Leadership

Standard FM
(3)
PM
(2)
MM
(1)
NM
(0)
NA
LD.1. The facility is in compliance with all Saudi
Arabian laws and health care regulating
bodies including the Ministry of Health (MOH).
LD.2. The hospital has a defined and clear
organizational structure that is known to all
staff and includes the following:
LD.2.1 There is an organizational chart which
identifies the names and titles of the
hospital leaders, and department
heads.
LD.2.2 The organizational chart is current.
LD.2.3 The organizational chart is explained
to all employees as part of his/her
orientation.
LD.3. Besides the hospital director, the following
positions are identified by the organizational
chart and hospital meetings as part of the
leadership group:
LD.3.1 Medical Director.
LD.3.2 Administrative Director.
LD.3.3 Nursing Director.
LD.3.4 Quality Management Director /leader.
LD.3.5 Department heads.
LD.4. The leadership meets regularly (at least
monthly) in a minuted formal meeting (like an
executive committee) to discuss all aspects of
medical care, and services provided to
patients.
LD.5. There is evidence that all members of the
leadership group are qualified by appropriate
education and experience.
LD.6. Each member in the leadership group has a
defined scope of responsibility as outlined in a
current job description.
LD.7. The hospital has a mission, vision, and values
statement that is clearly written known to all
staff, and:
LD.7.1 The mission, vision and, values
statement is clearly written.