Version
V.2026/0001
Riyadh · Kingdom of Saudi Arabia
Masharef
Hospital®
Comprehensive Hospital Profile
"Affordable & Equitable Care"
Scope of Services
Centers of Excellence
High Reliability
Value-Based Care
Capacity & Capabilities
KPIs & SLAs
Classification
Published
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Table of Contents
01
Identity & Profile
About Masharef Hospital
Masharef Hospital® is a tertiary-care hospital in Al Riyadh, KSA, serving a primary catchment of approximately 13 million residents. Established in 2026, it operates as a 50-bed integrated private institution.
2026
Year Established
50
Licensed Beds
~13M
Primary Catchment
24·7·365
Always Open
Facility exterior
Drop in a photo of the hospital building
Drop in a photo of the hospital building
1.1At a Glance
| Year established | 2026 |
| Ownership | Private — value-based, profitable healthcare organization |
| Facility type | Tertiary hospital · general hospital |
| Licensed beds | 50 beds |
| Accreditation(s) | — |
| Annual patient encounters | — |
| Workforce | — |
| Address | King Abdulaziz Road, Al Arid, Al Riyadh, KSA |
| Contact | 920000205 |
| Operational hours | 24 hrs · 7 days / week · 365 days / year |
What this means for every patient
R
Reliability
You get the right care the same way every time — never depending on luck or which day you visit.
Q
Quality
Your care is safe, effective, and built around you, your needs, and your dignity.
O
Operational Excellence
Smooth, well-run services mean shorter waits and more time with your care team.
02
Direction & Purpose
Mission, Vision & Values
Masharef Hospital® is committed to being a Highly Reliable Healthcare Organization (HRHO) meeting the expectations of every member of the community it serves.
2.1Vision
Our Vision
To be the most trusted healthcare provider in Riyadh — recognized nationally for clinical excellence, patient safety, and compassionate, equitable care for every member of our community.
2.2Mission
Our Mission
To improve the health and wellbeing of the communities we serve by delivering safe, high-quality, accessible, and patient-centered care; advancing knowledge through education and research; and continuously improving the value we provide.
2.3Core Values — C·A·R·E·S
| Value | What it means in practice |
|---|---|
| Compassion | We treat every patient and family with empathy, dignity, and respect. |
| Accountability | We take ownership of outcomes, are transparent about performance, and learn from error. |
| Respect | We honor diversity, protect privacy, and value every member of the care team. |
| Excellence | We pursue the highest standards in clinical quality, safety, and service. |
| Stewardship | We use resources responsibly to deliver sustainable, value-based care for the whole community. |
2.4Strategic Pillars
The mission is operationalized through five strategic pillars, each aligned to measurable goals:
P1
Quality & Safety
Zero preventable harm and reliable clinical outcomes.
P2
Patient & Family Experience
Compassionate, coordinated, person-centered care.
P3
People & Culture
An engaged, well-supported, continuously developed workforce.
P4
Access & Community Health
Equitable access and proactive population-health management.
P5
Sustainability & Value
Financial stewardship and operational efficiency that lower the cost of care.
03
Breadth of Care
Scope of Services
Masharef Hospital® provides a comprehensive range of clinical and support services across the full care continuum, continuously updated as part of our resiliency strategy.
3.1Clinical Service Lines
| Service Domain | Representative Services |
|---|---|
| Emergency & Trauma | 24/7 Emergency Department, trauma resuscitation, triage, fast-track, observation unit, ambulance/EMS coordination. |
| Critical Care | Adult ICU, Cardiac ICU, Neuro ICU, Neonatal ICU (NICU), Pediatric ICU (PICU), High-Dependency Units. |
| Internal Medicine & Sub-specialties | Cardiology, Pulmonology, Gastroenterology, Nephrology, Endocrinology, Infectious Diseases, Rheumatology, Hematology, Geriatrics. |
| Surgery & Sub-specialties | General, Orthopedic, Urology, Ophthalmology, Plastic & Reconstructive, Bariatric. |
| Women's & Children's Health | Obstetrics & Gynecology, Maternal-Fetal Medicine, Labor & Delivery, Pediatrics, Neonatology. |
| ENT — Head & Neck Surgery | Otology & Neurotology, Rhinology & Endoscopic Sinus Surgery, Head & Neck Oncologic Surgery, Laryngology & Voice, Thyroid & Parathyroid, Salivary Gland, Skull Base, Paediatric ENT, Audiology, Swallowing & Dysphagia. |
| Diagnostics & Imaging | Radiology (CT, MRI, Ultrasound, X-ray, Interventional), Nuclear Medicine, Laboratory & Pathology, Cardiac diagnostics. |
| Mental & Behavioral Health | Psychiatry, Psychology, Counseling. |
| Rehabilitation | Physical, Occupational & Speech therapy, Cardiac & Pulmonary rehab, Prosthetics / Orthotics. |
| Ambulatory & Primary Care | Outpatient clinics, Day surgery, Primary care, Specialty clinics, Telemedicine. |
| Support & Allied Health | Pharmacy, Nutrition & Dietetics, Social Services, Respiratory therapy, Infection Prevention & Control. |
3.2Care Continuum
1
Prevention
Screening, education, immunization, outreach
→
2
Primary Care
First-contact & chronic-disease management
→
3
Acute Care
Emergency, surgical, medical, critical care
→
4
Rehabilitation
Therapy & functional restoration
→
5
Home Care
Discharge planning & remote monitoring
01
Prevention & Wellness
Screening, health education, immunization, community outreach.
02
Primary & Ambulatory Care
First-contact care, chronic-disease management, specialty clinics.
03
Acute & Inpatient Care
Emergency, surgical, medical, and critical care.
04
Rehabilitation & Recovery
Therapy services and functional restoration.
05
Transitional & Home Care
Discharge planning, home health, remote monitoring.
3.3Patient Support Services
- Patient & Family Relations / Advocacy office and complaints management.
- Interpreter and translation services; culturally and linguistically appropriate care.
- Financial counseling, insurance coordination, and charity-care assistance.
- Patient transport, family accommodation for critical patients, and accessibility services.
Clinical Excellence
Patient Safety
Innovation & Research
Education & Training
Value-Based Care
04
Concentrated Expertise
Our Centers of Excellence
Centers of Excellence (CoEs) concentrate specialized expertise, advanced technology, and standardized evidence-based pathways to deliver superior outcomes in high-complexity conditions.
| Center of Excellence | Focus & Distinguishing Capabilities | Status |
|---|---|---|
| Cardiac & Vascular Center | Cath lab, primary PCI for STEMI, electrophysiology, cardiac surgery, structural-heart program, cardiac rehab, door-to-balloon pathway. | Soon |
| ENT — Head & Neck Center | Comprehensive diagnosis, surgical management, and rehabilitation across the ear, nose, throat, larynx, salivary glands, thyroid, parathyroid, and skull base. | Implemented |
| Neuroscience Center | Comprehensive stroke pathway, neurosurgery, epilepsy and movement-disorder programs, neurorehabilitation. | Soon |
| Orthopedic & Spine Center | Joint replacement, sports medicine, complex spine surgery, fracture liaison, rapid-recovery pathways. | Soon |
| Mother & Child Center | Maternal-fetal medicine, Level III NICU, high-risk obstetrics, pediatric specialties, family-centered birthing. | Soon |
| Digestive Diseases Center | Advanced endoscopy, hepatobiliary and colorectal surgery, IBD program, bariatric / metabolic surgery. | Soon |
| Emergency & Trauma Center | Designated trauma levels, rapid resuscitation, integrated EMS, disaster-response capability. | Implemented |
| Pediatric Center | Outpatient clinical management for children, including vaccination. | Implemented |
| General Surgery & Bariatric Center | Comprehensive general surgical procedures. | Implemented |
| Plastic & Reconstructive Surgery Center | Reconstructive microsurgery, breast and oncologic reconstruction, burns, hand and craniofacial surgery, trauma reconstruction, and aesthetic surgery. | Implemented |
| Dental & Maxillofacial Center | Comprehensive dental and oral-and-maxillofacial care: implants, orthognathic and trauma surgery, endodontics, periodontics, prosthodontics, orthodontics, and paediatric dentistry. | Implemented |
Implementation Status
Implemented6
Coming Soon5
6 Centers of Excellence operational at launch; 5 in planned phased roll-out.
Cardiac & Vascular
ENT — Head & Neck
Neuroscience
Orthopedic & Spine
Mother & Child
Digestive Diseases
Emergency & Trauma
Pediatric
General Surgery
Plastic & Reconstructive
Dental & Maxillofacial
4.1Architecting a Center of Excellence
- Dedicated medical and nursing leadership with sub-specialty credentialing.
- Standardized, evidence-based clinical pathways and protocols.
- Multidisciplinary case review (tumor boards, heart team, trauma review).
- Defined volume thresholds linked to outcome quality.
- Transparent outcome reporting against national or international benchmarks.
- Active participation in research, clinical trials, and continuous education.
- Investment in advanced technology and infrastructure specific to the program.
Mission Statement
To deliver world-class ENT and head-and-neck surgical care through subspecialty expertise, advanced endoscopic technologies, oncologic excellence, and patient-centered pathways — restoring hearing, voice, breathing, and quality of life.
What defines this Center of Excellence
01
Clinical Excellence
High surgical success rates (e.g. sinus surgery, cochlear implants); low complication and infection rates; evidence-based protocols aligned with global standards (AAO-HNS).
02
Highly Specialized Team
Subspecialists in otology, rhinology, laryngology, and head & neck oncology, supported by audiologists, speech therapists, and anesthesiologists.
03
Advanced Technology
Endoscopic sinus-surgery systems, image-guided navigation for skull-base cases, laser surgery, audiology labs, and hearing-implant programs.
04
Standardized Protocols & KPIs
Defined pathways (pre-op → surgery → post-op) tracked by surgical success rate, readmission rate, length of stay, and patient satisfaction.
Services provided
| Service / Program | Description | Multidisciplinary Team |
|---|---|---|
| Otology & Neurotology | Microscopic ear surgery, tympanoplasty, mastoidectomy, stapedectomy, cochlear implantation, BAHA/OSIA implants, acoustic-neuroma surgery, labyrinthine-fistula repair. | Otologist / Neurotologist, Audiologist, Vestibular Therapist |
| Rhinology & Endoscopic Sinus Surgery | FESS, balloon sinuplasty, nasal-polyposis management, septoplasty, turbinoplasty, endoscopic skull-base surgery, CSF-leak repair. | Rhinologist, Neuroradiologist, Neurosurgeon |
| Head & Neck Oncologic Surgery | Resection of malignant tumors of oral cavity, oropharynx, hypopharynx, larynx, thyroid, parotid and neck; neck dissection; sentinel node biopsy; transoral robotic surgery (TORS). | H&N Oncologic Surgeon, Medical & Radiation Oncologist |
| Laryngology & Voice Disorders | Microlaryngoscopy, vocal-cord lesion excision, thyroplasty, injection laryngoplasty, subglottic/tracheal-stenosis management, professional voice clinic. | Laryngologist, Speech-Language Therapist, Pulmonologist |
| Thyroid & Parathyroid Surgery | Total/hemithyroidectomy, completion and robotic thyroidectomy, parathyroidectomy, intraoperative nerve monitoring (IONM). | Endocrine H&N Surgeon, Endocrinologist, Nuclear-Medicine Physician |
| Salivary Gland Surgery | Parotidectomy with facial-nerve preservation, submandibular-gland excision, sialoendoscopy, salivary-stone and tumor management. | H&N Surgeon, Facial-Nerve Monitoring Technician |
| Skull Base Surgery | Anterior, lateral and posterior skull-base tumor surgery; endoscopic pituitary-adenoma resection; cholesteatoma; glomus tumors; combined approaches. | Skull-Base ENT Surgeon, Neurosurgeon, Interventional Neuroradiologist |
| Paediatric ENT | Adenotonsillectomy, ventilation tubes, choanal-atresia repair, congenital-ear correction, paediatric airway management and cochlear implantation. | Paediatric Otolaryngologist, Paediatric Anesthesiologist, SLT |
| Facial Plastics & Reconstruction | Rhinoplasty, septorhinoplasty, otoplasty, facial-trauma reconstruction, post-oncologic flap and microvascular free-flap surgery. | Facial Plastic & Reconstructive Surgeon, Plastic Surgeon |
| Audiology & Hearing Rehabilitation | Pure-tone and speech audiometry, ABR/ASSR, otoacoustic emissions, hearing-aid fitting, cochlear-implant programming, aural rehabilitation. | Audiologist, Cochlear-Implant Specialist, SLT |
| Swallowing & Dysphagia Clinic | VFSS, FEES, dysphagia rehabilitation, tracheostomy weaning and decannulation. | Speech-Language Therapist, Gastroenterologist, Dietitian |
| Allergy & Immunotherapy Clinic | Allergic-rhinitis management, skin-prick and intradermal testing, subcutaneous and sublingual immunotherapy, biologic therapy. | Rhinologist, Allergist / Immunologist, Pharmacist |
4.3Our Eminent Multidisciplinary Consultants
Prof. Ahmed Yousif AlammarConsultant Paediatric Otolaryngologist
Profile
Extensive experience in managing paediatric ENT disorders, including adenotonsillar surgery, paediatric sinus surgery, airway surgery, and congenital head-and-neck anomalies.
نبذة
استشاري أنف وأذن وحنجرة للأطفال، ذو خبرة واسعة في تشخيص وعلاج اضطرابات الأنف والأذن والحنجرة لدى الأطفال، وتشمل: جراحات اللوزتين واللحمية، وجراحات الجيوب الأنفية والمجرى الهوائي، وتشوهات وعيوب الرأس والعنق الخِلقية.
Prof. Abdulrahman AlsanosiProfessor & Consultant Otolaryngology / Otology & Neurotology, King Saud University
Profile
Subspecialized in otology and neurotology, balance disorders, and cochlear-implant and hearing-aid surgery, with experience exceeding 26 years in ear-related medical and surgical disease and balance disorders.
نبذة
أستاذ واستشاري أنف وأذن وحنجرة، وجراحة الأذن والقوقعة وزراعة المعينات السمعية بجامعة الملك سعود. التخصص الدقيق: أمراض وجراحات الأذن، وأمراض الاتزان، وجراحات القوقعة والمعينات السمعية، بخبرة تتجاوز 26 عامًا.
Dr. Saleh Fahd Al-DhaheriConsultant Head & Neck Oncologic Surgery — Canadian Fellowship & American Board (ENT)
Profile
American Board–certified in Head and Neck Tumor Surgery. Consultant at King Abdulaziz University Hospital and King Fahd Medical City. Former Chairman of Surgery at King Fahd Medical City; former Head of Otolaryngology & Head-and-Neck Tumor Surgery, College of Medicine, King Saud University. Subspecialized in thyroid, parathyroid and salivary-gland disease, reconstructive oncologic surgery, and endoscopic sinus surgery.
نبذة
الزمالة الكندية والبورد الأمريكي في جراحة وأمراض الأنف والأذن والحنجرة، والبورد الأمريكي في جراحة أورام الرأس والعنق. استشاري جراحة أورام الرأس والعنق بمستشفى الملك عبدالعزيز الجامعي ومدينة الملك فهد الطبية. رئيس أقسام الجراحة سابقًا بمدينة الملك فهد الطبية، ورئيس قسم الأنف والأذن والحنجرة سابقًا بجامعة الملك سعود.
Assoc. Prof. Dr. Manal Ahmed BukhariConsultant Otolaryngology & Phonosurgery — Head, Laryngology / Phonosurgery Unit, KAUH
Profile
Associate Professor, King Saud University, and Head of the Laryngology / Phonosurgery Unit at KAUH, Riyadh. 20+ years clinical practice. Subspecialty in advanced laryngology, voice-disorder management, phonosurgery, laryngeal pathology, airway surgery, and laser techniques.
نبذة
أستاذ مشارك بجامعة الملك سعود، واستشارية أنف وأذن وحنجرة وجراحة الحنجرة والصوت، ورئيسة وحدة أمراض الحنجرة وجراحة الصوت بمستشفى الملك عبدالعزيز الجامعي بالرياض. خبرة سريرية تتجاوز 20 عامًا في جراحات الصوت ومجرى الهواء وتقنيات الليزر.
Dr. Mohammed Al-OulaConsultant ENT Surgery — King Saud Medical City
Profile
Consultant in ENT surgery, with focused practice in endoscopic septoplasty for deviated nasal septum and surgical reduction of enlarged turbinates.
نبذة
استشاري جراحة الأنف والأذن والحنجرة بمدينة الملك سعود الطبية، متخصص في جراحة المنظار لتصحيح انحراف الحاجز الأنفي وتصغير القرينات الأنفية المتضخمة.
Dr. Ahmed Alsayed DhaheriConsultant Otolaryngology — Head & Neck / Sleep Surgery
Profile
Consultant in Otolaryngology — Head and Neck surgery, with a focus on sleep surgery.
نبذة
استشاري جراحة الأنف والأذن والحنجرة والرأس والعنق، مع اهتمام بجراحات اضطرابات النوم.
Mission Statement
To deliver world-class plastic, reconstructive, and aesthetic surgical care through subspecialty expertise, advanced microsurgical technology, oncologic and trauma reconstruction, and patient-centered pathways — restoring form, function, appearance, and quality of life for patients of all ages.
What defines this Center of Excellence
01
Clinical Excellence
High flap-survival and graft-take rates; low complication, infection, and revision rates; evidence-based protocols aligned with global standards (ASPS / ISAPS / EURAPS).
02
Highly Specialized Team
Subspecialists in microsurgery, craniofacial, hand, burn, and aesthetic surgery, supported by anesthesiologists, wound-care nurses, physiotherapists, and psychologists.
03
Advanced Technology
Operating microscopes and loupes, microvascular instrumentation, indocyanine-green perfusion imaging, 3D surgical planning, negative-pressure wound therapy, and laser platforms.
04
Standardized Protocols & KPIs
Defined pathways (assessment → surgery → rehabilitation) tracked by flap success rate, revision rate, length of stay, wound-healing time, and patient-reported outcomes.
Scope of services
| Service / Program | Description | Multidisciplinary Team |
|---|---|---|
| Reconstructive Microsurgery | Free-tissue transfer and microvascular reconstruction for head & neck, breast, extremity, and complex defects; replantation; lymphedema (LVA / vascularized lymph-node transfer). | Microsurgeon, Anesthesiologist, Reconstructive Nurse |
| Breast Reconstruction | Implant-based and autologous (DIEP, TRAM, latissimus) reconstruction, oncoplastic surgery, nipple-areola reconstruction, fat grafting, symmetrization. | Plastic Surgeon, Breast / Oncologic Surgeon, Radiation Oncologist |
| Hand & Peripheral Nerve Surgery | Tendon and nerve repair, brachial-plexus reconstruction, nerve grafting/transfer, congenital-hand correction, Dupuytren’s, replantation, microvascular toe-to-hand transfer. | Hand Surgeon, Hand Therapist, Neurophysiologist |
| Craniofacial & Cleft Surgery | Cleft lip and palate repair, craniosynostosis correction, distraction osteogenesis, orbital and midface reconstruction, syndromic facial anomalies. | Craniofacial Surgeon, Neurosurgeon, Orthodontist, SLT |
| Wound Care & Limb Salvage | Complex and chronic wound management, pressure-injury reconstruction, diabetic-foot salvage, negative-pressure therapy, hyperbaric coordination. | Plastic Surgeon, Vascular Surgeon, Endocrinologist, Podiatrist |
| Facial Trauma & Reconstruction | Soft-tissue and facial-skeletal trauma repair, post-traumatic deformity correction, facial-nerve reconstruction, scar revision. | Plastic Surgeon, Maxillofacial Surgeon, Ophthalmologist |
| Body Contouring & Post-Bariatric | Abdominoplasty, brachioplasty, thigh and body lifts, liposuction, post-massive-weight-loss reconstruction. | Plastic Surgeon, Bariatric Surgeon, Dietitian |
| Aesthetic / Cosmetic Surgery | Rhinoplasty, facelift, blepharoplasty, breast augmentation/reduction, fat grafting, non-surgical rejuvenation (injectables, laser, skin resurfacing). | Aesthetic Plastic Surgeon, Dermatologist, Aesthetician |
| Paediatric Plastic Surgery | Congenital-anomaly correction, vascular malformations and haemangiomas, paediatric burns and trauma, ear reconstruction (microtia). | Paediatric Plastic Surgeon, Paediatric Anesthesiologist, SLT |
Mission Statement
To deliver world-class dental and oral-and-maxillofacial care through subspecialty expertise, digital dentistry, advanced surgical technology, and integrated multidisciplinary pathways — restoring oral health, facial function, aesthetics, and quality of life across all ages.
What defines this Center of Excellence
01
Clinical Excellence
High implant-survival and surgical-success rates; low complication and infection rates; evidence-based protocols aligned with global standards (AAOMS / FDI / ADA).
02
Highly Specialized Team
Maxillofacial surgeons and subspecialty dentists in implantology, endodontics, periodontics, prosthodontics, orthodontics, and paediatric dentistry, with anesthesia and dental-lab support.
03
Advanced Technology
CBCT and digital radiography, intraoral scanners, CAD/CAM and 3D-printed surgical guides, computer-guided implant placement, piezosurgery, and dedicated maxillofacial operating theatres.
04
Standardized Protocols & KPIs
Defined pathways (diagnosis → treatment → maintenance) tracked by implant-success rate, complication rate, treatment-completion time, and patient satisfaction.
Scope of services
| Service / Program | Description | Multidisciplinary Team |
|---|---|---|
| Oral & Maxillofacial Surgery | Surgical extractions, impacted third molars, cyst and benign-lesion removal, pre-prosthetic surgery, apicectomy, biopsy and minor oral surgery. | Maxillofacial Surgeon, Oral Surgeon, Anesthesiologist |
| Dental Implantology | Single and full-arch implants, computer-guided placement, immediate loading, bone grafting, sinus lift, ridge augmentation, All-on-4 / All-on-6. | Implantologist, Periodontist, Prosthodontist, Dental Lab |
| Orthognathic & Corrective Jaw Surgery | Surgical correction of jaw deformities and malocclusion, virtual surgical planning, distraction osteogenesis, obstructive-sleep-apnoea surgery. | Maxillofacial Surgeon, Orthodontist, Sleep Physician |
| Maxillofacial Trauma | Management of facial fractures (mandible, maxilla, zygoma, orbit), dento-alveolar trauma, soft-tissue injuries, and post-traumatic deformity correction. | Maxillofacial Surgeon, ENT Surgeon, Ophthalmologist |
| Oral & Maxillofacial Pathology / Oncology | Diagnosis and surgical management of oral and jaw tumours, resection and reconstruction, oral-cancer screening, salivary-gland and cyst surgery. | Maxillofacial Surgeon, Pathologist, Oncologist |
| Cleft & Craniofacial | Alveolar bone grafting, cleft-related dental rehabilitation, distraction, and coordinated craniofacial care across the lifespan. | Maxillofacial Surgeon, Orthodontist, Plastic Surgeon, SLT |
| TMJ Disorders | Diagnosis and management of temporomandibular-joint dysfunction, arthrocentesis, arthroscopy, joint reconstruction, splint therapy. | Maxillofacial Surgeon, Physiotherapist, Prosthodontist |
| Endodontics | Root-canal therapy, retreatment, microscopic endodontics, apical surgery, management of dental trauma and cracked teeth. | Endodontist, Dental Assistant |
| Periodontology | Non-surgical and surgical periodontal therapy, gum grafting, crown lengthening, regenerative procedures, peri-implant maintenance. | Periodontist, Dental Hygienist |
| Prosthodontics | Crowns, bridges, removable and fixed dentures, implant-supported prostheses, full-mouth rehabilitation, maxillofacial prosthetics. | Prosthodontist, Dental Technician |
| Orthodontics | Fixed and clear-aligner therapy, interceptive and surgical orthodontics, dentofacial orthopaedics for children and adults. | Orthodontist, Maxillofacial Surgeon |
| Paediatric Dentistry | Preventive care, fluoride and sealants, restorations, pulp therapy, dental treatment under sedation/general anaesthesia, special-needs dentistry. | Paediatric Dentist, Anesthesiologist, Dental Assistant |
| Restorative & Cosmetic Dentistry | Fillings, veneers, teeth whitening, smile design, digital CAD/CAM restorations, and aesthetic rehabilitation. | Restorative Dentist, Dental Lab |
05
Safety by Design
A High Reliability Organization
We are designing systems, culture, and leadership so that safe care is the consistent, reliable default. The journey rests on three foundations: committed leadership, a robust safety culture, and a disciplined process-improvement engine.
5.1Our Principles of High Reliability
| HRO Principle | Application at Masharef Hospital |
|---|---|
| Preoccupation with failure | Treat every near-miss as a free lesson; encourage proactive reporting; review weak signals before they become harm events. |
| Reluctance to simplify | Resist easy explanations; investigate root causes and system factors rather than blaming individuals. |
| Sensitivity to operations | Maintain real-time situational awareness through huddles, safety briefings, and visible-management boards. |
| Commitment to resilience | Build capacity to detect, contain, and recover from error; rapid-response teams and rehearsed contingency plans. |
| Deference to expertise | Decisions migrate to the person with the most relevant knowledge, regardless of rank or hierarchy. |
5.2Reliability Tools & Practices
| Domain | Reliability Practices |
|---|---|
| Standardization | Evidence-based bundles, checklists, order sets, and clinical pathways to reduce unwarranted variation. |
| Communication | Structured handoffs, surgical-safety checklist, read-back of critical results, daily safety huddles. |
| Error prevention | Two-patient identifiers, time-outs, barcode medication administration, forcing functions, alarm management. |
| Detection & response | Early-warning scores, rapid-response and code teams, escalation protocols, simulation training. |
| Learning systems | Root Cause Analysis (RCA), Failure Mode & Effects Analysis (FMEA), morbidity & mortality review, safety-event trending. |
5.3Our Commitments to the Community
| Commitment | Focus |
|---|---|
| 5.3.1 Quality & Patient Safety | Low hospital-acquired-infection rates below benchmark; reduced 30-day readmissions; mortality and adverse-event monitoring; public safety dashboards; transparent incident reporting. |
| 5.3.2 Financial Stability & Transparency | Positive operating margins and liquidity; controlled debt-to-equity; audited statements and annual reports; evidence-based procurement; supply-chain optimization. |
| 5.3.3 Operational Efficiency | Standardized processes (Lean / Six Sigma); reduced wait times and improved throughput; minimized surgical cancellations; real-time KPI dashboards; modern EHR; advanced analytics. |
| 5.3.4 Clinical Excellence | Accreditation (Joint Commission, CAP); evidence-based protocols and pathways; benchmarking; board-certified providers; rigorous credentialing and privileging. |
| 5.3.5 Communication & Transparency | Regular performance reporting on quality, cost and outcomes; transparent utilization and claims data; automated real-time reporting; value-based contracting. |
| 5.3.6 Patient Experience | Monitored and improved satisfaction (HCAHPS); prompt complaint resolution; patient-centered care models; enhanced communication and education. |
| 5.3.7 Compliance & Risk Management | Full regulatory compliance; comprehensive compliance training; regular audits and risk assessments; appropriate malpractice and liability coverage. |
The seven foundations of our reliability system
01
Leadership Commitment
02
Safety Culture
03
Robust Process Improvement
04
Sensitivity to Operations
05
Learning System
06
Patient & Family Engagement
07
Workforce Resilience
06
Outcomes that Matter
Value-Based Care for the Whole Community
We define value as health outcomes achieved per unit of cost, measured over the full cycle of care — shifting focus from volume of services delivered to health results that matter to patients.
Clinical
Outcomes — robust pathways on an evidence base
Functional
Outcomes — healthy recovery for life
Financial
Outcomes — meeting cost expectations, reducing redundancy
6.1The Value Equation
Outcomes that matter to patients ÷ Total cost of delivering care
Outcomes include survival, functional recovery, complication and readmission rates, and patient-reported quality of life. Cost is measured across the full care cycle — not per service — and includes avoidable utilization such as readmissions and complications.
6.2Core Strategies for Value-Based Care
| Strategy | Description |
|---|---|
| Organize around the patient | Integrated practice units (CoEs) deliver the full cycle of care for a condition, not fragmented departmental services. |
| Measure outcomes & cost | Track condition-specific outcomes and true cost of care for every patient population. |
| Care coordination & integration | Seamless transitions, shared care plans, case management, and reduced duplication across settings. |
| Population-health management | Risk-stratify the community; target chronic-disease and preventive programs at high-risk groups. |
| Prevention & early intervention | Screening, immunization, health education, and management of social determinants of health. |
| Bundled, outcome-linked payment | Move from fee-for-service toward bundled payments and shared-savings or outcomes-based contracting. |
| Digital enablement | Telehealth, remote monitoring, patient portals, and analytics to extend reach and lower cost. |
6.3Equity & Access — Care for All
- Community Health Needs Assessment to identify and prioritize unmet needs.
- Addressing social determinants of health — housing, nutrition, transport, literacy — through partnerships and screening.
- Financial-assistance and charity-care policies that protect vulnerable patients.
- Outreach, mobile clinics, and telehealth that extend care to underserved and remote populations.
- Culturally and linguistically appropriate services and disability-accessible facilities.
- Stratifying quality data by demographic group to detect and close equity gaps.
6.4The Quadruple Aim
Population Health
Improve the health of the whole community
Patient Experience
Safe, effective, timely, person-centered care
Lower Per-Capita Cost
Reduce avoidable utilization & total cost
Care-Team Wellbeing
An engaged, resilient workforce
Quadruple
Aim
Aim
| Aim | Goal |
|---|---|
| Better population health | Improve the health of the whole community, not only those who present for care. |
| Better patient experience | Deliver care that is safe, effective, timely, and person-centered. |
| Lower per-capita cost | Reduce avoidable utilization and the total cost of care. |
| Better care-team wellbeing | Support an engaged, resilient workforce — the foundation of sustainable value. |
07
Resources & Infrastructure
Capacity & Capabilities
This section quantifies the physical, human, and technological resources of Masharef Hospital®. Figures marked — are placeholders awaiting confirmed operational data.
7.1Physical Capacity — Bed Complement
Stated Bed Allocation by Category
Indicative category figures from the profile; categories marked — and the licensed total are to be confirmed with final operational data.
| Bed Category | Licensed Beds | Notes |
|---|---|---|
| Medical / Surgical (general ward) | 50 | Acute inpatient capacity |
| Adult Intensive Care (ICU) | 5 | Incl. medical & surgical ICU |
| Cardiac Care (CCU) | — | Coronary / cardiac ICU |
| Neonatal Intensive Care (NICU) | 5 | Level II / III |
| Pediatric Intensive Care (PICU) | — | — |
| High-Dependency / Step-down | — | Intermediate care |
| Maternity / Obstetrics | 3 | Incl. labor & delivery |
| Emergency observation | 10 | Short-stay / observation |
| Isolation / negative-pressure | 3 | Infection-control capacity |
| Day-care / ambulatory | — | Day surgery & infusion |
| Total Licensed Beds | — | Capacity baseline |
7.2Clinical Infrastructure
| Facility | Quantity | Capability Highlights |
|---|---|---|
| Operating theatres | 5 | Incl. major & minor OR rooms |
| Emergency Department bays | 2 | Resuscitation, fast-track, triage |
| Catheterization labs | — | Cardiac & interventional radiology |
| Endoscopy suites | — | Diagnostic & therapeutic endoscopy |
| Delivery rooms / LDR | 3 | Family-centered birthing |
| Dialysis stations | — | Hemodialysis capacity |
| Outpatient clinic rooms | — | Multispecialty ambulatory clinics |
| Infusion / chemotherapy chairs | — | Oncology day treatment |
7.3Diagnostic & Technology Capabilities
| Modality / System | Capability |
|---|---|
| Imaging | Computed tomography (CT), ultrasound, and X-ray imaging. |
| Laboratory & Pathology | Automated core lab, microbiology, histopathology, blood bank, molecular diagnostics, 24/7 STAT testing. |
| Surgical technology | Surgical platform, laparoscopic / endoscopic systems, intraoperative imaging, neuro-navigation. |
| Health information systems | EHR, PACS, computerized physician order entry (CPOE), e-prescribing, clinical decision support. |
| Digital & connected care | Telemedicine platform, remote patient monitoring, patient portal, analytics & BI dashboards. |
| Critical-care technology | Advanced ventilators and hemodynamic monitoring. |
7.4Human Capital
| Workforce Category | Headcount | Notes |
|---|---|---|
| Physicians (consultants & specialists) | — | Across multiple specialties |
| Resident / training physicians | — | Teaching program (if applicable) |
| Registered nurses | — | Incl. specialty-certified nurses |
| Allied health professionals | — | Therapy, lab, radiography, pharmacy |
| Administrative & support staff | — | Operations, facilities, IT |
| Total Workforce | — | — |
7.5Targeted Annual Activity & Throughput
| Activity Metric | Annual Volume |
|---|---|
| Inpatient admissions / discharges | — |
| Emergency Department visits | — |
| Outpatient clinic visits | — |
| Surgical procedures (in / day-case) | — |
| Deliveries / births | — |
| Diagnostic imaging studies | — |
| Laboratory tests processed | — |
| Telehealth consultations | — |
08
Monitor & Control
Key Performance Indicators
We use leading & lagging KPIs that translate strategy into measurable, monitored performance across quality, safety, access, efficiency, experience, and finance.
All KPIs feed a balanced scorecard to monitor alignment with our strategic goals.
8.1Operational Efficiency & Access KPIs
| KPI | Definition | Target | Frequency |
|---|---|---|---|
| Average Length of Stay (ALOS) | Mean inpatient days per discharge | — | Monthly |
| Bed occupancy rate | % of licensed beds occupied | — | Daily / Weekly |
| ED total length of stay | Arrival to departure time | — | Daily |
| ED door-to-physician time | Arrival to first clinician assessment | — | Daily |
| Left-without-being-seen (LWBS) | % ED patients leaving before assessment | — | Weekly |
| OR utilization rate | % of available theatre time used | — | Weekly |
| OR first-case on-time start | % first cases starting on schedule | — | Weekly |
| Surgery cancellation rate | % elective cases cancelled on day | — | Weekly |
| Discharge before noon | % discharges completed before 12:00 | — | Daily |
| Outpatient appointment wait time | Days to third-next-available appointment | — | Monthly |
| Bed turnaround time | Time between discharge and next admission | — | Daily |
8.2Patient Experience KPIs
| KPI | Definition | Target | Frequency |
|---|---|---|---|
| Overall patient satisfaction | % top-box / would-recommend score | — | Monthly |
| Net Promoter Score (NPS) | Likelihood-to-recommend index | — | Monthly |
| Complaint resolution time | Avg. days to close a formal complaint | — | Monthly |
| Communication with nurses / doctors | Survey-domain score | — | Monthly |
| Discharge information clarity | % rating discharge instructions clear | — | Monthly |
| Responsiveness to call bells | Avg. response time | — | Weekly |
8.3Financial & Value KPIs
| KPI | Definition | Target | Frequency |
|---|---|---|---|
| Operating margin | Operating surplus as % of revenue | Per budget | Monthly |
| Cost per patient day / case | Total cost ÷ activity | ↓ vs. benchmark | Monthly |
| Revenue cycle — days in A/R | Avg. days to collect receivables | < 45 days | Monthly |
| Claim denial rate | % claims initially denied | < 5% | Monthly |
| Supply cost as % of revenue | Clinical supply-spend ratio | Per benchmark | Monthly |
| Capacity-adjusted productivity | Output per available resource unit | ↑ trend | Quarterly |
sec8-4KPI Governance — Monitor & Control
- We use Statistical Process Control (SPC) — real-time control charts and process-capability analysis — to monitor and control recurring operational processes and identify bottlenecks before they become errors.
- A Six Sigma strategic framework governs alignment with our committed service-level agreements.
- Leading KPIs ensure that process outcomes meet expectations — the core of our commitment to being a Highly Reliable Healthcare Organization.
09
Accountable Commitments
Service Level Agreements
Masharef Hospital® defines measurable performance commitments with internal and external customers. Our SLAs make expectations explicit, enable monitoring, and create accountability.
9.1SLA Structure
01
Service description
The specific service being delivered.
02
Performance metric
The quantifiable measure of service quality or timeliness.
03
Target / threshold
The agreed acceptable level of performance.
04
Measurement & reporting
How, how often, and by whom performance is tracked.
05
Escalation & remedy
Action taken when the SLA is breached.
9.2Clinical & Operational SLAs
| Service | SLA Metric | Target Threshold |
|---|---|---|
| Emergency triage | Time from arrival to triage | — |
| Emergency — critical patient | Time to physician for high-acuity cases | — |
| OPD patient lead time | Registration to pharmacy time | — |
| OPD moving time | Door-to-CT / door-to-needle | — |
| Inpatient admission from ED | Decision-to-admit to ward transfer | — |
| Specialist consultation (inpatient) | Referral to consult completed | — |
| Discharge process | Discharge order to patient departure | — |
| Rapid-response team | Activation to bedside arrival | — |
9.3Diagnostic & Support Service SLAs
| Service | SLA Metric | Target Threshold |
|---|---|---|
| Laboratory — STAT results | Order to result reporting | — |
| Laboratory — routine results | Order to result reporting | — |
| Radiology — urgent imaging | Order to image acquisition | — |
| Radiology — report turnaround | Image to verified report (routine) | — |
9.4Facility, IT & Administrative SLAs
| Service | SLA Metric | Target Threshold |
|---|---|---|
| Housekeeping — bed turnaround | Discharge to cleaned / ready bed | — |
| Biomedical equipment repair | Fault report to resolution (urgent) | — |
| IT / EHR system support | Critical incident response | — |
| IT system uptime | Core clinical-system availability | — |
| Facilities maintenance | Non-urgent work-order completion | — |
| Medical-records retrieval | Request to record availability | — |
| Billing / financial counseling | Patient-query response time | — |
| Catering — meal delivery | On-time meal-service rate | — |
9.5SLA Monitoring & Compliance
- Each SLA is owned by a named department head accountable for performance.
- Compliance is measured continuously and reported on operational dashboards.
- An SLA is 'met' when performance equals or exceeds the agreed threshold for the reporting period.
- Breaches trigger documented root-cause analysis and a corrective-action plan with a target resolution date.
- SLAs are formally reviewed at least annually and renegotiated as service capacity or demand changes.
10
Closing the Loop
Governance & Continuous Improvement
Performance monitoring is sustained through a defined governance structure that connects frontline operations to executive leadership and the governing board.
10.1Performance Governance Structure
| Level | Body | Focus |
|---|---|---|
| Board | Governing Board / Quality & Safety Committee | Strategic oversight, accountability, risk. |
| Executive | CEO & Executive Leadership Team | Organization-wide KPI and SLA performance. |
| Division | Clinical & Operational Divisions | Service-line performance and improvement. |
| Department / Unit | Department heads & unit managers | Daily operations, huddles, frontline action. |
10.2Continuous Improvement Methodology
Masharef Hospital® applies a structured improvement methodology — Plan-Do-Study-Act (PDSA), Lean, or Six Sigma — to close performance gaps:
1
Plan
Identify variation via KPI/SLA monitoring
Identify variation via KPI/SLA monitoring
2
Do
Test improvements in small-scale cycles
Test improvements in small-scale cycles
3
Study
Analyze root causes (RCA, FMEA, fishbone)
Analyze root causes (RCA, FMEA, fishbone)
4
Act
Standardize successful changes org-wide
Standardize successful changes org-wide
5
Sustain
Audit, control charts, recalibrated targets
Audit, control charts, recalibrated targets
10.3Conclusion
This profile presents an integrated picture of Masharef Hospital® — its identity, the breadth of its services and Centers of Excellence, its commitment to becoming a High Reliability Organization, and its pursuit of value-based care for the entire community. The capacity, capability, KPI, and SLA frameworks provide the practical instruments to monitor, control, and continuously improve operational performance.