Patient Safety & Quality Manager

Role Overview

Patient Safety & Quality Manager at NMC Healthcare. The role is responsible for designing, implementing, coordinating, evaluating and reporting the Patient Safety and Quality Program and its adherence to Regulatory and applicable accreditation standards.

Role Purpose

Lead the organization's patient safety and quality initiatives to ensure adherence to regulatory and accreditation standards. Ensure regular communication of performance metrics, data analysis results, and quality improvement efforts to all staff.

Key Responsibilities

Leadership & Strategic Oversight

• 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 initiatives on Quality, Patient safety, and Risk management.
• Promote a culture of safety, high-reliability, patient and staff engagement, and performance excellence.
• Develop Patient Safety & Quality Improvement Plan for the facility.
• Orchestrate Patient Safety & Quality Improvement Initiatives & Activities hospital-wide and cluster level.

Stakeholder Collaboration & Communication

• Collaborate with hospital/cluster leaders, department managers, physicians, and staff to envision, develop, and implement systems that result in improved patient care management, improved clinical outcomes, increased workflow efficacy and efficiency, increased cost effectiveness, high patient satisfaction and strategic initiatives.
• Proactively educate leadership and staff regarding regulatory issues, new guidelines, and safety/quality performance improvement activities.
• Serve as a resource to all departments, divisions and units, hospital/cluster, and to established committees in all areas relating to Quality Assurance.
• Communicate appropriate information from studies and data sources to committees, departments and persons affected by the studies.
• Facilitate Quality Improvement plan meetings.
• Provide educational and technical assistance to committees and departments in meeting their PSQ objectives.

Program Development & Implementation

• Participate effectively in implementing and follow up of Patient Safety and Quality Plan Activities.
• Develop effective patient care review and evaluation mechanisms and monitors to assure results are achieved.
• Direct implementation and maintenance of technical guidelines and frameworks within which quality of care is evaluated.
• Identify and share across the system best practice models and care processes that achieve optimal patient outcomes, enhance patient/family and staff satisfaction, are cost effective and resource appropriate.
• Develop training/orientation programs for key members to facilitate system expansion and standardization.
• Justify need for training in Continuous Quality Improvement processes and methods and either work with appropriate groups to initiate training or teach in areas of expertise.

Data Management & Analysis

• 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.
• Ensure data reported is validated and analyzed for implementing improvements and evaluating if the improvements were sustained.
• Establish system-wide variance database for benchmarking, system improvement opportunities, Length of stay and resource management.
• Arrange with Quality Facilitators in the unit for staff education, variance collection and analysis.

Compliance & Accreditation

• Contribute to relevant Committees/Groups such as the Quality Improvement & Patient Safety Committee and the Higher Management Committee.
• Have a deep understanding of the standards, measurable elements and intents for various accreditation bodies.
• Maintain all necessary records pertinent to the accreditation process.
• Coordinate and monitor required Accreditations compliance activities and participate in the survey process.
• Conduct Mock surveys coordination.
• Approve data for submission to regulatory authorities including DOH on JAWDA KPIs, DHA KPIs & MOH KPIs etc as and when required.
• Conduct Annual Evaluation of Quality Improvement Program and submit reports to the CQPS committee.
• Submit a quarterly report of quality activities to the CQPS committee.

Documentation & Records Management

• Maintain records of policies, procedures, guidelines, forms and other documents and ensure the circulation of current documents and the de-circulation of expired documents.
• Maintain records of all Patient Safety and Quality (PSQ) activities.

Clinical Space & Infrastructure

• Maintain active involvement in all aspects of clinical space design, construction and hygiene.
• Identify concern areas based on evaluation of the patient's medical records and plan for improvement.

Occupational Safety & Health (OSH) Management

• Notify and optimize the reporting of OSH Hazards, other incidents, Near misses and issues and assist with the preparation of risk assessments.
• Coordinate Risk management program of the facility in coordination with all stakeholders.
• 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.
• Designate 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.
• Develop, monitor and support implementation of the hospital/cluster OSHMS in line with DHA/DOH/MOHAP/MOH Health Sector OSHMS policies and standards and entity requirements.
• Support development of objectives and monitor achievement of objectives and compliance with DHA/MOHAP/MOH/DOH Health Sector OSHMS requirements across all departments.
• 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.
• Conduct or participate in incident and outbreak investigations as applicable.
• Establish 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.

Infection Prevention & Control

• Promote and facilitate cost-effective resource utilization related to infection control policies and procedures.
• Ensure the strictest hand hygiene, 5 moments of hand hygiene, bare below the elbows and environmental care standards are maintained by all staff at all times.

General Responsibilities

• Perform administrative responsibilities applicable to the role.
• Perform miscellaneous related duties as requested by general manager.
• Be familiar with emergency and evacuation procedures.
• Attend applicable OSH/Infection control training programs, mock drills and awareness programs.
• Provide ongoing assessment and support for continuous quality improvement, quality assurance and risk management for the Hospitals/cluster priority programs and support its infrastructure.

Qualifications & Experience

• Master's degree in Hospital/Healthcare Administration/Management with bachelor's degree in healthcare field.
• At least 5 years of experience in healthcare quality management in a hospital setting.
• Proven experience in incident and risk management systems.
• Experience working with multidisciplinary teams across various facilities.
• Experience in policy formulation and implementation.

Skills & Competencies

• 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.
• Effective project management skills with a results-oriented approach.
• Familiarity with digital healthcare tools and software, including HIS and quality management systems.
• Excellent command of oral and written English.
• High adaptability to evolving technologies and quality trends.
• Responsibility for own continued professional growth beyond minimum preparation.
• Understanding of management objectives and the ability to implement a systems approach.