Responsible for developing and implementing appropriate quality improvement practices and coordinating the development of appropriate frameworks and processes for the establishment of quality standards and operational procedures. Also responsible for disseminating knowledge pertaining to quality assurance procedures and best practices, quality audits, and statistical analysis.
Responsibilities:
Key Responsibilities of the role Corresponding Key Activities performed by the role Responsible to support the Regional Quality Department. Responsibilities include:
Risk Management and Patient Safety
- Coordinating and supporting the development and implementation of an integrated risk management framework in accordance with SEHA’s mission and strategic goals, federal and state laws and regulations and accreditation standards, to identify, assess and mitigate risk and improve quality and patient safety.
- Coordinating and supporting the development of plans to effectively measure, monitor and improve outcomes in key areas such as incident reporting and management, management of sentinel events, case reviews, morbidity and mortality review, safety alerts, etc
- Coordinating, supporting and facilitating system-level taskforces to develop and align system-level risk management initiatives.
- Tracking and monitoring risk data (from incident reports, sentinel events, claims, complaints, performance indicators etc.) to:
- Detect patterns/trends, system errors and process deficiencies
- Develop statistical reports
- Escalate concerns to risk management leadership
- Facilitating and supporting the region in the development and implementation of action plans related to any deficiencies
- Coordinating and supporting in compiling risk key performance indicators data on regular basis to monitor compliance with SEHA risk program and escalate concerns
- Supporting the implementation of system-wide risk reduction strategies by working with subject-matter experts
- Coordinating and supporting risk related performance improvement projects/initiatives
- Coordinating, supporting and collaborating with subject matter expert taskforces to address risk management priorities
- Researching trends and new approaches for clinical quality and patient safety and advise on implementation of new methodologies
- Recommending educational initiatives to support quality improvement activity across SEHA e.g. workshops/training on quality and patient safety.
Audit and Continuous Quality Improvement
Policy Management
- Participating, facilitating and supporting the collaboration and effective communication with the relevant stakeholders for the timely development, review and approval of policies and procedures that are in compliance with requirements of the regulatory authorities and the relevant accreditation / certification programs
Region Level Quality Improvement Projects
Patient Safety Culture
Accreditation and Certification
Regulatory Audits
- Overseeing the implementation of DOH Quality Audit (Ranking) compliance framework to support healthcare services improvement and standardization of care.
- Ensuring compliance with DOH Quality Audit and identifying improvement initiatives to address deficiencies across the healthcare system.
- Facilitating all DOH related audits including Ranking, ADPHC and Licensing audits.
- Conduct internal audits as required by regulators and accreditors i.e. ISO/ADPHC/JDC.
Excellence
- Working collaboratively with the Readiness and Business Continuity team and Laboratory team to maintain required excellence awards and certifications which includes:
- Working collaboratively with the different teams to ensure continuous compliance with the awards requirements.
- Addressing all the excellence awards assessment findings across the region and identifying region-level areas for improvement.
Occupational Safety and Health (OSH)
Developing a Safety Management Program
- Facilitating, participating and supporting the development of new and revising existing standards and procedures consistent with the mission of the facility, current recognized international best practice and applicable UAE legislation
- Facilitating, participating and supporting in using of the safety standards as a framework to create procedures on safe work practices organization-wide, within specific departments/areas, or for particular risk factors and issues within the workplace
- Facilitating, participating, supporting and collaborating with engineers and facility management staff to institute control and remedial measures for hazardous and potentially hazardous conditions or equipment
- Facilitating, participating, supporting and ensuring all departments are effectively monitored for compliance with safety standards and procedures
- Facilitating, participating, supporting, ensuring and performing assessments of safety hazards, unsafe conditions, risks and practices within the workplace and based on this assessment, recommending a plan for safety that minimizes risk and promotes safety
- Ordering suspension of activities that pose threats to patient, worker or visitor health and safety
Evaluating and developing training and educational programs related to safety
- Facilitating, participating and supporting the development of training and educational programs related to safety, fire protection, emergency preparedness, hazardous materials etc.
- Facilitating, participating, supporting and ensuring of training / education is implemented, evaluated and improved on a regular basis
- Acting as a key resource for employees and safety staff
- Facilitating, participating and supporting in driving safety improvement projects.
- Facilitating, participating, supporting and ensuring the coordination of the emergency preparedness program; ensuring that equipments, procedures and training are in compliance with facility, SEHA and UAE requirements
Leading the investigation for accidents, incidents and near misses
- Facilitating, participating and supporting the investigation of accidents to identify causes and to determine how similar accidents might be prevented in the future
- Facilitating, participating and supporting the determination of root causes, trends and adequacy of precautions and training
- Facilitating, participating and supporting in making revisions to current training programs or developing new trainings in order to change current practices, to alter process design or recommend changes in equipment
- Facilitating, participating and supporting the investigation of health and safety related complaints.
- Performing other applicable tasks and duties as assigned, within the scope of his/her knowledge, skills and abilities
Developing hazardous materials program
- Facilitating, participating and supporting the development of the hazardous materials program, including auditing and training
- Facilitating, participating and supporting the maintenance of the database and documents
- Facilitating, participating and supporting the coordination of the program with all departments/section
- Facilitating, participating and supporting the development of training materials, ensuring delivery of education to all departments where hazardous materials are used or stored
- Facilitating, participating and supporting of ensuring transportation, segregation and storage are product appropriate.
- Facilitating, participating and supporting the departments in safe removal of hazardous waste
- Facilitating, participating, supporting and maintaining of master inventory of hazardous materials and ensuring that materials are handled properly
- Facilitating, participating and supporting the collection and dissemination of safety information related to hazardous materials, personal protective devices and safe work practices
Auditing
- Facilitating, participating and supporting the development of the development, implementation and improvement of the auditing process and procedures.
- Facilitating, participating and supporting the environmental care audits and assisting all departments in completing the recommended corrective actions
- Facilitating, participating and supporting the development of the performance of random audits to identify opportunities for improvement; ensuring reports are appropriate prior to distribution
- Facilitating, participating and supporting the development of the monitoring and follow-up to ensure corrective actions are completed
Developing occupational safety and health management plan
- Assisting the organization in meeting UAE legislative requirements related to Occupational Safety and Health Management Plan
- Investigating the adequacy of ventilation, exhaust equipment, lighting, and other conditions that could affect employee health, comfort, or performance
- Developing and maintaining hygiene programs such as noise surveys, air monitoring, ventilation surveys, asbestos management plans etc
Financial and Budget Control
- Facilitating and supporting in setting and managing budgets related to risk management and safety activities.
Qualifications:
Required:
- Bachelor’s degree in a medical, clinical, quality or relevant health related field
Desired:
Master’s degree or equivalent in Public Health, Health & Safety, Risk Management, or relevant field
