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 ensures 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 the department. This position will support all regulatory submissions for the hospital licenses and other relevant regulatory documentation requirements.

Continuous Quality Improvement

• To promote Patient Safety Culture and Quality Improvement activities for the hospital such as Patient Safety Week, and Root Cause Analysis, and to publish Quality news.
• Utilizes quality round findings to initiate improvement and make the quality round an educational opportunity for staff.
• Coordinates routine reporting processes utilizing metrics to monitor the 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 the 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 the hospital and feedback to respective HODs.
• Provide training to heads of departments on planning performance indicators.
• Provide advice to head of the 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 find 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 ensure compliance with relevant regulations and standards. This includes: coordinating the review cycle and working across the organization to accomplish on-time reviews; ensuring policy and procedure are accurate, reflect best practices, and meet regulatory requirements; executing quality review of policy and procedure to ensure consistency and clarity; seeking 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 the time frame.
• Compile and analyze incident reports and report to management on a monthly basis through CEO reports.

Internal Audit

• Coordinate and schedule of Internal survey exercise as planned.
• Compile survey findings and schedule for the 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 the risk register.
• To schedule for risk presentation to evaluate the 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 discussions.

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 of MSQH & JCI Standard Requirements.
• Good knowledge of PHFSA and relevant regulations 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 PowerPoint presentation, Microsoft Excel, Microsoft Office.
• Good communication and writing skills i.e., English & Bahasa.
• Ability to maintain a high level of accuracy and attention to detail, while meeting deadlines for assigned projects.