Quality of care in university hospitals in Saudi Arabia: an updated systematic review.

Background: Academic hospitals in Saudi Arabia are major providers of specialised healthcare and serve as training centres for future health professionals. With ongoing reforms under Vision 2030, evaluating the quality of care in these institutions is essential. Despite their strategic importance, no recent systematic review has synthesised evidence on their performance. Aim: The aim of this systematic review is to identify major issues, barriers, and challenges impacting the quality of care in Saudi university-affiliated hospitals and provide evidence-based recommendations for improvement. Methods: This systematic review followed PRISMA 2020 guidelines. PubMed, Scopus, Web of Science, Embase, and the Saudi Digital Library were searched for empirical studies published between January 2015 and June 2025-a timeframe chosen to update the last available review, which covered literature up to early 2015, and to capture evidence emerging during major healthcare reforms associated with Saudi Vision 2030. Eligible studies included quantitative, qualitative, or mixed-methods research examining any of the Institute of Medicine quality domains in Saudi university-affiliated hospitals. Data were extracted using a standardised form, and study quality was assessed using the Newcastle-Ottawa Scale adapted for cross-sectional studies. Due to heterogeneity across study designs and outcomes, findings were synthesised narratively. Results: Twenty-eight studies were included. Patient-centredness was most frequently assessed, showing high satisfaction with communication, respect, and clinician interactions, although waiting times and referral delays were common barriers. Effectiveness was evident in paediatric care and pain management, while chronic disease and rehabilitation outcomes were less favourable. Innovative models such as telemedicine and hypofractionated radiotherapy improved both effectiveness and efficiency. Timeliness challenges were identified in emergency and discharge processes, whereas digital health supported faster access. Efficiency concerns included overcrowding and workflow delays, offset by alternative care models. Safety issues included medication errors, infection control gaps, and punitive cultures, though improvements in teamwork and organisational learning were noted. Equity was least studied, with disparities linked to demographics and geography. Most studies were of moderate quality; six were rated high. Conclusion: Saudi university hospitals demonstrate strengths in patient-centredness, effectiveness, and efficiency, but persistent gaps in timeliness, safety, and equity remain. Targeted improvements are needed to strengthen their role in advancing healthcare quality and achieving Vision 2030 goals.