Job Description
1. Continuous Quality Improvement
- Leads and coordinates quality improvement, patient safety and clinical effectiveness initiatives to support organizational goals.
- Analyze processes and collaborates with staff and managers to implement sustainable improvements and innovations.
2. Incident Report Management
- To administer hospital-wide incident reporting, review all incidents to ensure corrective and preventative actions are implemented, incidents are graded and learning is communicated.
- Perform investigation on incidents using tools such as Root Cause Analysis to identify the root causes of the incident and prevent recurrence.
- Consolidate and analyzes incident data, preparing summary reports on trends, key issues and remedial actions for relevant HODs.
- Identify potential sentinel events and escalates promptly for comprehensive investigation and full Root Cause Analysis.
- Ensure timely submission of mandatory reports to the MOH for designated reportable incidents.
3. Accreditation and Audits
- Be the champion to lead, guide, and advice head of department on the requirement of accreditation standards, such as Malaysian Society for Quality in Health (MSQH), Joint Commission International (JCI), The Australian Council on Healthcare Standards (ACHS) and etc.
4. Clinical Data Management
- Coordinate data collection and analyze clinical information related to patient safety, resource use and quality performance.
- Identify trends and improvement areas and work with multidisciplinary teams to support quality initiatives.
- Provide departmental statistics to reflect daily operations and identify opportunities to improve clinical outcomes.
- Maintain accurate data to meet accreditation and regulatory standards.
5. Quality Improvement Projects
- Lead and coordinate departmental quality improvement initiatives.
- Use quality improvement methodologies such as Plan-Do-Study-Act (PDSA), Root Cause Analysis (RCA), Failure Mode Effect Analysis (FMEA) or Lean Six Sigma tools in quality improvement projects.
6. Risk Management
- Work with departments to develop departmental risk registers.
- Engage in Audit to ensure the controls identified in the risk register is implemented.
7. Education
- Develop and deliver education and training to the relevant staff.
- Raise Patient Safety awareness of staff through actively providing education via various platform such as workshop, ad hoc small group discussion, bulletin and etc.
Job Requirements
- MBBS or Bachelor of Nursing or equivalent.
- Minimum 7 years of experience in healthcare setting.
- Possess Valid Annual Practicing License.
- Good knowledge in hospital regulatory requirement, JCI / ACHS / MSQH standard requirements.
- Well-versed in quality improvement tools.
- Ability to work independently and good problem solving skills and analytical ability.
