Planning & Monitoring 

Monitor and review the task accomplishment per each round. 

Follow up and ensure that meeting minutes of the Hospital committees are sent in a timely manner. 

Monitor the in-charge & discharge measures of the hospital and monitor the compliance accordingly to ultimately enhance bed utilization of each unit. 

Monitor the compliance & adherence of physicians and nurses to hospital’s codes and efficient response time on all shifts.
 Operational Excellence | Quality Rounds: 

 Rounds Monthly for each department at least once per month. 

Rounds should be done with accompanying the related department supervisor, nurse or coordinator. 

Calculate the progress of the last round comments and tasks accomplishment per each round. (Task accomplishment is calculated through dividing the number of resolved last round comments by the total number of last round’s comments) Review the items of the checklist to report the actual findings. 

 Fill the checklists and write down his/her notes, in order to prepare report of round findings and communicate the finding to the accompanying supervisor. The report should include the findings, suggested corrective actions 

 Send the “Round Report” to the Quality Supervisor for revision then send it to the related head of departments and the area, regional and group managers. Hospital Committees  :  Attends the committee and uses the “Audit grid” to check the effectiveness of the committee. 

Shares the score of the committee as per the committee audit grid excel sheet at the end of the committee to all the attendees highlighting main comments affecting the committee score.

 Training Management:  Develops monthly “training plan” Ensures the availability of the below documents for the training topic before conducting the training session: 1. Pretest 2. Training Material (PowerPoint) 3. Post Test 4. Audit Tracer §  Ensures that the above documents are updated as per the latest GAHAR requirements and the updated hospital policies and procedures. 

  Organizes with the department head or supervisor the suitable time to conduct the training session. 

 Collects pre and post tests and calculate % improvement in the trainees’ scores and submit training plan & monitor report to the quality manager and head of department. 

Performs an audit tracer 3 to 7 days after finalizing the training and calculate % of compliance to the training topic and send the results of the audit tracer to the quality manager and head of department. 

Project Management :  Provides effectively project support such as coordinating with all departments in preparing documents and materials, etc. 

Coordinates with project managers and implementation teams or units to facilitate submission of required project reports. 

Submits monitoring reports on the status of projects using prescribed forms, on time, and with the detail specified by management. 

 Manages project data in an organized manner by maintaining a project database. §  Proficient in the use of project management software (e.g. Microsoft Project) for representing data, measuring progress and performance, and taking immediate corrective or preventive actions. 
 Customer Satisfaction |  Make sure all services provided meet the customer requirement standardized for quality, time& effectiveness.
Planning & Monitoring |  Monitor mortality & morbidity incidences of the hospital, report to Quality Manager & take corrective/preventive actions accordingly. §  Follow up on medication errors or drug interaction incidence, make sure each is documented and investigate the cause. 

 Monitoring the staff compliance with set policies & procedures in assessment, double checking & administration. 

 Follow up that all OVRs are reported based on hospital policies & regulations
 | Operational Excellence |   Possesses basic understanding of the application of the organization-wide risk management policies. 

 Completes the OVR forms and reports which are incomplete or require additional information. 

 Starts investigation through phone, interviewing or document check with involved persons and send the incident to involved manager for investigation, corrective and preventive action within 48 hours of receiving the OVR. (Should include the area, regional and group departmental directors in the OVRs related to their departments as CC in all related emails along with notifying the operational manager for corrective action needed with concerned departments.) 

  Finalize the investigation and agreeing about the corrective action and preventive action with the support of the quality supervisor shall close the OVR with the confirmed category, corrective and preventive actions.
 Planning & Monitoring |   Follows up and ensures that the agreed corrective actions and decisions related to his/her KPI reports are implemented in a timely manner according to their due dates.
Operational Excellence  |   Reviews the data sent from each department according to his/her KPI reports and assess the data compliance according to the below criteria (CUIKA). 

  Performs complete data analysis identifying the main root cause of improvement or decline and can seek the support of any concerned parties to reach this root cause and send the complete report to the concerned departments. 

  Prepares reports which summarize and clarify the results of data gathering. 

  Analyzes basic information using quantitative techniques to evaluate decisions as well as determines and challenges the assumptions that drive such decisions.
 Customer Satisfaction  |   Make sure all records generated by hospital staff members are meeting required standards supporting patients’ confidentiality & data accessibility.
 Planning & Monitoring |   Monitor the effective compliance to the hospital policies and procedures along with adherence to documentation methods of all departments. §  Report bugs and defects observed in a clear and organized manner to quality manager especially in quality improvement projects implementation, adherence to policies& procedures, compliance to documentation& validation processes.
Operational Excellence  |   Demonstrates awareness of key business & healthcare processes and key metrics associated with each unit. 

  Complies with relevant processes and operating procedures and draws attention to issues that get in the way of process compliance. 

  Contributes to and makes suggestions for process improvement activities. 

  Forms a task force team from multi-disciplinary approach to manage the project. 

 Uses the project charter to outline the project objective, baseline and milestones with the duration of the project is from 3 to 6 months.
  Customer Satisfaction | §  Support staff members in the implementation of hospital-agreed communication plan, responsibility of each department in all quality improvement projects & service meetings to ensure generating best outcomes possible.
Innovation Process |   Review existing policies and make suggestions for changes and improvements and how to implement them. 

  Advice on changes to improve process and workflow, update current policies or generate new ones to enhance the performance and process flow of each department.
 Planning and Monitoring  |  Follows-up on action plans resulting from quality audits and organizational excellence assessments. 

  Monitors and follow-up the implementation and effectiveness of the generated quality improvement projects & hospital’s Quality Management system closely with relevant staff members.
  Operational Process Excellence | Conducts regular meeting with the department head related to the manual and communicate GAHAR requirements regarding the manual with them. 

 Possesses the ability to enter data into the relevant systems accurately and in a timely manner. 

  Follows-up on action plans resulting from quality audits and organizational excellence assessments. 

 Interprets and provides basic analysis of management information and links it to business units’ objectives and operational performance.   

Analyses process performance results, identifies learning points and helps to communicate them across the organization. 

  Possesses basic knowledge of quality management and organizational excellence concepts and models. 

 Identifies, analyzes, and classifies information related to quality programs adopted by the organization.
  Innovation Process |  Research and design appropriate hospital-wide performance and quality trainings based on employees’ & hospital’s trends and further needs. 

 Optimize process flow with automation tools for better tracking, validation and monitoring.

Qualifications:  

Age group: |   28-33 years
Work nature: | Based in BUs (AMH/SMH/ASH) § Possible business mission to AHQ, Daily Rounds & Audits. 

 Office based documentation, analysis &reports.
 Language needed: |   Arabic §  English
Essential/Preferable Education: |   Bachelor degree of Pharmacy, Medicine, Dentistry.
Years of Experience/ Qualifications: |   3+ years of experience in quality improvement in relevant hospitals or healthcare entities. 

Demonstrates understanding of healthcare organizations best practice & protocols. 

Previous experience on Egyptian accreditation whether governmental or private hospital.

  Comprehensive understanding of health care organizations best practices & protocols. §  Leadership skills, team-oriented, flexibility and strong adaptability to rapidly changing environment.  

Proficiency in Microsoft office tools.
 Essential/Preferable Certifications: | §  TQM