Job Duties:
Administrative
In conjunction with the executive team, participate in the development and implementation the organization’s operating plan. Lead the development and implementation of department operating plans that supports the larger organization plan in the areas of, Quality Assurance, Integrity Unit, Accreditation and Hospital Licensing Risk Management and Infection Control. Participate in administrative meetings. Maintain department records. Any other duties as assigned by the CEO Quality Assurance
Develop, implement and oversee quality improvement to ensure delivery of the highest quality patient care, optimal patient flow, provider productivity and continuity of care. Review organization’s quality management system at planned intervals to ensure its continuity, suitability, adequacy and effectiveness. Planning and implementation of internal audits and report the result to the top management. Responsible for monitoring and updating of policies and SOPs to include regulatory changes, and ensure accessibility and communication hospital wide. Regular update divisional leadership on current performance and discuss new Quality Improvement (“QI”) initiatives. Contributes to the development and implementation of Quality Management System in the organization. Works closely with key stakeholders to identify and monitor implementation of quality process improvement initiatives to improve processes, efficiency and ensure patient safety. Applies quality management tools to improve systems and processes. Contributes to the development and review of policies and SOPs and ensure accessibility and communication hospital wide. Responsible for document control and validity. Coordinates data collection of quality and clinical performance indicators. Assists in the analysis and trending of indicators. Contributes to the effective management and evaluation of hospital wide of accreditation program. Conducts regular audit to monitor compliance to laws and regulations and meeting the accreditation standards.
Integrity & Governance Unit
To plan, develop and implementing integrity and governance framework which include but not limited to Integrity and Governance Policy, No Gift Policy, Anti-Corruption Pledge and etc. To plan, organize and facilitate awareness workshops and briefing sessions on integrity and governance practices on regular basis To prepare and provide mandatory half-yearly Integrity Reports to IGU/MACC or whenever necessary outside the mandatory period. To ensure the protection of whistleblowers. To carry out yearly audits or whenever necessary and continuously enhance integrity and governance practice in RRI. To maintain risk registers for all areas in RRI Accreditation & Hospital Licensing
Lead, coordinate and monitoring of the hospital internal and external certification and accreditation – hospital licenses, ISO, MSQH etc Risk Management
Reviews and assesses risk management policies and protocols; makes recommendations and implements modifications and improvements. Conducts risk assessments, collecting and analyzing documentation, statistics, reports, and market trends. Establishes policies and procedures to identify and address risks in the organizations services and departments. Manages patient care/clinical outcomes related to complaints and identify resolution measures Coordinates root-cause analysis processes and review potential medico-legal cases/sentinel events. Drafts and presents risk reports and proposals to executive leadership and senior staff To conduct ESH committee meeting as and when required. Infection Control
Coordinates, educates and implements hospital-wide infection control program to hospital personnel on healthcare associated infections, communicable diseases and isolation procedures. Coordinates and conducts audit monitor compliance in infection control standards and practices. Training
Conducts training related to management of incident, quality management and infection control as required. Provides education to staff about accreditation standards. Facilities Management
Responsible to ensure adequate facilities and equipment are available that will enable for the department to achieve its objectives. Ensures department meets environment of care requirements on an ongoing basis. Others
1. Responsibilities and tasks outlined in this document are not exhaustive and may change as determined by the needs of the Company.
Minimum Skills, Knowledge & Abilities (including licensure, certification and other job-related credentials)
Education / Professional Qualifications
BSc / MSc in Nursing preferred (or equivalent Masters in Healthcare related field) Experienced in hospital accreditation – MSQH, ISO, JCI State Registered Nurse recognized by the Malaysian Nursing Board preferred Post Basic Certificate preferred CPR / ACLS preferred Professional Experience / Minimum Requirements
Wide experience in nursing leadership in a hospital environment with a minimum of 5+ years of management experience Member of Malaysian Nurses Association Good analytical and problem solving skills Good knowledge of written and spoken English Strategic thinker with strong interpersonal, emotional intelligence, communication and cross-cultural skills Self-starter with drive and initiative and able to problem solve with minimal supervision Considerate and deliberate in dealing with people and managing conflict Remuneration:
According to qualifications and experience. We provide attractive remuneration package; inclusive of basic salary, SOCSO, EPF, allowances, annual bonuses, personal accident and medical insurance plan. High performance and committed team members will expect an attractive remuneration packages and excellent career advancement paths.
If you are the talent that we are looking for and you think you can help us to get closer to our vision, we would like to meet with you. You need to act and apply to us now. Tell us how your past achievements prepare you an exciting and promising career with US!
