​

Key Responsibilities

• Develop, implement and oversee quality improvement to ensure delivery of the highest quality patient care, optimal patient flow, provider productivity and continuity of care.

• Develop a conceptual framework for quality measurement and improvement activities across clinic sites. Summarize findings in the annual Quality Improvement (QI) Plan.

• Work with Head of Operations and members of SMT to develop and ensure the implementation of policies to minimize risk within the organization.

• Develop, and carryout monitoring and evaluation of a Quality Assurance Strategy.

• Develop and implement a Quality Assurance system for Hospital services including a continuous quality assurance program and an annual assurance program.

• Audit operational services against expected standards and requirements across the full range of Hospital’s services to ensure compliance with external regulatory guidance notably the Quality Assurance Framework for Hospitals.

• Lead and conduct the planning and management of internal reviews and support and assist in the coordination of external reviews and inspections; working closely with the Head of Operations, SMT and other stakeholders to co-ordinate effective data capture and validation procedures for the production of annual monitoring documentation that form the basis of Quality Assurance review inspections.

• Lead, advise management and staff on developments within the fields of quality assurance and enhancement, answer questions from all stakeholders regarding the Q.A policy and implementation of Quality as assigned by the Head of Operations.

• Coordinate with the Medical Directorate and SMT to ensure improvement in patient care management.

• Work with the Head of Operations and Medical Directorate to develop new or update existing OPD and IPD clinical outcome measures, protocols, policies and procedures to ensure compliance with policies through a peer review process.

• Engages in the planning and implementation of the Corporate Compliance Program, including risk management reduction, which includes ensuring compliance with Hospital policies and procedures as well as health, safety and regulatory requirements including Health Insurance privacy laws, OSHA, and Lab Certification standards.

• Investigate and act, in conjunction with Head of Operations on matters related to compliance, including coordinate internal investigations and any resulting corrective action with all departments, contracted vendors, etc.

• Develop and review policies and programs that encourage managers and employees to report suspected fraud or other improprieties.

• Participate in long-range planning including the evaluation of patient satisfaction, current services and programs to increase, and market services to the community and to position Hospital for change and growth.