Quality Resources Manager

Job Purpose

• Works across the organization to assure compliance with regulatory, accreditation and/or patient safety standards. Independently performs a variety of audits, surveillance activities, quality improvement initiatives and analysis of the data as well as ensure compliance with regulatory audits and quality standards. Serves as support for on-site surveys and works with others to facilitate system process and outcome improvements. Oversees the policy life cycle process.
• Responsible for keeping abreast of any regulatory requirements or changes applicable to the hospital and communicating these requirements to the relevant head of department. This position will support all regulatory submissions for the hospital licenses and other relevant regulatory documentation requirement.

Continuous Quality Improvement

• To promote Patient Safety Culture and Quality Improvement activities for the hospital such as Patient Safety Week, Root Cause Analysis and to publish Quality news.
• Utilizes quality rounds findings to initiate improvement and make the quality round as educational opportunity for staff.
• Coordinates routine reporting processes utilizing metrics to monitor impact of process improvement.

Accreditation and Audits

• Maintains responsibility for ensuring that all accreditation and regulatory standards related to licensure/accreditation are being met.
• Works closely with head of department to help coordinate survey follow-up activities, including plans of action, monitoring systems, clarifications and challenges.
• Schedules and coordinates survey related activities including but not limited to agendas, site visits and educational opportunities.
• Develops and oversees the implementation of corrective action plans to address survey findings. Monitors and analyzes all data related to action plans and reports results to leadership.

Performance Indicators

• Review and compile performance indicators monitored by hospital and feedback to respective HODs
• Provide training to head of departments on planning of performance indicators.
• Provide advice to head of department in data collection methodology, data validation and graphical data presentation.
• Conduct data validation to ensure the reported data are accurate.
• Develop and maintain indicator / data dashboard.
• Guide and facilitate data owners to review the indicators, understand the causes of not meeting the target and finding a suitable solution.
• Ensure submitting the required data to the regulatory / external bodies within the required timeline.

Policy Review

• Coordinates review and revisions of organization wide policies and procedures to assure compliance with relevant regulations and standards. This includes: coordinating review cycle and working across the organization to accomplish on time reviews; ensure policy and procedure are accurate, reflect best practices, and meet regulatory requirements; execute quality review of policy and procedure to ensure consistency and clarity; seek appropriate staff feedback through multiple channels; and ensure staff are able to navigate the policy portal.

Hospital Incidents Reporting

• Coordinate with head of departments and division head to ensure closure of incident investigation within time frame.
• Compile and analyze incident reported and to report to management on monthly basis through CEO report.

Internal Audit

• Coordinate and schedule of Internal survey exercise as plans.
• Compile survey findings and schedule for closing meeting.
• Follow up on corrective and preventive action with lead auditors and HODs.

Risk Management

• To assist in updating the master list risk register, compile risk submitted by respective HOD in risk register.
• To schedule for risk presentation to evaluate risk identified.

Others

• Prepare Quality Improvement and Patient Safety quarterly report to the Board of Directors.
• Prepare monthly and quarterly reports as and when necessary.
• Prepare meeting minutes for various committee meetings.
• Prepare reports and PowerPoint for various meetings and discussion.

Job Requirements

• Degree Nursing or Pharmacist
• 3 to 5 years of experience with Accreditation and Quality Improvement, Regulatory related work.
• Must have clinical experience or from clinical background
• Good knowledge in MSQH & JCI Standard Requirements
• Good knowledge in PHFSA and relevant regulatory in Healthcare Industry
• Good knowledge in Incident Management, Risk Management, Data validation, Data Analysis and Quality Improvement such as PDSA, FMEA, RCA
• Good skill in power point presentation, Microsoft excel, Microsoft office
• Good communication and writing skill i.e English & Bahasa
• Ability to maintain a high level of accuracy and attention to detail, while meeting deadlines for assigned projects.