Serves as a resource to all departments, division and units and ambulatory and establishes committees relating to Quality Assurance.
Promotes and facilitates cost-effective resource utilization related to infection control policies and procedures.
Establishes priorities for investigation of problem areas based on the degree of adverse impact on patient care that can be expected if the remains unresolved.
Develops and monitors effective patient care review and evaluation mechanisms to assure results are achieved.
Directs implementation and maintenance of technical guidelines and frameworks within which quality of care is evaluated.
Liase with quality facilitators to coordinate staff education, variance collection and analysis.
Establish system-wide variance database for benchmarking, system improvement, opportunities, length of stay and resource management
Provides ongoing assessment and support for continuous quality improvement, quality assurance and risk management priority programs and supports its infrastructure.
Based on the evaluation of the patients medical records intensifies concern areas and plans for the improvement.
Communicates appropriate information form studies and data sources to committees, departments and persons affected by the studies.
Identifies and shares across the system best practice models and care processes those, which achieves optimal patient outcomes, enhance patient/family and staff satisfaction are cost effective and resource appropriate.
Maintains all necessary records pertinent to the DOH , JCI, other health regulatory audits and OSH process.
Facilitates Quality improvement plan meetings.
Submits monthly reports of quality activities to the PSQ Committee.
Maintains records of policies, procedures, guideline, forms and other documents and ensures the circulation of current documents and the de-circulation of expired documents.
Maintains records of all quality assurance activities.
Provides educational and technical assistance to committees and departments in meeting their quality assurance objective.
Actively involved in all aspects of clinical space design, construction and hygiene.
Performs administrative responsibilities.
Justifies need for training in quality assurance process working with appropriate groups to initiate training to teach in areas of expertise.
Coordinates and monitors all Joint Commission on Accreditation compliance activities and participates in the survey process.
Coordinates Mock survey.
Does an Annual Evaluation of Quality Improvement program and submits reports to the PSQ committee.
Develops training/orientation program for key members to facilitate system expansion and standardization.
Demonstrates ability to perform under pressure.
Promotes a culture of safety in the department /& across the hospital.
help in formulating and executing the JDC Methodology, JAWDA KPIs process, audits, accreditations, certifications and preparing reports and reporting the status to Head of Department.
