Hospital’s Quality Improvement Council (QIC):
QIC was developed during the last few years under the supervision of hospitals directorship and is formed by the managers of different administrative and clinical departments in hospital . The main task of this council is to lead the Continuous Quality Improvement process in close collaboration with all departments throughout hospital.
Under the supervision of QIC, the twelve Continuous Quality Improvement teams, divided in 4 administrative and 8 clinical teams, continuously monitor the quality of care and follow up the progress of service delivery in all aspects. In essence, the aim of development and activity of this group is to improve the quality of care in concordance with the vision and the mission of hospital and to implement the strategic goals in determined time table.
As you could notice from our vision statement, our patients are center of all these efforts and we hope to provide them excellent healthcare services in a safe and reliable environment. Our vision: Accessible & Reliable for All And Excellent in Healthcare Services in the Region.
You can Here are some of our guidelines in quality improvement:

What is CQI?
Continuous Continuous Quality Improvement (CQI) is a the philosophy of continuously progress in a step by step manner - much like a mountain climbing. The keys of CQI are: knowing how to climb (the process); trying different paths to the peak (by learning by trial) and holding the gained elevation (by adopting the successful methods into our day to day routine).
EEvery MBA student knows about the CQI process, but in healthcare, we either do not know it or have failed to realize its potential. Today doctors and executives in all around the world are paying thousands of dollars to learn this process and have clinician accept this methodology for improvement in health care services.
The result of throughoutCQI is costs reduction for the organization, better care and more saved lives and an overall reduction of medical error. The main elements of CQI are: problem solving, interpersonal skills, teamwork and the quality improvement process itself.

Healthcare: A system property
The delivery of healthcare today is complex - it is a 'system' property not just an isolated event such as a doctor giving medicine to the patient. Lack of success is not due to individuals rather it is the responsibility of the system that was created and is being redesigned.

Three fundamental questions for achieving improvement
Improvement is based on knowledge.Knowledge must then be applied. The answers to three fundamental questions form the basis of improvement based on applied knowledge.
-What are we trying to accomplish?
-How will we know that a change is an improvement?
-What changes can we make that will result in improvement?

All our lives, we have used 'trial and error' to evolve and improve. The new process of improvement is similar but with a twist. It's not 'trial and error' but 'trial and learning'. The above three questions lead to this new process of 'trial and learning'.
Trail means we do a small test of change. Learning means that we identify the criteria that have led to the change and then we measure the change and incorporate it as our fundamental way of working.
What are we trying to accomplish? We may be trying to improve our cricket game or trying to reduce the infection rate in the ICU, but we must have an 'aims statement'. This statement must be focused, succinct and written down so that others can become partners in the process.
How will we know that a change is an improvement? This question implies that we must measure and if we improve and the improvement is sustained over time then we must conclude that the change lead to the improvement.

Plan-Do-Study-Act Cycle
What changes can we make that will result in improvement?
So here lies the core of the improvement process. It is the PDSA cycle or the Plan, Do, Study and Act. What this emphasizes is:
Plan: A change or test. Here you ask questions and predict what will change the process. You plan to carry out the cycle, the details of which include who, what where when.
Do: Carry out the plan. You collect the data and begin analyzing the data
Study: Summarize what was learned by completing the analysis of the data and comparing the data to predictions
Act: Determine what changes are to be made and what will be the next cycle. Also, evaluate what changes to keep and what to discard?
The cycle is then repeated again and again, each time with a small test of change, data gathering, analysis and a decision to keep or discard the change.

Summary
As humans we will always strive for improvement. However we have the options of following trial and error where we have to wait decades for the improvement to work or trial and learning where we can see the change in days.
Healthcare is an ideal setting to test the model of change - and no doubt we have much to improve in the area of drug delivery, hospital care, medical error reduction, and hospital infection reduction.
The model of improvement of Plan-Do-Study-Act is the first bold step any executive or clinician can take in trying to improve care at his/her facility. Surprisingly, after the initial hesitation, the clinicians are often quick to adopt this method, because this process is data driven and utilizes the rigorous scientific methods in which they are well trained.