Quality health care, Training and Research


Definitions of Quality “...proper performance (according to standards) of interventions that are known to be safe, that are interventions that are known to be safe, that are interventions that are known to be safe, that are disability, and malnutrition.” (M.I. Roemer and C. Montoya Aguilar, WHO, 1988) Background The Quality Assurance and Accreditation Unit opened its door in CHUB since July 2012. It started with only one Personnel who was supposed to carry out all activities, took a whole month to get all needed equipment in order to be able to start with Quality Assurance program in CHUB. In December 2012, a Baseline survey was conducted in order to initiate Accreditation processes by COHSASSA. Now the required Accreditations Committees are in place and Quality Office required staff to help the office to implement its mission. In December 2019 HQS Consulting conducted an internal survey to evaluate the progress of accreditation in the Hospital where the hospital was scored highly as it was planned and from that, the hospital is in intermediate level. The Quality Assurance unit has a purpose to help CHUB to improve Quality of care given at the Hospital basing on international standards.

The unit of quality assurance and accreditation is responsible for assessing and addressing needs for Quality Improvement; Means use of Plan, Do, Study and Act cycle in services delivery to patients, visitors and patient’s family, training for all employees who work in contract and grant. Full time Quality Improvement staff are responsible for overseeing the implementation and evaluation of the Quality Assurance Plan under the Authority of Director General of the Hospital, in conjunction with the Quality Improvement Committee which provides ongoing operational leadership of continuous quality improvement activities at CHUB. AIM: Coordinates and implements the operation of quality assurance and Accreditation, and utilization review units within the hospital.

Goals and Objectives

The Quality Improvement Committee identifies and defines goals and specific objectives to be accomplished each year.

Goals include quality and patient safety as well as training of hospital staff.


The following are the goals for CHUB Quality Improvement Program and the specific objectives for accomplishing these goals:


 To increase the effectiveness of the Quality Improvement Committee;

 To implement all of the critical and core accreditation standards;

 To prioritize identified problems;

 To implement quantitative measurement to assess key processes or outcomes;

 To achieve measurable improvement in the highest priority areas;

 To implement a process to review and trend major hospital sentinel events;

 To provide Quality Improvement education and training to managers, clinicians, and staff;

 To develop or adopt clinical practice guidelines.



The mission and objectives of the Quality Assurance service is the development of quality services in CHUB through teaching quality management in health services, health and safety environment for employee, patients and visitors; initiating quality improvement projects to improve the services delivery; to monitor and educate about the measurements of quality. The evaluation of all processes will be concluded by the problem solving and decision making for future improvement and change of CHUB.




 Co-ordinating all Quality Assurance and Accreditation activities;

 Identifying Quality Assurance activities to mitigate project risks;

 Evaluating contractors' Quality Plans;

 Identifying new risks;

 Progressing the Quality Assurance surveillance plan and agree to change;

 Making recommendations regarding the Project's documented Quality Strategy and its maintenance and/or configuration management;

 Agreeing the responsibilities and timescales for Quality Assurance activities;

 Establishing a communication strategy for Quality Assurance issues;

 Updating members on Project issues;

 Reviewing applicable quality requirements and associated procedures and establish a common understanding;

 Evaluating surveillance reports and progressing Quality Deficiency Reports;

 Reviewing and evaluating all corrective actions;

 Maintaining records of proceedings and actions.



Quality Assurance &Accreditation Director



Mob: +250788728877

E-mail : nsawiki73@yahoo