Quality and Patient Safety Director

Ensure the provision of efficient and effective leadership in Quality Improvement/Infection Prevention & Control Services in the hospital.

ESSENTIAL DUTIES:

I. Quality Improvement and Patient Safety

1. Coordinates all approaches, and initiatives for implementation of Quality & Patient Safety structure at the specific CURE Network Hospital.
2. Ensures that processes needed for the Quality Management System/Infection Control are reviewed, revised, implemented, and maintained.
3. Leads the department in a cost-effective manner by accurately forecasting budgetary needs and managing expenses within budgetary constraints.
4. Establishes, implements, and administers departmental goals, and objectives that are in line with CURE’s strategic plan – focusing on SafeCare Accreditation.
5. Identify and investigate performance improvement events, opportunities, trends, and sentinel events.
6. Develop hospital quality improvement action plans for internal and external audits.
7. Schedule and coordinate internal Quality and Patient Safety audits.
8. Coordinate and support risk assessment and management audit schedule.
9. Monitor clinical and non-clinical processes and outcomes, and system issues related to quality and patient safety.
10. Implement open and closed chart audits and disseminate results to the users.
11. Follow up on corrective actions for departmental action plans.
12. Keep custody of all documents and data related to Quality and Patient Safety.
13. Interpret and conduct staff training on Quality and Patient Safety standards, policies, procedures, clinical protocols/guidelines/pathways for implementation.
14. Support for Data collection and collation for identified Quality Improvement indicators feedback, and analysis.
15. Keep custody of Quality Improvement data dashboards.
16. Support and actively participate in the activities of the hospital Quality and Patient Safety councils and committees.
17. Keep custody of all the hospital Quality and Patient Safety councils and committees meeting minutes.
18. Coordinate and monitor occupational safety and health programs/action plans
19. Liaise with external parties on quality management issues.
20. Ensure periodic but regular assessments of patients’ satisfaction and identify/implement consequent improvements.
21. Perform other duties as required within the applicable scope of practice and policies.

II. Infection Prevention and Control

1. Oversee the implementation of the policies and procedures laid down in the infection manual in all areas of the hospital.
2. Coordinate the infection control departmental link staff and operational meetings internally and externally for infection prevention issues.
3. Perform surveillance activities to capture and monitor infection, prevention and control data, and share.
4. Take appropriate action to prevent and control hospital-acquired infections in patients and also analyze the data every month.
5. Plan, organize, and coordinate audit and monitoring of wards, and hospital environments to ensure infection prevention and control practices.
6. Monitor the process of biomedical waste segregation, handling, and transportation and implement the national guidelines on hospital premises.
7. Develop and implement a hospital infection control training program for both clinical and non-clinical staff.
8. Coordinate and update the senior management teams on infection prevention and control every month and advise to improve practices for infection prevention.
9. Monitor and implement the laundry and kitchen sanitation, health checkups, disinfection protocols as well as other scheduled hospital infection prevention activities.
10. Act as an educational resource both to untrained and trained members of staff on issues related to Infection Control/Quality Improvement and SafeCare accreditation.
11. Perform other duties as required within the applicable scope of practice and policies.

OTHER DUTIES

• Uphold the highest standards of quality and efficiency in line with hospital quality programs (e.g. Safecare, DOH, etc.) requirements.
• Ensure a safe and secure work environment by strictly adhering to infection prevention and control protocols such as but not limited to handwashing, wearing of PPE, etc.
• Commit to sustainable and eco-friendly work practices by minimizing waste, optimizing resource usage and actively participating in initiatives that promote environmental stewardship.

EDUCATION/EXPERIENCE REQUIREMENTS:

1. Minimum Education Required: Degree in Nursing/Clinical Medicine from a Recognized Institution.
2. Licenses/Certifications Required; if any: Current PRC (Professional Regulation Commission) license
3. Minimum Experience Required: At least 6 years of post-education experience. Experience in coordination of Hospital Infection Control Implementation. Experience in quality management certification or accreditation.

KNOWLEDGE, SKILLS & ABILITIES:

1. Excellent writing skills
2. Good problem-solving and decision-making abilities.
3. Excellent interpersonal, verbal, and written communication skills.
4. Proficient in computer skills (MS-word, Excel, PowerPoint)
5. Knowledge of governmental and other regulatory standards, requirements, and guidelines related to quality improvement/Infection Control