Procedure for Management Review

1. SCOPE

This procedure applies to all the activities within the scope of the XXX Quality Management System.

2. PURPOSE

2.1 To ensure that top management systematically reviews the QMS and its performance
in accordance with the established operating procedures.

2.2 To review the adequacy. suitability. and effectiveness of previous corrective and
preventive actions including those related to outsourced service and supplier
performance.

3.3 To identify strengths and opportunities for improvement and make recommendations for continual improvement.

3. REFERENCE DOCUMENTS

3.1 XXX Quality Manual,
3.2Procedure for Internal QMS Audit.
3.3 Procedure for Correction & Corrective Action
3.4 ISO 19011:2018 standard

4. TERMS & DEFINITIONS

4.1 Management Review: cross-functional review by an organization’s top management which takes place at regular intervals aimed to assess the organization success at achieving objectives established thus ensuring its continued suitability, adequacy and effectiveness and to take action to correct it when necessary.

4.2 Quality Objective: A statement describes what should be achieved within the time frame and available resources. It shall be consistent with the evidence-based practice and the visions that the institution creates itself to achieve.

4.3 Audit: A systematic, independent and documented process for obtaining audit evidence (records, statements of fact or other information which are relevant and verifiable) and evaluating it objectively to determine the extent to which the audit criteria (set of policies. procedures or requirements) are fulfilled.

5. RESPONSIBILITY AND AUTHORITY

The following will be responsible for the process of preparing for the Management Review Meeting :
5.1 CEO :
5.1.1 Assure the implementation of the MR policy
5.1.2 Chair the MR meeting
5.1.3 Invite members of the top management to the meeting
5.1.4 lnvite other categories of staff as per necessity (e.g. quality focal points, internal auditors)
5.2 Director/ Head and Staff of department:
5.2.1 Set in coordination with the Director General & Hospital Director. the date and time of the meeting.
5.2.2 Prepare and present the agenda of the meeting according to the agenda stated above.
5.2.3 Take the list of attendance.
5.2.4 Make minutes of the meeting that includes discussion points raised with the suggestions as well as the decisions that have made during the output session.
5.2.5 Follow-up the decisions that have been taken during the output discussion.
5.2.6 Follow up implementation of the MR.

6. DETAILS OF PROCEDURE

6.1 Attendants:

6.1.1 Top management review meeting shall be held twice a year (first week of July and last week of December). The meeting is allocated a maximum of 2:30 hours. The distribution is according to the following:

1 hour: presenting the review input.
30 minutes: questions and answers
1 hour: review output (it is recommended that this section is attended by CEO, directors and  heads of departments)

6.1.2 The Managment review meeting to be chaired by CEO

6.2 Agenda of MR:

6.2.1 Review Input: this part of the review shall include information on:

  1. Results of audits. By reporting the results of audits carried during the previous period (internal and external). It should include the presentation of data analysis showing strengths and opportunities of improvement at the system.
  2. Customer feedback. Through analysis of reporting results of customer feedback that have been collected through various channels such as satisfaction surveys and compliments and complaints system. It is simply referring to what do your customers think of you and your organization. The reporting should look closely at both the negative and positive feedback.
  3. Changes in external and internal issues that are relevant to the quality management system.
  4. The result of the Incident Reporting System and analysis.
  5. Process and result of performance conformity. This refers to reporting whether the institution is reaching and/or maintaining performance targets.
  6. Status of preventive and corrective actions. This refers to reporting of steps have been taken to manage failures detected as well as steps to avoid the occurrence of any potential problems that are likely to rise.
  7. Follow-up actions from previous management reviews. This refers to all issues raised or resolved since the last review to make sure problems are being resolved properly. and to look for trends in the data.
  8. The effectiveness of actions taken to address risks and opportunities:
  9. Changes that could affect the quality management system. This refers to reporting any changes to standards. regulations, technology, competition. staffing. and other business activities that could affect the quality system in either a positive or negative manner.
  10. Recommendations for improvement. This refers to proposing corrective and preventative actions to be taken based on the outcome of the review of the system carried out since the last MR in order to improve the quality of services.

6.2.2 Review Output: This part of the review shall be allocated to discuss and decide on actions to be taken to improve the management system, services/ processes. and resource needed. The output shall include any decisions and actions related to:

  1. Improvement of the effectiveness of the quality management system and its processes. This refers to the fact that based on the information that has been discussed whether there are areas where worthwhile improvements can be made.
  2. Improvement of services related to customer requirements. This refers to whether there are any improvements that can be made to the processes and products.
  3. Resource needs. This refers to listing the resources (Human — current adequacy and future needs. competency and training; material resources — adequacy. suitability and maintenance of equipment and building, work environment and services) that are needed to achieve the improvements stated above. Here comes the importance of Top Management attending these reviews as they control the resources.
  4. Any need for change in QMS

6.3 Forms and records of the review:
The record of the review will be maintained by the QM department and a summary report of the meeting will be sent to the Management Representative.

7. RETAINED DOCUMENTED INFORMATION

7.1 Management Review record (QMS F027)
7.2 Data analysis reports. (QMS F028)
7.3 Management review agenda and minutes(QMS F029)

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