Assumes complete departmental responsibility in the absence of the HOD.
Responsible for interpreting, defining, implementing, coordinating, monitoring, evaluating and reporting as a field wide authority, the Quality Improvement and Patient safety Program for the Organization and the Organization’s adherence to various regulatory and certification requirements.
Responsibilities
Will assume complete responsibility for the functioning and administration of the department, in such cases where the HOD is unavailable due to being on leave or otherwise.
Assist and facilitate in developing NMCSH Quality Improvement Plan
Participating effectively in Implementing & Follow up of Q.I. Plan Activities.
Promotes and facilitates cost-effective resource utilization related to infection control policies and procedures.
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 priority programs and support its infrastructure.
Serves as a resource to all departments, divisions and units, hospital and ambulatory, and to established committees in all areas relating to Quality Assurance.
Arranges with Quality Facilitators throughout NMCRHS for staff education, variance collection and analysis.
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.
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.
Develops and maintains records of policies, procedures, guidelines, forms and other documents and ensures the circulation of current documents and the de-circulation of expired documents.
Establish system for the regular review of operational policies, procedures, strategies, job descriptions etc
Work with heads of departments to ensure hospital licensing requirements of the DHA and other agencies are always met or exceeded.
Maintains records of all Quality Assurance activities.
Provides educational and technical assistance to committees and departments in meeting their Quality Assurance objectives.
Maintains active involvement in all aspects of clinical space design, construction and hygiene.
Justifies need for training in Quality Assurance processes and methods and either works with appropriate groups to initiate training or teaches in areas of expertise.
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.
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.
Qualifications
Bachelor’s degree in a clinical or allied health field with post graduation in the field of Hospital Administration preferred.
Three years or more in healthcare Quality management positions with demonstrated administrative skills.
