Training & Development
Safety Department

Al –Mostaqbal Hospital safety department main aim is to provide our patients, visitors and staff a physical environment that is free from hazards. To protect patients, visitors and staff and to minimize any disaster, life safety equipments is available in hospital every floors. Safety department provides education and training to all hospital staff. New hire orientation program also mandatory for hospital staff. Safety is a prime concern in hospital. Hospital implementing the Civil defense all requirements and CBAHI standards. Safety department implemented the followings:

Safety of the Building Plan:

The principles of the plan practiced and adhered to by hospital staff, patients, visitors and contract services personnel. Safety department to ensure safety of the patients, visitors and staff through the level of their education, awareness and implementation of their knowledge. Directive signs and warning signs are posted hospital every floor. Patient’s bathroom provided all safety measures. Smoking is prohibited in the hospital and its facilities. Hospital develops and implemented a policy to limit smoking.

Hazardous Materials:

Al Mostaqbal Hospital main aim to safely control the hazardous materials and waste. Safety department provided orientation program yearly schedule for medical and non-medical staff. Hospital provided all necessary equipments and facilities for safe handling and storage of hazardous materials and waste.
For save environment of hospital, hazardous waste/chemical is collected and transported away for treatment daily by an external company.

Internal Disaster Plan:

Aim of this plan is to protect patients, visitors and staff and to minimize property damage from any internal disaster. To reduce the risk of fire and safe work habits, safety department made a fire drill schedule monthly and yearly for all hospital staff. Simulated fire drill is practiced at unit level in accordance with the schedule. It increased confidence and efficiency of the staff. Under the guidence of safety department a unit full fire drill and emergency evacuation is conducted yearly for each of the ward by using evacuation matrix and stairs stretcher.

Any internal disaster Hospital Control Room in ground floor direct and control disaster response activities. Action card is available here. During disaster the role of emergency members, their bleep, bravo and mobile number is mentioned in these cards.
Hospital fire protection equipments and emergency power generator system maintained in fully operational condition at all times.

Fire Safety Plan:

Al Mostaqbal hospital fire safety plan main aim is to maintain properly the life safety system in the hospital facilities. It includes the fire alarm, fire equipments, fire suppression system and related equipments.
To prevent fire and to protect patient’s hospital has plans to buy fire resistant furniture, curtains and drapes.
Hospital elevators and smoke exhaust fans are connected to the fire alarm system. All areas provided emergency lights and generator power supply. Emergency exit doors and fire exits are free from any obstruction. Safety department conducted practical fire extinguishing (PFE) training for medical and non-medical staff yearly schedule. For encouragement and motivation of safety activities, participant received appreciation certificate.
Training & Development
Infection Control

Infection control is a discipline that applies epidemiologic and scientific principles and statistical analysis to the prevention or reduction in rates of nosocomial infections. Effective infection prevention and control is central to providing high quality health care for patients and a safe working environment for those that work in healthcare settings.
Infection Prevention & Control is the responsibility of each employee; everyone plays a part in breaking the chain of infection. This can be achieved by making hand hygiene practice a key patient safety issue and utilizing standard precautions. Infection prevention and control is integral to clinical care and the way in which it is provided. We provide service for the prevention, surveillance, investigation and control of infection. This is achieved through staff and patient education, development of policies and guidelines, surveillance/ reporting, audit of infection control practices, research, implementation of national guidelines and performance improvement projects to eliminate hospital acquired infection.
We are passionate about reducing the incidence of hospital and facility acquired infections amongst patients and residents. Whatever we can do to affect improvements in patient care practices that can reduce cross infection, we are keen to role model and promote.

History of Infection Control

The scientific study of hospital or nosocomial cross-infection began during the first half of the 18th century, and from that time until the start of the ‘Bacteriological Era’ many of the most notable contributions originated in Scotland. However it was only 100 years later in 1858 that Florence Nightingale promoted the case for hospital reform. The real understanding of hospital infection followed upon the discoveries of Pasteur, Koch and Lister and the beginning of the ‘Bacteriological Era’. The close of the 19th century saw the triumphs of hospital reform and asepsis and seemed to herald the final victory over hospital cross-infection. However, the victory was short-lived. It was soon realized that infections occurred not only in obstetric and surgical patients, but in medical patients as well, and that air could also be a source of infection. Streptococcal, staphylococcal and then Gram-negative bacilli as a cause of hospital infection became a focus of attention, as did antibiotic-resistant organisms.

Healthcare-associated infection is preventable

HAIs are infections that patients get while receiving treatment for medical or surgical conditions, and many HAIs are preventable. Modern healthcare employs many types of invasive devices and procedures to treat patients and to help them recover. Infections can be associated with procedures (like surgery) and the devices used in medical procedures, such as catheters or ventilators. HAIs are important causes of morbidity and mortality in the United States and are associated with a substantial increase in health care costs each year. At any one time in the United States, 1 out of every 25 hospitalized patients is affected by an HAI. Any person working in or entering a healthcare facility is at risk. However, healthcare-associated infection is a potentially preventable adverse event rather than an unpredictable complication. It is possible to significantly reduce the rate of HAIs through effective infection prevention and control.

Infection prevention and control is everybody’s business

Understanding the modes of transmission of infectious organisms and knowing how and when to apply the basic principles of infection prevention and control is critical to the success of an infection control program. This responsibility applies to everybody working and visiting a healthcare facility, including administrators, staff, patients and carers.

Infection prevention and control programs

The introduction of infection control (IC) programs to monitor such infections did not occur until the mid-1950s, in response to a pandemic of hospital staphylococcal infections. Changes in the health care system have expanded the range of IPCP activities. These changes necessitate an increase in infection prevention and control resources in order to be effective in the current health care system and to maintain the essential IPCP components. The emergence of new infectious diseases such as MERS-CoV has emphasized the need for surge capacity in infection prevention and control as well as in other health care services.
Infection prevention and control programs are providing basic and continuing education to health care providers regarding principles of infection prevention and control to help prevent the transmission of emerging infectious diseases such as MERS-COV.
We are pleased to welcome you to Al-Mostaqbal Hospital’s Infection Control Department where our aim is to reduce the incidence of hospital acquired infections amongst patients. Whatever we can do to affect improvements in patient care practices that can reduce cross infection, we are keen to role model and promote.
This can be achieved by making hand hygiene practice a key patient safety issue and utilizing standard precautions. Infection prevention and control is integral to clinical care and the way in which it is provided. We provide service for the prevention, surveillance, investigation and control of infection. This is achieved through staff and patient education, development of policies and guidelines, surveillance/ reporting, audit of infection control practices, research, implementation of national guidelines and performance improvement projects to eliminate hospital acquired infection.

Infection control programs include:

• Comprehensive risk reduction strategies necessary to minimize the risk of HAIs to patients, staff and visitors.
• Reporting of HAI and surgical site infections.
• Organized surveillance and control activities.
• Education is an important tool in ensuring that health care personnel and visitors comply with IPCP policies.
• Compliance to use basic infection control techniques such as appropriate hand washing as the major factor for cross transmission in hospitals.
• Regular program evaluation and auditing of infection prevention and control measures with timely feedback for optimal improvement.
• Reporting of communicable diseases to the Kingdom of Saudi Arabia’s Ministry of Health for proper epidemiology protocols, monitoring, education and institution of proper and national control measures.
• Staff Immunization
• Annual staff’s respirator fit testing


Handwashing with soap and water has been considered a measure of personal hygiene for centuries and has been generally embedded in religious and cultural habits. Nevertheless, the link between handwashing and the spread of disease was established only two centuries ago, although this can be considered as relatively early with respect to the discoveries of Pasteur and Lister that occurred decades later.
In the mid-1800s, studies by Ignaz Semmelweis in Vienna, Austria, and Oliver Wendell Holmes in Boston, USA, established that hospital-acquired diseases were transmitted via the hands of HCWs. In 1995 and 1996, the CDC/Healthcare Infection Control Practices Advisory Committee (HICPAC) in the USA recommended that either antimicrobial soap or a waterless antiseptic agent be used for cleansing hands upon leaving the rooms of patients with multidrug-resistant pathogens. More recently, the HICPAC guidelines issued in 2002 defined alcohol-based handrubbing, where available, as the standard of care for hand hygiene practices in health-care settings, whereas handwashing is reserved for particular situations only. Hands may easily become contaminated with infectious microorganisms, which can enter the body through a break in the skin or be transmitted to a susceptible host and cause infection. All personnel, physicians, nurses, technicians and others who are responsible for complying with the hand hygiene policy should lead by example and call observed infractions to the attention of any offenders.
Cleaning hands promptly and thoroughly between contacts and after contact with blood, body fluids, secretions and equipment or potentially contaminated surfaces is an important strategy for preventing healthcare associated infections.


Infection Control and Prevention Orientation is being rendered to new and old staffs.


Month of May- Hang Hygiene Month
Patient education about influenza and the vaccine is conducted during the month of October.


Staff’s personal protective equipment return demonstration.
Fit testing is conducted annually to ensure the right respirator size for each hospital staff.
Each hospital staff is entitled to yearly influenza vaccination.

Ministry of Health KSA is visiting Al-Mostaqbal Hospital to ensure infection control and prevention compliance. 


Dr. Lorelina Salcedo
Infection Control Practitioner
Al-Mostaqbal Hospital

Gary Ann Jimenez
Infection Control Nurse
Al-Mostaqbal Hospital 
Training & Development
Total Quality Management

I would like to welcome everyone for visiting our website. Here at TQM department we highlighted some concepts and strategies on how Quality is performed and measured in our hospital and to make sure that we give the best quality service for our customers.

Total quality management is a management system for a customer focused organization that involves all employees in continual improvement of all aspects of AMH. TQM uses strategy, data, and effective communication to integrate the quality principles into the culture and activities of the organization, in order to give the best quality of service and patient satisfaction.

Our Five Key Concepts are:

1. Customer Focused – we make survey to measure customer satisfaction.
2. Continuous Improvement and learning
3. Participation and teamwork by all employees
4. Commitment by top management
5. A Process Approach amounts to seeing organizational function as a series of interconnected steps of which is reflected in the measurement of length of stay, costs of service and labor productivity and can be improved individually

TQM Implementation Approaches:

1. Train top management on TQM principles.
2. Assess the current: Culture, customer satisfaction, and quality management system.
3. Top management determines the core values and principles and communicates them.
4. We develop TQM Patient Safety Plan
5. Identify and prioritize customer needs and determine products or service to meet those needs.
6. Determine the critical processes that produce those products or services.
7. Create process improvement teams.
8. Managers support the efforts by planning, training, and providing resources to the team.
9. Management integrates changes for improvement in daily process management. After improvements standardization takes place.
10. Evaluate progress against plan and adjust as needed.
11. Provide constant employee awareness and feedback. Establish an employee reward/ recognition process.

Thank you for visiting our website. 
Training & Development
Training Calendar 2016

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