Quality & Patient Safety Department

Brief Description Department

MTI Bannu Quality and Patient Safety Department was established in December 2023 with a focus on hospital clinical and non clinical performance, continuous quality improvement, quality management system, development of quality & patient safety culture, patient complaints and satisfaction. Provide the essential guidance and assistance for all administrative and clinical department with in organization.

The Quality & Patient Safety Department primarily focuses on compliance with regulatory requirements, Joint Commission International (JCI) accreditation, ISO certifications, clinical governance, comprehensive risk management and patient safety, performance improvement, clinical performance indicators, patient comments handling, and patient satisfaction and experience surveys.

At present all departments of Khalifa Gul Nawaz Teaching Hospital is ISO 9001 Quality Management System certified by IQS, UKAS inspection, verification, testing and Certification Services Company. We look towards the horizon, having more valuable national and international accreditations in the future.

Overall, the goal of our Quality and Patient Safety Department is to instill a culture of excellence and accountability throughout the organization. By promoting best practices and ensuring adherence to standards, we strive to deliver the highest quality of care and maintain a safe environment for all patients.

Lead Quality & Patient Safety 

Attiq Ur Rehman

Dedicated Resource



Waqar Ahmad Khan

Incharge KGNTH MTI Bannu

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Incharge DHQTH MTI Bannu

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Incharge W&CTH MTI Bannu

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Incharge BMC MTI Bannu

QPSD Services 

Our department provides following services  

Policies Formulation and Control

The QPS department is responsible for developing and implementing policies that guide our quality and patient safety practices. These policies are regularly reviewed and updated to ensure compliance with regulatory requirements and best practices.

Quality Management System and ISO Certification

Our quality and patient safety department (QPSD) is dedicated to ensuring that we maintain a high standard of quality in our services and operations. We have implemented a Quality Management System that complies with ISO standards to continuously monitor and improve our quality performance.

Performance Management System & Non Clinical Audit

We have a robust performance management system in place that allows us to track and measure our quality and patient safety performance. Regular audits are conducted to evaluate the effectiveness of our quality and patient safety practices.

Strategic and Operational Management

Our team works closely with the leadership to align quality and patient safety goals with the organization's strategic objectives. We ensure that quality and patient safety considerations are integrated into all aspects of our operational and strategic planning..

Patient Safety Guidelines

QPSD develop plan to adhere strict patient safety guidelines to ensure the well-being and safety of our patients. Our department stays up-to-date on current best practices and guidelines to continually improve our patient safety measures.

Clinical Governance and Medical Charts review

There is a multi-disciplinary approach in conducting review of patient clinical record content, quality and the completeness of patient clinical records, and the results are incorporated into the hospital’s quality over sight mechanism. .

Regulatory Compliance

We adhere to all regulatory requirements and standards to ensure compliance with healthcare industry regulations like Healthcare Commission KP. Our department stays informed on any updates or changes in regulations to maintain our commitment to compliance.

Quality Improvement

Continuous quality improvement is at the core of our department's mission. We regularly assess and analyze our processes to identify opportunities for improvement and implement initiatives to enhance quality and patient safety. QPS departments develop departmental improvement plans.

Patient Satisfaction Reporting

We regularly collect and analyze patient feedback to measure satisfaction levels and identify areas for improvement. This information is used to enhance our quality and patient safety practices and improve patient outcomes.

Incident and Risk management

Incident and Risk management is an approach that focuses on identifying situations where patients are at risk of harm and taking appropriate action to prevent or control those risks in order to improve the quality of healthcare. Staff and patients at MTI Bannu can report incidents electronically. Root cause analysis (RCA) is carried out for sentinel events .

Training and Development

We provide ongoing training and development opportunities to our staff to ensure they are knowledgeable and skilled in quality and patient safety practices. This helps to instill a culture of quality and patient safety throughout our organization. Over 70 separate training sessions have been held so far.

Creating a Culture of Quality and Patient Safety

Our department is dedicated to fostering a culture of quality and patient safety within our organization. We promote transparency, open communication, and a commitment to continuous improvement to ensure the highest quality of care for our patients.