Senior Performance Improvement & Risk Management Officer
Taiba Hospital
مجموع سنوات الخبرة :15 years, 4 أشهر
• Responsible for analyzing, tracking and monitoring the performance improvement indicators and for collecting and analyzing quality surveys and other quality activities.
• Responsible for facilitation and development of hospital-wide performance indicators and departmental performance indicators.
• Track and analyze the hospital performance indicators to report on areas requiring immediate attention.
• Conduct hospital surveys, data collection, analysis and generation of survey results.
Consult with leaders on data-driven improvement opportunities and make recommendations for improvement approaches.
• Participate in quality improvement projects and compile and distribute reports.
• Developing and maintaining the incident management system. Monitoring the effectiveness of incident management and making recommendations for improvement.
• Driving, developing, managing and maintaining the incident reporting process and associated procedures Accreditation Compliance/Governance Function
• Assist in the coordination of accreditation compliance activities for quality management, performance improvement, and patient safety.
• Timely coordination of data collection and reporting of performance -improvement data to meet requirements.
• Serve as resource/liaison/educator to all hospital departments, service line teams, and medical staff regarding performance timely coordination of performance issues and resolutions.
• Coordination of Joint Commission compliance activities for quality job success factors management, performance improvement, and patient safety improvement processes.
• Responsible to prepare, implement and monitor the ISO 9001:2008 Accreditation standards in the Medical Centre
• Coordinate with Internal Quality Audit Team for conducting Internal Audit as per QA Plan
• Coordinate with user department staff to improve overall quality in the organization by assisting in SOP preparation & revision, non conformity closer.
• To assist the departments with the audit’s findings and recommend appropriate remedial action plan/ data-gathering mechanisms/procedures, etc.
• Collect, analyze and interpret the needed information to management by periodic reports.
• Assist to organize the management review meeting by coordinating with quality team.
• Responsible to prepare quality committee’s functioning protocols and procedures.
• Assist with the monitoring of unusual occurrences (sentinel events / near misses); prepare incident reports to the management and conduct root cause analysis.
• Coordinate with functional department and implement the ISO 9001:2015 amendments.
• Any other responsibility as deemed by the management
Health information Management
• Developing process flowcharts for HIM Dept statistics work activities
• Compiling & analyzing monthly, quarterly and annual hospital wide statistics reports including ministry reports (Bed Occupancy of ward and critical care, diagnostic dept service usage, OPD and ER visits, follow-up & procedures , deliveries, surgeries, new born data, birth & death data..etc )
• Facilitator of hospital medical record forms committee
• Compiling bed status @ given time
• Coordinating with IT department to upgrade existing SAP application
• Preparing customized reports based on data requests &presenting information in a variety of formats
• Preparing / revising HIM Dept policies & procedures under the supervision of Dept head
• Responsible for conducting required statistical analyses on patient care data to identify quality of care improvement opportunities in the hospital and presenting the reports to administration
• Responsible to assure the data quality in all the HIM Dept outflow statistical reports to hospital administration and ministry of health
Quality
• Developing & Implementing department specific quality policies and procedures as per management direction
• Monitor continuous quality improvement initiatives in various departments of the hospital.
• Assisting the departments in identifying quality indicators.
• Guiding departments towards method of data collection, collation and analysis of data.
• Assisting the departments to analyze areas of improvements based on their own recommendations.
• Implement improvements in collaboration with the Quality & departmental heads .
• Work in close coordination with under the guidance of Director - Quality.
• Prepare quality objectives for individual departments.
• Continuously work upon finding newer ways of improving the quality of service
• Responsible for the implementation and monitoring of various policies & procedures
• Play a role of a risk manager and monitors every incident under the purview of patient and staff safety.
• Analyze incident reports and maintain data of the same
• Analyze sentinel events that happen within the hospital in close coordination with the Quality team.
• Any other responsibility as deemed by the management
Hospital Statistics, Insurance &Billing
• Compiling Hospital Statistics and Ministry Reports
• Responsible for coordinating with insurance companies and patients with regard to- pre approvals, cost estimations, invoices and claim submission.
• Responsible for preparing ministry invoices as per agreed terms and condition
• Check & make sure all utilized medical consumables charged properly in the IP invoice.
• Preparing monthly incentives reports of physicians in the hospital.
Customer satisfaction
• Appraising Inpatient & Outpatient satisfaction.
Outpatient coordination
• Check & make sure all OPD Appointments scheduled properly in the system by consultants
Medical Records
• Responsible for giving ICD10, CCHI, ICPM medical codes to all discharges
Inventory Management
• Performing periodic & annual inventory checking in - pharmacy and in wards
• Responsible to approve all indents to material dept and pharmacy
Human resource
• Responsible for checking hospital staff attendance reports and leaves
• To develop, Interpret and implement all department's quality assurance procedures and policies as per Accreditation standards
• To coordinate with all clinical, non clinical, supportive Dept HOD with regards to setting key performance indicators, Data collection, Analysis and interpretation.
• Responsible to coordinate with internal quality audit team while performing audit as per QA plan.
• To assist departments with the coordination of audit information, and recommends appropriate data-gathering mechanisms, procedures, etc.
• Responsible to organize and develop various hospital committee's functioning protocols
• To assist the quality head for revising quality policies, procedures and data collection formats.
• Assist with the monitoring of unusual occurrences(sentinel events / near misses); prepare incident reports to the quality head
• Assist with developing and maintaining an unusual occurrence procedure.
• Conduct risk assessment as per quality head instruction.
• Make certain every medical test, operation and treatments are performed as per quality standards
• Responsible to compile and submit periodic hospital quality statistic data reports to QA Committee through quality head.
• Maintain current and accurate records of all relevant communications, audits, corrective action plans, and effectiveness monitoring.
• Evaluate the effectiveness of the quality control program as per quality head direction
• Review and update hospital quality documents as per Accreditation Board direction
• Conduct system study in client organisation (Hospitals, Laboratories ) to notify service deficiency to management
• Preparing client organisation staff to quality culture
• Explain Quality Accreditation(NABH, ISO 9001 -2008, NABL) standards and requirement to staff and management
• Support the client administration HOD for preparing applicable Quality Control manuals, policies and procedure.
• Provide consultancy service to client organisation till Accreditation
Commerce , Accountancy , Business management , Computer Application