Quality and accreditation officer
As-Salam International Hospital
Total years of experience :5 years, 9 Months
• Facilitated Implementation of Improvement projects for Cath-lab, HDU, ED, Medical Laboratory, and Medical Imaging Department, by applying approaches like FOCUS-PDCA, and Lean six sigma.
• Conducted Compliance with Clinical Pathways analysis for (COVID-19, AMI STEMI/ NS-TEMI, Tonsillectomy, and Kidney transplantation) Pathways.
• Developed KPIs. Aggregate, review, Validate, and analyze statistical data collected in the departments/ services measures.
• Participated in the Preparation for JCI Accreditation, and Attended JCI Accreditation Survey.
• Participated in Risk Assessment Processes and Handling OVRs, using RCA, and FMEA.
• Member of Team Responsible for Implementation & Overseeing Patients Safety Culture, IPSGs, and Risk Management Protocols, Conducting& Coordinating quality and Patient Safety training sessions.
• Developed internal auditing tools and conducted internal audits and reports for Recertification for ISO 9001:2015, ISO 14001:2018, and HACCP Projects.
•Manage the staffing process, including recruiting, interviewing, hiring, and onboarding
•Ensure job descriptions are up to date and compliant with all local, state, and federal regulations
•Develop training materials and performance management programs to help ensure Volunteers understand their responsibilities
•Investigate Volunteer issues and conflicts and bring them to resolution
•Ensure the organization’s compliance with local, state, and federal regulations
•Use performance management tools to provide guidance and feedback to the team
•Ensure all Organization HR policies are applied consistently
•Maintain Organization charts and employee directory
•Partner with management to ensure strategic HR goals are aligned with Volunteer initiatives
•Maintain HR systems and processes
•Conduct performance analysis and Implement Performance Improvement Strategy
•Provide support and guidance to HR`s department volunteer
•Design and implement Volunteering strategies.
•Work with Heads of Departments to strengthen SHO’s internal tools to evaluate program implementation progress and wellbeing in the workplace and lead internal evaluation process to determine volunteer satisfaction and wellbeing, report to Executive Office possible improvements based on evaluation results.
•Design, implement and monitor surveys
•Lead monthly volunteer feedback and/or bonding activity.
• Developing internal auditing tools and conducting internal audits and reports.
• Determining data-driven solutions and implementing quality improvement plans.
• Conducting or assisting with regulatory and quality training sessions.
• Implementing and maintaining quality monitoring and analysis of processes that support the quality improvement plan.
• Review, analyze, and integrate statistical data collected in the department/ service measures.
• Performs a variety of clinical laboratory tests in the areas of hematology, microbiology, immunology, clinical chemistry, and urinalysis, as assigned; conducts quantitative and qualitative chemical analyses of body fluids such as blood, urine, and spinal fluid; performs blood counts using a microscope.
•Performs quality control on test results, ensuring validity and accuracy.
•Performs calibration and troubleshooting on testing systems and instruments to ensure adherence to established standards of accuracy.
•Practices safety, environmental, and/or infection control methods.
• Keeps records and reports on results according to established procedures.
• Performs miscellaneous job-related duties as assigned.
• Collects, processes, and handles blood and/or other biological specimens according to established procedures.
• Performs a variety of clinical laboratory tests in the areas of hematology, microbiology, immunology, clinical chemistry, and urinalysis, as assigned; conducts quantitative and qualitative chemical analyses of body fluids such as blood, urine, and spinal fluid; performs blood counts using microscope.
• Conducts blood tests for transfusion purposes.
• Develops and maintains cell/tissue cultures for testing purposes, as appropriate; isolates and identifies specimens, using advanced laboratory techniques.
• Performs quality control on test results, ensuring validity and accuracy.
• Performs calibration and troubleshooting on testing systems and instruments to ensure adherence to established standards of accuracy.
• Keeps records and reports on results according to established procedures.
• Practices safety, environmental, and/or infection control methods.
• Performs miscellaneous job-related duties as assigned.