Reporting To: Chief Executive Officer (CEO)
Position Summary:
Responsible to coordinate, implement and monitor quality systems and risk management in support of the hospital business strategy, goals and objectives.
Manage all aspects of the programs to focus on patient-centeredness, process efficiency and waste reduction and safe and reliable patient care.
Responsible for submission of relevant reports to Ministry of Health.
Duties and Responsibilities:
1. Communicate to the organization the importance of meeting customer as well as statutory and regulatory requirements.
2. Promote continuous improvements to productivity, quality and customer satisfaction.
3. Work to ensure that quality improvement and innovation work remains focused on agreed goals.
4. Monitor and advise on the performance of the quality management system. Ensure application of a tracking method to monitor progress towards goals by collecting accurate, timely data, report on performance, and to display the quality and service outcomes.
5. Coach and guide Heads of Departments in the analysis of performance indicators and presentation of such data.
6. Attend Quality Assurance and Patient Safety Review Committees and present all quality assurance related matters and statistics.
7. Provide training related to quality assurance programs.
8. Work with relevant department managers to ensure the core foundation knowledge and skills training in quality is provided to all employees and repeated as necessary.
9. Where appropriate, the quality manager advises on changes and their implementation and provides training, tools and techniques to enable others to achieve quality.
10. Enhance organization image by sharing quality initiatives with RCEO/CEO in obtaining market Share and competitive edge in protecting stakeholders interest.
11. Periodically review quality related policies, programs, and practices to keep RCEO/CEO and hospital staff informed of new developments.
12. Prepare internal audit schedules and assist with internal audits and audit results.
13. Responsible for compiling incidents (assessable deaths) and submit to Ministry of Health.
14. Ensure incident reporting mechanism is complete.
15. Review non-conformances, corrective actions, observations, and patient complaints for repetitive trends, recommendations for changes and/ or processes.
16. Coordinate, implement and monitor of hospital external certification and accreditation.
17. Lead the Team in the post-audit report, assist in closing the non-conformances identified for submission to relevant group/ person concerned.
18. Enable HODs and staff to learn and understand compliance management and its responsibilities.
19. Ensure the responsibilities are carried out and meet mandatory regulatory requirements.
20. Coordinate with Administrative Assistant/ Executive the compliance register, monitor and update the register annually.
21. Provide support and periodic training on risk awareness and risk management to all staff.
22. Assist managers in conducting risk assessment of their respective departments and develop the necessary risk controls.
23. Monitor the progress of the risk register to ensure all mitigating factors are appropriately addressed.
24. Coordinate yearly risk register review process of department risk register.
25. Ensure timely submission of the updated risk registers of all departments to Management Office.
26. Monitor to ensure annual safety and disaster mitigation activities are being carried out by each related team.
27. Ensure compliance and risk registers, BCP and operation manuals are timely uploaded in the Document Management System (DOMS).
28. Perform any other duties as assigned and/ or directed.
Education and Requirements: Bachelor's Degree in any healthcare discipline. MBA is advantageous for managerial position.Minimum 5 years relevant experience in this job field.Good knowledge in Statistical Process Management.Effective communication, training and interpersonal skills.Broad networking with various bodies dealing with Accreditation, Certification and Standards.Communicate well in English and Bahasa Malaysia (oral and written).
Special Demands: High energy, drive and initiative.Display professionalism at all times.Possess good communication, interpersonal relationship skills and good judgment.Has good analytical skill to interpret and analyze data and reports.