Quality and Risk Coordinator
Doha Clinic Hospital
Total years of experience :7 years, 11 Months
Development and coordination of policies and procedure
Coordinates the development, production, and distribution of the policy and procedure manuals Technically reviews, edits drafted copies, and searches for references.
Ensures accuracy and completeness of policy and procedure and any other manual following the approval and revision mechanism.
Ensures consistency in the format and writing.
Ensures that all written and dated policies and procedures reflect the current professional knowledge and principles of each service area, department and function.
Ensures that there is evidence of compliance with existing laws, regulations and policies.
Document Control
Ensure all policies, procedures, forms and checklists in a standardized format.
Developing the checklist and forms and ensure the completeness with essential elements and compliance with accreditation standards
Performance Indicators Analysis and Management
Coordinate with the department / service leaders for selection, data collection, validation, analysis, improvement and control of the measures across the hospital and for the hospital’s priorities for improvement.
Enhance data collection throughout the hospital by assisting with data collection issues such as creating tools to collect data, identifying which data to collect, and how to validate data.
Create monthly and quarterly analysis report.
Report the collected HSPA & QHFMP data to MOPH on quarterly basis.
Accreditation Coordination
Monitors the compliance with Accreditation Canada Standards.
Coordinates activities of the different teams who are working through the self-assessment process using the Accreditation Canada self-assessment tool.
Clinical Quality Review
Reviews Medical Records of selected cases (criteria /indicators-based list approved by the Medical Department) and finds out the medical necessity for admissions, severity of illness and discharge criteria to assure the appropriate, cost effective use of hospital resources, continued stays and services rendered.
Incident Management
Managing all clinical and non-clinical incidents, analysis of all incidents and preparing corrective actions and preventive actions for the all incidents.
Preparing severity assessment code for all incidents as per NSW Health-2011 guidelines. Analysis of Incidents related to nature, severity and categories and volume.
Preparation of analysis report on monthly and quarterly basis.
Integrated Risk Management
Development of risk management register with inputs from stakeholders. Conduct training and education to the staffs.
Release of Medical Information
Review and update of policy on Release of Medical Information and consent form whenever required as per laws and regulations and enhance communication with requester by explaining the process.
Collect the consent form from the requester and validate the information
Release the medical information without delay after approval from medical director.
Emergency and Disaster Preparedness
Prepare and Review of policies and procedure for Emergency and Disaster preparedness. Coordinate the drills and training for emergency and disaster preparedness team. Coordinate the emergency and disaster preparedness committee.
Leadership and Safety Rounds
Coordinate the Leadership and Safety Rounds as per schedule and enhance the communication to the concern team members.
Monitor the compliance of the closure of observations/findings.
Training and Capacity building:
Quality coordinator will participate in providing education sessions to all DCH staff at different levels on all matters related to Quality Improvement.
Development and coordination of policies and procedure
Coordinates the development, production, and distribution of the policy and procedure manuals Technically reviews, edits drafted copies, and searches for references.
Ensures accuracy and completeness of policy and procedure and any other manual following the approval and revision mechanism.
Ensures consistency in the format and writing.
Ensures that all written and dated policies and procedures reflect the current professional knowledge and principles of each service area, department and function.
Ensures that there is evidence of compliance with existing laws, regulations and policies.
Document Control
Ensure all policies, procedures, forms and checklists in a standardized format.
Developing the checklist and forms and ensure the completeness with essential elements and compliance with accreditation standards
Performance Indicators Analysis and Management
Coordinate with the department / service leaders for selection, data collection, validation, analysis, improvement and control of the measures across the hospital and for the hospital’s priorities for improvement.
Enhance data collection throughout the hospital by assisting with data collection issues such as creating tools to collect data, identifying which data to collect, and how to validate data.
Create monthly and quarterly analysis report.
Report the collected HSPA & QHFMP data to MOPH on quarterly basis.
Accreditation Coordination
Monitors the compliance with Accreditation Canada Standards.
Coordinates activities of the different teams who are working through the self-assessment process using the Accreditation Canada self-assessment tool.
Clinical Quality Review
Reviews Medical Records of selected cases (criteria /indicators-based list approved by the Medical Department) and finds out the medical necessity for admissions, severity of illness and discharge criteria to assure the appropriate, cost effective use of hospital resources, continued stays and services rendered.
Incident Management
Managing all clinical and non-clinical incidents, analysis of all incidents and preparing corrective actions and preventive actions for the all incidents.
Preparing severity assessment code for all incidents as per NSW Health-2011 guidelines. Analysis of Incidents related to nature, severity and categories and volume.
Preparation of analysis report on monthly and quarterly basis.
Integrated Risk Management
Development of risk management register with inputs from stakeholders. Conduct training and education to the staffs.
Release of Medical Information
Review and update of policy on Release of Medical Information and consent form whenever required as per laws and regulations and enhance communication with requester by explaining the process.
Collect the consent form from the requester and validate the information
Release the medical information without delay after approval from medical director.
Emergency and Disaster Preparedness
Prepare and Review of policies and procedure for Emergency and Disaster preparedness. Coordinate the drills and training for emergency and disaster preparedness team. Coordinate the emergency and disaster preparedness committee.
Leadership and Safety Rounds
Coordinate the Leadership and Safety Rounds as per schedule and enhance the communication to the concern team members.
Monitor the compliance of the closure of observations/findings.
Training and Capacity building:
Quality coordinator will participate in providing education sessions to all DCH staff at different levels on all matters related to Quality Improvement.
Regular Monthly audits are carried out for clinical and nonclinical areas. (JCIA tracers, NABH, 5S Audits, ISO 9001, 14001)
Doing focused audit on international patient Safety goals (IPSG), Hand Hygiene, Safe surgery compliance and medical records and documentation audit.
Maintaining legal and statutory requirement compliance tracker and updating.
Monitoring and evaluation of compliance on clinical pathways outcomes and analysis of data.
Managing all clinical and corporate incidents, analysis of all incidents and preparing corrective actions and preventive actions for the all incidents.
Preparing severity assessment code for all incidents as per NSW Health-2011 guidelines. Quality monitors data collection and analysis for all departments.
Data validation for all quality monitors.
Preparation and reviewing of SOPs for clinical and nonclinical departments.
Preparation of Risk assessment and Aspect Impact Analysis for all departments.
Designing and preparation of clinical forms and checklists for quality improvement and patient Safety.
Assessing and planning nursing care requirements
Providing care to the patient
Monitoring and administering of medication and intravenous infusions Taking patient samples,
Checking and monitoring vital signs
Provide back care and hygiene care
Conducting patient fall risk assessment
Assist with physician for bedside procedures
Writing records and nursing care plans
Providing emotional support to patients and relatives
Assessing and planning nursing care requirements
Providing care to the patient
Monitoring and administering of medication and intravenous infusions Taking patient samples,
Checking and monitoring vital signs
Provide back care and hygiene care
Conducting patient fall risk assessment
Assist with physician for bedside procedures
Writing records and nursing care plans
Providing emotional support to patients and relatives
The Master of Hospital Administration (MHA) is a full time post graduate Program spread out over 4 semesters spanning 2 years, with thesis work included in the final semester.