Hossam Elamir

To provide consultation and technical support for Adan Hospital, Ibn Sina Hospital, KCCC and Palliative Care Center in the field of healthcare quality, accreditation, and safety. In addition, the team liaises with the hospital and the MOH Quality and Accreditation Directorate to achieve the objectives of both entities.

1. Facilitating, monitoring, educating, conducting and coordinating National Accreditation Program:
The Kuwaiti National Accreditation Program -based on Accreditation Canada Standards- was launched in 2011. Mubarak Al-Kabeer Hospital was selected to be surveyed in May 2013 and was accredited from the first time. I was appointed as an accreditation coordinator in the hospital. In addition to my active participation in and support of the self-assessment teams, I was responsible for the strategic and human resources planning.
2. Implementation of continuous improvement initiatives including:
• Lean Healthcare.
• New Quality Management Systems
• Patient Safety Walk rounds Program
• Sentinel Events & Root Cause Analysis
• Training for Quality Improvement, FOCUS PDSA, FMEA & RCA
• Reviewing & investigating of mortality & morbidity rates
3. Participating in developing of the National Incident Reporting System for MOH Hospitals in 2013
4. Recommendations regarding annual review within QM activities, indicators
5. Retrospective & concurrent reviews on assigned area using IMS DB, indicators or criteria
6. Site visits to Mubarak Hospital to work with staff on QM, reporting within 3 days.
7. Training of staff in areas of QM Programs, records requirements, CQI, Quality tools, Conduct QM workshops, Conduct QM orientation for new staff.
8. Participate in Area wide mini focus studies
9. Reviewing results of committee meetings, mini focus studies, QM team activities and report to Q&A directorate.
10. Coordinate with directorate as assigned to maximize staff expertise in QM
11. Prepare monthly & quarterly reports regarding QM Programs & compliance
12. Recommendations regarding annual review within all QM activities, DB, indicators
13. Day to day support to reviews, utilization reviews, retrospective monitoring, committees
14. Incident Report review
15. Medication Safety Program
16. Patient Medical Record Audits
17. Clinical pathways formation, analysis & reporting
18. Reviewing, developing Policies and Procedures & Guidelines, Developing QI plans
19. Assigned as coordinator of the following Committees:
i. Hospital Board
ii. Safety & Risk Management Committee
iii. Mortality & Morbidity Committee
iv. Accreditation Preparation Committee
v. Utilization Review Committee
20. Representing Mubarak Al-Kabeer Hospital in Hawalli Health Area Quality and Health promotion committees: Participating in planning and execution of Strategic and Health promotion plans in the primary healthcare sector -which servicing around 850, 000 population.

1. Coordinating (meetings are scheduled, ALS members are informed, rooms are booked, etc.)
2. Advising on process and group dynamics
3. Coaching and helping the ALS members to become more inquiry-oriented than advocacy-oriented (powerful questions are essential to good exploration and learning)
4. Guiding the ALS in their exploration of subjects
5. Helping the ALS work effectively through ensuring the right balance of support and challenge, task-orientation and people- or relationship-orientation
6. Reviewing the process at the end of each meeting

Quality, Patient safety and Accreditation -Egyptian and Arab programs- activities as assigned

Quality, Patient safety and Accreditation -JCI- activities as assigned

Professional Healthcare services Provider, Full time work, 48 hours per week working in the outpatient clinic as well as the inpatient wards to examine, assess, diagnose, treat, follow up and evaluate outcome of many referred patients. Managing obesity and diet related diseases. Also sharing in improving the department services, planning for implementing new ones designing plans for improving the hospital and Night Shift Manager.

Member of Organizing Committee, Performed the different assigned duties with great flexibility, commitment and teamwork, specially the tasks that relevant to security and safety

Obligatory on hand training year in different medical and surgical specialties. It is a cornerstone requirement to be legitimate and authorized physician.