Quality management Department





1. Name of department: Quality Management Department


2. Contact :

       Add:No. 234, 2nd – C2 building – Viet Duc UniversityHospital

       Tel: (04) 38.253.531 - ext: 814


3. History of development:

       The Hospital was founded in 1906 as a part of Indochina Medical College. Since then, the quality of medical examination and treatment is always the most important subject of Hospital. The hospital has invested more facilities, equipped with modern technical equipment, training to improve quality and management for both hospital personnel as well as quality of services on medical consultation and treatment. However, the activities of quality has not been strategic and systems.

       On July 12, 2013, the Ministry of Health issued Circular No.19/2013/TT-BYT on guiding the implementation of quality management for medical services (examination and treatment) at the hospital. MoHaskes the hospital to implement quality management systems in the hospital of the content and implementation of the work related to hospital quality.

       Understanding from the fact and demand, on Oct 10, 2013, hospital’sDirector has signed Decision No. 1041/QD-VD to establish Quality Management Department.The Deputy Director - Prof. Trinh Hong Son was assigned as head, for the purpose of consolidating quality control, which is appropriated with the size and position of Viet Duc hospital.


4. Functions and duties:

       Quality Management Department is specialized for implementation and advising the directors, management board on hospital quality management:

       - Develop a plan and content of quality control activities in hospitals to the Director;

       - Monitor, supervise, evaluate, report, coordinate, support the deployment implementation of quality management and project to improve quality of service in each department;

       - Establish an errorand incidents management system including inspecting, synthesis, analyzing, reporting and proposing for solutions;

        - Coordinate with related departments to address petitions, complaints and denunciations and problems related to patient satisfaction;

       - Collect, aggregate, analyze data, management and security of information related to hospital quality. Collaborate with statistical department, IT department to conduct hospital quality measurementindicators;

       - Organize training, coaching and retraining of hospital quality management;

       - Organization of internal quality assessment based on hospital criteria as well as quality control standards of the Ministry of Health;

       -  Make an assessment of compliance with the regulations and technical guidelines of the Ministry of Health;

       - Develop and implement patient safety programs.


5. Personnel:

       5.1 Current leadership:

       Head: Prof. Dr. Trinh Hong Son

       Deputy Head: Prof. Dr. Nguyen Xuan Hung

       5.2.Organizational structure9 members


6. Achievement:

       Here is the results of the Department of Health about evaluating the quality of hospitals through the years:


  1. Reviewsofthetotal applicable criteria: 77/83 criteria
  2. The ratio of the applicable criteria out of 83 criteria: 93%
  3. The total score of the applicable criteria: 311
  4. The mean score of the criteria: 4.04


  1. Reviews of the total applicable criteria: 77/83 criteria
  2. The ratio of the applicable criteria out of 83 criteria: 95%
  3. The total score of the applicable criteria: 272
  4. The mean score of the criteria: 3.44


  1. Reviews of the total applicable criteria: 77/83 criteria
  2. The ratio of the applicable criteria out of 83 criteria: 94%
  3. The total score of the applicable criteria: 234
  4. The mean score of the criteria: 3.00

       - Coordinate in making a list of allof surgeries in hospitals, complete 17,001 techniques at Viet Duc hospital in 2015 (By decision No. 692/QD-BYT of the Minister of Health, approved the 17,001 techniques made at Viet Duc hospital).

       - Improve the quality of hospital in some aspects such as: reduce waiting time patient's examination; increase the satisfaction of the patient as well as satisfaction of medical staff; train quality management network (100% in 2015); reduce hospital infection rate (from 4.3% in 2014 to3.9% in 2015), equip queuing system in blood concentration, imaging diagnosis and clinical areas.

       - Associate with the clinical departments to write surgical procedures at Viet Duc hospital. The total number of technical proceduresabout surgery, laparoscopic surgery, microsurgery, maxillo-facial modeling: 1,320 procedures; in which520 procedures are sentMOHfor approvaland issuing; andother 600 procedures are going on.

       - Associate with the Accounting Department and Planning Department to build servicesfees in hospitals: Formulate cost of all technical services of Surgery, Endoscopic Surgery, Microsurgery, Plastic Beauty.

       - Applying the approved techniques from from Circular 43/2013/TT-BYT, Circular No. 50/2014/TT-BYT to Circular No. 37/2015/TTLT-BYT, according to specialties assigned by the MOH (surgery, laparoscopy, intervened diagnostic endoscopy, microsurgery) and the MOH has issued to use regularlyin all provinces. Prof. Trinh Hong Son is acouncil’s chairman for 28 specialties in Vietnam to approvean equivalent listto apply the new hospital fee.