The post holder will:

• Take on a Leadership role within the Facility and ensure patient safety and quality of care is upheld to the highest standards.

• Be the Lead contact for the organization for applicable regulatory body’ s initiatives on Quality, Patient safety, Risk management.

• • Collaborates with hospital/cluster leaders, department managers, physicians, and staff to envision, develop, and implement, designing and implementing systems that result in improved patient care management, improved clinical outcomes, increased workflow efficacy and efficiency, increase cost effectiveness as well as ensure high patient satisfaction and strategic initiatives.

• • Contribute to relevant Committees/ Groups such as the Quality Improvement & Patient Safety Committee and the Higher Management Committee.

• • Proactively educates leadership and staff regarding regulatory issues, new guidelines, and safety/quality performance improvement activities.

• • Help to support data collection throughout the hospital/cluster by assisting with data collection issues such as creating forms to collect data, identifying which data to collect, how to validate data, and creating reports.

• • Ensures data reported is validated and analyed for implementing improvements and evaluating if the improvements were sustained.

• • Promotes a culture of safety, high-reliability, patient and staff engagement, and performance excellenc

• • Has a deep understanding of the standards, measurable elements and intents for various accreditation bodies.

• • Developing Patient Safety & Quality Improvement Plan for the facility.

• • Participating effectively in implementing & follow up of Patient Safety and Quality Plan Activities.

• • Orchestrating Patient Safety & Quality Improvement Initiatives & Activities Hospital-Wide and cluster level.

• • Serves as a resource to all departments, divisions and units, hospital /cluster, and to established committees in all areas 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 problem remains unresolved.

• • Develops effective patient care review and evaluation mechanisms and monitors to assure results are achieved.

• • Directs implementation and maintenance of technical guidelines and frameworks within which quality of care is evaluated.

• • Arranges with Quality Facilitators in the unit for staff education, variance collection and analysis.

• • Establishes 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 for the Hospitals/cluster priority programs and support its infrastructure.

• • Based on the evaluation of the patient’s medical records identifies concern areas and plans for the improvement.

• • Communicates appropriate information from 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 achieve optimal patient outcomes, enhance patient/family and staff satisfaction, are cost effective and resource appropriate.

• • Maintains all necessary records pertinent to the accreditation process.

• • Facilitates Quality Improvement plan meetings.

• • Submits a quarterly report of quality activities to the CQPS committee.

  • • Approves data for submission to regulatory authorities including DOH on JAWDA KPIs, DHA KPIs & MOH KPIs etc as and when required.

  • • Maintains records of policies, procedures, guidelines, forms and other documents and ensures the circulation of current documents and the de-circulation of expired documents.

  • • Maintains records of all Patient Safety and Quality (PSQ)activities.

  • • Provides educational and technical assistance to committees and departments in meeting their PSQ objectives.

  • • Maintains active involvement in all aspects of clinical space design, construction and hygiene.

  • • Performs administrative responsibilities, applicable to the role.

  • • Justifies need for training in Continuous Quality Improvement processes and methods and either works with appropriate groups to initiate training or teaches in areas of expertise.

  • • Coordinates and monitors required Accreditations compliance activities and participates in the survey process.

  • • Mock surveys coordination.

  • • Does an Annual Evaluation of Quality Improvement Program and submits reports to the CQPS committee.

  • • Develops training/orientation program for key members to facilitate system expansion and standardization

  • • Performs miscellaneous related duties as requested by general manager.

  • • Be familiar with emergency and evacuation procedure.

  • • Notifying and optimizing the reporting of OSH Hazards, other incidents, Near misses and issues and assistance with the preparation of risk assessments

  • • Coordinate Risk management program of the facility in coordination with all stakeholders

  • • Attend applicable OSH/Infection control training programs, mock drills and awareness programs

  • • Ensure as far as reasonably practicable that any workplaces they manage, or control are safe and without risks to health, safety or the environment.

  • • Ensure implementation of applicable regulatory body standards, NMC OSHMS and infection control policies and standards.

  • • Ensure adequate budget and resources for FMS/OHS/PCI management.

  • • Designating a Safety facilitator who will be responsible for coordinating OSH activities within the department.

  • • Regularly discuss OSH issues or matters in departmental/ management meetings

  • • Ensure provision of OSH information, training and Supervision

  • • Implement and monitor effectiveness of risk management program

  • • To develop, monitor and support implementation of the hospital/cluster OSHMS in line with DHA/DOH/MOHAP/MOH Health Sector OSHMS policies and standards (and other policies and standards as applicable) and entity requirements.

  • • Support to develop objectives and monitor achievement of objectives and compliance with DHA/MOHAP/MOH/ DOH Health Sector OSHMS requirements across all departments.

  • • To report and provide guidance to the entity OSH Committee, the Prevention and Control of Infection and the Clinical Quality and Patient Safety Committee in developing programs and policies for implementing and monitoring applicable OSHMS and Infection Control and Patient Safety standards.

  • • To conduct or participate in incident and outbreak investigations as applicable

    • Occupational Safety and Health Management Systems

    • • Comply with reasonable OSH instructions, policies and safe working procedures

    • • Use of appropriate personal protective equipment and safety systems.

      • • Be familiar with emergency and evacuation procedures

      • • Not willfully or recklessly endanger anyone’s health and safety

      • • Assist with the preparation of risk assessments

      • • Report OSH Hazards, incidents, Near misses and issues

      • • Reduce, Reuse, Recycling of waste as much as possible

      • • Attend all OSH Trainings, awareness programs and mock drills.

      • • Participates in the OSHMS audits, inspections, ensuring standards are maintained

      • Infection Prevention and Control:

      • • IPC is everyone’s responsibility. All staff are required to read and implement the NMC IPC Policy and Strategy in an effort to maintain the highest possible standards of cleanliness at all times, thus reducing the risk of infection in patients, staff and visitors.

      • • The strictest hand hygiene, 5 moments of hand hygiene, bare below the elbows and environmental care, will be expected of all staff, including the post holder, at all times

• Master’s degree in Hospital /Healthcare Administration/ Management with bachelor’s degree in healthcare field.

• Proven experience in incident and risk management systems.

• Familiarity with digital healthcare tools and software, including HIS and quality management systems.

• Experience working with multidisciplinary teams across various facilities.

• Experience in policy formulation and implementation.

• At least 5 years of experience in healthcare quality management in a hospital setting.

• Excellent command of oral and written English.

• Strong knowledge of healthcare clinical fundamentals, patient safety standards, and performance improvement standards.

• Strong knowledge of CQI tools and techniques, ability to perform data analytics, and lead performance improvement teams.

• Strong data analysis and reporting skills with proficiency in advanced Excel tools or statistical software.

• Ability to design and deliver training programs on quality and patient safety.

• Strong interpersonal and negotiation skills for managing diverse stakeholders.

• High adaptability to evolving technologies and quality trends.

• Effective project management skills with a results-oriented approach.

• Responsibility for own continued professional growth beyond minimum preparation. An understanding of management objectives and the ability to implement a systems approach.