Job description / Role
Provides leadership to support the quality initiatives for the Hospital.
Facilitates and implements and manages a quality assurance system for the Hospital; audits and recommends performance of the ED against documented standards, policies and procedures and best practice.
Directs, coordinates and evaluates Hospital ED QI Program, utilization review program and risk/safety management program to ensure compliance with hospital standards and ensures that facility resources and professional and non-professional services are utilized efficiently and effectively to provide quality care of all patients.
Monitors indicators and takes corrective action to ensure that clinical programs and services at the ED continue to operate efficiently and effectively.
Supports the development of clinical pathways and clinical practice guidelines through utilization data and analysis within the ED.
Coordinates with medical records and admissions to develop information capture requirements to support QI program.
Identifies and communicates variations of care and participates in the development / review / revision of policies, protocols, procedures, clinical practice guidelines and clinical pathways using evidence-based research.
Designs and implements a system for monitoring identified problems within the ED and progress towards solution.
Organizes and ensures implementation of ED department’s reports and abstracts for the Hospital’s QI Committee.
Prepares and delivers quality reports on ED clinical service review, audits and remedial action.
Regularly reports, as required, on the KPIs that are to be reported upon regarding the activities in the ED;
Participates on assigned internal, and external committees; chairs and/or leads discussion as requested; prepares status reports and/or develops recommendations on follow up action to be taken; implements approved recommendations for the assigned service.
Liaises with external accreditation bodies as required.
Establishes and maintains an effective working relationship and ongoing communications with medical staff and other department heads.
Ensures the Clinical Director is informed of and aware of significant events and activities in the area(s) of responsibility.
Ensures ICML is informed of and aware of significant events and activities in the area(s) of responsibility and ensure collection and compilation of all documentations, IP and other relevant information about ICML activities within the ED as may be required by ICML.
Provides input to the monthly reports to be produced by the Clinical Director to the ICML Project Manager and to ICML on the activities of the ED with particular emphasis on the activities of the ICML Staff at the ED for the preceding month highlighting areas of success, areas of deficiency and forecasting possible future encumbrances including laying out the steps for overcoming the same with the aim of providing safe and efficient healthcare services;
Generally, has a duty of care to ICML and works with and works with and cooperates fully with ICML and the ICML Project Manager in the implementation of all aspects of the Agreement between the Ministry of Health and ICML;
Performs other professional duties as may be assigned within his/her scope and ability