Ejada Performance Intervention Report
Hospital Name: Al Zahra Hospital
Date: 22 March 2025
Reporting Authority: National Ejada Oversight Committee
Executive Summary:
Al Zahra Hospital has demonstrated consistently high performance across all five Ejada pillars, achieving an overall score of 87%. Particular strengths are noted in clinical safety, operational efficiency, and staff engagement in innovation. This report serves to document current best practices and outline opportunities for Al Zahra to act as a leadership site for quality mentorship and peer collaboration.
1. Clinical Excellence
| Indicator | Target | Actual | Deviation | Status |
|---|---|---|---|---|
| 30-day Readmission Rate | <10% | 7.8% | -2.2% | Achieved |
| Surgical Site Infection Rate | <1.5% | 1.2% | -0.3% | Achieved |
| Antimicrobial Stewardship Compliance | >90% | 92% | +2% | Achieved |
| Inpatient Fall Rate | <2 per 1,000 pt days | 1.3 | -0.7 | Achieved |
Issues Identified:
- Comprehensive safety culture program
- High compliance with infection prevention standards
Recommended Corrective Actions:
- Share medication safety and fall prevention models nationally
2. Operational Efficiency
| Indicator | Target | Actual | Deviation | Status |
|---|---|---|---|---|
| ED Waiting Time (mins) | <45 | 36 | -9 | Achieved |
| Average LOS (days) | 4.0 | 3.7 | -0.3 | Achieved |
| OR Utilization Rate | >80% | 82% | +2% | Achieved |
| Bed Turnover Rate | >3.5 | 3.9 | +0.4 | Achieved |
Issues Identified:
- Efficient patient transfer workflows
- Strong collaboration between nursing and case management
Recommended Corrective Actions:
- Host peer workshops on patient flow optimization
3. Financial Sustainability
| Indicator | Target | Actual | Deviation | Status |
|---|---|---|---|---|
| Claims Rejection Rate | <5% | 3.5% | -1.5% | Achieved |
| Billing Accuracy Rate | >98% | 99.0% | +1.0% | Achieved |
| Revenue Cycle Turnaround Time | <30 days | 24 days | -6 | Achieved |
Issues Identified:
- Streamlined claims management processes
- Active clinical-financial data alignment practices
Recommended Corrective Actions:
- Lead financial integrity webinars under Ejada
4. Patient Experience
| Indicator | Target | Actual | Deviation | Status |
|---|---|---|---|---|
| Overall Patient Satisfaction | >85% | 90% | +5% | Achieved |
| Staff Courtesy (PREM Domain) | >90% | 93% | +3% | Achieved |
| Noise Level at Night (HCAHPS) | <10% complaints | 7% | -3% | Achieved |
| PROM: Symptom Relief | >85% | 88% | +3% | Achieved |
| Understanding of Medication Plan (PREM) | >90% | 92% | +2% | Achieved |
Issues Identified:
- Excellent communication skills training program for staff
- Real-time feedback collection at discharge
Recommended Corrective Actions:
- Contribute to Ejada’s national PREM/PROM standard-setting panel
5. Innovation & Learning
| Indicator | Target | Actual | Deviation | Status |
|---|---|---|---|---|
| EHR Utilization Rate (Full Entry) | 100% | 98% | -2% | Achieved |
| Staff Participation in CME | >80% | 90% | +10% | Achieved |
| Innovation Projects Initiated | >3 | 4 | +1 | Achieved |
Issues Identified:
- Multidisciplinary innovation council established
- High staff engagement in quality improvement
Recommended Corrective Actions:
- Collaborate with DHA Innovation Unit to host case study webinars
Overall Ejada Performance Score: 87%
Status: High-Performance Recognized Hospital
Next Review Date: March 2026
Final Recommendations:
- Nominate for Ejada Clinical Excellence Award
- Publish quality improvement case studies in Ejada repository
- Host peer learning visits for hospitals in recovery phase
- Expand innovation projects with national impact potential
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