Quality Specialist Dr soliman fakkeh hospital

1. Quality & Accreditation Alignment

- Review, update, and align EMS policies and procedures with requirements of international accreditation bodies (JCIA, ACHS, ABBA s).

- Conduct regular gap analyses against accreditation standards and develop action plans for compliance.

- Coordinate readiness activities for accreditation surveys, including documentation, staff preparation, and evidence collection.

- Maintain updated knowledge of accreditation standards and regulatory requirements applicable to EMS.

2. Policy & Procedure Development

- Draft, revise, and implement policies, procedures, and clinical guidelines in collaboration with EMS leadership.

- Ensure documents are standardized, properly formatted, version controlled, and easily accessible.

- Provide training and orientation to staff on updated or new policies.

3. Monitor and Compliance:

- Performs qualitative review of documentation in EMR, ensuring proper documentation practices across the Fakeeh Health Care facility in compliance with clinical documentation policy,

- Perform regular quality audits on EMS operations, clinical documentation, and patient safety practices.

- Track key performance indicators (KPIs) related to EMS quality and safety, identify non-conformities and work with relevant departments to implement corrective and preventive actions.

4. Audit and Reporting:

- Generates and analyzes monthly audit reports, identifying discrepancies and areas for improvement catering to both internal Fakeeh Health Care facility standards and external regulatory requirements.

- Communicates findings to the Quality Risk Management (QRM), Chief Medical Officer (CMO), and other OUL and suggest actionable improvements.

5. Committee Involvement:

- Serves as an active member of selected committees.

6. Data Management:

- Essential part of validation process of new KPI s and responsible for collection of manually collected KPI s from assigned end users.

7. Privacy and Security Oversight:

- Continuously monitors the privacy and confidentiality of patient documents and information throughout the Fakeeh Health Care Group.

8. Risk & Patient Safety Management

- Monitor incident reports, near-misses, and adverse events; ensure timely follow-up and reporting in OVR system.

- Support root cause analysis (RCA) and recommend system improvements to prevent recurrence.

- Promote a safety culture across EMS staff through education and active engagement.

9. Data Management and Reporting:

- Collect, analyze, and present quality data, trends, and dashboards for management decision-making.

- Prepare and submit regular quality and compliance reports to the Quality Manager and senior leadership.

- Support research and benchmarking activities for EMS quality improvement.

10. Training and Development:

- Contributes educational initiatives on audit processes, quality standards, and regulatory compliance. This includes conducting workshops on documentation accuracy, patient safety, and the effective use of patient feedback to drive service improvements.

- Facilitate ongoing professional development to keep staff updated on the latest practices in healthcare quality management and audit techniques.

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Skills and Abilities:

- Committed to enhancing service quality and organizational standards.

- Manage high-pressure situations effectively, maintaining focus and composure.

- Takes ownership of duties and organizational goals; proactive in resolving issues.

- Collaborates effectively to achieve shared objectives.

- Responsive to changing environments and effectively manages transitions.

- Ensures superior service delivery to enhance patient satisfaction.

- Deep understanding of job responsibilities and the broader organizational impact.

- Mastering and practicing the following skills:

Methods and processes of improvement

Data aggregation, validation, and analysis

Risk identification and management

Experience:

Minimum of 3 years' experience in the healthcare field, with at least 2 years in a QRM department in a large healthcare facility