' banks locally, regionally and internationally. Moreover, provision of services to donors, educational awareness among citizens to the importance of blood donation and call to rationalize the optimum use of blood among health providers and physicians.

A mobile Blood Bank

155

5| Auxiliary Departments

Table 11: Statistic comparison: #

2013

2014

2015

2016

2017

Donors

4793

4464

4728

4611

5200

Procedures

Inside KFHU Blood Bank

Blood Bank

156

93120

102409

97823

106608

119426

Annual Report | 2018 - 1439

Chemistry Lab

157

5| Auxiliary Departments

In Histology Lab

Blood Bankูก Services of Pharmacy Care

158

Annual Report | 2018 - 1439

Services of Pharmacy Care This department provides best pharmaceutical care services for inpatients Outpatient ambulatory, Works in Section pharmacists and technicians have the expertise and distinctive skills in the preparation and disbursement of pharmaceutical compounds with using the exchange pharmacological unit which provides treatment to the patient within 24 hours, The department encourages education and training activities in the field of pharmaceutical care to all providers of health care service.

Include services basic section work in the fields of clinical and patient care inpatients and outpatients and provide the required information on medicines.

OPD Pharmacy

159

5| Auxiliary Departments

Services of Pharmacy Care consists of the following parts: • Internal pharmacy: It provides services for admission patients along day 24 hours.

• External pharmacy: It serves OPD. • ER Pharmacy: It provides services for emergency cases patients along day 24 hours.

• Psychiatry pharmacy • OR pharmacy • IV solutions pharmacy • Substances under control section • Clinical pharmacy: it provides services for ICU, pediatric, surgery and internal medicine departments where a member of the department contributes in physicians rounds to evaluate drugs prescription.

Medicines Prescription

Services of Pharmacy Care

160

Annual Report | 2018 - 1439

Pharmaceutical Complex

161

5| Auxiliary Departments

Solutions Preparation Services of Pharmacy Care

162

Annual Report | 2018 - 1439

Achievements/2017 1. Extension of e-prescription to involve OPD, ER and Psychiatry to assure high levels of safety and quality.

2. Extension of Omnicell dispensing system to involve most of the departments.

3. Activation of quality and safety department for work development and to meet quality requirements.

4. Contribution in Quality Week of Health Care.

New Pharmacy Reception

Recommendations: 1. Expansion of OPD pharmacy to meet safety international standards.

2. Expansion of internal pharmacy for a better provision of service to patients.

3. Establishing of mixing and compounds pharmacy to provide cures that are unavailable commercially.

4. Mail service to save patient time and enabling delivering cure to his/her house.

5. Reconsideration of cure delivery mechanisms over all the pharmacy parts to comply with international standards of safety.

6. Establishing of drugs information center.

163

5| Auxiliary Departments

Table 11: Pharmacy statistics/2017: Service

#

Internal pharmacy via Omnicell

714049

IV solutions

144407

OPD/ER/Psychiatry pharmacies Other Drugs under control Compounds Preparation

858968 72394 438

OR pharmacy

20072

Clinical advices

2609

Advices of information center Cures delivered in wards Other Total

6653 3083

1946 1824619

Health Information Department It includes: A. Medical Records and B. Patient Affairs Medical records consist of three main sections: 1. medical records with its 3 branches: • Management and Arrangement Unit • Analysis and Abstracts Unit • Disease & Treatment Procedure Coding Unit 2. Filing Section: It includes 3 units: • Incoming and Outgoing File Unit: All details of medical file movements and computerized • File Maintenance Unit: This unit repairs any damaged sheet in the medical file.

• Record Preservation Unit

Services of Pharmacy Care ١ Health Information Department

164

Annual Report | 2018 - 1439

Table 12: Statistics of medical records: Service

#

Collected files

13449

Files of full abstracts

5619

Analyzed files

In-complete files filling Withdrawn files

Files sent back to shelves Completion of in-complete files by physicians

5619 2087 2392 3800 2531

3. Medical Transcription The role of this unit is to type the various medical documents among reports, memos, discharges and operations surgery. Currently it uses one of the most famous software in this field which is (Dragon Medical Dictation) where the physician voice would directly be transferred into words typed by the system after dictation. It is a tool that saves the time and effort of both the physician and the patient.

Table 13: Services provided by the unit: Provided service

No. of Records

Medical reports

130

Operative reports typed Medical reports

138

Discharge summaries Memos/letters/fax Total

607 764 1639

165

5| Auxiliary Departments

Medical Records

Health Information Department ูก Patient Affairs Department

166

Annual Report | 2018 - 1439

Patient Affairs Department Information Section It consists of several sections: It receives the patients, responds to the public questions and shows the visitors the various wards and departments of KFHU. 1. Birth Section It issues birth notification for birth cases that occur inside KFHU. 2. Death Section It issues death notifications. It also receives bodies of persons who died inside KFHU and then hands over such bodies to their families after making sure that all required regular actions are done.

3. Medical Report Section This section issues medical reports with both Arabic and English languages after the completion of the regular procedures of KFHU. It also issues sick leaves according to the system of the hospital.

4. Admission Office This office admits the referred patients to the inpatient departments of KFHU. All the procedures of admission are computerized.

5. Eligibility Office The office receives all patients referred from the other hospitals and medical centers then check whether they are eligible to be treated in KFHU. The patient documents are sent to the clinical departments of the hospital so as to be considered prior being referred to the relevant outpatient clinic.

Table 14: Activities and achievements/2017: Activties & Tasks

No.

Medical Reports.

5666

Death Reports.

476

Police Reports.

Delivery Reports.

Admission cases Treatment Eligibility

1052 1582 9500 7980

167

5| Auxiliary Departments

Electronic Health Information Services & IT The administration keeps following its activities in field of management and operation and updating of computer software in collaboration with one of the national companies specialized in this domain according to a 3-years contract for the interest of KFHU. The contract provisions include; maintenance, training of employees, programming with periodical reports and reports upon KFHU request. The administration works to make available all internet services for purposes of scientific research.

In compliance with the ambitious vision of KSA 2030 and as implementation to H.E , the president of IAU in regard of lifting the competency and quality of services in academics , administration and operation of KHU to keep updated to modern developments in health sector and work toward providing the best services for citizens and residents, the administration succeeded in implementation of many projects in collaboration with IT Deanship of IAU. After reviewing the bid requirements and preparation of the conditions by a team from this administration a resolution was released to conform a professional commission to study and analyze the offers of the contest companies in the bid of the integrated electronic system under the leadership of Vice-dean for College of Medicine, KFHU Manager with membership of representatives of other medical and administrative departments.

The professional commission concludes meetings and discussions with contestant companies, each company separately. An integrated electronic medical system was carefully selected to be applied in KFHU after fulfilling the technological conditions and the bid description.

The role of I.T administration of KFHU is to follow, manage and operates in collaboration with national contractors for operations within 3 years. The provisions almost include: - Computers maintenance - Training of health providers as physicians, nursing staff and employees.

- Programing and monthly reports preparation when requested by KFHU administration.

- General technical support, particularly for purposes of scientific research.

Electronic Health Information Services & IT

168

Annual Report | 2018 - 1439

I.T servers central room

Important traits: - (Quadra Med CPR) which is an integrated medical system.

- Annual updates.

Developments: - Completion of the eventual procedures of medical records archiving bid.

- Optimum use of medical information system.

- Lifting the work competency by application medical information environment free of papers.

- Effective communication between the administration and representatives of departments and directorates.

169

5| Auxiliary Departments

Another shot for servers central room

Electronic Health Information Services & IT ูก Patient Rights and Relations Department

170

Annual Report | 2018 - 1439

Patient Rights and Relations Department It was established in 2012 and it is considered the link between the patient and the various departments of KFHU. The department, which falls under the direct supervision of the Medical Services Director, removes almost all obstacles that encounter patients in the hospital.

Patient Rights Department consists of three sections: 1. Patient Complaint Section: It was receiving daily more than 70 complaints / suggestions the year under the report. These complaints and suggestions were forwarded to the KFHU administration to be solved.

2. Medical Co-ordination Section: The activities of this section are as follows: • To refer certain cases to the appropriate specialized hospital in Saudi Arabia • To coordinate the waiting list with other hospitals in Riyadh or any other city • To receive and send medical reports of inpatients 3. The Administrator on Call Section: The main tasks of this section are: • To solve problems that might occur between the patient and the medical cadres.

• To encourage the patient to accept and use the prescribed medicine or treatment as per the rules and regulations of KFHU. • To document the criminal medical cases and to co-ordinate with the pertinent government bodies concerning the appropriate actions.

• To facilitate the procedures of the inpatients interested to leave the hospital as per the acceptance or advice of the concerned physician.

• To coordinate with morgue in delivering dead bodies to their relatives according to regulations.

• To report the problems unsolved to the higher administration of KFHU. • To contribute in solving problems by receiving remarks and suggestions of patients whether in admission wards, ER, OPD or other diagnostic departments.

• Receiving patients referred to KFHU. • Referral of patients to Eastern Region hospitals of health affairs.

• Referral of patients to KFSH in Dammam.

• Referral of patients to SAUD ALBABTIN hospital in Dammam • Referral of patients to King Fahad Medical Complex in Dammam • Referral of patients to King Faisal Specialized Hospital in Riyadh (Evacuation) • Referral of patients to King Faisal Specialized Hospital in Riyadh (Ambulance) • Referral of patients to other hospitals out of Eastern Region in Riyadh (Evacuation) • Referral of patients to King Faisal Specialized Hospital in Riyadh

171

5| Auxiliary Departments

Patients relations office

Patient Rights and Relations Department ูก Rights of patients and limits of their responsibility in KFHU

172

Annual Report | 2018 - 1439

Rights of patients and limits of their responsibility in KFHU As a patient in KFHU you enjoy the following rights: • Medical team must greet you in decorum • You have the right to get acquainted names of the medical team and their professionalism.

• To be treated respectfully and in full privacy.

• To receive the required protection from any physical or psychological harm.

• To get acquainted with available religion resources.

• To get acquainted with health information about your case, options and alternatives of cure.

• To get another medical opinion in or out KFHU with no hesitation and we guarantee the level of service will not get affected.

• To accept or reject the cure if you are not sure about the method of the suggested treatment but you will be responsible for your decision.

• To have a full copy about your health report or diagnostic rays.

• To get acquainted with the medical research would be run during your cure.

• To get the required care that help you to get rid off pain according to the physician or consultant advice.

• To get acquainted with the medical check results or tests • To assign an agent to talk on behalf of you and takes decision.

• To be checked in privacy by a doctor from other gender but in the presence of your fellow.

• Protection of your personal luggage from theft.

• If you encounter any problem you could complain orally or in a written complain, or even you could contact the office of PRR, and the level of care will not get affected for this complain.

In contrary you are responsible to: • Provide full information, name, nationality, etc.…

• To treat in decorum all the employees, visitors and other patients • To provide physicians with your medical case history and details of the drugs you use • To make sure of the medical treatment plan, and to get acquainted what is expected rom you with following the physician instruction • To inform the medical team with any sudden change occurs to your health • To respect and implement the regulations of the hospital that might affect the care of other patients • To keep the date and time of your appointment. If you want to postpone or cancel your appointment date, please call the appointments reception.

173

5| Auxiliary Departments

Central Sterilization & Supply Department Central Sterile Supply Department (CSSD) centralizes the sterile processing activities, in which reusable medical devices, surgical instruments, and equipment are processed. The Department’s goal is to decontaminate all instruments and equipment received in CSSD and to re-process, are cleaned, prepared processed, sterilized, stored, and distribution of sterile supplies for use in clinical areas within the hospital.e.g. O.R, O.P.D, E.R., D.R, Burn Unit, Day Surgery wards etc.

Electronic machine for sterilization

Central Sterilization & Supply Department

174

Annual Report | 2018 - 1439

Ongoing work in sterilization dept.

175

5| Auxiliary Departments

Socio-medical Services Department The department works to provide specialized socio-medical services to achieve the integration of provided health care and to provide a humanitarian work in a professional method to all patients.

Table 15: Statistics of 2017: No.

Activities and services

Frequency

1

Inpatients counseling

9750

Procedures termination for neonates

70

2 Social procedures

3

4 5 6

Medical requirements Donated to patients

400

Follow-up for documents completion

120

Follow-up for infection cases irresponsible for treatment

-

Follow-up for changing bracelets for mothers and babies

20

Total

10360

1

Medical equipment for male and female

383

2

Transportation from the house to the hospital (Tarabut charitable society)

56

3

Transportation from the hospital to the house (Tarabut charitable society)

30

4

Housing

83

Total

1056

1

Social insurance

20

2

Comprehensive rehabilitation center

10

Socio-medical Services Department

176

follow-up of Long stay patients

Annual Report | 2018 - 1439

3 Referral cases from socio-medical service

Other achieved tasks

2

4

Specialized charitable institutions

28

6

Human rights

5

5

7 8 9

Referral cases to socio-medical service

Social eldercare

1

2 3 4

Police and princeship

60

Social protection unit

30

Specialized governmental organizations for patients aid Total

31 190

ER

52

Referral cases that only provide nursing services

OPD

OBS & GYNE (sterility) Psychiatry

4

45 30 33

Total

160

1

Official transactions from medical administration relevant to patients

304

2

Medical evacuation

6

3

Letters to blood banks in the Eastern Region for blood donation

10

4

ER needed by the physician after discharge

22

5

Appointments for patients and their families in socio-medical department

43

6

Contributions in annual events

2

7

Training of students referred from health specialties / females

14

8

Training of students referred from health specialties / males

-

9

Volunteers opportunity in the department / females

-

10

Volunteers opportunity in the department / males

-

Total

403

177

5| Auxiliary Departments

1 Administrative works

52

Training courses

9

2

Monthly statistics

4

Outbox letters

446

Total

88

1

Number of children use the library in admission wards

1029

2

Entertainment activities in admission wards

450

3

Volunteers visits for activities with admitted children

3

5

Library works

Monthly reports

Arrangements and reception of schools and delegations

12

-

Total

Department tasks 1. We study the cases and suggest suitable intervention in treatment plan via daily rounds in admission wards.

2. We work to ensure patient requirements via available resources in collaboration with external charitable societies.

3. We contribute in training and educational programs relevant to our specialty.

4. Professional treat with disabled cases.

5. Researches and studies, beside statistical data base of the department work.

6. Professional treat with chronic and infectious cases.

7. Training program preparation in collaboration with relevant departments of KFHU. 8. Training of students from different universities and health specialties commission.

9. We a futuristic plan in coordination with universities and commission I field of socio-medical to enhance employee's 0capacity.

The department also runs various activities includes: • Entertainment programs: The department prepares and organizes entertainment programs for inpatients during the official festivals.

• Arrangement of visits by school students, social clubs and voluntary organizations to the inpatients with the aim of boosting their morals.

• It also supervises and secures the needs of Child Library Section in cooperation with the voluntary societies.

Socio-medical Services Department ١ Department tasks

178

Annual Report | 2018 - 1439

Social activities in admission dept.

179

5| Auxiliary Departments

Th president with businessmen in a visit to KFHU

Department tasks

180

Annual Report | 2018 - 1439

Social activities

181

5| Auxiliary Departments

Dietary The department of Dietary performs a vital role in preventing disease and health consolidation via medical diets.

This department consists of two sections: Clinical Dietary and Normal Dietary.

1. The Clinical Dietary for inpatients and outpatients, in addition to medical consultations followed inside KFHU as: • Weight putting off.

• Obesity • Swallowing difficulty • Vomit • Diarrhea • Constipation • Anorexia • ICU patients • Cancer • Metabolism • Chronic diseases as diabetic, etc.

• Stomach upsets, inflammations….

• Burns, hypo and ulcers • Ante surgical operations, postsurgical operations • Others Other dietary clinics: - Nephron dietary clinic - Weight dietary clinic - Cardio and blood hypertension dietary clinic - Gastro dietary clinic - Pediatric dietary clinic - Neuro dietary clinic 2. The Normal Dietary Section looks after food imported for patient by application ISO on KFHU catering. In addition to educational awareness in and out KFHU. It also supervises food contracts, prepares reports and statistics in collaboration with risks unit of quality department.

Dietary 20١7 ١ Accomplishments

182

Annual Report | 2018 - 1439

2017 Accomplishments 1. ISO application.

2. Fulfilling of JCI standards.

3. E-system of evaluation the patient cases.

4. Special system for OPD and floors.

5. Mutual collaboration with IAU. 6. Represents KFHU in Saudi Association for Dietary.

7. Mutual collaboration with other departments 8. Educational programs: - Khobar health city partnership - Wd society partnership - Collaboration with health municipality - Schools and universities activities Table 16: Activities and achievements / 2017: Statement

Total

In-Patients full meals

105794

In-Patients advices

8008

In-Patients non-full meals OPD

Symposia and contributions in fairs inside KFHU Trainees students Other trainees

3921 857 15 80 6

183

5| Auxiliary Departments

KFHU kitchen

20ูก7 Accomplishments ูก Infection Control Department

184

Annual Report | 2018 - 1439

Infection Control Department This department provides quality patient care through surveillance, control and prevention of infectious diseases nosocomial infections. Communicable and epidemic diseases discovered in KFHU are reported to the Ministry of Health (M.O.H).

Significant attention is paid by the Department for the proper disposal of medical wastes.

Regular lectures, workshops and awareness campaigns on infection control are given to the hospital staff.

The department closely follows up the services provided by the various departments with the aim of taking joint efforts to prevent the spread of any epidemic disease in KFHU. The main functions of Infection Control Team are as follows: • Devise an annual plan for implementation of infection control program within the health establishment.

• Provide the necessary consultancy for the team in whatever relevant to infection control works, and create safe environment for both patients and the work team.

• Develop policies, procedures and bylaws of the Health establishment.

• Follow up and improve the daily activities relevant to infection prevention (especially infection that might occur while providing healthcare).

• Establish a monitoring system for infection acquired within the health establishment.

• Identify and find solutions for problems encountering infection control works. However, when no solution is found, the problem will be submitted to the Infection Control Committee of KFHU. • Develop an annual training and educational plan for the staff. The plan covers all aspects of infection control.

• Ensure availability of the requirements and equipment of infection control. In case of any shortage in such requirements and equipment, the Infection Control Committee of KFHU is to be informed.

• Co-investigate with the appointed medical team the spread of epidemic diseases in the health establishment.

Then inform the Infection Control Committee about the outcome of such investigation.

Table 17: Infection Control Section Activities & Tasks During the Year 2017: Activities & Tasks

No.

No. notifications of Communicable Diseases to M.O.H

585

Participations in Educational Activities outside the Hospital

0

Participations in Educational Activities inside the Hospital

13

185

6

SUPPORTIVE TECHNICAL ADMINISTRATIONS ι ι ι ι ι ι

Maintenance, Operation and Projects Cleaning, Laundry and Medical Waste Security Biomedical Engineering Landscaping Central

6| SUPPORTIVE TECHNICAL ADMINISTRATIONS

Maintenance, Operation and Projects It is an administration works for 24/7, providing maintenance and operation services for all KFHU premises, residency compounds in autonomous efforts by depending on engineering and technical teams spread over all different departments which include: • Mechanic works • Air-conditioning works • Electrical works • Electronic and telecommunication works • Civil works As it also assumes the below tasks: • Preparation of specifications • Contracting works supervision • Coordination with consultations houses involved in projects.

It is better mentioned that 2018 witnessed implementation of several projects, in addition to other projects under implementation and future projects mentioned in a separate chapter of this report.

Maintenance,Operation and projects

188

Annual Report | 2018 - 1439

189

6| SUPPORTIVE TECHNICAL ADMINISTRATIONS

Boiling major machines

Maintenance,Operation and projects

190

Annual Report | 2018 - 1439

Boiling major machines

191

6| SUPPORTIVE TECHNICAL ADMINISTRATIONS

linking parking bldg. with the hospital bldg.

Maintenance,Operation and projects

192

Annual Report | 2018 - 1439

193

6| SUPPORTIVE TECHNICAL ADMINISTRATIONS

Maintenance,Operation and projects

194

Annual Report | 2018 - 1439

195

6| SUPPORTIVE TECHNICAL ADMINISTRATIONS

Cleaning, Laundry and Medical Waste It is one of important administrations provides supportive services for technical, administrative and medical departments whereas general cleaning services are provided by a 3-years national contractor.

For the importance and sensitivity of this service it followed by a designated supervisor general from KFHU administration to follow the quality of the provided service in assistance from several other supervisors from both sides of the contractor and KFHU.The services include the hospital main building, other departments and residential compounds (1) and (2), in addition to rented compound of number (8), moreover the private clinics and royal clinics.

The service is provided 24/7 in a perfect coordination with departments.

Circulars were sent to all departments including telephone number to report any deficiencies. Workers receive training courses permanently for the purpose of guarding patients safety, specially in field of policies and procedures relevant to infection control, medical wastes as well as the disposal is done and performed according to scientific methods guidelines. There are baskets delivered everywhere for non-medical wastes to be transported to room (4) of garbage to be trucked by the contractor. For medical waste, disposal is run strictly by using special plastic sacks to be taken a way to a designated place for medical waste disposal.

All these sacks are tagged as medical waste for caution and following policies and procedures of infection control. Disposal of hazardous waste is also run a specialized national contractor.

The administration is keen to comply with intranational standards in this field as standards of JCI & CBAHI.

Cleaning, Laundry and Medical Waste

196

Annual Report | 2018 - 1439

197

6| SUPPORTIVE TECHNICAL ADMINISTRATIONS

Cleaning, Laundry and Medical Waste

198

Annual Report | 2018 - 1439

199

6| SUPPORTIVE TECHNICAL ADMINISTRATIONS

Cleaning, Laundry and Medical Waste ูก Security Department

200

Annual Report | 2018 - 1439

Security Department It supervises security services provided by a national security company to KFHU and the affiliating utilities and residences. The other tasks assigned to this department are: • To issue identity cards to the employees of KFHU and the contracting companies.

• To issue entry permits for vehicles of the hospital staff.

• To issue permits for vehicles entering the Housing Compound.

• To Supervise and follow up works of the company providing security service for KFHU. • To solve the security problems that might encounter the patients or the hospital staff.

• To compile a monthly report (abstract) on the performance of Al Yousuf Security Service Corporation.

• To maintain the security and safety of KFHU and the affiliating housing compounds.

• To make the necessary security arrangements when meetings were held.

• To issue co-patient cards.

• To conduct surveillance through security cameras.

• To make visitors leave the premises of KFHU after the end of the visiting hours.

• To arrange the traffic within the hospital and to issue traffic violations to those violators of traffic rules.

• To train security individuals regrading treating patients and their fellows.

Security statistics for 2018: • Entry permits without parking lots for employees=243 • Entry permits for physicians and employees to parking lots= 613 • Entry permits to residential compound (1) = 220 • IDs for employees= 719 • IDs for trainees= 209 • IDs for students= 615

201

6| SUPPORTIVE TECHNICAL ADMINISTRATIONS

Security available anytime

Security Department

202

Annual Report | 2018 - 1439

Catastrophe plan-KFHU administration in Follow-up

203

6| SUPPORTIVE TECHNICAL ADMINISTRATIONS

Security guarding to keep KFHU safe

Security Department

204

Annual Report | 2018 - 1439

Security chief in disasters plan

205

6| SUPPORTIVE TECHNICAL ADMINISTRATIONS

Bio-Medical Engineering Department The services of bio-medical engineering are provided by a national contractor undersupervision of specialized engineers work for KFHU. The department provides technical support to all administrative and medical departments in an integrated work includes the requests of maintenance, protective maintenance, technological assessment for medical equipment and its possession. We provide support for more than 5700 of equipment in different types as below: • High-sensitive medical equipment used for; radiology, anesthesia, MRI, respiratory which are 36% of KFHU total instruments.

• Mid-sensitive medical equipment used for; patients monitoring, labs which are 12% • Less- sensitive medical equipment as beds machines, weight and thermometers which are 52% Technical support tasks include scheduled maintenance services, repair, tests and defects invention, in addition to contribution in projects and supervision on contracts of equipment importing and maintenance.

Regarding operation tasks it is including but not limited to training of users, technical planning, evaluation pre-purchasing and equipment safety.

Tasks & activities: • Recommendation to renewal of old medical equipment and displacement • Updating advance technology • Compliance with standards and criteria

Bio-Medical Engineering Department ١ Landscaping

206

• Technology proper planning.

• Contractors of Importing follow-up.

• Preparation of technical specification.

• Pre-purchase assessment of instruments • Purchase approval regarding guarantee and maintenance.

• Check-up of equipment before delivering to users in compliance with policies, metrologies and safety.

• Technical consultations for equipment selection considering the hospital needs.

Annual Report | 2018 - 1439

Landscaping • It supervises all greensides in the hospital building, residential compounds, assisted in that by a specialized contractor. It implements, maintains and supervises the irrigation networks. It also carries the ornamentation trimming of trees and grass in the hospital’s premises.

• The section further plants seasonal flowers, treats plant diseases and keeps clean all grass areas of KFHU.

• This year witnessed a big expansion in the landscaped areas and number of cultivated trees, in addition to maintenance over the whole network. molorrovid que evenimu saperiae conet voleste velit lamet esenimaion rem quia quo dolesto volore:

Green Environment

207

6| SUPPORTIVE TECHNICAL ADMINISTRATIONS

Telephone Exchange Department It is the link between KFHU and other institutions.

Its main functions are as follows: • To receive internal and external telephone contacts then to refer them to the beneficiaries.

• To make calls through microphones.

• To receive the calls of the Ministry of Health and other relevant medical centers then refer them to the Administrator on Call.

Telephone Exchange Depatyment

208

• To contact the concerned physician or employee through the payer system to respond to the urgent cases.

• To report and make notification of the urgent cases.

Annual Report | 2018 - 1439

209

7

ADMINISTRATIVE DIRECTORATES ι ι ι ι ι ι ι ι ι

Transportation Administrative Communications Monitoring & Follow-up Human Resources Financial Affairs Purchasing Warehouses Medical Supplies and Medical Equipment Housing

7| ADMINISTRATIVE DIRECTORATES

Transportation Directoratet Vision

Availability of suitable and comfortable transportation means in high quality service 24/7.

Mission

Availability of suitable transportation services for all KFHU employees of the different departments via scheduled shifts.

Values • • • •

Commitment Accountability Collaboration Disciplinary

Scope of service

It carries out all transportation activities including the transportation of KFHU patients and employees as it performs a great role in activities and events that need transportation services.

Tasks • • • • • • • • • • •

Readiness of ambulance vehicles for patients' transport.

Transportation of employees, particularly ladies of nursing staff to residential compounds and KFHU centers.

Transportation of single ladies to the airport and vice-versa.

Transportation of new employees during vacations to airport and vice-versa.

Postal services.

Transportation of female employees for marketing.

Transportation of hospital supplies.

Transportation in activities and events.

Other transportation services upon request of the administration.

Vehicles maintenance.

The department possesses a fleet of 63 vehicles of various types including 11 ambulances.

Transportaion Directoratet ١ Administrative Communication Directorate

212

Annual Report | 2018 - 1439

Administrative Communication Directorate Vision

A center for all inbox and outbox transactions received and delivered by the hospital via a comprehensive state-of-the-art electronic system.

Mission

Efficiency and high quality of transaction services from KFHU to various department of IAU and external entities.

Values • • •

Accountability Commitment Honesty

• •

Receiving inbox transaction and delivering them to departments.

Sending outbox transactions out of KFHU to IAU administrations with support from the governmental post office inside the hospital.

Sorting and distribution of letters and messages delivered to the post office.

Scope of service

•

Table 18: A Table shows Communications Admin. Activities & Tasks During the Year 2018 Type

Number

Inbox from out KFHU

25074

Outbox to IAU

5145

Routinely outgoing letters

350

Total

1780

213

7| ADMINISTRATIVE DIRECTORATES

Monitoring and Follow-Up Directorate Vision

Close monitoring and coordination between KFHU various department and follow-up directorate of IAU via application of modern electronic procedures for assurance staff disciplinary and work steering.

Mission

Monitoring and follow-up of work steering in KFHU for assurance of staff commitment in their various departments with official hours of work and performance of duties via an electronic fingerprint system in collaboration with departments and directorates.

Values • • • • •

Commitment Accountability Transparency Disciplinary Honesty

Scope of service

It is affiliated to the Director General of KFHU and it is assigned to the following tasks: • To administer the finger print system used for monitoring the time-in and time-out of the staff.

• To inquire the various sections and departments of KFHU concerning the absence and unpunctuality of the employees.

• To practice monitoring procedures and to carry out any necessary investigations with regards to the performance of the various sections and departments of KFHU. • To conduct inspectional visits to the various departments of the hospital to find out the areas of short coming and to discover the cases of procrastination and breach of the functional duties to make the required corrections in cooperation and co-ordination with the relevant authorities of IAU. • The monitor the progress of work at KFHU with the aim of making sure it is done as per the dominant rules and regulations; besides reporting complaints to the Monitoring Department of IAU to be verified before taking the appropriate measures and actions.

• To conduct investigations, in co-ordination with the Monitoring Department of UD, with the employees in all breaches and contraventions prior suggesting the appropriate punishment to the administration.

• To prepare monthly report on the extent of the staff punctuality showing details of those who came late, the absentees and those who left their offices during the working hours without permission or acceptable excuse.

• To co-ordinate with the representatives of the Monitoring and Investigation Board as regards conducting monitoring rounds in the departments of KFHU.

Monitoring and Follow-Up Directorate ١ Human Resource Directorate

214

Annual Report | 2018 - 1439

Human Resource Directorate

Human Resources Administration

The administration follows planning strategy and strategic planning to achieve its targeted goals and implement them in a high fidelity to access success required levels by using statistics and analysis of KFHU labor force data, provision of continuous support and training to human resources in high quality, beside application of regulations of civil service, faculty and personnel, Saudi Organization of Health Specialty and KFHU contracts, moreover application and expenditure of financial dues of promotions , courses and allowances or incentives without neglecting availability of other social services introduced to the employees in below departments.

The administration now studies a mechanism for development of the procedures and introduced services to employees as it develops an organizational structure serves general service, facilitates procedural operation and guarantees the outputs quality.

It is better mentioned that the number of introduced services in this year received (31789) transaction.

1- Department of Planning & Statistics

MFrom its name, it is clearly that this administration works for planning and statistics as it works for building a data base for KFHU employees. Under supervision of HR Director, it makes strategies and follows it for achieving the required success for the general interest. Now it works to inaugurate the electronic file and e-service for KFHU employees.

2 - Governmental relations and awareness

The role of this department is to introduce Saudi and contracted employees the services of finalizing measurements of Saudi Organization of Health Specialty, issue of residential cards, passports renewal, visas and all relevant governmental transactions.The department now includes periodical meetings and training courses of employees’ awareness of such measurements.

3 - Personnel

This department performs all Saudi and contracted employees’ measurements of recruitment and contraction from the beginning to the retirement and record end, in addition to passengers’ orders and attendance of internal and external forums relevant to employees’ procedures.

4 - Faculty department

This department is responsible for transactions of Saudi and contracted employees’ measurements of recruitment and contraction from the beginning to the retirement and record end, in addition to passengers’ orders and attendance of internal and external forums relevant to employees’ procedures.

215

7| ADMINISTRATIVE DIRECTORATES

4 - Faculty department

This department is responsible for transactions of Saudi and contracted employees’ measurements of recruitment and contraction from the beginning to the retirement and record end, in addition to passengers’ orders and attendance of internal and external forums relevant to employees’ procedures.

5 - Administrative formations

The role of this department is to attract and search jobs for contraction and recruitment of administrative and health positions by registration, documentation and establishing of jobs competitions.

6 - Salaries and performance (payroll)

It concerns with auditing of salaries of all hospital employees monthly beside delivering them to each employee bank account and delivering other dues after systematically have been approved by personnel.

7 - HR development department (training)

It measures the needs to training of labor force in order to promote and upgrade the performance in coordination with administrations and departments, preparation of annual training plans, coordination of courses conclusion with relevant institutions, and finally measuring of training effect reflected on performance level.

8 - Archive and vacations department

It takes the responsibility of paper and electronic archiving of all resolutions and documents and saving them in special dossiers, guard the privacy of information an d data , scheduling employees vacations according to the followed system.

9 - Saudi Organization of Health Specialty Follow-up Office

It is an office facilitates difficulties might face doctors and medical cadres in following up of ranking and their documents renewal.

Table 19: Number of introduced services transactions according to each department.

No.

Department

Number of transactions

1

Personnel-Saudi

720

2

Personnel non-Saudi

5230

3

Faculty

2458

4

Administrative formations

2395

5

Human Resources Development

1887

Human Resource Directorate

216

Annual Report | 2018 - 1439

No.

Department

Number of transactions

6

Salaries and performance

6524

7

Governmental relations

7255

8

Inbox and outbox transactions

5320

Inbox and outbox transactions

Governmental relations

Salaries and performance

Human Resources Development

Administrative formations

Faculty

Personnel non-Saudi

31789

Personnel-Saudi

Total

Figure39: Chart showing the services provided by human resources department for 2017

217

7| ADMINISTRATIVE DIRECTORATES

Financial Affairs Directorate Vision

A pivotal administration for implementation of all KFHU works relevant to activities of accounting and finance by use of an integrated e-system meet the requirements.

Mission

Implementation of all financial works and their accounting and audit procedures for accruals of employees and contractors in commitment with KSA and KFHU regulations.

Values • • • •

Transparency Honesty Commitment Disciplinary

Scope of service

The Financial Affairs Department undertakes all financial procedures of KFHU and its employees.This includes accounting and auditing procedures in addition to the staff salaries and the financial dues of individuals, companies and private institutions with financial transactions with KFHU.

Financial Affairs Directorate ١ Purchasing Directorate

218

Annual Report | 2018 - 1439

Purchasing Directorate Vision

To assure cost-effective and high-quality equipment as per the specifications and requirements of KFHU various departments, whether medical or administrative bodies.

Mission

Implantation of all purchase transaction, bids or any for KFHU various departments and directorates as comply with relevant governmental regulations.

Values • • • •

Honesty Transparency Commitment Accountability

•

Implement the governmental bidding and purchasing law and its executive regulation. And follow up the secure of KFHU needs through direct purchasing.

Develop annual bids for medical, laboratory, pharmaceutical and medical solutions' requirements, and conclude contracts relevant to them.

Follow up implementation of ongoing projects' contracts.

Secure the needed medical instruments.

Inform the concerned officials with all KFHU's contracts and take part in the meetings of relevant committees.

Audit the approved letters and contracts of direct purchasing as well as bids and budget reports.

Undertake all purchasing works of KFHU.

Scope of Servic • • • • • •

219

7| ADMINISTRATIVE DIRECTORATES

Warehouses Directorate Vision

KFHU major center for storing stationary and spare parts connected electronically to IAU major warehouses.

Mission

Availability and delivering of stationary ad spare parts for maintenance to all departments of KFHU, medical or administrative.

Values • • •

Accountability Commitment Honesty

Scope of service

It is one of the important administrations in KFHU. Financial affairs depend on this administration in storing and saving of different types, sustainable (fixed assets) or consumed. It supplies all departments with forms, stationaries, or equipment included in delivery processes. It is a major control point between the importers and the hospital.

Available Items • • •

+400 forms for administrative and health departments.

Stationaries (pens, files, etc…)

Computers, photocopiers, etc…

• • •

To meet all requirements of the various departments Promotion of the administrative work to suit the level of KFHU Collaboration with all departments to boost their tasks.

Goals

Warehouses Directorate ١ Medical Supplies and Medical Equipment

220

Annual Report | 2018 - 1439

Medical Supplies and Medical Equipment Scope of service

It is one of the supportive departments and lies under the allied medical services. It consists of group of stores and each store is considered as independent work unit, each unit (store) is allocated for the storage of items depending on the nature of those items .

Tasks

Tasks are divided according to units as below: • Medical supplies and disposables unit: in which the medical disposables and instrument are stored.

• Medicines unit: in which the medicines and IV solutions are stored.

• Narcotic and Ex-controlled drugs unit: in which the narcotics and psychiatric drugs are stored.

• Laboratory supply unit: in which the reagents and laboratory disposables are stored.

• Respiratory supply unit: in which the respiratory instrument and disposable are stored.

Each unit is working separately and has its supervisor and staff, and all under the umbrella of the Medical Supply Department.

Main services provided by the directorate •

• • • •

aintain the availability of all medical equipment and machineries, disposables and biological items either medicines or laboratory reagents that required to -provide the optimal service of the hospital and patient care, store medical supplies under the required conditions, distribute medical supplies to the hospital department through the proper channels, Find alternative solutions for medical supplies not available in the local market.

Follow up implementation of medical supplies' contracts.

Take part in meetings of committees relevant to the Medical supplies Department.

Provide KFHU with the annual consumption and the statistics necessary for budget estimations.

• • • • • • • • • • • •

Full implementation of 12 main bids with a total of 9024 medical supplies detailed as follows: Orthopedic & physiotherapy: 1055 items General medical requirements bid: 450 items General surgery and endoscopy bid:815 item Specialized surgery bid: 1237 item Kidney dialysis bid: 148 items Health care bid: 323 items Labs requirements bid: 1472 item Dental requirements bid: 2415 items General medications requirements bid: 610 items Cancer and kidney medications bid: 98 items Psychiatry medications bid: 63 items

•

Other Services and Achievements

221

7| ADMINISTRATIVE DIRECTORATES

• • • • • •

The department contributed in the laboratory's accreditation by the College of American Pathologists (CAP).

The department took part in KFHU's journey of accreditation by the Joint Commission International.

Establishing of dealing with medical sorts in ER cases.

A new shift for employees.

Modification of works plans and regulations One of major administration assumed to establish and apply the new computer system.

Housing Directorate Vision

Availability of a comfortable housing environment for employees and their families to support them in achieving their duties perfectly.

Mission

Suitable housing units for the staff and single ladies with supervision and maintenance.

Values • • • •

Accountability Commitment Honesty Collaboration

Scope of service

This department supervises all utilities of KFHU with special focus on the housing of staff affiliating to the hospital and the College of Medicine. This includes: • • • • • •

Housing Compound Site 1: It is assigned for family accommodations and some single female staff.

It consists of 32 villas and 327 apartments.

Housing Compound Site 2: It consists of 114 apartments and it is allocated for female single staff.

Residential Building No. (8): consists of 20 apartments assigned for the senior staff of KFHU. The department also supervises the sports hall at the housing compound site as well as the Sports Center.

The swimming pool and plays grounds.

Medical Supplies and Medical Equipment ١ Housing Directorate

222

Annual Report | 2018 - 1439

Tasks • • • • • • • • • •

To receive and distribute electricity bills to the residents of Housing Compound Site 1.

To issue statements to the Personnel Department regarding the accommodation allowance of employees resident outside Housing Compound Site 1.

To issue statements concerning residents of the Housing Compound.

To secure accommodation for new employees arriving from other countries.

To issue exit permits for employees and their families.

To coordinate with the Maintenance and Housekeeping Departments regarding the works to be done at the Housing Compounds.

To renovate and expand the sports center.

To coordinate with the Housekeeping Department regarding the provision of housekeepers to remove scrap electrical appliances from the housing compounds.

Swimming pool wit a rescuer works daily from 4-11pm Sport center works from 4-11pm

223

8

Academic Affairs and Training ι ι ι ι ι ι ι ι ι ι

Continuous Professional Development Unit Post-graduates Follow-up External Training Unit Internal Training Unit Audio-visual Unit Medical Photography Unit Design Unit Life Support Programs Evidence Based Medicine Program Researches support unit

8| ACADEMIC AFFAIRS AND TRAINING

1. Continuous Professional Development Unit This unit is concerned with the constant professional development activities such as training sessions, symposia, conferences, workshops, lectures and other professional activities.

These activities are usually carried out in coordination with the concerned departments inside and outside KFHU. The total number of activities done by the department this year reached 39 and the number participants stood at 3,580.

2. Post-Graduate studies Follow-up Unit The role of this essential unit is to follow the programs as an accredited center by Saudi Council for Health Specialties in coordination with IAU deanship of post-graduate studies. The unit is exerting valuable efforts to computerize the admission and scheduling the training and academic programs.

The previous year witnessed an electronic system activation aims to facilitate the required documents from the trainees and follow of KFHU rules and conditions relevant to post-graduates' programs, and to arrange training requests whereas the hospital receives requests from several physician amounted in 43 doctor every month.

Departments of Post-Graduate Studies: Firstly: IAU Programs • Radiology fellowship • Pathology fellowship • Hematology fellowship • Microbiology fellowship • Neurology fellowship • Ophthalmology fellowship • Family and community fellowship • General surgery fellowship • Pediatrics fellowship • Occupational medicine fellowship • Clinical psychology fellowship Secondly: SCHS Programs KFHU is considered a training center for a big number of SCHS programs as there are 26 current programs graduated 789 trainee physicians in the previous year.

We enlarged our capacity of training seats to receive 17. Now we have 325 training seats.

Continuous Professional Development Unit ١ Post-Graduate studies Follow-up Unit ١ External Training Unit

226

Annual Report | 2018 - 1439

Table 20: In the previous year 51 physician completed SCHS requirements and now are fellows in the following programs.

Pain Medicine

SCHS programs 16

Gastro & hepatology

1

Orthopedics

18

Diabetes / adult

4

Pediatrics

20

Psychiatry

22

Dermatology

24

ER

10

26

Infectious diseases

12

27

Neurosurgery

Ophthalmology Pathology

Plastic surgery and pains Radiology Urology

Endocrinology

Oral & Maxillofacial surgery -new Clinical pharmacy-new Neonates-new -

17

Cardio/adult

2

19

Critical care / adult

5

21

Anesthesia

7

23 25

27

28

Nephrology /adult

E.N.T

FAMCO

Internal medicine Gynecology

6 8

9

11

13

14

15

3. External Training Unit The unit serves as a coordination point for the training opportunities offered by KFHU to the medical and assisting medical cadres as well as the students of medicine of IAU, KFU , KSU, KAU, KFUPM, Administration Institute and ministry of health for training in fields as: radiology, pharmacy service, medical supply, health information, medical secretariat, hospital administration, computer, finance, physiotherapy, respiratory therapy, nursing, dietary, diagnostic laboratories, intensive care, emergency cases and other opportunities availed by the various departments of the hospital.

The External Training Unit closely supervises the training process. This is usually done in coordination with the relevant departments of KFHU to guarantee a conducive environment of training. No doubt this conducive environment would enable trainees to pick up knowledge and up-grade their skills and abilities.

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4. Internal Training This division is concerned with the development of KFHU employees' skills as well as the orientation of new staff. (1522) trainees took part in the training session organized by this division the year under report.

5. Audio-visual Unit The unit performs the following activities: • Audio-visual services • Auditorium services We serve all study and educational activities relevant to students of medicine, nursing and applied medical sciences as well as post graduate students. We coordinate the auditoriums according to schedules using the designated electronic program. The available auditoriums are 4 with 19 classrooms and 2 computer labs, in addition to clinical skills lab.

Booking request number for this year received 1437, among it 443 for classrooms, auditorium and clinical skills labs. (204) of these requests were for students teaching, 76 for teaching post-graduate students, 83 for different departments activities, and 80 for exams.

6. Medical Photography Unit It carries out all photographing activities at KFHU including taking photos for some medical cases. The films are developed and distributed to the various medical departments for research academic purposes. The unit also covers the conference and symposia held at the hospital. There are advanced digital cameras that give picture with high quality.

7. Designing Unit It designs all poster, booklet, brochure and pamphlets relevant to the activities of the Continuous Medical Education and Health Education.

Internal Training ١ Audio-visual Unit ١ Medical Photography Unit ١ Designing Unit ١ Life Support Center ١ Evidence-based Medicine Program

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8. Life Support Center This center includes: • BLS, • ACLS, • NARP, • PALS • ATLS • DMEP

10.EVIDENCE-BASED MEDICINE PROGRAM This program was established to meet researchers and practitioners' requirements in KFHU. It is accredited

by Gulf National Center for evidence-based practice, and now it was accredited center in eastern region in 30/12/2018 as reaccredited in 30/1/2018 11.researches support unit This unit was mainly inaugurated to assist medical staff, nursing staff and other health practitioners in running their researches and to provide them by needed technical support. The unit assisted running of (19) research projects in KFHU various programs for the year 2018.

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9

Training/KFHU ι ι ι ι ι ι ι ι

Introduction Continuous Professional Training Courses Post-Graduate studies Follow-up External Training Internal Training College of Nursing Contribution to training College of Medicine Contribution to training Training Projects implemented by Directorate of Quality & Safety

9| TRAINING/KFHU

Introduction KFHU gives a special concerning to training for its importance in updating and development of staff skills in this vital sector at all levels; administrative, and clinical. In addition to necessity of continuous education toward scientific and practical approach via achieving of professional fellowships in fields of medical and health care, quality and safety.

In this chapter an accentuation for KFHU achievements represent in preparation of HR ambitious cadres which resembles a professional balance for health care professional across KSA.in 2018, IAU & KFHU witnessed implementation of several training programs as mentioned below in details:

The 8th Alumni Day

Introduction

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Introduction ูก Continuous Professional Development training courses

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Continuous Professional Development training courses KFHU runs constant professional development activities such as training sessions, symposia, conferences, workshops and lectures that promote the performance.

Table 21: The following table presents these activities for the year 2018.

No 1 2

Activity

Participants number

Lecture: Care and management of Shock

57

Vascular Access

30

3

Retrograde Access Percutaneous Nephrolithotomy-PCNL

11

4

Basic Surgical Skills Course

22

Advanced Surgical Skills Course

21

5

Lecture: Prevention of Pre-operative pressure ulcers

7

Lecture: Medication related issues preparation

9

Pre-Conference Workshops/ Research & Quality in Radiology/ Fibro scan & Liver Ultrasound

100

11

Advanced Urology Laparoscopic Course

17

13

11th Hot Topics in Pediatrics

1210

15

Lecture: Proper storage and handling of high alert medication

83

17

Fundamentals of Laparoscopy Course

6 8

10 12 14 16 18 19

Osteoporosis Update

61 67

118

6th Radiology Conference

747

Basic Surgical Skills Course

29

Wound Care Management Course

Lecture: Care of instruments/equipment

2nd Flexible ureteroscopy and Retrograde intra renal surgery (RIRS) workshop

80 96 12 8

Knee Sports Injury Update

157

21

Lecture: Procedure delay/cancellation

52

23

Advancing Safety for Patients in Residency education – ASPIRE

20 22

Basic Surgical Skills Course Hemostasis Workshop

28 23

58

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No 24

Activity

Lecture: Consent-related issues

Participants number

25

Lecture: Medication related issue – administration

57

26

Basic Assessment and Support in Intensive Care September

11

27

Lecture: The six international patient safety goal

22

1st Ophthalmology Review Course

77

28

Lecture: Nursing assessment and reassessment/OV issues

30

Basic Surgical Skills Course

29 31

Lecture: Care of specimen

30

61 26

50

32

Advanced Mode of Mechanical Ventilation Symposium

117

34

1st Speech Language Auditory Verbal Therapy Workshop

46

33

35 36

Lecture: care of drain and catheters

2nd Audiology Course on Cochlear Implants: Tools of Diagnosis and Management

11

8th BAHA Workshop & 8th Cochlear Implant Workshop

10

16th Temporal Bone Dissection Course and Workshop November

39

Basic Surgical Skills Course

40

9th Endoscopic Sinus Surgery & Skull Base Course

41

Septoplasty and Functional Aesthetic Rhinoplasty Symposium

43

Advanced Surgical Skills Course

42

56

First Endoscopic Otology Workshop

37 38

20

Basic Head & Neck Hands on Course

27 24

31 35 12 24

44

Surgical Resident Fellowship Workshop

45

Lecture: Handling Med (High Alert) IV Therapy

54

46

Basic Surgical Skills Course

27

47

Lecture: Maternal in newborn identification

27

Continuous Professional Development training courses ŮĄ External Training Unit

236

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No

Activity

Participants number

49

28th Annual Scientific Meeting in Internal Medicine on Geriatrics

589

51

Lecture: Hospital codes activation

31

48 50

Trauma Team Leader Course

15

Update on Nephrology

63

External Training Unit Regarding external training, KFHU has performed a good work in preparation and training of several cadres over KSA various universalities from colleges of medicine, applied medical sciences and health sector colleges as in the following table: Table 22: External Training No 1

Ref IAU

Specialty

Number of trainees

Radiology

25

1

Applied medical sciences college Applied medical sciences college

Physiotherapy

3

Applied medical sciences college (2nd year)

Respiratory

132

4

Applied medical sciences college (4th year)

Physiotherapy

35

5

6

Applied medical sciences college(students)

Applied medical sciences college (bridging)

ML

34

7

Pharmacy college (post-graduates)

Pharmacy

23

9

Public health college

Health I.T

18

2

8

10 11 12

Nursing college (interns) Computer & I.T college

Applied studies and community service college Applied studies and community service college

ML Nursing

Computer

Medical records Finance

14

18 59 3 1 1

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No 1 1

Ref

IAU

Dental college

Specialty

Number of trainees

Dental

4

2

College of medicine

(Medicine (summer

17

4

Applied medical sciences

Dietary

88

6

KSU in Riyadh Interns

Nursing

7

3

5 7 8 1 9 6 7 8 9

ML master /Female

Applied medical sciences Interns /m KFU Interns /m Prince Sultan Military College

ML

Social service Optics I.T

1

36 2 1

Respiratory ML Nursing ER Anesthesia

46 3 5 47 5

Physiotherapy

4

10

King Abdul-Aziz University

Physiotherapy

12

Taibah University

Physiotherapy

1

Nursing

1

Physiotherapy

1

11

AL-Jouf University

9

10

11 1

University of Jizan

1 2 3 4

External Training Unit

238

ML

Qassim University

2

ML

1

Dental

4

Optics

Hail university

2

E.N.T

4 1

Annual Report | 2018 - 1439

No

Ref

Specialty

5

Shaqra University

Nursing

Number of trainees 1

Nursing

1

ML

1

6 7 8 9

Umm Al-qura University Al-Baha University

10

Prince Sattam University - Kharj

11

Nursing

Labs

1

2

12

Taif University

King Khalid University

Pharmacy

1

4

SCHS

Pharmacy

1

5

SCHS

Pharmacy technician

2

7

SCHS

ML

7

6 8 9

SCHS SCHS

Nursing

Respiratory

SCHS

Physiotherapy

SCHS

ER

10

SCHS

12

SCHS

11

Pharmacy

College of technology in Qatif

1

4 1 1

Social service

26

Dietary

1

Computer

1 1

Bassam Higher Institute

Computer

1

Yanbu university college

Accounting / financial

1

10

Saudi electronic university

Saudi electronic university

5

11

General rehabilitation center

General rehabilitation center

1

Jubail technical institute

Total number of trainees

Computer

1

707

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Internal Training For internal training, KFHU is keen about concluding of training courses that develop staff skills over various specialties , in addition to life support programs as in the following tables: Table 23: Interbal Training No

Department

Students

Interns

Employees

Total number

2

college of Medicine

242

35

0

295

4

Quality & safety

6

11

3

20

6 7 8 6 7 8 9

Health information Medical records Medical supply Nursing Dietary Pharmacy SCHS physicians

0 0 0 393 0 1 0

Respiratory

23

24

ENT Internal diseases Neurology Neurosurgery Orthopedic surgery Pediatrics Psychiatry General surgery Radiology Physiotherapy Cardiology ER Health information technology

0 0 0 0 0 0 0 0 0 54 0 0 0

0 1 0 0 0 0 0 0 21 14 0 0 2

1

Anesthesia

3

Dentistry

5

ER technicians

10 11

Infection control ML

12 9

10 11 2 3 4 11 2 3 4 3 3 4 3

Internal Training

240

Dermatology

0

242 0

0 19 0

4

5

13

2 0 0 92 19 14 0

0 30 0

15 2 0

19 7

13

0 0 0 104 1 10 0

2 0 0 589 20 25 0

3

50

9 11 19 5 17 6 21 31 24 6 2 7 0

9 12 19 5 17 6 21 31 45 74 2 7 2

0 28 2

0 77 2

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No 4 1 2

3 4 5 6 7 8 6 7 8

9

Department

Students

Interns

Employees

Total number

Central sterilization

0

0

0

0

Ophthalmology Cardio technology

Training & academic affairs HR Laundry Maintenance and operation Social services Urology FAMCO ICU Obstetrics & Gynecology SOPHS TOTAL

0 30 0 0 0 0 6 0 0 0 0

0 774

2 14

3 0

0 0 0 0 0 0 0 0 0

5 44

1 2 0 60 10 2 24 8 12

0 301

1 2 0 60 16 2 24 8 12

1 447

1 1522

Table 24: Life Support programs No

Program

Courses number

Trainees number

2

ACLS

16

190

4

ATLS

6

First aid & resuscitation

1

3 5

BLS

PALS NRP

TOTAL

33 7 5 1 3

65

898 52 90 8

33

1271

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Table 25: Life Support programs The program

Trainees number

Pathology fellowship

13

Microbiology fellowship

7

Radiology fellowship

6

Hematology fellowship

14

Neurosurgery fellowship

2

Neurology fellowship

26

Family medicine fellowship

27

Ophthalmology fellowship

17

General surgery fellowship

4

Pediatrics fellowship

1

Professional medicine master

6

Clinical psychology master

29

Total

152

Table 26: Saudi fellowship programs of health specialties.

The program Hepatology & gastro Cardio / adults

242

Male

Female

2

3

5

Total number

2

7 5

Diabetics/adults ICU/adults Nephron/adults Anesthesia

2 5 2 29

3 3 3 26

5 8 5 55

E.N.T

12

15

27

Derma

Internal Training

Trainees

5

13

18

Annual Report | 2018 - 1439

The program ER FAMCO

General surgery

Infectious diseases Internal medicine Neurology Neurosurgery Gynecology

Pain medicine Ophthalmology Orthopedic surgery Pathology

Trainees Male

Female

69

30

28 8

1 25 8 10 12

2 25 49 5

Total number

20 0

48 8

0 53 12 3

1 78 20 13

33

0 15 9

11

45

2 40 58

16

Pediatrics Burns & plastic surgery

23 0

Radiology Urology Endocrinology Maxillofacial surgery (new)

26 11 1 1

13 4 1 0

39 15 2 1

Neonates ICU (new)

0

0

0

Psychiatry

Clinical pharmacy (new) Total

1

0

401

33 1

99

0

0

388

56 1 1

0

789

Nursing college training contributions

The college contributed with excelled services in training of graduate students, bridging students, and interns as in below tables: 1438/1439H

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Table 27: BACHELOR PROGRAM- 1ST SEMSTER / FEMALE DEPT. Psychiatry nursing (3rd year)

TRAINING INSTITUTION

DURATION

KFHU

12 weeks

NUMBER of STUDENTS

KFHU

13 weeks

Pediatric surgery (4th year)

KFHU

14 weeks

46

Management & leadership (4th year)

KFHU

10 weeks

46

DEPT.

TRAINING INSTITUTION

DURATION

NUMBER of STUDENTS

Nursing basics (2nd year)

KFHU

10 weeks

92

Internal or surgical nursing (3rd year)

KFHU

9 weeks

50

Gynecology surgery (3rd year)

KFHU

10 weeks

49

Critical cases nursing (4th year)

KFHU

10 weeks

49

TRAINING INSTITUTION

DURATION

NUMBER of STUDENTS

KFHU

11 weeks

Internal or surgical nursing (3rd year)

53 53

Table 28: BACHELOR PROGRAM- 2nd SEMSTER / FEMALE

Table 29: BACHELOR PROGRAM- 1ST SEMSTER / MALE DEPT. Psychiatry nursing (3rd year)

KFHU

13 weeks

Pediatric surgery (4th year)

KFHU

13 weeks

37

Management & leadership (4th year)

KFHU

13 weeks

36

Internal or surgical nursing (3rd year)

Nursing college training contributions

244

37 37

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Table 30: BACHELOR PROGRAM- 2nd SEMSTER / MALE TRAINING INSTITUTION

DURATION

Internal or surgical nursing (3rd year)

KFHU

10 weeks

37

FAMCO (4th year)

KFHU

11 weeks

36

Critical cases nursing (3rd year)

KFHU

10 weeks

36

TRAINING INSTITUTION

DURATION

NUMBER of STUDENTS

Management & leadership

KFHU

14 weeks

50

Information nursing

KFHU

14 weeks

45

DEPT.

TRAINING INSTITUTION

DURATION

NUMBER of STUDENTS

Psychiatry nursing

KFHU

6 weeks

43

Internal or surgical nursing

KFHU

6 weeks

41

DEPT. Nursing basics (3rd year)

KFHU

10 weeks

NUMBER of STUDENTS 34

Table 31: BRIDGING PROGRAM – 1ST SEMSTER/ FEMALE DEPT. Gynecology nursing

KFHU

10 weeks

Table 32: BRIDGING PROGRAM – 2nd SEMSTER/ FEMALE

50

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Table 33: BRIDGING PROGRAM – 1st SEMSTER/ MALE TRAINING INSTITUTION

DURATION

Management & leadership

KFHU

9 weeks

30

Information nursing

KFHU

9 weeks

29

TRAINING INSTITUTION

DURATION

KFHU

7 weeks

NUMBER of STUDENTS

DEPT.

TRAINING INSTITUTION

DURATION

NUMBER of STUDENTS

Internal or surgical nursing

KFHU

15 weeks

3

Gynecology nursing

KFHU

10 weeks

4

Quality improvement

KFHU

10 weeks

-

DEPT.

TRAINING INSTITUTION

DURATION

NUMBER of STUDENTS

Critical cases nursing

KFHU

11 weeks

9

Psychiatry nursing

KFHU

12 weeks

2

Pediatric nursing

KFHU

12 weeks

1

DEPT. Gynecology nursing

KFHU

9 weeks

NUMBER of STUDENTS 31

Table 34: BRIDGING PROGRAM – 2nd SEMSTER/ MALE DEPT. Internal or surgical nursing Table 35: MASTER PROGRAM – 1ST SEMSTER

23

Table 36: MASTER PROGRAM – 2nd SEMSTER

Nursing college training contributions

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Table 37: Internship program TRAINING INSTITUTION

TRAINING INSTITUTION

TRAINING INSTITUTION

DURATION

NUMBER of STUDENTS

2017/2018

KFHU

52 weeks

Male:20 Female:38

2018/2019

KFHU

52 weeks

Male:35 Female:41

Nursing

Table 38: Training statistics for College of Medicine / internship: 4TH year Male

Female

121 5TH year

Male

Female

87

6TH year

Male

Female Male

Female

127

122 152

Internship

144 111 121

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Training projects implemented by Directorate of Quality & Safety Here are details about training projects implemented by DQS, goals and general brief:

1. DATA MANAGEMENT

INTRODUCTION Effective data management plays an important role in improving the performance of an organization’s health care systems. Collecting, analyzing, interpreting, and acting on data for specific performance measures allows health care professionals to identify where systems are falling short, to make corrective adjustments, and to track outcomes.

This workshop is designed to help users understand the relationship between quality improvement and data management and to provide information on how to gather, analyze, interpret, and act on data for a specific performance measurement.

This workshop offers information about some of the most important issues in healthcare quality namely, information management. The workshop will present the application of statistics, epidemiology and quantitative analysis in health care quality.

The participants are expected to gain a solid foundation in the implementation of quality tools and quantitative methods. This workshop will include such topics as Statistics and quantitative analysis for primary use in Healthcare Quality and the process of Quality Improvement.

The workshop will include the use of SPSS computer software as the main analytical tool. It involves a combination of practical demonstrations, discussion groups, case studies and interactive exercises.

LEARNING OBJECTIVES: At the completion of this workshop, the participant will be able to: • • • • • • •

Explain the main categories of statistics used in Healthcare Quality Learn vital information regarding data analysis and reporting systems Identify the major statistical tests applied in quality improvement and control and be able to apply each to the appropriate scenario Define the different forms of the Quality Improvement process Use SPSS in conducting statistical analyses and produce the appropriate reports Identify the different approaches to a successful survey process in Healthcare Quality and become familiar with all the steps of surveying methodology from start to finish Identify the key dimensions of quality care and performance, and apply them to their current work environment

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• • •

Discuss and apply the different tool used commonly in Healthcare Quality problem solving exercises and scenarios Perform basic techniques and methods of identifying quality deficient areas and ways to correct them Apply quality improvement tools to a healthcare issue of concern that needs improvement

2. EFFECTIVE STRATEGIC PLANNING IN HEALTHCARE INTRODUCTION Having a clear strategy is essential for competitive advantage in today’s tough healthcare market. A properly articulated strategy will chart the course of a healthcare organization, enabling it to sail cohesively through its external environment, to focus the efforts of both managers and clinicians, provide a way to understand your hospital or clinic and distinguish it from others, reduce ambiguity and deliver first class, high quality patient care. Yet, the failure of strategy in many healthcare organizations reflects the fact that too many hospitals, clinics and health systems fail to think in terms of how they can really add value for patients and the communities they serve.

LEARNING OBJECTIVES: • Take the right approach to strategic management by understanding the 10 different possible approaches to strategic planning and strategic change that a healthcare organization can take and subsequently selecting and applying the best approach.

• Understand the importance of strategy and its role in the hierarchy of mission statement, vision, strategy, objectives and tactics.

• Understand the context for strategic management in your organization by identifying the key internal and external factors that, taken together with your organization’s mission statement and vision, create the environment in which you must manage strategy and strategic change.

• Understand the importance of setting stretching and explicit objectives to provide clear direction for your organization.

• Manage the ‘softer’ issues of communication, buy-in and willingness to change – factors that are crucial to successful strategy execution.

3. Executive Course in Healthcare Management INTRODUCTION The study of leadership and management is essentially the study of how to work effectively with other people, how to influence others towards achieving the group goals and how to elicit from each employee “creativity, consistent excellent productivity, and maximum potential contribution toward continuous

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improvement of process, product and service. Because of this we designed this course to develop and improve the middle managers leadership and management knowledge and skills which for sure will lead to improve their performance and will increase the employees and customers satisfaction and will be reflected positively on the whole organization performance and reputation.

Loosely, we could probably all agree that management positions can be generally categorized as supervisory (or entry-level) management, middle-management and executive-management. We would probably agree that different training topics are most appropriate for each level, because they align most closely with the new duties of the person who is a neophyte in this tier of management.

Effective learning organizations have effective departments, this does not happen by chance. Senior Management Teams strive continuously hard to encourage, develop and nurture established Middle Managers; identify that aspiring staffs who have the potential to become future Heads of Departments and Learning Managers.

This course curriculum includes goal setting, time management, coaching, business writing, interviewing, communication skills/feedback techniques, and the performance-appraisal process.

LEARNING OBJECTIVES: • Understand your role in a constantly changing work environment • Plan, organize and manage change in a more productive way • Work more closely with your colleagues and senior management • Encourage high performance from your teams • Take better decisions and achieve more effective implementation • Manage conflict in a more effective way • Understand the need to develop yourself and those who report to you

4. FAILURE MODE & EFFECT ANALYSIS (FMEA) INTRODUCTION This workshop will demonstrate what a Design FMEA is and what the many benefits of constructing one are. Participants will learn how to construct and analyze a Designs FMEA over the life of the new product or process.

LEARNING OBJECTIVES: • Understand the important benefits of the Design FMEA. • Determine when it is appropriate to develop a Design FMEA and how it should be maintained.

• Learn and develop the important components of a Design FMEA. Training projects implemented by Directorate of Quality & Safety

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• •

Understand the process requirements.

Learn how to effectively select cross-functional teams to develop a Design FMEA.

5. INFECTION CONTROL MANAGEMENT INTRODUCTION According to the U.S. Centers for Disease Control and Prevention (CDC), approximately 36 million people are admitted to U.S. hospitals every year, and nearly two million patients annually acquire an infection while being treated; over 80,000 patients die from complications resulting from the infection. The CDC estimates that up to one-third of infections acquired in health care settings are preventable.

From relatively minor urinary tract infections to life-threatening infections of the bloodstream and pneumonia, hospital-acquired infections vary in gravity. The CDC reports that hospital infections cost the American public nearly $5 billion in healthcare costs each year. The extra costs are the result of the additional days - or weeks - patients are required to stay in the hospital to treat the new infection.

While the precise causes are difficult to pinpoint, some hospital-acquired infections can be attributed to human error, such as failure to properly sterilize or disinfect objects coming into contact with a patient or properly isolate a susceptible patient from potential carriers.

This workshop is co-coordinated and presented by recognized experts in the relevant clinical fields of infection control, microbiology, epidemiology, infectious diseases, public health and occupational safety and health. It provides theoretical and practical methods to develop participants’ skills in infection prevention and control.

LEARNING OBJECTIVES: • Explain the benefit to patients and healthcare workers of adhering to scientifically accepted principles and practices of infection control.

• Describe / explain the professional’s responsibility to adhere to and monitor scientifically accepted infection control practices and the consequences of failing to comply.

• Describe / explain the professional’s responsibility to monitor infection control practices of those for whom she / he is responsible and intervene as necessary for compliance and safety.

• Describe how pathogenic organisms may be spread in healthcare settings.

• Identify factors that influence the outcome of an exposure and list strategies for preventing transmission of pathogenic organisms.

• Describe how infection control concepts are applied in professional practice.

• Define “engineering controls” and “work practice controls” and identify where these controls can be used to prevent exposure.

• Identify a hierarchy of exposure prevention strategies.

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9| TRAINING/KFHU

• • • • • • • • •

Describe specific practices and settings that increase the opportunity for exposure to healthcare workers and patients.

Describe circumstances requiring use of barriers and personal protective equipment to prevent patient or healthcare worker contact with potentially infectious material.

Identify specific barriers or personal protective equipment for patient and healthcare worker protection from exposure of potentially infectious material.

Discuss the importance of the correct application of reprocessing methods for assuring the safety and integrity of patient care equipment.

Identify the individual’s professional responsibility for maintaining a safe patient care environment.

Identify strategies for effective pre-cleaning, chemical disinfection, and sterilization of instruments and devices.

Discuss the role of occupational health strategies in protecting healthcare workers and patients.

Explain nonspecific disease findings that should prompt evaluation of healthcare workers.

Identify occupational health strategies for preventing blood borne diseases and other communicable diseases in healthcare workers.

6. The KPI (Key Performance Indicators) Professional INTRODUCTION Key Performance Indicators in Healthcare workshop introduces the concept of performance management and explains how performance can be measured. In common with all major industries, healthcare organizations are facing ever greater pressures to constantly improve performance and drive organizational excellence. What makes your industry different is the need to maintain standards of clinical care in addition to this business, quality and management focus.

By attending this course, participants will gain both theoretical knowledge and practical skills in working with KPIs, which will enable them to start a KPI implementation project, or to review existing KPIs, as soon as they get back in their organizations.

In addition, professionals have the opportunity to obtain the Certified KPI Professional status, a unique certification that provides a rigorous KPI approach, knowledge and practical skills.

LEARNING OBJECTIVES: Pre-course: • Guidance and schedule – analyze document presenting guidelines on how to maximize your learning experience • Introduction – share an introduction message to present themselves to other participants in an online group • Pre-course evaluation – includes a needs analysis, a short quiz to establish the current level of Training projects implemented by Directorate of Quality & Safety

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•

knowledge and a section for sharing expectations Prerequisite reading – review several materials, including topics such as history, management theories and KPI definitions should be reviewed

CORE COURSE: • Applying concepts in practical exercises • Analyzing case studies and identifying solutions • Using templates to develop performance measurement instruments • Sharing experiences and best practices • Creating a network of KPI Professionals • Constantly evaluating the participant’s knowledge, through short quizzes to support the final test AFTER THE COURSE: • Action plan – participants should submit a plan to state the changes they intend to make in their department or organization in terms of KPI measurement; Key Performance Indicators as part of the Performance Management System webinar.

• In-house presentation – participants should submit a Power Point presentation on key topics covered during the course • Additional reading – a list of resources (books, articles and videos) is provided in order to encourage the continuous learning experience LEARNING OBJECTIVES: • Identify key performance metrics to support the organization in achieving short and long term goals • Monitor and manage healthcare business performance across the organization • Develop a strategic plan with outstanding benchmarks • Gain knowledge of different performance models and their application • Implement an effective performance management system aligned with key management systems • Learn vital information regarding data analysis and reporting systems • Ensure that your performance model is flexible, responsive and adaptable

7. LEADERSHIP & MANAGEMENT SKILLS INTRODUCTION To be fully effective, anyone in a position of authority needs to be both a competent manger and an effective leader and the development of leadership skills cannot be left to chance.

The study of leadership and management is essentially the study of how to work effectively with other people, how to influence others towards achieving the group goals and how to elicit from each employee

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“creativity, consistent excellent productivity, and maximum potential contribution toward continuous improvement of process, product and service. Because of this we designed this module to develop and improve the leadership and management knowledge and skills which for sure will lead to improve their performance and will increase the employees and customers satisfaction and will be reflected positively on the whole organization performance and reputation.

And in a general sense, we would probably agree that different training topics are most appropriate for each level, because they align most closely with the new duties of the person who is a neophyte in this tier of management.

Effective learning organizations have effective departments, this does not happen by chance. Senior Management Teams strive continuously hard to encourage, develop and nurture established Middle Managers; identify that aspiring staffs who have the potential to become future Heads of Departments and Learning Managers.

This workshop includes goal setting, time management, coaching, business writing, interviewing, communication skills/feedback techniques, and the performance-appraisal process.

LEARNING OBJECTIVES: At the conclusion of this module, the attendees should feel more comfortable in the following areas: • Understand your role in a constantly changing work environment • Plan, organize and manage change in a more productive way • Demonstrate the abilities to be effective manager • Work more closely with your colleagues and senior management • Encourage high performance from your teams • Understand how to use the resources in an efficient and effective way • Take better decisions and achieve more effective implementation • Manage conflict in a more effective way • Understand the need to develop yourself and those who report to you.

8.PERFORMANCE IMPROVEMENT & MEASUREMENT INTRODUCTION The workshop introduces the concept of performance management and explains how performance can be measured.

This timely workshop analyses structure, process and outcome as key areas of safety and quality in healthcare. It will examine performance measures for the healthcare organization, performance indicators, benchmarking in healthcare and the notion of healthcare performance excellence. Performance models Training projects implemented by Directorate of Quality & Safety

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will be applied to evaluate performance tools and select the appropriate system for reporting. It will also focuses on measurement tools most appropriate for quality and safety in healthcare. The techniques and information outlined in the course will enhance existing management skills, leading to more focused targets and improved performance through employee engagement.

LEARNING OBJECTIVES: • Identify key performance metrics to support your organization in achieving short and long term goals • Monitor and manage healthcare business performance across your organization • Develop a strategic plan with outstanding benchmarks • Gain knowledge of different performance models and their application • Implement an effective performance management system aligned with key management systems • Learn vital information regarding data analysis and reporting systems • Ensure that your performance model is flexible, responsive and adaptable

9.PRINCIPLES OF QUALITY IN HEALTHCARE & PATIENT SAFETY INTRODUCTION This course is a well-established event and a preferred meeting place for people committed to the mission of improving the quality and value of healthcare on regional and international level.

The course in store for our participants represents the very best of new thinking from the global quality improvement movement.

This course is designed for those who seek an understanding of the administration and organization of quality definitions, practices, processes within the health care system. The course focuses on quality management in health care system using continuous quality improvement and team building techniques.

Topics to be examined include the history of quality, leaders and trends in health care quality, measure and measurement development, analysis of variation and quality practices in different health care environments, administrative responsibilities and structures with respect to production and service quality, including the function and roles of professional and non-professional staff.

The Principles of Quality in Healthcare and Patient Safety is useful in improving the quality and safety of patient care. Target audience are mostly hospital-based, focusing on reducing risk and improving quality via shared knowledge, solutions, and publications, that will make their jobs easier to perform, with less chance for error and more opportunities for collaboration.

The course strives to support the movement to healthcare improvement globally, foster effective innovation and connect healthcare leaders and practitioners worldwide.

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LEARNING OBJECTIVES: To provide participants with enhanced skills to initiate, develop, and sustain health care change. The course provides the participants with advanced skills in organizational development, team building, problem solving techniques, and process improvement The course is designed to provide the participants with: • An understanding of quality and patient safety history and trends • An understanding of health care measure and measurement • An understanding of management’s role in quality management of health care services • Demonstrate the abilities to implement quality principles.

• Gain the required skills to ensure patient safety.

• Implement the international patient safety goals.

10.QUALITY PLANNING INTRODUCTION Your organization, whether it is private, public or not-for-profit, faces a continuous barrage of requests to improve quality. Your front-line staff is quickly thrown into quality training workshops to improve the management of quality. Management attends quality sessions to acquire the latest strategy. Everyone is exposed to Six Sigma, Lean, process management, quality awards and so on, but the complaints continue.

The workshop is a highly interactive session that will use lectures, discussions and team format. It is case driven and uses examples from many different organizations.

The participant will learn the process for developing strategic quality plans, and actually apply it to “real” quality issues and develop strategies to better plan these. The outcome is measurable; as the participant can take the strategies back to their workplace and execute them immediately.

LEARNING OBJECTIVES: • Understand, at an overview level, all of the current quality strategies used today • Develop a quality statement • Identify quality standards for your organization and /or department • Create a quality vision • Develop quality strategies • Develop actions to successfully implement the quality strategies • Understand how to complete the strategic quality plan

Training projects implemented by Directorate of Quality & Safety

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11.RCA (ROOT CAUSE ANALYSIS0 IN HEALTHCARE INTRODUCTION This course will assist the participants in understanding, developing and implementing an effective risk management program and prepare them for future professional challenges.

LEARNING OBJECTIVES: • To understand the Root Cause Analysis and risk management • The tools and techniques used to undertake a RCA. • And methods for integrating patient safety and enterprise risk management tools into a comprehensive risk management program.

12.TRAIN-THE-TRAINER (TOT) FOR HEALTHCARE PROFESSIONALS INTRODUCTION The workshop will transform the participant from a new trainer to a professional trainer who feels more comfortable and more competent. You will explore how adults learn and take a systematic approach to delivering training sessions that meet participants' needs.

The workshop will give the participant access to practical tools, strategies, and techniques that will make your training dynamic, engaging, and effective. We show you how to optimize your training environment and training programs to achieve outstanding learning results.

LEARNING OBJECTIVES: • Identify the characteristics of an exceptional trainer • Conduct short group training sessions that incorporate key training concepts • Explain what a solid training program looks like • Recognize the importance of considering the participants and their training needs, including the different learning styles and adult learning principles • Enhance your understanding of learning styles and how to accommodate them in the classroom • Develop an effective training style, using appropriate training aids and techniques • Understand the key principles of effective communication in a workshop setting • Explain various methods for making lecture-based programs active • Describe a needs analysis and why it is a necessary step in any training program • Know how to write training objectives and evaluate whether these objectives have been met at the end of a training session • Develop a training program structure • Develop a plan and prepare for an effective training session • Present information in a clear, concise, engaging manner

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13.UTILIZATION MANAGEMENT IN HOSPITAL SETTINGS INTRODUCTION The healthcare management industry has seen a number of dramatic changes for the past 20 years. One of the dramatic changes is the function and role of utilization management, which has evolved as a system to evaluate medical necessity and appropriateness of care related to optimal outcomes.

Utilization Management is a process performed in health care institutions to ensure that patients are hospitalized appropriately for the severity of their illness and the intensity of service (resources) needed for the management of their care.

King Fahd Hospital of the University of the University of Dammam is proud to present a locally developed, practitioner led, intensive program that does meet all your needs regarding utilization management.

This workshop introduces principles of quality improvement and utilization management in health care.

Topics include the continuous quality improvement philosophy, including tools, data analysis/application, and related committee functions; utilization management and credentialing, accreditation and regulation.

LEARNING OBJECTIVES: To understand the major components which form the structure of the utilization review process such as: • Develop the Utilization Management Plan • Understand the Screening Criteria • ISD-A Review System • Hospital Reason Acute Code List •

Learn the review process: • Admission Review • Continued Stay Review • Discharge Review • Focused Review

Health Education Department Introduction: This department is supervised by the director of assistant medical services. It performs a vital role in implementation of several programs related to community services as well as it effectively promotes awareness among community sectors toward prevention against diseases, all of that at levels of ; individuals, community, and its application on clinical departments of KFHU and it OPDs.

Training projects implemented by Directorate of Quality & Safety ١ Health Education Department

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The department boosts the efforts that enable patient to coexist with chronic diseases as diabetes.

It also gives a special care for international health occasions and events by establishing health campaigns, activities through schools and societies. The people benefited from these activities received (1540).

The department concludes academic activities annually for interns of health education specialty, moreover, training of new employees.

Table 39: Health Education Department No

Statement

No

1

Health education, diabetics

2033

3

Insulin pump

786

2 4

Diabetes consultations

390

Pediatric diabetes

887

6

Blood sugar measurement

2000

8

Community health education

6000

9

KFHU employee health education

1540

10

Trainees

3

5 7

11 12

Pregnant diabetes

Congregational education

Distributed booklets Prepared booklets

200 170

12000 65

259

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PROJECTS ι Futuristic projects ι Computer projects

10| PROJECTS

Projects This chapter of KFHU 2018report reviews the implemented projects, in addition to futuristic projects, and computer projects. They are all aiming the expansion of KFHU capacity in order to improve performance ad operation quality to maintain patients and employee's safety, moreover, improving of time management.

2018 implemented projects 1. OPD pharmacy development 2. Internal pharmacy development 3. Construction of nephrology warehouse 4. Development of warehouse of under-monitoring drugs 5. Construction of Syrup medicines warehouse 6. Construction of a connecting building between the hospital main building and parking building 7. Construction of new offices for faculty staff 8. Expansion of radiology department 9. Pediatric nephrology department furniture.

10. Psychiatry department furniture 11. Psychiatry clinics development 12. Site 2 rebuilding scheme 13. Morgue renewal and development 14. ER department expansion

Projects

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Connection bldg.. between parking bldg. and KFHU major bldg

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Futuristic projects 1.

2.

3.

4.

5.

6.

7.

8.

Urology department development Development of Operations unit & cardiovascular radiology Central coolers for building (B) and ER Importing and testing of all special installations of processing and control system for air conditioning, water lines, sanitation, architectural works, electrical and mechanical works for implementing the project typically to conditions of GCC relevant to infection control.

Rehabilitation of fuels tanks project Medical supplies warehouse. this project will be implemented in two stages, the first one includes collaboration with one of the specialized engineering offices for preparation of the bid. The second one will include the constructions.

Renewal of electrical major networks (13.8 kilo volt) Fire alarming system renewal.

Computer projects

These are (26) projects according to the Arabic copy of the report delivered from Information Technology Administration to the unit of decision support of Directorate of Quality and Safety in KFHU. The projects durations vary from 6 months for the shortest project to 18 months for the longest project.

Here we will put all the projects in a table explains the titles of the directorates attached with projects. For the advantages, challenges, team members and suggested solutions relevant to the projects in more details it is available in the Arabic copy.

Table 40: Computer Project No

Directorate/Department

Project title

1

Academic affairs &Training

Trainees data entering and registration automation

2

Anesthesia /ORs

Automation of all medical procedures of anesthesia and operation rooms

3

Medical records

Patients' Files electronic archiving

4

I.T & Electronic Health Information

Promotion of KFHU Data Center

6

I.T & Electronic Health Information

8

Cardio department

5 7

Medical Administration Cardio department

Futuristic Projects ูก Computer projects

264

Automation of paper medical forms

(VDI)visualization desktop infrastructure

Electronic linking of (Cath Lab) to (QCPR)

Activation of MUSE system and its linking to (QCPR)

Annual Report | 2018 - 1439

No

Directorate/Department

Project title

9

Electronic Health Services

Evaluation of KFHU Electronic Health Services

10

KFHU Human Resources

Technological Development for administrative services

12

KFHU

11

FAMCO, IAU

Technical Support & Administrative Services Promotion

13

Follow-up

Technical Support

14

Dental Hospital

15

Electronic Health Services

Linking of radiology system of the dental hospital and Dentistry college to KFHU

17

Blood Bank

18

University hospitals of IAU

19

Pharmacy

16

KFHU

E-mailing without papers

Activation of the internal e-mail system Medical ambulance vehicle

Operation of (E-Delphine) System

Bid conditions of the new integrated electronic medical system of IAU hospitals Technological development

20

Quality & safety

Complaints electronic documentation

22

Quality & safety

Application of electronic statistics

23

security & safety

Housing technological system development

24

security & safety

Technological system development of KFHU visitors

26

Private medical center

E-billing management system

21

25

Quality & safety

Social services

KPIs

Automation of forms

265

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QUALITY AND SAFETY ι ι ι ι ι ι ι ι ι ι ι ι ι ι ι ι ι ι

Vision Mission Values Introduction Executive Summary Central Board for Accreditation of Healthcare Institutions (CBAHI) Certified Professional in Healthcare Quality (CPHQ) Training Summary of Units’ achievements (full report for each unit are enclosed) Accreditation Unit Decision Support Unit Documents Control Unit Environmental Safety Unit Performance Measurement Unit Risk Management Unit Training Unit Significant Achievements & Activities for 2017 Johns Hopkins Aramco Healthcare (JHAH) General Technical Survey PSI/Applied Measurement Professionals (PSI/AMP)

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DIRECTORATE FOR QUALITY AND SAFETY

Vision Commitment to support KFHU toward achieving the highest standards of quality in field of health care via planning and facilitation.

Mission Provision of services characterizes of quality and professionalism to develop care quality via supporting the administration with the system required to meet the strategic goals and community needs.

Values • Quality: we will work through all departments to guarantee the positive influence over the whole health care system in KFHU. • Continuous improvement: we will work to build the culture of inquiring, learning and innovation to provide the best of support for health care system in KFHU in a developed patient-centered experience • Transparency & trust: we will work to gain the trust via bravery, honesty and ethical behavior.

• Accountability: we will work to build the bridges of trust and respect by encouraging the culture of integrity and accountability.

• Teamwork: we will work to collaborate and respecting of work relations.

• Excellence: we will work to achieve the optimum performance.

Vision ١ Mission ١ Values

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DQS Director of KFHU in JCI 1st week of survey

Introduction ูก Executive Summary

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Introduction DQS delivered to Decision Support Unit a full-detailed long report includes the achievements to each unit of DQS various units with indication to the goals of 2018 with reviewing to weaknesses, strengths, opportunities and threats. Here Decision Support Unit trace the executive summary of the whole DQS for it is a comprehensive summary covers all of the units essential hints.

Executive Summary It is with great pleasure to present our 2017 Directorate of Quality and Safety (DQS) Annual Report and reflect on our many achievements throughout the year in leading and coordinating quality improvements in the safety and quality of health care provided at King Fahd Hospital of the University (KFHU).

It has been another busy and productive year for DQS. One of the most significant areas of work during the past 12 months has been the survey of the Johns Hopkins Aramco Healthcare (JHAH) and the accreditation survey of the Saudi Central Board for Accreditation of Healthcare Institutions (CBAHI).

In delivering on our healthcare safety and quality priorities, we wish to acknowledge and thank His Excellency, the President of Imam Abdulrahman Bin Faisal University and Supervisor General of King Fahd Hospital of the University, Dr. Abdullah Al Rubaish and the leaders of KFHU who have contributed significantly to DQS’s successes throughout the year.

We look for ways to PROTECT and DEFEND our patients and we aim to provide a rich patient experience from beginning to end. We use data to help us optimize outcomes of care. The KFHU staff shares an interest in providing safe, high-quality care and exceptional service for every patient, every time at King Fahd Hospital of the University (KFHU).

Our annual quality and performance program starts with clearly defining desired goals. From there, we work in teams to build the processes and structures to achieve those goals. Thereafter, we frequently measure and evaluate our outcomes. For which it allows us to rapidly amend, to gain understanding and to continuously improve. We compare ourselves to performance of other hospitals to demonstrate the validity and relevance of our activity. This report has looked at the way our department manages one of the most pressing challenges in healthcare: the fact that, in all modern health systems, patients frequently suffer avoidable harm while receiving care The 2017 report highlights several essential projects that, through hard work and dedicated effort, produced outcomes that often met and sometimes exceeded our visions.

Finally, we would like to acknowledge the dedication and significant efforts of the DQS’s staff in delivering our extensive work plan during 2017. Their commitment to improving the safety and quality of the health care provided at KFHU is unfaltering. Their many achievements are described in detail throughout this report. We will continue our work in such a way that we truly earn the privilege of the respect and trust.

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Central Board for Accreditation of Healthcare Institutions (CBAHI) In November 12-14, 2017, DQS worked along with the entire KFHU staff to obtain Central Board for Accreditation of Healthcare Institutions (CBAHI) accreditation. CBAHI is the agency that grants accreditation certificates to all governmental and private healthcare facilities in Saudi Arabia.

KFHU achieved its first CBAHI accreditation after a very meticulous survey. Once achieved and even when we were not CBAHI accredited, KFHU is working maintaining and improving our standards of practice as we work towards to uphold our accreditation status.

This achievement was the result of combined hard work and continuous support from all the leaders and staff of King Fahd Hospital of the University (KFHU) and determination to commit to providing high quality services and achieve excellence in patient safety.

There are more than 23 standards identified by the CBAHI as a criterion for achieving this accreditation related to quality, leadership, medical records, human resources, medical services, nursing services, nutrition, pharmacy and infection control as well as laboratories, environmental safety and safety of the facility. For the past years (2015-2016), DQS ensure that the quality of services provided based on the preparations made by KFHU helped us realize this achievement to a high degree, which, in turn, will help to improve the quality and patients’ safety to achieve our vision and mission.

There has been continuous follow-up by DQS to ensure that the policies are up to date and to guarantee adherence to the implementation of policies and standards. For the past 12 months, intensive efforts have been made by DQS staff working to implement all standards in different fields.

It is worth mentioning that all units of DQS aims to create an environment that focuses on improving the quality of healthcare at KFHU, and devoted its services to improving the quality, safety and effectiveness of KFHU healthcare services.

Central Board for Accreditation of Healthcare Institutions (CBAHI)

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273

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DIRECTORATE FOR QUALITY AND SAFETY

Certified Professional in Healthcare Quality (CPHQ) Training Being a Certified Professional Healthcare Quality (CPHQ) can be one of the best careers moves for anyPhysician, Nurse, Healthcare executive or any other member of the healthcare team involved in quality management, performance improvement, risk management, environmental and occupational safety and health information.

After obtaining an approval from the office of His Excellency, Dr. Abdullah Al Rubaish, President of Imam Abdulrahman Bin Faisal University and Supervisor General of King Fahd Hospital of the University, the Directorate of Quality & Safety arranged for Anexas, a leading provider of Healthcare Consulting and Education to conduct the CPHQ Exam Preparation Course at KFHU. The training program was held on March 26-27, 2017.

Eighteen (18) personnel were listed as an attendee for the training. The CPHQ preparation training exam is an essential review for all healthcare professionals planning to take the CPHQ exam. The Course aims to provide healthcare professionals with the knowledge and skills to obtain the Certified Professional in Healthcare Quality Certification administered by the National Association for Healthcare Quality (NAHQ).

This Course involves a combination of practical demonstrations, discussion groups, case studies and interactive exercises. The participants are expected to gain a solid foundation In the Implementation of quality Initiatives In healthcare by acquiring common understanding of quality terminology such as quality assurance, continuous quality Improvement and total quality management.

Certified Professional in Healthcare Quality (CPHQ) Training

274

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51

60 50

24

30

Jun

4

May

4

Apr

Oct

Nov

1

Feb

5

2

Jan

5

2

10

4

14

20

24

40

0 Mar

Jul

Aug

Sep

Dec

Figure 40: Number of examinees

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DIRECTORATE FOR QUALITY AND SAFETY

104

120 100 80 60 40

CRISC

1

CISA

1

NBISE

2

CPHQ

2

1

2 CPHRM

1

CAEE

2

ASHRAE

3

0

3

6

8

20

TMC

IRC

CISM

CPPS

CSE

PFT

Figure 41: PSI/AMP comparison to other professional fellowships

Certified Professional in Healthcare Quality (CPHQ) Training

276

4

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4.0

3

3.0

3

3

3.5

DCU

AC

2

2

2.0

2

2.5

1.5 1.0 0.5 0.0

PM

ENV

ADM

RM

DSU

Figure 42: DQS total employees

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Summary of Units’ achievements (full report for each unit are enclosed) In keeping with the mission and vision of King Fahd Hospital of the University (KFHU), the Directorate of Quality & Safety (DQS) works closely with KFHU staff to continuously improve the quality of care provided; maintain a risk-free environment and assure compliance with national and international accreditation standards.

The executive leadership involvement and support for Quality and Safety activities are reflected through our achievements for 2017.

DQS determines improvement aspects that are available to patients through reviewing the performance data and carrying out appropriate quality improvement projects to ensure high quality services.

DQS has established the leadership and organizational infrastructure to ensure the safety, efficiency and high standard patient care are essential part of everyday practice of all KFHU employees.

Organization-wide awareness and support of these concepts is our goal. We work collaboratively with health care providers to achieve these goals and improve our patients and families experience while receiving services at KFHU.

Accreditation Unit The Accreditation Unit coordinates and supports all quality activities and initiatives at KFHU in accordance with national and international best practice to ensure safe and quality-based care and practices are delivered to all KFHU patients.

The Unit continuously provide consultation to all departments regarding the CBAHI and JCI (Joint Commission International) standards. In preparation for the JCI Triennial Survey in 2018, the Unit update all the JCI evidence binders.

In collaboration with the Documents Control Unit, the Accreditation Unit oversee the review, development & approval of all hospital policies & procedures, clinical guidelines & Pathways as the JCI & CBAHI standards.

Through daily tracer activity, the Unit monitor compliance to all CBAHI and JCI standards through patient tracers including environmental safety. The Unit also educate all hospital staff on quality & related CBAHI & JCI topics including accreditation, quality, patient safety, FOCUS-PDCA, Six Sigma, etc.

Summary of Units’ achievements (full report for each unit are enclosed) ١ Accreditation Unit

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Preparations for JCI

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DIRECTORATE FOR QUALITY AND SAFETY

Preparations for JCI

Accreditation Unit ูก Decision Support Unit ูก Documents Control Unit

280

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Decision Support Unit The Unit is responsible for the support of the development of meaningful tools for data collection, definition, and validation.

For 2017, the Unit was able to generate the monthly and annually hospital wide statistical performance report essential to provide timely decision support for the higher management.

Documents Control Unit The Unit keep track of all documentation, specifications and processes. The purpose of this is to ensure all KFHU employees uses the correct and most current processes and specifications. The Unit is also responsible to manage document flow and storage and to ensure that all KFHU employees has easy access for all KFHU controlled documents.

In 2017, the university name was changed from University of Dammam to Imam Abdulrahman Bin Faisal University. All related documents needed to be changed with the new logo and name. For this, the Unit had a strenuous job to complete changing of the names and logo for all controlled documents before the scheduled Saudi Central Board for Accreditation of Healthcare Institution (CBAHI) in November 2017.

The Unit was able to update a total of 221 policies and procedures, after the concluded CBAHI survey. Also, the Unit was able to develop a total of 140 new forms. Clinical pathways and guidelines were changed and updated with the new logo and name, which totaled to 114.

Table 41: Summarizes the number of policies that were changed after the CBAHI visit.

Department

No. of Updated Policies post CBAHI

Infection Control

35

Admin Hospital-wide Obstetrics and Gynecology Hemodialysis

Coronary Care Unit Anesthesia Nursing

Operations and Maintenance Biomedical

110 31 26 8 6 2 2 1

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1%

0%

1%

Admin Hospital-wide

3%3%

Infection Control

Obstetrics and Gynecology

12%

Hemodialysis 50%

14%

Coronary Care Unit Anesthesia

Nursing

Operations and Maintenance Biomedical

16%

Table 42: Number of newly developed Forms Available, Printed and Uploaded in the Intranet Form Proponent

No. of Newly Developed Forms

Admin Form

19

EMS

1

Academic Affairs Clinics

Health Education

4 7

Internal Medicine - Diabetic Center

51

Obstetrics & Gynecology

1

Nursing Dietary

Laboratory

Documents Control Unit

282

8

1 3

30

Annual Report | 2018 - 1439

Form Proponent

No. of Newly Developed Forms

Radiology

2

Pharmacy

9

Socio medical Services Infection Control Total

2 140

15%

Total of forms

Total of updated forms

85%

Figure 43: Percentage of updated forms

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Environmental Safety Unit The Environmental Safety Unit is responsible for evaluating risks of physical, chemical or biological agents in the workplace and for providing guidance to those who may be exposed in order to minimize risks. The Unit serves KFHU community by providing a safe environment for the delivery of excellent quality services through the various safety management programs.

To be able to educate all KFHU staff, the Environmental Safety Unit is responsible for conducting training programs on health hazards of chemical and biological agents, investigating air quality / odor concerns, and responding to emergencies such as chemical spills.

The unit facilitated two external disaster drills in November 2 & 6, 2017. Part of the mandate of the Unit is to promote health, safety, protection of the environment and regulatory compliance.

Environmental Safety Unit

284

Annual Report | 2018 - 1439

CBAHI reviews

285

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DIRECTORATE FOR QUALITY AND SAFETY

Dept with above 90%

Dept between 70 - 90%

Dept with below 70%

100

Environmental Safety Unit

77

0 16

0 17

32

2014

1

2013

Figure 44: Safety rounds

286

32

0

8

0

21

20

14

40

11

60

84

57

80

2015

2016

2017

Annual Report | 2018 - 1439

Dept with above 90%

Dept between 70 - 90%

Dept with below 70%

100

77 0 17

2014

0 16

2013

1

32

32

0

8

0

21

20

14

40

11

60

84

57

80

2015

2016

2017

Figure 45: Department compliance to requirements of safety

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DIRECTORATE FOR QUALITY AND SAFETY

100 97

96.35

95 91.03

90 Average Safety Compliance KFHU

85

80

2015

2016

Figure 46: KFHU average of safety compliance

Environmental Safety Unit ูก Performance Measurement Unit

288

2017

Annual Report | 2018 - 1439

Performance Measurement Unit The Performance Measurement Unit has implemented 125 KPIs (key performance indicators) in 2017 both clinical and non-clinical. Data is collected, analyzed, trended, benchmarked and displayed regularly. The Unit produce the quarterly KFHU Balanced Score Card report.

The Unit is responsible for the process of monitoring the overall hospital performance in both clinical and managerial areas as well as highlighting areas with improvement opportunity.

Different departments are involved in these measures and Performance Improvement Project are made based on data findings and identified gaps. The Unit facilitate hospital-wide performance improvement projects utilizing FOCUS-PDCA and Six Sigma methodologies.

125

35

68

114

As part of the performance improvement program, open and closed medical records are regularly reviewed and action taken to improve any deficiency detected.

KPI 2014

KPI 2015

KPI 2016

KPI 2017

Figure 47: KPIs

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70

67

80

60 44

50

26

24

30

29

40

(n=62) 2015

(n=109) 2016

20 10 0

(n=12) 2013

(n=34) 2014

Figure 48: Ratio of KPIs require an improvement

Performance Measurement Unit ูก Risk Management Unit

290

(n=123) 2017

Annual Report | 2018 - 1439

Risk Management Unit Risks to patients, staff and organizations are prevalent in healthcare. Thus, the Risk Management Unit of DQS aims to improve the safety of KFHU patients, visitors and employees through assessing, developing, implementing and monitoring and reducing adverse incidents, and ultimately promoting a Just culture.

10000

9947

The Risk Management Unit of the Directorate of Quality & Safety devote a lot of time and energy to determining whether an incident constitutes a reportable event. Implementation of various risk management plans at KFHU allows for the identification of opportunities for improvement and to reduce injury to patients, visitors and staff members. In 2017 the total reported OVR was 5,286. There was a decreased percentage rate of 47% against the 2016 total number of 9,947.

5286

8000 6000 4000 2000 0

Figure 49: OVR

2016

2017

291

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Evacuation at times of risks

Risk Management Unit ูก Training Unit ูก Significant Achievements & Activities for 2017

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Training Unit The Educational program at KFHU begins with initial orientation and basic training collaborated with the Directorate of Academic Affairs & Training. Each new employee must complete an orientation period and training in order to learn the specific work processes at the respective Department. After the training, an evaluation of the employee will be performed and on the basis of its results, he/she becomes involved in the work process.

The Unit provided continuous training for interns of College of Applied Medical Sciences – Department of Health Information Management and Technology, Imam Abdulrahman Bin Faisal University. A total of 7 interns were trained for year 2017.

The following training programs were conducted by the Environmental Safety Unit: • Medical Technology Management Plan • Security Management Plan – Hospital Lockdown • Train-the-Trainers Orientation • Hazardous Management Plan & Code Orange • Medical Management Plan • Utility System Management Plan • Facility Safety & Safety Management Program • Life/Fire Management Program & Fire Emergency (Code Red) • Emergency Preparedness: Hospital Codes (Code Pink) • Emergency Preparedness: Internal & External Disaster (Code Yellow) • Scenario: Response to Fire Drill • Understanding SDS & HazCom

Significant Achievements & Activities for 2017 Throughout 2017, Directorate of Quality & Safety made significant achievements towards our mission and vision for a quality management services that is better informed, supported and organized to deliver a safe and high-quality care to our patients at King Fahd Hospital of the University.

293

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DIRECTORATE FOR QUALITY AND SAFETY

Johns Hopkins Aramco Healthcare (JHAH) General Technical Survey King Fahd Hospital of the University (KFHU) in collaboration with DQS was surveyed by a team of Subject Metter Experts from the Johns Hopkins Aramco Healthcare (JHAH) for two days last January 15 – 16, 2017.

All units of the Directorate of Quality & Safety work together with the departments’ chairpersons & directors of all departments of the hospital to ensure that we will be able to comply with the standards that were required by the JHAH Subject Metter Experts team. After the successful survey, KFHU was able to get a compliance score of 94%.

PSI/Applied Measurement Professionals (PSI/AMP) Another breakthrough of DQS during the first quarter of 2017 was the announcement of designating KFHU as the nominated testing center in the Eastern Province to offer and administer all certifications services to PSI/AMP clients.

The certification program of DQS in collaboration with the PSI/AMP offer support for clients across a wide variety of healthcare and non-healthcare industries, including medical specialties, nursing, allied health, building and engineering, and information technology. DQS provides PSI/AMP clients with innovative testing solutions and a full range of healthcare certification services that offers every candidate a better testing experience.

Since the announcement of KFHU as the designated testing center, a total of 140 examinees

Safety & Occupational Health Unit The unit collaborates with other directorates and departments of KFHU to avail a safe and secured facilities support patients, visitors and employees. It particularly works to: • Commitment to laws, legislations and standards of local and international accreditation institutions as CBAHI and JCI • Risk reducing and control • Avoiding accidents and casualties via precautions procedures • Maintain environment safety.

Johns Hopkins Aramco Healthcare (JHAH) General Technical Survey ١ PSI /Applied Measurement Professionals (PSI/AMP)

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Preparation of Disasters Plan

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KFHU DQS Director, Admin. & Financial Director and Transportation Director follow Implementation of Disasters Plan

PSI /Applied Measurement Professionals (PSI/AMP)

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Implementation of Disasters Plan

297

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Roles of Safety & Occupational Health Unit • • • • • • • • • • • • •

To get acquainted with all relevant laws, local and international.

To asses, analyze and manage safety risks before accidents occurrence.

To implement KFHU program, plans and procedures relevant to safety.

To participate in evacuation, emergencies and conclusion of relevant exercises.

Daily and periodical inspection to prevent accidents occurrence.

To assure compliance to conditions and procedures, particularly to systems of civil defense, ministry of health or any other official entities in KSA. To assure employees commitment to full uniform of personal protection and their following to measures To inspect emergencies exits, fire alarming devices and fire extinguishers and their validity To conclude training program for new recruited employees Effective participation in committees of safety and disasters, and committees of facilities safety ad infection control Management of hazardous materials program relevant to chemicals Management of safety against fire program Saving records relevant to safety as inspection reports, accidents investigations reports, minutes of safety committee and training records.

PSI /Applied Measurement Professionals (PSI/AMP)

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All KFHU departments come together to enhance safety

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NCB Breast Cancer Chair Background Administrative Communication Arabic Transcription Monitoring & Follow-Up Human Resource Finance Purchasing Warehouse Medical Supplies And Medical Equipment ι Housing ι ι ι ι ι ι ι ι ι

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Administrative Departments

Background IAU president, Dr. Abdullah Al-Rubayish commended the efforts exerted by NCB for establishing a specialized chair in field of tumors and breast cancer. IAU appreciates the initiative had taken by NCB for its great fruits reflected on community service, post-graduates, training and scientific research.

NCB adoption of this initiative comes as a result to the effective partnership with IAU toward community service and development, in addition to NCB trust in IAU cadres of long careers an experience in this field of tumors which enable training opportunities to Saud nationalities who intend to specialize in breast diseases as the need is urgent in Eastern Region for this specialty.

On 18/01/2011G , IAU received a delegation from NCB chaired by the executive manger ,H.E/ Assad Abu-Alnasr to sign the agreement of the radiological surgery therapy of breast cancer.

IAU president signs the agreement with NCB D.G.

Background

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Administrative Departments

Supervisor of NCB chair for breast cancer Prof.Maha Abdul-Hadi is the supervisor of the chair who presented the proposal of the study in details include; vision, mission, and goals that serve the community and benefit the university. She is one of the surgeons in her fields.

She built a long and distinguished career in the specialty of breast surgery. It is better mentioned that the number of patients increased in the last periods, thus came this project to avail therapy options and encounter the urgent need for the cure and care in compliance with international standards.

Chair professor The chair professor was selected by the supervisor according to regulations set for academic chairs in IAU, and due to experience, leadership and published researches I the sociality of surgical therapy of breast cancer. So, Dr.Muhammed Kachtigar , the consultant of tumors in British Royal College was one of the first surgeons in this type of therapy in Europe.

It is of the chair professor role to follow and facilitate linking with the international community via researches and mutual experiences.

Supervisor of NCB chair for breast cancer ูก Chair professor ูก Introduction ูก About NCB chair of Breast Cancer

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Introduction The NCB chair for breast cancer is considered as one of the successful partnerships with IAU to fight this disease in its first stages. The project is in permanent progress.

Internationally, breast cancer occupies the first center among all types of tumors infect women. Surgery still considered as the major therapy for the disease at all stages depending on therapeutic allied services as: chemotherapy, radiotherapy, harmonic or biological therapy. The therapy of breast cancer recently overtook many of obstacles toward integrated therapy. According to the current inserted statistics, the radiological therapy is an essential element for breast cancer therapy, but the scarcity in such field aggravated the problem of availability of surgical options instead of total eradication. Cure is run by following the international standards and procedures and by following therapies lead to decrease of therapeutic periods.

International studies confirm the success of radiological surgery therapy as one of the available options for breast cancer therapy in compliance to international standards.

As for practice and academic aspects, the chair comprises a distinguished teamwork of a log experience in this field. The teamwork has efforts for international contributions for experience exchange and work to avail therapy methods, in addition to achieving of IAU objectives and vision in order to hang international pioneering institutions in the specialty of breast diseases.

Moreover, the importance that NCB gives to breast cancer chair and its readiness for contribution I this distinguished project in an ongoing follow-up established to communication and successful collaboration between community services and IAU as a pioneering an academic institution.

About NCB chair of Breast Cancer As per regulations set for academic chairs in IAU, and under direct supervision of H.E, the president of IAU as the executive director for academic chair, the approval for this great project ratified, and Prof. Maha was appointed as the supervisor and chair for the unit of breast at KFHU. After the setting and accreditation of the chair strategies, the chair supervisor tasks and responsibilities include: • • • • • •

Medical team Selection and training Tasks Distribution and follow-up Budget and accruals follow-up Monitoring and implementation of researches International contribution Encouraging of trainees to specialize in breast diseases

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Breast Unit Teamwork Breast Unit Teamwork consists of distinguished physicians of a long career in field of breath therapy; surgical, chemical and radiological. We receive referral cases and divide them upon symptoms with support of medical teams from diagnostic and therapeutic departments as: radiology dept., pathology dept., respiratory, psychiatry and physiotherapy for providing the best health care in an integrated system, as well as to provide the most modern methods for breast cancer therapy, keeping updated to scientific development. It is mentioned that IAU owns the most modern therapy machine in the region. The unit witnessed ongoing expansion for the increase of patients from neighboring gulf countries.

Breast Unit Teamwork

Breast Unit Teamwork

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19% Full eradication

24%

57%

Radiotherapy

Partial eradication

Figure 50: Breast Cancer/KFHU

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NCB Breast Cancer Chair

Breast Clinic

400 360

356

350

Total

340

300

250

200

150

282 270 232

236

206

157

Jan

Feb

March

Breast Clinic ูก Breast Tumors Clinic

April

May

June

July

Augest

3178

Series 1

219

220

Figure 51: Number of cases

308

300

Sep

Oct

Nov

Dec

Annual Report | 2018 - 1439

Breast Tumors Clinic

60

60

50

40

470

39

37

31

31

30

Series 1

26

20

10

Total

50

44

30

57

55

10

Jan

Feb

March

April

May

June

July

Augest

Sep

Oct

Nov

Dec

Figure 52: Number of cases

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NCB Breast Cancer Chair

One day surgery /2018 25 21

20

Total 16

15 14 11

10

12

8

5

7

0

Jan

Feb

March

April

May

Figure 53: Number of cases

One day surgery /ูก 20ูก8 Aid care procedures

310

12

10

Series 1

8

0

133

14

June

July

Augest

Sep

Oct

Nov

Dec

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Aid care procedures 30

28

25

Total

20

15

116 15 14

12

10

Series 1 10

7

9

7

5 5

4

3

0 Jan

2

Feb

March

April

May

June

July

Augest

Sep

Oct

Nov

Dec

Figure 54: Number of cases

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NCB Breast Cancer Chair

Admission

15

15

14

Total

13

13

12

12

12

133

11 10

10

Series 1

9

6

9

7

Jan

Feb

March

April

Figure 55: Number of cases

Admission ูก Operating Room ( OR )

312

May

June

July

7

Augest

Sep

Oct

Nov

Dec

Annual Report | 2018 - 1439

Operating Room ( OR )

25 21

21

20

Total

20 18

15 13

12

13

165

14

11

Series 1

11

10

7

5 4

0

Jan

Feb

March

April

May

June

July

Augest

Sep

Oct

Nov

Dec

Figure 56: Number of cases

313

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NCB Breast Cancer Chair

Patients referred centers of primary healthcare

15 13

9

10

10

10

98

8

8

8

7

6

6 5

3

0

1

Jan

Feb

March

April

May

June

July

Augest

Sep

Figure 57: patients referred centers of primary healthcare

Patients referred centers of primary healthcare ูก Researches

314

Total

12

12

Oct

Nov

Dec

Series 1

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Researches Table 43: Explains Statistics For Researches Support.

1

Calculation of sample volume

5

2

Study type

2

Data entering

7

3

Optimum methods for samples collection

5

Data processing

7

Data interpretation

4 6 8

2 1

Data analysis

15

Scientific research writing

1

9

315