Assistant Director Quality and patient safety
Shaukat khanum Hospital and Research Centre Peshawar
Total years of experience :11 years, 10 Months
JCI Enterprise 1 edition accreditation Lahore, Peshawar and Karachi sites.
JCI Ambulatory Care 4th Standard accreditation.
JCI 7th Standard accreditation.
Develops Quality and strategic plans on yearly basis and provide comparative assessment report to Program Director (Major General) of Armed forces hospitals Southern region.
Active Participant and Chairman of Data Validation Team of accreditation and Data Management Unit (JCIA and CBAHI Standards) in Armed Forces Hospitals Southern Region to ensure the effective implementation of all JCIA standard requirement and involving Data report writing, Analyzing and Interpreting on weekly, monthly, quarterly and yearly basis for re accreditation.
Heading various Quality improvement and Hospital Strategic project, Medical Supplies Improvement(Critical and Non-critical zero stock medication, Direct purchase and Expired Medication), Self Finance (Targeted income from approved budget, Service Provided by private sector Out of Targeted), Operating Room Utilization ( URAC 20$ Per Minutes OR Utilization 83.5%) Emergency Room Utilization (Boarding time, Median time arrival to departure), ICU Utilization, OPD Utilization, IPD Utilization and others non clinical department utilization as per Utilization review and Accreditation Council.
Conduct frequent tracer, audit and prepare self assessments report chapter vise for reaccreditation of JCIA, AABB, CBAHI, CAP.
Collaborates with hospital and physician organization leaders to envision, develop, and
implement the organization’s quality and patient safety plan.
Creates functional strategies and specific objectives for the sub-function and develops budgets/policies/procedures to support the functional infrastructure.
Conduct frequent Trainings and Teaches quality and patient safety concepts to clinicians, trainees, and other staff in various educational settings.
Manage patient’s satisfaction through Datix in region with more help of WIPRO and Oracle.
Organizes and staffs the hospital and board quality committees and key strategic CQI/PS initiatives.
Establishes quality measurement and improvement activities, including methods to track
implementation of action plans following site surveys and critical events reviews. Participates in root cause analyses and failure modes and effects analyses and debriefings.
Submitting more than 94 Hospital wide and departmental vide Hospital KPI to medical services directorate (MSD) on monthly, Quarterly and Yearly basis and maintain the confidentiality of data.
Achieves quality assurance operational objectives by contributing information and analysis to strategic plans and reviews; preparing and completing action plans; productivity, quality, and customer-service standards; identifying and resolving problems; completing audits; determining system improvements; implementing change according to JCIA 6th Edition.
Meets quality assurance financial objectives by estimating requirements; preparing an annual budget with Quality perspective; scheduling expenditures; analyzing variances; initiating corrective actions.
Develops quality assurance plans by conducting hazard analyses; identifying critical control points and preventive measures; establishing critical limits, monitoring procedures, corrective actions, and verification procedures; monitoring inventories.
Validates quality processes by establishing product specifications and quality attributes; measuring production; documenting evidence; determining operational and performance qualification; writing and updating quality assurance procedures.
Maintains and improves service quality by completing Service, Hospital, system, compliance, and surveillance audits; investigating customer (Patients) complaints; collaborating with other members of management to develop new Service and engineering designs and training methods.
Prepares quality documentation and reports by collecting, analyzing and summarizing information and trends including failed processes, stability studies, recalls, corrective actions, and re-validations.
Enhances department and organization reputation by accepting ownership for accomplishing new and different requests; exploring opportunities to add value to job accomplishments.
TQM Department is liable for effective implementation of quality management system in northern western region of Saudi Arabian Armed Hospital by complying institutional rules and govt. regulations & to strive for hospital accreditation according to JCI standards, CBAHI, ISO IMS (9001, 18001, 14001).
Why-Why Analysis to obtain solution of problem to fix the process variation.
Utilize six sigma and yield calculator to oppress the lean in different healthcare process.
Responsible for Measurement System Analysis, Gauge repeatability and reproducibility tests to minimize the measurement errors.
Responsible for SIPOC diagram to acquire procedure deep study to obtain the process flow of each step running in the department.
Seven QC Tools (Pareto, Bar, Cause and Effects, Control Chart etc.) use for Data Information and Analysis.
Fix and Analysis of OVA (Occurrence variance accident report) according to JCIA given procedure (Sentinel event, adverse event, Near miss).
Patients Satisfaction survey according to JCIA method twice in year.
I am responsible of different CQI & PS reports such as Medical Services Division Reports (MSD), Program Management and Development Reports (PMD), International Patients Safety Goals Indicator reports, International Laboratory of Measurement Indicator Reports, Hospital Activity & Utilization Reports, Bench-marking and data Validation Reports, Operating Room Utilization Report, OPD Waiting time and OPD Doctor Utilization Report, Managerial Indicator (Inpatients Data), Department Performance Report (KPI), Patients Safety Survey.
To Standardize processes by having international standards certifications (ISO 9001:2008); project management, gap analysis, process identification and standardization, SOP implementation, system compliance assessment, certification and support for continual improvement Assist / Suggest Q.M.R. in developing training plan for management and staff.
To support and train personnel of certified functions on activities related to continuous improvement like 5S, Kaizen, Six Sigma, TQM, HSE and Lean.
To perform Job Safety Analysis, Risk Assessments, Incident Investigation, Incident Reporting and Controls identification to manage risks as low as reasonably practical.
Root cause analysis study for issues occur at customer premises using qualitative tools like Fish bone diagram and why-why analysis.
Ensure smooth running of operations on production Line by studying trends of control charts.
Use of statistical process control and seven QC tools for data analysis.
To ensure compliance against laboratory standard of ISO 17025
Develop Equipment Calibration schedule, Preventive maintenance schedule and work instructions for operators.
To carry out job safety analysis, risk assessments and outline safe operational procedures which identify and take account of all relevant hazards.
Conduct Total Quality Management training & Responsible for carry out External & Internal Audit.
Close interaction with vendors for design and development of new parts.
Monitor all Quality assurance function and Responsible to manage QA inspection team.
Responsible to follow procedure defined in quality management system for document & data control.
Responsible to assist management representative in maintaining QMS system.
Responsible for distribution of controlled documents
Responsible for Measurement System Analysis, Gauge repeatability and reproducibility tests to minimize the measurement errors.
Develop corrective action requests against any non-conformity and develop Performance reports of all suppliers.
To ensure ‘Permit to Work System’ in place and Safe Systems of Work available for different high risk activities.
To ensure emergency procedures are developed and relevant arrangements are in place.
Introduce different technique by the using of forecasting Analysis to transforming performance from Corrective to preventive measure.
Extrapolating data for quality assurance and monitoring purpose.
Analysis of Patients and Medical Students data (Medical Coding, Hypothesis, Descriptive Statistics).
Improve service Quality of Sharif Medical City Hospital (Gap Analysis, Service Quality Model Sources).
Recommends quality tools and techniques to be used in measuring the Hospital’s quality performance and variations; and solving quality problems.
Prepare different report for PHC (BOD, MSDS, SOP and Protocol) as well as for PMDC (Pakistan Medical and dental Council).
PhD Scholar working on thesis dissertation.
Strategic Human Resource Management, Quantitative Techniques, Strategic Quality Management, Statistical Process Control, Research Methodology, Project Management, Metrology & Testing Labs, Lean Six Sigma, Quality Management Systems & Standards
Production and Operation Management, Linear Algebra and Calculus, Introduction to Probability theory, Introduction to Programming-I, Introduction to Operation Research, Numerical Analysis, Statistical Inference, Linear Programming, Introduction to Programming-II, Data Base Management System, Stochastic Processes, Network Analysis, Introduction to Management, Simulation and Modeling, Decision Theory/Org. Design & Behaviour, Inventory Systems and Modeling, Statistical and OR Computing (SAS/QAS), Nonlinear and Dynamic programming, Nonlinear optimization, Reliability Theory, Queues and stochastic service systems, Applied simulation: Design and Analysis, Sequential optimization, Genetic Algorithms for tree-related structures, System Modeling Theory
Business and Commerce