Risk Manager, Quality Management Department
National Guard Health Affairs
Total years of experience :31 years, 11 months
Current Projects
• Advisor for the HFMEA project in the newly commissioned Children Specialist Hospital’s ER
• Member Task Force for revision of Medical Staff Bye-laws, NGHA
• Designing of Clinical Pathways Program for NGHA, Central Region
• Redesigning the Process for Clinical review of Mortalities, NGHA
• Redesigning the Policy on Sentinel events & Root Cause Analysis, NGHA
• Designing of Clinical Audit Program for NGHA, Central Region
• Member On-going HFMEA projects for NGHA, Central Region
• Member Task Forces to conduct Root Cause Analysis for Sentinel events, NGHA
Past Projects
• Member of QM’s core group for JCIA Re-accreditation in 2012
• Project Manager and Speaker at the International Risk Management Workshop at NGHA in November 2012.
• Project Manager for re-designing the Hospital Morbidity Process 2011-2012
• Project Manager for re-designing the Hospital Mortality Process 2011-2012
• Member of Task Force to design the Disclosure process for all adverse events to patients (2011)
• Member of QM’s core group for JCIA re-accreditation in 2009
• Project Manager for re-designing and implementation of the Incident reporting process and its electronic automation during 2008-2009
• First HFMEA project in King Abdulaziz Medical City (2009)
• Designing and setting up a Sentinel Event Review Process for Root cause Analysis (2007-2008)
• Member of QM’s core group for JCIA Accreditation in 2006
Major Responsibilities
1) Process owner for the Sentinel Event Review Process and Root Cause Analysis
2) Master trainer and chief facilitator for FMEA projects
3) Master trainer and chief facilitator for the Sentinel events & Root Cause Analysis workshops at hospital level
4) Master trainer for the JCI related chapters and their respective standards
5) Trainer for the Joint Commission International Patient Safety Goals
6) Trainer for the Physicians’ documentation (in medical records) campaign
7) Master trainer in Quality & performance improvement workshops
8) Trainer, Clinical Practice Guidelines workshop
9) QM representative in all Sentinel Event Review task forces, constituted by the Medical Services’ Directorate, to investigate Sentinel Events and conduct root cause analysis
10) Review mortality & morbidity reports based on peer reviews in all clinical departments
11) Clinical review of medical charts on the advice of the Chief Medical Officer (CMO)
12) Member, Patient Safety Walk-around Teams
13) Quality Management representative in several task forces to review & re-design corporate policies
14) Direct supervision of staff in the Risk Management unit
Membership in Departmental teams & multi-disciplinary Task Forces
• Member, Quality Management Core Group
• Member, ALL Task Forces for investigation of Sentinel Events and conduction of Root Cause Analysis
Membership in Hospital Committees
• Member, Medical Practice Review Committee (representing QM Director)
• Member and Coordinator, the Risk Management Committee, Central Region (CR)
• Member, Hospital Mortality Committee
• Member, Hospital Morbidity Committee
• Member, Regional Safety Management Committee, CR (representing QM Director)
Training at NGHA
• High Reliability Organizations (HRO) Workshop (departmental plan in OR/Surgical Services) - By Dr Martin Makary, Director of Quality & Safety (Surgery) Johns Hopkins - at King Saud Bin AbdulAziz University for Health Sciences --- June 17 to 19, 2014.
• Building Capability for Innovation Workshop (International) at King Saud Bin AbdulAziz University for Health Sciences --- January 13 to 15, 2014.
• Evidence Based Health Management Workshop (International) at King Saud Bin AbdulAziz University for Health Sciences --- December 15 & 16, 2013.
• Risk Management Workshop (International) at NGHA --- November 10 to 14, 2012.
• Institute for Healthcare Improvement (IHI) Executive Quality Academy Workshop (International) at NGHA --- February 18 to 20, 2012.
Major responsibilities at SKMCH & RC
1) JCIA Coordinator for the Hospital
2) Quality Management Representative (QMR) of the Hospital for ISO QMS
3) Coordinator for mainstay activities related to Clinical Governance
4) Comprehensive Risk Management
5) Critical analysis of patient related processes
6) Supervise and conduct Institutional clinical audits and Utilization reviews
7) Trainer for ISO QMS and other quality related modules
8) Supervision of satisfaction surveys
9) Facilitator and resource person for all hospital committees
Membership in Hospital Committees
• Chair, Hospital Committee for departmental Quality Management Representatives
• Ex-officio member of Clinical Executive Board
• Secretary, Professional Standards Board
• Member, JCIA Core Group
• Member, Quality Council & JCIA Task Force
• Member, Hospital Safety Committee
• Member, Hospital Ethics Committee
• Member, Operating Room and Surgical Day Care Committee
• Member, Radiation Protection Committee
• Member, Nutrition Support Committee
• Member, Intensive Care Unit Committee
• Member, Hospital Operations Team
• Member, Medical Records Committee
• Member, Infection Control Committee
• Member, Tissue Committee
• Member, Blood Utilization Committee
• Member, Pharmacy and Therapeutic Committee
• Member, Clinical Audits Committee
Major responsibilities:
1. Supervision of Quality Executives, and Stats Officers, and their individual job responsibilities
2. Clinical Risk Management
3. Patient Safety issues
4. Assistance for JCIA accreditation
5. Analysis and reporting of Hospital Clinical performance indicators
6. Training of staff
Membership in Hospital Committees:
1. Secretary Hospital Patients' Safety Committee
2. Secretary Hospital ICU Committee
3. Secretary Patient Safety Newsletter Editorial Board
4. Member Surgical Quality Assurance Committee
5. Member Medical Quality Assurance Committee
6. Member Patient Safety Walkabout group
7. Department's representative in various surgical and medical M7M meetings
Major Job responsibilities:
1. Clinical Risk Management
a) Handling and resolution of patients' complaints
b) Investigation, analysis, & reporting on clinical incidents
c) Root cause analysis of sentinel events
d) Legal eagle for all issues pertaining to patient care
2. Process owner for credentialing & privileging of medical staff
3. Supervision and facilitation of the activities pertaining to maintenance and improvement of clinical quality within the hospital by working with the faculty, nursing division and operational staff
4. Supervised and conducted workshops on Risk Management, CQI, & TQM for the staff
5. Technical support to clinical departments on ISO certifications and JCIA accreditation
1. Membership in Hospital Committees:
• Secretary, Hospital Ethics Committee
• Secretary, Credentials Committee
• Member JCIA Task Force
• Member JCIA Oversight group (OSG)
• Member Hospital Service Excellence Committee
• Member, Risk Management Forum
• Ex-Secretary and member of Quality Assurance Coordinating Committee (QACC)
• Member of sub-committee on Safety Management
• Member, Complaint Handling Network
• Member of the former Multidisciplinary Committee for Policies and Procedures
2. Membership in Departmental Committees:
• Member, QAC department of Obstetrics & Gynaecology
• Member, QAC department of Medicine
• Member, QAC department of Surgery
• Member, ER Management Review Committee (MRC)
• Member, MRC Clinical Affairs department
• Ex member, Radiology MRC and QAC
• Ex member, Paediatrics MRC
• Ex member, Psychiatry MRC
3. Some Key Achievements:
• Designing and implementation of the Risk Management system
• Designing and implementation of the Incident reporting system
• Designing and implementation of the new Informed Consent Policy and form
• Designing and implementation of the external customer complaints system
• Designing policies/procedures for QA, CAD and other clinical departments
• ISO 9002 and ISO 9001:2000 certification of QA, CAD, and Paediatrics, ER, Psychiatry (as a Buddy)
• Organising two conferences, on Clinical Quality Management and Clinical Effectiveness, in Karachi
Major Job responsibilities:
1. Clinical Risk Management
a) Handling and resolution of patients' complaints
b) Investigation, analysis, & reporting on clinical incidents
c) Root cause analysis of sentinel events
d) Legal eagle for all issues pertaining to patient care
2. Supervision and facilitation of the activities pertaining to maintenance and improvement of clinical quality within the hospital by working with the faculty, nursing division and operational staff
3. Supervised and conducted workshops on Risk Management, CQI, & TQM for the staff
4. Technical support to clinical departments on ISO certifications
5. Clinical Audits / Utilisation reviews
Major Job responsibilities:
1. Clinical Risk Management
a) Handling and resolution of patients' complaints
b) Investigation, analysis, & reporting on clinical incidents
c) Root cause analysis of sentinel events
d) Legal eagle for all issues pertaining to patient care
2. Supervision and facilitation of the activities pertaining to maintenance and improvement of clinical quality within the hospital by working with the faculty, nursing division and operational staff
3. Conducted workshops on Risk Management,
4. Technical support to clinical departments on ISO certifications
5. Monitoring, analysis, and reporting on Hospital's performance indicators
1. Routine clinical responsibilities
2. Day to day management of operational matters
Chaired Board meetings and represented the firm in meetings with Government officials and labour representatives in the absence of the Managing Director. Involved in routine administration of the staff, in office and on site, and their social welfare.
Routine clinical responsibilities
Routine clinical responsibilities
Routine clinical responsibilities
Routine clinical responsibilities
Degree: M.B, B.S. (Bachelor of Medicine & Bachelor of Surgery)