Pascale Kiwan

Preparing and updating policies and procedures for all departments
Monitoring compliance with and application of policies and procedures
Conducting internal audits, coordinating and overseeing the implementation of health standards
Defining and implementing KPIs (key performance indicators) to ensure consistency with best practices
Tracking and reviewing performance indicators to identify and suggest actions to improve quality of service
Investigation and analysis of incidents using root cause analysis
Measuring patient satisfaction, issuing reports and implementing necessary changes
Managing patient complaints
Measuring employee satisfaction, issuing reports and implementing necessary changes
Setting annual quality improvement plans
Managing and coordinating authority visits (HAAD)
Setting up the laboratory for ISO 15189:2012 accreditation

Preparing internal audit schedules, assisting with internal audits and audit results
Recommending quality tools to be used in measuring hospital's performance
Reviewing non-conformances and corrective actions
Reviewing patient complaints for repetitive trends and recommending changes in practice
Staff counseling and education
Providing support and advice to Hospital Director on quality issues
Preparing yearly education plan in coordination with Human Resources
Training of masters candidates as part of their practicum
Training and orientation of newly hired quality coordinator
Performing close follow up on main tasks conducted by quality coordinator
Arranging weekly meetings with heads of departments to follow up on pending tasks and provide support or assistance

Notable contributions

Setting a quality management system including policy and procedure manuals for all departments
Creating a culture of quality and safety, and persuading reluctant staff to adopt this culture
Creating a new Central Supply Sterilization Department (CSSD) to eliminate risk of infection and cross contamination
Improving patient satisfaction by 15% over the years 2011 to 2014
Creating a patient-centered approach to all healthcare services provided

Devising and/or revising policies, procedures and forms for all hospital departments
Applying accreditation standards set by the Ministry of Public Health
Conducting monthly audits on all departments to assess the level of compliance to policies and accreditation standards
Performing root cause analysis and failure mode effect analysis (FMEA) for arising problems
Setting key performance indicators (KPIs) and quality improvement plans (QIP) in coordination with heads of departments
Revising and updating statistical reports prepared by all hospital departments
Investigating incidents reported to the Quality Department, reporting on a quarterly basis and issuing necessary recommendations
Devising hospital emergency preparedness plan
Devising patient satisfaction questionnaire, reporting on a quarterly basis and issuing necessary corrective actions
Devising employee satisfaction questionnaire
Devising and/or revising orientation manuals and checklists for all hospital departments
Conducting EPP Projects (Evaluation of Professional Practice) on Safe Surgery and Cost Effectiveness
Maintaining and updating physician credentialing files
Member of the following committees: Accreditation and Quality Committee, Medical Committee, Administrative Committee and Operating Room Committee.

Research Topics
The Association between the Quality of the Work Environment and the Intention to Quit Work among Direct Healthcare Providers in Long Term Geriatric Facilities
Effect of Leukotriene Antagonists Treatment on Adenoid Hypertrophy and Implications for Management
Prevalence of Burnout Syndrome among Lebanese Faculty Physicians: a study from two academic centers
Pulmonary Tuberculosis among Expatriates Screened