Responsible for supporting the Quality Team in all accreditation and regulatory body surveys, clinical and non-clinical audits, and inspections. Support regulatory readiness, quality measurement, and regulatory reporting by preparing appropriate tools, conducting training, and internal audits.
Assist in developing and maintaining a Patient Safety and Quality Improvement Plan by collating and analyzing performance data, performing evaluations, and providing feedback.
Ensure organizational compliance with mandated quality indicators, both internal and external. Also, update the performance indicator database.
Utilize, integrate, and interpret data to assist the organization in its improvement efforts and promote optimal patient outcomes.
Involve in training and communicating improvement initiatives, quality, and patient safety issues throughout the hospital.
Analyze all assigned areas for opportunities for improvement and make applicable recommendations for process, system, procedure, and operational changes to improve healthcare value, patient safety, quality, and reduce costs.
Ensure organizational compliance with required KPIs and mandated quality indicators by conducting audits and validation for both internal and external KPIs like DOH JAWDA, DHA KPIs, Departmental KPIs, and NMC Healthcare Corporate KPIs.
Support regulatory readiness, quality measurement, and regulatory reporting (e.g., DOH Jawda Program).
Perform Risk Assessment and Hazard Analysis in collaboration with the Quality and MDT.
Strengthen incident and near-miss reporting and perform Root Cause Analysis systematically as needed.
Involve in notifying the Department of Health of critical accidents in collaboration with the Quality Lead and Medical Director after conducting proper root cause analysis.
Provide training to staff based on the training plan and training needs analysis.
Assist the Quality Lead in maintaining records of policies, procedures, guidelines, forms, and other documents, and ensure the circulation of current documents and the de-circulation of expired documents.
Prepare periodic reports like Quality reports, audit reports, etc.
Perform highly responsible office functions; assist in arranging and coordinating department activities.
Accompany staff from the Department of Health, Dubai Health Authority, and external agencies during workplace inspections.
Conduct quality compliance audits in a homecare setting and follow up on any deficiencies noted during audits to ensure they are corrected.
Establish and maintain records, filing systems, and logs.
Promote good interpersonal relationships by displaying professional behavior and practice.
Perform miscellaneous duties as assigned by the Quality Lead.
Operational Responsibilities
Awareness of NMC policies and procedures and access to documents in the Patient Safety and Quality portal.
Compile and validate DOH JAWDA KPIs, DHA KPIs, Corporate KPIs, IPSG KPIs, and Departmental KPIs on a monthly basis.
Ensure quarterly submission of DOH JAWDA KPIs.
Update the KPI dashboards and share KPI analysis with HODs.
Conduct staff training, prepare appointment letters, and evaluate the competency of Data Collectors and Data Validators as per Jawda Data certification methodology.
Conduct monthly audits to ensure compliance with regulatory and accreditation standards. Also, ensure tracking of action items based on audit findings.
Receive, assign, investigate, follow up, and close incident reports through the IRIS portal.
Strengthen incident and near-miss reporting and facilitate the nomination of quarterly IRIS FOCUS near-miss submissions.
Facilitate the sharing of lessons learned from incidents raised.
Conduct education sessions as per the annual education calendar.
Facilitate five improvement projects annually and at least one FMEA project annually.
Monitor compliance with committee schedules, participate in relevant committees, and conduct CQPS meetings as per schedule.
Attend safety huddles and receive input from the multidisciplinary team to maximize quality and continuity of patient care.
Assist and participate in the learning experience through rounds, interdisciplinary patient care conferences, and informal and formal education sessions.
Facilitate the review of the risk register and ensure annual review of the risk register by the HODs.
Prepare annual reports and facilitate sharing with relevant stakeholders.
Ensure updates to documents based on regulatory and accreditation updates.
Complete JCI accreditation tasks assigned by the Quality Lead and corporate PSQ team.
Act as a role model in the provision of quality care by reinforcing the philosophy, mission value statement, roles, objectives, policies, and procedures to staff.
Assess for a safe environment for patients to minimize risks to clients and staff.
Exercise good time management skills.
Adapt quickly to change, offer constructive feedback, set high ethical standards, stay positive, offer encouragement, and remain optimistic yet realistic.
Act as the department liaison for Patient Safety and Quality.
