Quality Manager

Job Purpose / Objective

Responsible for managing, coordinating and implementing quality, patient safety, and clinical risk management initiatives designed by Dr. Sulaiman al Habib Hospital to continuously improve all aspects of health care delivery. This include communication and monitoring of initiatives as well as promoting culture changes that support an environment of quality. Work closely and collaboratively with various functional areas of the delivery system and to achieve the goals and objectives of the Institution according to the Vision and Mission of Dr. Sulaiman al Habib Hospital.

Key Responsibilities / Accountabilities

• Basic Function
  • Design, Implement and Monitor Quality, Patient Safety and clinical risk management Initiatives.
  • Report to top management on the performance of the assigned functions and any need for Improvement.
  • Provide leadership and support in establishing and directing the Quality Program consistent with the delivery system.
  • Develop and maintain policies and procedures that support the initiatives that meet National (MOH / CBAHI), International (JCI) and other accreditations requirements and standards.
  • Ensure that an internal audit program is adopted to verify that confirms to planned arrangements and is effectively implemented and maintained.
  • Ensure that appropriate action is taken when this is not the case.
  • Analyze data on the effectiveness of the QMS and evaluate where continual improvements of the QMS can be made. This shall include data generated as a result of monitoring and measurement and from other relevant sources.
  • Collaborate with physicians and allied staff to execute the implementation of the clinical quality data initiatives as defined by Dr. Sulaiman al Habib Hospital Compliance.
  • Works with leadership to provide information or data as requested.
  • Facilitate, integrate, and coordinate the implementation and evaluation of identified quality improvement areas.
  • Liaise with the external assessment body on all matters related to the external accreditation process.
• Principal Duties:
  • Conduct all kinds of audits for Quality Improvement, Patient Safety, Risk Management, Clinical Governance, Patient Experience and Personnel Files.
  • Manage and support the identification and mitigation of patient and caregiver safety risk. Facilitate root cause analysis, event and data reporting, and policy updates.
  • Maintain a working knowledge of current best practices to maintain a high reliability, low risk care delivery system.
  • Promote understanding, communication and coordination of all quality improvement program components.
  • Participate in requested evaluations and audits.
  • Coordinate reporting on quality, patient safety and clinical risk management initiatives to all appropriate committees.
  • Assist with the development of the QM and RM Work Plan, Evaluation and the monitoring of Work Plan activities.
  • Participate in various teams, committees and meetings at any level required to maintain business necessity.
  • Maintain QI program documents, reports, and committee minutes and follow all internal privacy and confidentiality policies and procedures.
  • Lead accreditation efforts as required by Dr. Sulaiman al Habib Hospital.
  • Ensure that a document control procedure is adopted to approve, review and update all changes to critical documents within the scope of the QMS.
  • Ensure that records are established and maintained to provide evidence that the QMS is being followed and that there is a system in place for the identification, storage, protection, retrieval, retention time and disposition of such records.
  • Ensure that the performance of the QMS is reviewed at planned intervals to ensure its continuing suitability, adequacy and effectiveness. This review means assessing opportunities for improvement and the need for changes to the QMS.
  • Ensure that all new staff are inducted into the requirements of the QMS related to their own roles and responsibilities. Provide update training as necessary.
  • Ensure that all suppliers used by the organization are selected, evaluated and reevaluated and that records of this assessment are maintained.
  • Ensure that top management undertakes periodic but regular assessments of customer satisfaction and those consequent improvements are identified and implemented.
  • Identification of Sentinel/Adverse Events as defined by CBAHI, JCI-defined Hospital-Acquired Conditions, and Insurance Non-Coverage Decisions in collaboration with the entity quality improvement staff, compliance, and billing staff and in accordance with the Policies & Procedures of Dr. Sulaiman al Habib Hospital
  • Identify all events that meet requirements for reporting to government health agencies to ensure that reporting occurs and is tracked.  
  • Participation on committees, task forces, and in Quality Initiatives education programs as assigned, including preparation of materials for discussion at committee meetings such as Dr. Sulaiman al Habib Hospital quality improvement committee meetings and independent preparation and delivery of educational materials and programs.
  • Participate in, lead person-centered care initiatives undertaken by HMG.
  • Enrich patient experience with compassion, respect and dignity.
• Team & Resource Management 
  • Ensure sufficient resources and staffing is available for quality improvement, patient safety and clinical risk management.
  • Ensure staff members participate in quality improvement and patient safety activities and receive training on quality assessment and improvement.
  • Review performance of staff and perform counselling on unsatisfactory performance. In addition, discuss personnel and administrative issues and address and solve problems among staff.
  • Perform other applicable task and duties assigned within the realm of his/her knowledge, skills and abilities.

Education/ Professional Qualification

• Bachelor’s degree in medicine or nursing or Hospital Management or Administration from a recognized national or international university.

Experience 

• Minimum of Six (6) years of experience in Quality Improvement and Patient Safety and accreditation (CBAHI, JCIA etc.) in a tertiary healthcare organization.

Professional Licensing / Certification / Training 

• Certification: Relevant Certificates in quality management, patient Safety and Accreditation.