Lesson 1Competence, training and awareness records: designing a minimal QMS training matrixDis section explain how to define competence needs, design a minimal but effective QMS training matrix, plan and record training, and ensure staff know policies, procedures, and dem roles in keeping quality and safety.
Defining competence for clinical and support rolesDesigning a minimal QMS training matrixPlanning induction and refresher trainingRecording attendance and competence evidenceEvaluating training effectiveness in practiceLesson 2Continuous improvement: CAPA process, PDSA cycles and small tests of changeDis section detail how to structure CAPA, use PDSA cycles, and run small tests of change so hospitals can respond to incidents, analyze root causes, implement fixes, and embed continual improvement into everyday clinical practice.
Standard CAPA workflow for hospital eventsRoot cause analysis tools for clinical issuesDesigning and running PDSA cyclesSmall tests of change on pilot unitsMeasuring and sustaining improvementsLesson 3Performance monitoring: defining KPIs, internal audit program and management review inputsDis section cover how to define meaningful KPIs, plan and do internal audits, and prepare management review inputs so leadership can check QMS performance, spot gaps, and prioritize improvements across hospital services.
Selecting hospital-wide and unit-level KPIsDesigning an annual internal audit programConducting risk-based clinical auditsPreparing data for management review meetingsTracking actions from reviews and auditsLesson 4Understanding ISO 9001 clauses relevant to healthcare (context, leadership, planning, support, operation, performance evaluation, improvement)Dis section translate key ISO 9001 clauses into hospital talk, clarifying how context, leadership, planning, support, operations, performance evaluation, and improvement apply to clinical and non-clinical services.
Analyzing internal and external hospital contextLeadership roles and quality culture in hospitalsRisk-based quality planning for clinical servicesSupport processes for safe, reliable careOperational control of clinical and support servicesLesson 5Process mapping and standardization: critical clinical and non-clinical process flows (medication cycle, perioperative pathway, patient admission/discharge)Dis section guide mapping and standardizing critical clinical and non-clinical processes, like medication management, perioperative care, and patient admission and discharge, to cut variation, clarify roles, and support safe, efficient care.
Basics of process mapping in hospitalsMedication management end-to-end flowPerioperative pathway mapping and controlsAdmission, transfer and discharge workflowsStandardizing handoffs and documentationLesson 6Establishing scope, quality policy, quality objectives and key roles (Quality Coordinator responsibilities)Dis section explain how to define QMS scope, write a practical quality policy, set measurable quality objectives, and formalize key roles, with focus on de Quality Coordinator’s duties in driving and keeping de system.
Defining hospital QMS scope and boundariesDrafting a clear, relevant quality policySetting SMART quality objectives for careAssigning QMS governance and committeesQuality Coordinator duties and authorityLesson 7Risk-based thinking and documented risk registers for clinical processesDis section show how to put risk-based thinking into daily hospital operations by spotting, assessing, and documenting clinical risks in structured registers, den linking dem to controls, audits, KPIs, and improvement priorities.
Identifying clinical and process risksRisk assessment scales and criteriaBuilding and maintaining risk registersLinking risks to controls and KPIsReviewing and updating risks routinelyLesson 8Documented information: creating mandatory procedures, work instructions and forms tailored to hospital needsDis section explain how to design, write, and control documented information dat lean but compliant, including mandatory procedures, work instructions, and forms dat match real hospital workflows and support safe, consistent patient care.
Identifying mandatory ISO 9001 documentsStructuring clear, usable hospital proceduresCreating concise clinical work instructionsDesigning simple, reliable hospital formsDocument control, versioning and access rulesLesson 9Operational controls and control of nonconforming services: incident handling and correctionDis section focus on operational controls for clinical and support services and managing nonconforming services, including incident detection, containment, correction, documentation, and link with CAPA and risk management processes.
Defining operational controls for key processesDetecting and recording nonconforming careImmediate containment and safe correctionDocumentation and communication of incidentsInterface with CAPA and risk registersLesson 10Implementation timeline, responsibilities and simple outputs for each step (who, what, deliverable)Dis section present a realistic ISO 9001 implementation roadmap for hospitals, defining phases, responsibilities, and simple outputs for each step so teams know who does what, when, and which tangible deliverables to produce.
Phased ISO 9001 rollout plan for hospitalsRACI for key QMS implementation tasksDefining simple outputs for each project stepProgress tracking and status reporting toolsManaging resistance and change fatigue
