Quality management Department





  1. Name of department: Quality Management Department
  2. Contact:

Address: Room 234 – C2 building, Viet Duc University Hospital

Tel: (024)38.253.531 (ext: 814)

  1. Development history:

On 12/7/2013, Circular 19/2013/TT-BYT by MOH guiding the quality management of medical examination and treatment services at hospital was issued that required hospitals deploy quality management system in hospital and perform activities relate to hospital quality activity. Stemming from the above facts and needs, on October 10, 2013, hospital's Director signed Decision No. 1041/QD-VD to establish a hospital quality management department led by Vice Director - Prof. Trinh Hong Son – MD, PhD is the head of department, aiming to consolidate the quality management activities, commensurate with the size and position of Viet Duc University Hospital.


  1. 4. Mission, duties:

The focal unit to implement and advise Director, Hospital Quality Management Council on hospital quality management:

  1. Development plans and programs for quality management activities in hospital and propose for Director to approve;
  2. Organizing, implementing, monitoring, supervising, evaluating, reporting, coordinating and supporting the implementation of quality management activities and quality improvement projects in departments;
  3. Act as the focal point to establish the error and incident management system, including detecting, synthesizing, analyzing, reporting and researching, and proposing solutions;
  4. Coordinating with departments and divisions to deal with letters, complaints, denunciations and issues related to patient satisfaction;
  5. Collect, synthesize, analyze data, manage and secure information related to hospital quality. Coordinate with the statistics and information technology department to measure hospital quality index;
  6. Deploy or coordinate to organize training, coaching, and retraining on quality management;
  7. Organize the internal quality assessment based on the sets of quality management criteria and standards issued or recognized by the Ministry of Health.;
  8. Assess compliance with regulations and professional guidelines of the Ministry of Health;
  9. Develop and implement a patient safety program.



  1. Personnel:

5.1 Predecessor leaders :

- Head of department: Prof. Trinh Hong Son, MD, PhD (2013- April 2019)

- Deputy head: Ass. Prof. Nguyen Xuan Hung, MD, PhD (2013 – March 2018)

5.1 Incumbent leaders:

- Head of department: Ass. Prof. Le Tu Hoang, MD, PhD (May 2019 – present)

- Deputy head: Mrs. Le Thi Kim Nhung, MA (Nov 2016 – present)

5.2 Number of staff: 12 in total:

- 01 head

- 01 deputy head

- 06 officers

- 04 part-timers



  1. Achievements:

With duties, missions of being the focal unit to deploy and advise Director, the Hospital Quality Management Council on hospital quality management, Department has implemented and completed a number of tasks, specifically as follows:

- To be the focal point coordinating with functional departments, Pharmacy Department, Nutrition Department to complete the construction of a quality management system according to ISO 9001: 2015 standards.

- Coordinate with Departments of Hematology, Department of Biochemistry to complete the construction of a quality management system according to ISO 15189: 2012 standards.

- The focal point to coordinate with Departments to develop improvement projects, slogans, quality goals, and indicators to measure hospital quality in order to improve processes and regulations accordingly towards patient satisfaction.

- Maintaining hospital quality management network, training, receiving, and analyzing medical incident reports at hospital. Design medical safety bulletin in hospital every 6 months.

- Survey the satisfaction of patients and medical staff periodically. Synthesize feedback, analyze root causes to promptly solve outstanding problems, improve quality towards patient satisfaction.

- Conduct internal assessment of quality criteria: ISO 9001:2015; Quality criteria to assess the level of surgical safety; Criteria to evaluate the quality level of medical laboratories, the set of quality criteria for Vietnamese hospitals.

- Completing hospital's list of surgery and procedures.

- Coordinate with functional departments to handle letters, complaints, denunciations and issues related to patient satisfaction, health insurance …

- Build technical service prices for all majors of Surgery, Endolaparosurgery, Microsurgery, Plastic Surgery and hospital fees.

- Coordinate with functional departments to participate in health insurance assessment.

- Striving for the Ministry of Health's assessment of hospital quality result in 2021: 4.01 points.

  1. Development orientation:

- Remain hospital quality evaluation point or increase 2% compare to 2020

- Reduce waiting time for patients from 30 minutes in 2020 to under 29 minutes

- The ratio of patients and relatives satisfied with examination and treatment activities in hospital ≥ 92%