Vernon Recreo

• Led the development and dissemination of the patient safety, risk, compliance and patient experience strategies within 2 sites - Finchley Memorial Hospital and Wood Green CDCs.
• Foster a culture amongst teams that ensures clinical quality, risk management and patient experience remain one of the top priorities within the service.
• Support the investigation leads of the Trust in the investigation of Serious Incidents using root cause analysis methodology.
• Write quality reports which clearly identify the issues, lessons learnt and changes to practice for shared learning, quality initiative and continuous improvement.
• Investigate patient concerns and complaints, feeding back to patients and drafting written responses supported by monthly reports to the Division.
• Enable all staff to actively participate in identifying, actioning and evaluating all patient safety, risk and patient experience issues.
• Analyse trends to ensure actions are put in place to reduce the risk of recurrence.
• Lead and support the communication and management of the issues through Datix in line with Trust policy.
• Triangulate all patient safety and patient experience data to ensure service focus is appropriate to risk and protects patient safety.
• Support clinical leads with CQC self-assessments and preparation for CQC inspections.
• Collate and review audit information to support service improvement.
• Work for both Finchley Memorial Hospital (FMH) and Wood Green (WG) to develop, implement and monitor an effective and compliance system of working to ensure robust quality governance for the community diagnostic hub which is in line with ISO 9001, ISO 45001, NICE, UKAS and CQC.
• Act as a self-relating practitioner who horizon scans to ensure service governance activities remain in line with current best practice, using initiative to implement changes when relevant in line with defined policies.
• Support and develop a culture of informed questioning, challenge, trend analysis triangulation to ensure lessons are learned and the business unit changes practice in a way which has a positive effect on patients, outcomes, patient experience and supports the trust ambition to reach zero avoidable harm
• Responsible for all aspects of the quality governance agenda for the CDC (FMH and WG), developing an effective patient safety framework that is quality centric.
• Ensure delivery of the rolling programme of governance activities in line with trust, business unit, hospital and service requirements.
• Investigate PALs and complaints, drafting response letters for the relevant Director of Nursing/Medical Director/Chief Executive
• Analyse complex information from complaints, PALS, claims, incident investigations (including serious incident investigations) and audits and working with performance and contracting colleagues to support the establishment of appropriate action plans to bring about positive change.
• Provide monthly, quarterly and yearly reports triangulating information and data from service activity including compliance performance, incidents, risks, complaints and PALS. Develop visual management systems to display such data for the service.
• Leading the management of Serious Incidents and the sharing of learning from these incidents. This includes reviewing and ensuring that investigations have been appropriately carried out in accordance with agreed guidelines and timeframes and to determine if the investigation is fair and/or in need of further information or interviews and providing feedback on key areas for improvement, challenge or further actions.

• Led and directed cross-functional teams (registrations, documentation & inspections) on governance initiatives to ensure compliance with CQC and UK health regulations
• Ensured all CQC registration and registered manager applications of our clients are checked and scrutinised according to the mandatory and statutory requirements of CQC
• Provided expert advice to registered managers, nominated individuals and operational managers on amendments in CQC regulations and updates.
• Oversight of Clinical Governance and the quality of care delivered by the clients
• Delivered Registered Manager Interview Preparation Training to all clients.
• Conducted thorough audits and mock inspections.
• Guided all clients in meeting the Standards and Key Lines of Enquiries (KLOEs).
• Collected and analysed data to improve the risk management system and minimise accidents and near misses.
• Advised on the implementation of effective and efficient clinical pathways and care plans.
• Translated identified non-conformances into opportunities and lessons learned. Cascade the best practices to a wider team and aim for continual improvement.
• Ensured all policies and procedures for all regulated activities including safeguarding are documented, monitored and properly implemented.
• Developed an agreed strategy with clients and their stakeholders on improving the CQC ratings of their organisations.
• Provided expert advice and guidance in safeguarding principles and issues, including support in complaint investigations where required.
• Knowledgeable of CQC registered service provision within care homes and nursing residential services.
• Knowledgeable in statutory requirements for registration and notifications including legislative and regulatory framework

A. Governance & Compliance
• Overseen the implementation and compliance of all Service Level Agreements (SLAs) and Memorandum of Understanding (MoU) between QR The Medical Centre and all healthcare service providers/facilities in Qatar and all Outstations across the globe. The sphere of governance did not only include the clinical requirements stipulated as per SLA but also the financial correlation as a result of using our third party health insurance (Allianz) for our 45, 000 employees located in 186 destinations worldwide; and the financial impact on our health insurance annual budget.
• Managed the efficient operations (clinical, administrative and financial) of the following departments within QR The Medical Centre: AeroMedical Centre (AeMC), Primary Care, Occupational Health & Safety, QR Medical Commission (QR MCom), Outsourced Service Providers, Psychology, Pharmacy, Nursing and Admin.
•Managed compliance requirements of QR The Medical Centre against international and national quality standards, legislative, regulatory and membership bodies such as Joint Commission International (JCI), UK Care Quality Commission, UK Royal College of General Practitioners, ISO 9001:2015, EASA, FAA, CASA, CAR, QCAA, Qatar Council for Healthcare Practitioners & Ministry of Public Health Qatar.
•Managed the full implementation of EU GDPR, Qatari Law No.13/2016 and Consent Policy for data protection, privacy of information, and protection of personal data
•Overseen and managed project budgets and overall budgets for the financial year
•Led the commissioning of new processes, equipment and software and establish contractual agreements for third party healthcare providers, subcontractors and suppliers.
•Led the QCAA accreditation of QR AeMC as the first AeMC in Qatar. Awarded 12 Dec. 2018
B. Risk Management and Safety
•Identified detrimental risks in the operations and translated them into Medical Risk Register Report with guidance from QR Enterprise Risk Management (ERM). Managed the implementation of mitigations, treatment initiatives & actions and lessons learnt. Maintained and updated the quarterly Medical Risk Register covering all departments and service providers
•Led the Business Continuity Plan and Strategy of QR The Medical Centre which is aligned with QR Total Business Continuity Plan
•Led and manage the Evacuation Procedure and Fire Safety Programme.
•Ensured compliance with all security laws and regulations within all areas of QR The Medical Centre as per Ministry of Interior requirements. Robust monitoring of all CCTV systems.
C. Quality Management Programs
•Developed, defined and implemented Quality Management System which embededPolicies, Procedures, Work Instructions, Guidelines and Forms to ensure compliance with legislative and regulatory bodies such as Joint Commission International (JCI), UK Care Quality Commission, UK Royal College of General Practitioners, ISO 9001:2015, EASA, FAA, CASA, CAR, QCAA, Qatar Council for Healthcare Practitioners & Ministry of Public Health Qatar.
•Delivered continuous improvement and minimised risks & harm through strategic implementation of robust quality assurance, control and security standards. These were driven by programs which effectively measured, assessed, evaluated and continually improved the quality of care and services provided to the patients.
•Developed a strategic annual audit plan for all processes within QR The Medical Centre. This was a rolling audit programme with audit cycles.
•Defined, established and implemented quality metrics and key performance indicators (KPIs) and specified how these would be applied for monitoring, evaluation and quality improvement.
•Led in identifying quality, risk management and health & safety issues. Initiated development plans to address improvement opportunities.

• Ultimate clinical governance and quality assurance of National Screening Programme.
• Delivered continuous improvement in patient care and minimising risk and harm of patients through strategic implementation of robust quality assurance and standards.
• Governed systematic improvements in clinical governance of national screening programme.
• Creation and organisation of periodic, routine and adhoc analysis, evidence-based comparative studies and comprehensive reports for the Health Minister, National Cancer Committee and stakeholders (PHCC, HMC).
• Identified detrimental risks in the programme and risks from cancer screening implementation at healthcare provider’s level (PHCC and HMC) and translate them into the Risk Register Report for the Health Minister and National Cancer Committee.
• Implemented quality metrics and performance indicators to monitor service performance
• Reviewed, translated and implemented new national guidelines and legislation related to clinical governance.
• Developed a robust and effective mechanism in responding to complaints and concerns from patients and service users.
• Led and managed the clinical governance of the National Cancer Programme and National Cancer Screening Services to meet international healthcare delivery standards and changing demands of the services.
• Managed the quality assurance of all the cancer screening data received from PHCC and HMC.
• Addressed clinical audit findings and corrective actions required to all key stakeholders.
• Developed an organised population-based screening across the state of Qatar.
• Established the aims and objectives of Qatar Bowel, Breast and Cervical Cancer Screening Programmes.
• Collaboration with the National Cancer Committee, Hamad Medical Corporation (HMC), Primary Health Care Corporation (PHCC) and other stakeholders to develop an organisational and service model for all screening services.
• Defined quality metrics and key performance indicators for bowel, breast and cervical screening programmes and to specify how these would be applied for monitoring, evaluation and quality improvement.
• Ensured all areas under direct management were safely delivered with optimal utilization of personnel and equipment.
• Effective implementation of evidence-based clinical pathways to ensure that the services provided are in parallel to the standards of Qatar regulations, JCI accreditation and other professional associations.
• Developed policies, procedures and guidelines; and equally monitored and reported all related activities embedded within these documents with emphasis on health care quality and safety initiatives.
• Maintained and updated the QMS guided by the performance improvement programs such KPIs, Infection Control, Peer Review, Performance Review, Patient Safety, Patient Satisfaction, Cancer and Screening Registries and Core Measures.
• Liaised with stakeholders (PHCC, HMC or other private providers) on quality, risk management and health & safety issues. Initiated development plans to address improvement opportunities.
• Provided guidance in establishment of cancer screening activities to reach clinical consensus about the screening pathway for colorectal, breast and cervical cancers.
• Interpreted and translated highly complex clinical information and standards.
• Responsible for co-ordination and management of programmes for quality improvement, patient safety, and compliance initiatives, providing resource for best practice, regulatory compliance and performance improvement of the institutions and its services.
• Facilitated and translated the definition of goals and deliverables within the programmes.
• Monitored and reported on progress of the projects to the Director and other key stakeholders in National Cancer Committee, Primary Health Care Corporation, HMC and Qatar Foundation.

• Effectively implemented, delivered and maintained the Quality Management System
(QMS) and Clinical Governance in Cancer Screening Programmes, and achieved the requirements of the National Cancer Screening Programmes, London Quality Assurance Reference Centre, ISO 9001:2008 and St. George’s University Hospitals NHS Foundation Trust.
• Supervised and directed the Clinical Governance, Quality Management, Risk Assessment processes including Health & Safety Standard and Patient Care & Safety documentation across the programmes and host Trust, with appropriate scientific, technical and ancillary support.
• Implemented robust systems to continually 1) improve the quality of the services, 2) work processes, 3) minimise risks and 4) create value for patients across all screening programmes.
• Demonstrated competency in the analytical assessment of Quality Assurance data and in the application Quality Control results.
• Delivered prompt investigation and complete resolution of near misses, incidents and complaints from service users in conjunction with colleagues. Monitored corrective actions and improvements.
• Ensured compliance to documented and controlled quality standards, policies, procedures, work instructions and guidelines.
• Delivered effective internal audits and audits external to the Service. Managed NCR and CAR data (identification, evaluation, review, discrepancy resolution)
• Instigated a rolling multi-disciplinary clinical audit programme against defined quality performance measures covering all aspects of Quality Management System.
• Organised management and quality review meetings to highlight operational issues.
• Identified areas and initiated projects where there is potential for improvement of quality to the benefit of the Service.
• Supported the Director and Programme Manager in the planning and implementation of contingency arrangements to enable the continuance of service under any circumstance.
• Participated in valuation of tender specifications, procurement, implementation and information management of equipment within the Quality Management System.
• Carried out relevant research and development activities under the direction of the
Director and Programme Manager.
• Facilitated the implementation of safety instructions and notices to all section staff
\[i.e. Material Safety Data Sheet (MSDS), Control of Substances Hazardous to Health (COSHH)\].
• Managed the calibration of all equipment being used by the programmes.
• Provided Quality Systems and Health & Safety trainings to members of staff.

• Robust, effective and uniform implementation of the Quality Management System in accordance with the requirements of ISO 9001:2008 at a regional level.
• Advised the Director of Quality Assurance and Head of QA on the QMS performance of the programme and KPI’s, units and individuals, with due regard for confidentiality.
• Provided Primary Care Trusts (PCTs), and Trust Management with advice on QMS performance and good Clinical Governance.
• Co-ordinated and monitored the implementation of national cancer screening guidelines.
• Acted as resource to provide specialist advice and expertise in cancer screening quality management systems (QMS).
• Led, co-ordinated and monitored quality assurance activities for the QMS profession in the London Cancer Screening programmes. Screening Centres covered in London - West of London, North London, Central and East, South East and Barking, Havering, Redbridge & Brentwood.
• Handled, investigated and resolved all client complaints.
• Represented QMS at national, regional levels and providing effective communication to disseminate relevant information.
• Provided support, advice and information to ensure QMS quality assurance standards are met.
• Primary point of contact for all Quality related issues across the covered region.
• Participated in Quality Assurance Visits, Right Results Walkthrough, Peer Review and inter unit exchange visits.
• Chaired the London QMS Co-ordinator’s Group and attend relevant regional and national meetings.
• Developed and maintained links with the Chairs of the Health Promotion and QMS Groups.
• Conducted QMS and Health & Safety trainings to new staff as and when required.
• Co-ordinated and contributed to the identification of quality issues arising from other disciplines and assist the Head of QA and QA Director as required.

• Executed the robust development and implementation of Quality Assurance Programme in contract business operations which include airline equipment logistics (in-flight alcohols, duty free products, laundry, cutlery, etc.), food logistics (food safety, food preparation, hygiene and H&S) and deployment of transport fleet for airside/tarmac utilising ISO 9001:2008, ISO 22000:2005, OHSAS 18001:2007 and BRC Global Standard for Food Safety.
• Ensured that Quality Assurance Programme was maintained and aligned with British Airways’ policies, procedures and methodologies. Reviewed, developed, monitored and maintained
all QMS documents such as Quality Manual, Policies, SOPs, Work Instructions and Protocols.
• Promoted continuous improvement and monitored compliance through internal and
external auditing throughout all business operations and areas such as food production
areas and assemblies, kitchens, bakery, fridges, dry goods, storage warehouses, airport lounges, transport vehicles and aircrafts in tarmac.
• Conducted scheduled and ad-hoc internal audits & external audits (suppliers and subcontractors) in food safety, HACCP, Health and Safety, hygiene, GMP & pest control.
• Developed, instigated and maintained a rolling audit programme (audit schedules) covering all business areas incorporating all the international and national standards.
• Managed the corrective action implementation programme.
• Reviewed and evaluated KPIs, audit reports, trends and recommended performance & improvements. Participated in evaluation and commissioning of new equipment
• Recorded, investigated and resolved completely all customer complaints.
• Conducted risk assessments (incl. HAZOP studies and Near Misses) of facilities, processes, equipment and any staff activities as required (guided by UK H&S Regulations).
• Conducted scheduled trainings for Food Safety & Hygiene; Health & Safety and Safe Work Practices; Process Critical Control Points (HACCP) and Standard Operating Procedures.
• Improved the product acceptance procedures for all incoming raw materials and analysed trends that could affect operational costs and processes by using Statistical Process Control.
• Achieved performance target for Food Safety and Health & Safety for 2007 through effective implementation of corrective action plan.
• Decreased the number of complaints by reviewing the quality procedures and implementing Hazard Analysis Critical Control Point (HACCP) for each core processes.
• Minimised raw material rejection up to 80% for 2007 by increasing supplier audit frequency.
• Eliminated RIDDOR cases by conducting regular Health & Safety meetings with the management team and ensuring H&S issues have been addressed, rectified and resolved.
• Liaised with external regulatory bodies (i.e. Environmental Health Officer) to ensure local laws and regulations were followed by the facilities across the region.

• Reviewed, updated and developed QA procedures and protocols to maintain BRC Global Standard for Food Safety.
• Conducted internal audits within the factory and external audits with suppliers and customers (Waitrose, Marks & Spencer, Sainsbury’s, Tesco, Morissons, Pizza Express and Co-op).
• Investigated customer complaints and resolved accordingly within timeframe.
• Performed weekly calibration and verification of equipment used in the facility.

• Drove food safety, hygiene and health & safety standards in a company with more than 500 staff covering 24-hour continuous operation.
• Conducted internal and extensive supplier audits (including Subcontractors) and inspections (food safety, GMP, HACCP, hygiene, pest control, product acceptance, H&S).
• Developed internal and external auditing procedures and verified their effectiveness and impact on batch and continuous manufacturing processes.