Manager, Quality and Patient Safety

Overview

The Manager, Quality and Patient Safety ensures high quality, patient-centered care by leading facility quality and patient safety activities. 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 eamwork 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

KEY DECISIONS THE ROLE MAKES AND THE EXTENT OF THE IMPACT OF THE DECISION

• Translates the organization’s vision into strategic plans for the Quality division.
• Participates in organization-wide strategic decisions on quality assurance and controls and leads operational implementation of policies, processes and programs.
• Work towards meeting departmental strategies and KPIs and display a shared commitment towards contributing to the Hospital’s mission and vision.
  
  

Key Accountabilities And Activities

Business Strategy

• Oversees the development and refinement of the department’s strategic plans and initiatives and continuously monitors progress and development in alignment with the facility strategic goals and direction.
• Provides leadership direction and ensures high performance of the Quality and Patient Safety program.
• Works toward meeting departmental strategies and KPIs and display a shared commitment towards contributing to the Hospital’s mission & vision.
• Ensures providing services that comply 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’s continuous survey readiness, maintaining current knowledge of regulatory and accreditation standards.
• Fosters a culture of safety and Just Culture.
  
  

Quality Operations

• 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.
• Collects, analyzes, and reports quality and patient safety data in relation to cost containment, performance improvement and outcomes.
• Serves as a resource and subject matter expert to proactively address quality and patient safety issues.
• Provides ongoing assessment and guidance for continuous quality improvement, quality assurance and risk management and supports its infrastructure.
• Conducts audits, incident investigations and inspections as and when required and reports results to senior management and the relevant caregivers.
• Oversees the conduction of surveys and/or site visits by external parties as and when required.
• Provides educational and technical assistance to caregivers in selecting improvement measures and using continuous improvement tools.
  
  

Quality Improvement

• Participates in the development of the Quality and Safety Plan which is aligned to the strategic plan of the organization.
• Facilitates internal audits periodically to evaluate effectiveness of the Quality and Safety Plan.
• Coordinates the identification of performance criteria including benchmarks, frequency of data collection, and validation.
• Analyses complex, multi-factorial data emerging from stakeholders. This will require fluency with quality improvement charts and ability to analyze relevant and appropriate trends and shifts in data that might be attributable to the improvement approach.
• Acts as resource or consultant to committees/departments/services in Quality Improvement.
• Identifies and leads process improvement projects and teams.
  
  

Regulatory Readiness

• Imbeds an ‘accreditation ready’ approach across the organization to maintain regulatory and accreditation compliance.
• Manages a portfolio of activities to ensure regulatory compliance including mock inspections, surveys, and tracers.
• Coordinates the dissemination of results of inspections and audits.
• Leads the activities during and following regulatory and accreditation inspections and internal audits.
• Identifies and escalate significant non-conformance with laws, regulations, or standards to Director of Clinical Governance.
• 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).
  
  

Clinical Risk Management

• 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.
• Champions and promotes quality as a key focus when reviewing the learning from incidents to improve patient outcomes and effectiveness.
• Ensures that all clinical services have in place, mechanisms for reviewing and analyzing themes arising from incidents, monitoring implementation of action plans, and that learning from incidents are identified and disseminated.
• Acts as a resource or consultant to committees/departments/services in Clinical Risk Management.
  
  

Policies, Processes and Procedures Improvement

• Oversees the implementation of the division's policies and procedures to ensure all relevant requirements are fulfilled.
• Guides in developing and 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 policies and procedures in a timely manner.
  
  

Self and People Management

• Provides input in areas of manpower planning including recruitment, training, capability enhancement and drives a high level of caregiver engagement.
• Oversees the efficient utilization of the division's resources including its people, processes, and technology requirements.
• Promotes and provides continuous constructive feedback and coaching to employees and takes prompt action where necessary to ensure progressive development.
• Establishes clear direction, assigns, and delegates responsibilities effectively to ensure smooth operational flow.
• Builds opportunities for employees to suggest, participates and contributes to improvement, innovation and knowledge sharing.
• Maintains and promotes professionalism and confidentiality at all times as per the organization's standard code of conduct.
  
  

Education & Training

• Actively participates in organizational training programs and on the job learning to continuously enhance skillset required to perform the job.
• Ensures Caregivers at all levels are educated on high reliability methodologies in support of evidence-based practices, the reduction of medical/health care errors and other factors that contribute to unintended adverse outcomes.
  
  

Engaging with Stakeholders

• Liaises with external parties such as Department of Health (DOH), JCI, and other relevant accreditation and Government bodies on all matters related to the external audit and accreditation process.
• Oversees the implementation of High Reliability and Safety within the facility. Facilitates consistency in facility policies and practices.
• Champions a proactive patient safety, quality improvement and risk management culture that reflects best practice.
  
  

Communication

• Strong written and verbal communication skills, with the ability to tailor messages to a variety of audiences throughout the organization.
• Communicates clearly and impactfully to achieve high productivity and to maintain strong relationships with external/internal stakeholders and team members.
• Maintains good interdivisional liaison to ensure smooth implementation of strategic and operational activities.
  
  

Qualifications

Education

• Bachelor’s 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 three (3) years in healthcare Quality and Patient Safety.
• A working knowledge of Quality Improvement principles and statistical methodologies and experience in oversight/management of regulatory compliance
• Experience in managing large, complex projects and initiatives.