Quality & Accreditation

Safe care. Kind care. Every patient, every time—guided by robust clinical governance and continuous improvement.

Quality and safety rounding

Our Quality & Patient Safety Policy

Nazareth Hospital is committed to delivering compassionate, evidence-based care that meets or exceeds national standards. We foster a culture where every staff member is responsible for quality, safety, and a dignified patient experience.

  • Patient-centred care and informed consent
  • Clinical effectiveness built on guidelines and audit
  • Safety systems that prevent harm and reduce risk
  • Continuous learning, reporting, and feedback
  • Respect, privacy, and compassion in every interaction
Quality policy display

Patient Safety Goals

Correct Patient Identification

Use two identifiers on bands, forms, meds, labs, and procedures.

Effective Communication

Read-backs for verbal orders, standardized handovers (SBAR).

Medication Safety

High-alert meds, look-alike/sound-alike lists, double-checks.

Safe Surgery

WHO checklist, site marking, time-out & sign-out in theatre.

Infection Prevention & Control

Hand hygiene, isolation, sterilization, environmental cleaning.

Fall & Pressure Injury Prevention

Risk assessments, rounding, repositioning, and safe mobility.

Clinical Governance

Our governance structure integrates quality, safety, and education across all departments with clear lines of accountability. Multidisciplinary committees review indicators monthly and execute targeted improvement projects.

  • Quality & Patient Safety Committee
  • Infection Prevention & Control Committee
  • Medicines & Therapeutics Committee
  • Theatre & Critical Care Committee
  • Mortality & Morbidity Reviews
Clinical governance meeting

Continuous Improvement (PDCA)

Plan

Identify gaps via audits, incidents, and patient feedback; set SMART targets.

Do

Implement change ideas, train staff, and standardize procedures.

Check

Track indicators monthly and share dashboards and learning.

Act

Scale what works, update SOPs, and launch next PDSA cycles.

Key Quality Indicators

>95%
Hand Hygiene Compliance
< 1%
Surgical Site Infection (SSI)
100%
Theatre Checklist Use
>90%
Patient Satisfaction

*Sample target thresholds. Replace with your live monthly values from QI dashboards.

Accreditation & Compliance

We align with the Kenya Ministry of Health quality standards and payer requirements, and we maintain readiness for external assessments. Our teams update SOPs, train staff, and conduct periodic mock surveys.

  • National clinical and facility standards compliance
  • SHA/NHIF contract adherence and claims quality
  • Radiation safety, laboratory quality, and pharmacy best practice
  • Document & records management (version control/SOPs)
  • Emergency preparedness & disaster drills
External quality audit

Quality Documents & Downloads

Help Us Raise the Bar

Partner with our quality teams to support new equipment, staff training, and community safety programs.

WA