QUALITY ORGANIZATION STRUCTURE
Departmental Quality Representatives
Each department is represented by personnel at the managerial or supervisory level.
Quality “Organization Chart”
I – Top Management and Main Responsibilities
| Position | Roles and Authority |
|---|---|
| Responsible Manager / Chief Physician | Ultimately responsible for the implementation and sustainability of the Quality Management System (QMS). Approves the allocation of resources. |
| Finance and Administrative Affairs Director | Responsible for the management of administrative and financial operations that support quality processes. |
II. Quality Management Structure (Coordination)
This unit coordinates all quality activities and reports to senior management.
| Position / Unit | Main Area of Responsibility |
|---|---|
| Quality & Training Services Manager / Specialist | Establishes, implements and audits the QMS in line with national and international standards; coordinates corrective and improvement actions. |
| Quality Management Department | Conducts all quality activities; ensures documentation control; coordinates field implementation and prepares for audits. |
| Departmental Quality Representatives | Implements quality documentation in their clinical/administrative units and coordinates with the Quality Management Department. |
III. Boards
| Board | Mandate |
|---|---|
| Executive Board | Develops institutional strategies and projects in line with legal regulations and quality standards; evaluates effectiveness based on reports of the Executive Committee and approves key decisions. |
| Management (Executive) Committee | Enhances decision-making efficiency when the Board cannot convene frequently; tracks sectoral developments; ensures coordination between the administrative structure and the Board; analyses process effectiveness and reports implementation to the Board. |
| Disciplinary Board | Defines rules per legislation and quality standards; determines disciplinary measures and regulates procedures for their application. |
| Ethics Board | Ensures that medical services are delivered in accordance with ethical and deontological principles; evaluates scientific events and publications; investigates complaints; proposes corrective actions. |
| Occupational Health & Safety Board | Sets OHS working principles and risk-assessment methods; ensures coordination among multiple OHS boards where applicable. |
| Risk Assessment Board | Identifies risks concerning patients, visitors, employees, the facility and environment; ensures prevention and risk reduction at source. |
| Archive Review & Disposal Board | Ensures medical record archiving processes comply with national and international quality standards. |
| Information Security Board | Ensures the information security management system functions in line with national and international standards; oversees policies and risk management. |
Committees
| Committee | Purpose |
|---|---|
| Employee Health & Safety Committee | Creates a comprehensive Employee Safety Programme, prevents incidents, reduces harm and ensures corrective measures. |
| Training Committee | Plans training needs; reviews decisions and improvement actions; submits recommendations to the Quality Training Department. |
| Infection Control Committee | Controls institutional infections in accordance with policy, law and standards; ensures timely preventive measures and implementation. |
| Patient Rights & Safety Committee | Identifies patient-rights/safety risks; builds a Patient Safety Programme; prevents incidents and reduces harm. |
| Facility Safety Committee | Manages risks related to physical areas, devices, infrastructure and environment to maintain a safe setting. |
| Radiation Safety Committee | Plans and implements radiation-protection practices in line with regulations and national guides. |
Teams
| Team | Purpose |
|---|---|
| Emergency & Disaster Management Team | Prepares and drills emergency plans to minimise harm; coordinates all facility-safety efforts. |
| Blue Code Team | Provides rapid response and advanced life support for cardiac/respiratory arrest situations. |
| White Code Team | Responds to verbal/physical violence against staff; ensures protection, support and legal notification (white code). |
| Red Code Team | Ensures fast, safe intervention in fires; conducts extinguishing and evacuation activities. |
| Pink Code Team | Prevents and manages cases of missing/abducted newborns, infants or children within the institution. |
| Self-Assessment Team | Conducts internal assessments using national/international healthcare quality standards and patient/employee-safety criteria. |
| Facility Tour Team | Surveys physical conditions and operations; identifies issues on site and initiates corrective actions. |
| Departmental Clinical Quality Improvement Team | Supports auditors; manages documentation and indicators; ensures practical implementation in the field. |
| Sustainability & Social Responsibility Team | Plans sustainability practices and coordinates social-responsibility projects to enhance service efficiency and satisfaction. |
IV. Quality Monitoring by Service Areas
The quality system monitors processes according to the main service areas below:
| Clinical Services |
|---|
| Patient care and follow-up processes |
| Standardisation of diagnostic and treatment procedures |
| Medication management and safety |
| Radiation safety |
| Support Services |
|---|
| Sterilisation and disinfection |
| Medical records and archiving |
| Material and device management |
| Waste management |
| Indicator Management |
|---|
| Defining target quality indicators (e.g., appointment-cancellation rate, infection rate, patient-satisfaction score); conducting data collection and analysis; monitoring and reporting results. |
