Overview

Reporting to the Executive Director, the Senior Manager, Quality and Patient Safety ensures high quality, patient-centered care by facilitating the daily operations of the Quality & Patient Safety Program (QPSP). This program includes: Accreditation, Clinical Process Improvement, Clinical Risk Management, Data Resources Management and Infection Prevention & Control. The Manager works closely with facility leadership to optimize and meet hospital strategic goals and objectives. The Manager collaborates with the Corporate Quality Office to develop and implement programs, initiatives, and improvement strategies, in compliance with corporate objectives, applicable laws, regulations, and other governmental requirements. The manager promotes interdisciplinary collaboration; fosters teamwork and champions service excellence throughout the facility. The manager serves as a resource and subject matter expert to proactively address quality and patient safety issues. The manager provides supervision for robust process improvement projects ensuring high reliability methods, quality measures monitoring and ongoing regulatory
compliance and readiness.

Responsibilities

• Oversees the development and refinement of the department\xe2\x80\x99s strategic plans and initiatives and continuously monitors progress and development in alignment with the facility strategic goals and direction.
• Provides support, advice and direction on related issues that have a strategic impact on the business.
• Provides leadership direction and ensures high performance of the Quality and Patient Safety program.
• Work towards meeting departmental strategies and KPIs and display a shared commitment towards contributing to the Hospital\xe2\x80\x99s mission & vision.
• Ensure providing services that are in compliance with all applicable standards and requirements of Joint Commission International (JCI), Legislation, Policies, Quality Standards, DOH/DHA, and all other applicable regulatory bodies.
• Responsible for the direction and oversight of the organization\xe2\x80\x99s continuous survey readiness, maintaining current knowledge of regulatory and accreditation standards.
• Provides leadership direction and ensures high performance of the Quality and Patient Safety program.
• Coordinates programs and/or processes designed to assess and evaluate the risk, quality and safety of patient care and outcomes including medical staff quality processes.
• Oversees the collection, analysis, and reporting of quality and patient safety data in relation to cost containment, performance improvement and outcomes.
• Ensures the facilitation, validation and reporting of all improvement activities addressed at different levels.
• Serves as a resource and subject matter expert to proactively address quality and patient safety issues.
• Conducts audits, incident investigations and inspections as and when required and reports results to senior management and the relevant caregivers.
• Presents QI data at the organization\'s various QI committees and to senior leadership.
• Develops, implements, and monitors the clinical risk management program taking a proactive approach to ensure incidents and near misses are reported to help minimize and mitigate clinical risk.
• Provides expert advice, support, and guidance to the organization when serious incidents and significant events occur/ensures internal and external deadlines are met and actions implemented.
• Provides oversight in the use of proactive risk management tools such as Failure Mode Effect Analysis Analyses and reactive analysis tools such as root cause analysis.
• Facilitates the development and maintenance of risk registers, ensuring that these correlate with risks identified from patient safety incidents.
• Identifies and leads process improvement projects and teams.
• Manages a portfolio of activities to ensure regulatory compliance including mock inspections, surveys, and tracers.
• Serves as a subject matter expert regarding UAE, DOH/DHA laws and regulations, JCI standards and other accreditation agencies.
• Assists in all accreditation and regulatory activities, including surveys, survey preparation, readiness assessments and Tasneef audits.
• Collects, validates and reports data related to hospital accreditation, specialty certification, Department of Health and/or Dubai Health Authority regulatory requirements and Jawda Data Certification (where

applicable). * Submits data per internal requirements (i.e. QSC and Mubadala Health Corporate) and regulatory requirements (i.e. quarterly Jawda reporting).

• Provides leadership direction and ensures high performance of the Quality and Patient Safety program.
• Coordinates programs and/or processes designed to assess and evaluate the risk, quality and safety of patient care and outcomes including medical staff quality processes.
• Oversees the collection, analysis, and reporting of quality and patient safety data in relation to cost containment, performance improvement and outcomes.
• Ensures the facilitation, validation and reporting of all improvement activities addressed at different levels.
• Serves as a resource and subject matter expert to proactively address quality and patient safety issues.
• Conducts audits, incident investigations and inspections as and when required and reports results to senior management and the relevant caregivers.
• Presents QI data at the organization\'s various QI committees and to senior leadership.
• Develops, implements, and monitors the clinical risk management program taking a proactive approach to ensure incidents and near misses are reported to help minimize and mitigate clinical risk.
• Provides expert advice, support, and guidance to the organization when serious incidents and significant events occur/ensures internal and external deadlines are met and actions implemented.
• Provides oversight in the use of proactive risk management tools such as Failure Mode Effect Analysis Analyses and reactive analysis tools such as root cause analysis.
• Facilitates the development and maintenance of risk registers, ensuring that these correlate with risks identified from patient safety incidents.
• Identifies and leads process improvement projects and teams
• Manages a portfolio of activities to ensure regulatory compliance including mock inspections, surveys, and tracers.
• Serves as a subject matter expert regarding UAE, DOH/DHA laws and regulations, JCI standards and other accreditation agencies.
• Assists in all accreditation and regulatory activities, including surveys, survey preparation, readiness assessments and Tasneef audits.
• Collects, validates and reports data related to hospital accreditation, specialty certification, Department of Health and/or Dubai Health Authority regulatory requirements and Jawda Data Certification (where

applicable). * Submits data per internal requirements (i.e. QSC and Mubadala Health Corporate) and regulatory requirements (i.e. quarterly Jawda reporting).

• Oversees the implementation of the division\'s policies and procedures in order to ensure all relevant requirements are fulfilled.
• Guides in implementing clinical processes supporting evidence-based practices.
• Drives the implementation for robust process improvements ensuring high reliability methods, quality measure monitoring, and in adherence with ongoing regulatory compliance and readiness.
• Leads the collaboration with the concerned departmental heads in reviewing, documenting and updating their policies and procedures in a timely manner.

Qualifications

This role is for Healthplus IVF

Education:

• Bachelor\xe2\x80\x99s Degree in nursing, Healthcare Management or equivalent field
• Certified Professional in Health Care Quality (CPHQ) or equivalent required or within 12 months of hire

Experience:

• A minimum of five (5) years in healthcare Quality and Patient Safety are required.
• A working knowledge of Quality Improvement principles and statistical methodologies and experience in oversight/management of regulatory compliance is required.

Job Specific Skills and Abilities:

• Strong knowledge of evidence-based practices or guidelines for clinical care and quality and patient safety
• Excellent communication and interpersonal skills.
• Strong statistical analysis or quantitative analysis
• Proficiency with Microsoft Office suite
• Fluency in written and spoken English

Mubadala Health