Minimum Bachelor’s Degree in health care profession (i.e. Nursing, Pharmacy, Hospital Administration, or other relevant discipline) is ESSENTIAL. Certification in Healthcare Quality (CPHQ) is PREFERRED.
• Minimum 4 years of relevant professional experience for bachelor’s degree holders.
• Minimum 2 years of relevant professional experience for master’s degree holders.
Experience must be in healthcare quality management activities in an acute care facility or large ambulatory care environment.
• Facilitate, monitor, educate, conduct, and coordinate Joint Commission Accreditation and Reaccreditations.
• Implement Continuous Improvement Initiatives including;
• New Quality Management System;
• Disease Management Program;
• Patient Safety WalkRounds Program- this involves, among other things, analyzing and reporting on clinical practices, processes, error reporting and the environment from the perspective of patient safety;
• Clinical indicators (working towards Data Warehouse/Balanced Scorecard);
• Sentinel Events and Root Cause Analysis as per Sentinel Events Guidelines;
• Training for Quality Improvement Initiatives and FOCUS PDCA (System Improvement Methodology) Projects- with a view to the next stages; FMEA and 6 Sigma;
• Review and investigate Mortality and Morbidity rates with reference to PCI’s;
• Facilitate the implementation, analyze, report, and review the effectiveness of the various initiatives and recommend, implement further improvements (Continuous Improvement Cycle).
• Responsible for recommendations regarding annual review/revision within all Quality Improvement programs/ activities, databases, indicators, etc.
• Perform retrospective or concurrent reviews on the assigned areas utilizing the approved Indicators Monitoring System (IMS) databases, indicators or criteria.
• Participate in site visits to the various facilities to work with staff on quality improvement programs and/or activities. Responsible for completion of a full and detailed Site Visit Report within three (3) working days of return from all visits.
• Assist in training staff from various Departments in areas of Quality Improvement, Quality Improvement programs, records requirements, techniques of continuous quality management and other related areas as assigned.
• Conduct Quality Improvement workshops as appropriate and as directed by the Director of the Department
• Conduct Orientation for QI system training for all new staff.
• Participate in area wide mini focus studies; to be undertaken in conjunction with the department and other Directorates.
• Responsible for reviewing results of committee meetings, mini focus studies, QI team activities etc. from all assigned facilities and participating in preparation of quarterly reports for the Director of QI & PS department.
• As assigned by the Director, coordinate QI Activities with other Affairs Directorates to maximize staff expertise in the area of Quality Management.
• Facilitate the preparation of monthly quarterly reports regarding the QI programs and compliance with same for all assigned facilities.
• Provide day-to-day operational support to, s assigned in terms of; concurrent reviews, utilization reviews, retrospective monitoring, committee and QI team assignments, referral of identified issues or concerns to appropriate department(s) or areas etc.
• Responsible for reviewing OVA (Clinical Incident Reporting System) into the database, referring PCI’s (action) reporting trends, analyzing of reports, and identifying any Sentinel Event.
• Facilitate, maintain the database, coordinate, analyze, and report on the Medication Safety Program.
• Develop, maintain, analyze and report Clinical Pathways.
• Attend QI Committee meetings in assigned critical area(s).
• Review, Facilitate, and develop APP, IPP, Guidelines. Assist in developing QI Plans.
• Perform other job related duties as required.
• Must have strong working knowledge of standards implementation and knowledge of clinical care processes.
• Familiar with data collection, analysis and statistical reporting.
• Proficient in working with the following computer applications: Word, Outlook, Power Point Excel and other related software applications.
• Effective interpersonal communications and teaching skills.
• Knowledge of the National and International Quality & Patient Safety Accreditation Standards such as: CBAHI, JCI, CAP, AABB, Planetree etc.