Department/Directorate
Quality & Development Department/ General Directorate
Reports to: Quality & Development Manager
Main Duties:
• Will be responsible for leading, coordinating and implementing a program of clinical audit in collaboration with the Quality Director, and in line with the Quality Management strategy
• Develops and implements tools (audit grids, registries, indicators...) to measure compliance with established standards. Reviews and revises tools as standards change.
• Perform regular audits on clinical practices, and ensure feedback to the concerned staff and leaders.
• Tracks and trends inspection and audit results, that the findings are acted on to achieve quality improvement and re-audit is carried out to confirm improvements and complete the audit cycle
• Assists in preparation for accreditation and regulatory audits as assigned to include the interpretation of standards and development of mechanisms for compliance. Manages activities and prepares files and documents to support accreditation and regulatory audits.
• Acts as staff and/or participating member of various committees as needed
• Main operational activities include:
o Performing regular inspection rounds and audits to ensure compliance of clinical practices to adopted procedures, accreditation standards and regulatory requirements
o Reviewing and evaluating patients' medical records, applying quality assurance criteria.
o Screening patient care cases and making recommendations for case review and for utilization review
o Collaborating with patient safety officer to complete incident investigations, including root cause, “near miss” and sentinel event analysis.
o Make written and oral reports/recommendations to the Quality Director, as necessary/required, concerning observed non-conformities and implementation of improvement actions
Qualifications:
• Bachelor of Science Degree in Nursing; Master’s Degree preferred
• A minimum of five years nursing experience as a registered nurse in an appropriate and relevant healthcare setting post qualification is required
• Previous Quality Management experience preferred International accreditation experience is preferred
• Knowledge of methods of investigation and review, statistical analysis and reporting, performance measures, performance improvement techniques, and the frequent use of discretion, initiative and independent judgment.
• Strong oral and written communication skills; attention to detail
• Experience in use of electronic hospital information system required
• Proficient in the use of PCs, spreadsheets and other software applications (MS Office, Powerpoint, Excel, SPSS)