Participate in the review of the hospital-wide quality improvement plan and implement its requirements
Provide support to departments/services in the selection of their quality measures
Coordinate quality review activities and track the data collected on the selected measures and prepare data collection sheets for the review activities, and Integrate data collected by various departments/services
Review and analyze clinical data to monitor for specific trends and patterns and to collect data for quality reviews
Analyze results and submit reports to the quality and patient safety committee
Provide staff training on quality principles and tools
Assist with monitoring of unusual occurrences
Utilize the appropriate performance improvement tools and techniques to identify problems and design action plans
Participate in root-cause analysis teams and other task forces related to quality and patient safety
Support all departments/services to comply with the national and international regulatory surveys/accreditation processes to ensure compliance with the accreditation standards.
Facilitate and coordinate amongst the various hospital departments to obtain and maintain the following accreditations:
JCI Accreditation (2 times)
ISO 9001 (2 times)
ISO 22000 (2 times)
HCAC Accreditation (2 times)