• Has in depth knowledge of the standards, measurable elements and objectives of DOH and JCI.
• Develops the hospitals quality improvement plan.
• Participates effectively in the implementation & follow up of Q.I plan activities.
• Undertakes quality improvement initiatives & activities
• Serves as a resource to all departments, division and units and ambulatory and establishes committees relating to Quality Assurance.
• Promotes and facilitates cost-effective resource utilization related to infection control policies and procedures.
• Establishes priorities for investigation of problem areas based on the degree of adverse impact on patient care that can be expected if the remains unresolved.
• Develops and monitors effective patient care review and evaluation mechanisms to assure results are achieved.
• Directs implementation and maintenance of technical guidelines and frameworks within which quality of care is evaluated.
• Liase with quality facilitators to coordinate staff education, variance collection and analysis.
• Establish system-wide variance database for benchmarking, system improvement, opportunities, length of stay and resource management
• Provides ongoing assessment and support for continuous quality improvement, quality assurance and risk management priority programs and supports its infrastructure.
• Based on the evaluation of the patients medical records intensifies concern areas and plans for the improvement.
• Communicates appropriate information form studies and data sources to committees, departments and persons affected by the studies.
• Identifies and shares across the system best practice models and care processes those, which achieves optimal patient outcomes, enhance patient/family and staff satisfaction are cost effective and resource appropriate.
• Maintains all necessary records pertinent to the DOH , JCI and OSH process.
• Facilitates Quality improvement plan meetings.
• Submits monthly reports of quality activities to the QPS Committee.
• Maintains records of policies, procedures, guideline, forms and other documents and ensures the circulation of current documents and the de-circulation of expired documents.
• Maintains records of all quality assurance activities.
• Provides educational and technical assistance to committees and departments in meeting their quality assurance objective.
• Activly involved in all aspects of clinical space design, construction and hygiene.
• Performs administrative responsibilities.
• Justifies need for training in quality assurance process working with appropriate groups to initiate training to teach in areas of expertise.
• Coordinates and monitors all Joint Commisssion on Accredition compliance activities and participates in the survey process.
• Coordinates Mock survey.
• Does an Annual Evaluation of Quality Improvement program and submits reports to the QPS committee.
• Develops training/orientation program for key members to facilitate system expansion and standardization.
• Demonstrates ability to perform under pressure.
• Promotes a culture of safety in the department /& across the hospital.
• Supervise and help in formulating and executing the JDC Methodology, JAWDA KPIs process, audits, accreditations, certifications and preparing reports and reporting the status to Chief Quality officer

NMC Healthcare