Functional/Technical Duties :

•  Act as a champion and content expert for patient safety and quality improvement at the department level.
• Work with the Chairman, Vice Chair, the Chief of Staff and QARM others to develop performance improvement targets for quality of service.
• Coordinate the design and implementation of initiatives and work collaboratively with the QARM to align quality improvement efforts.
• Apply patient safety and quality improvement knowledge in design of initiatives.
• Utilize appropriate patient safety and quality improvement methods in planning and implementation phases of PI projects.
• Develop measures and design data collection plans for patient safety, quality improvement and regulatory standards at the department level.
• Coordinate/perform collection of measurement data, including data from AUBHealth reviews.
• Conduct quality review activities to improve care quality and patient safety & analyze review results and submit reports on findings to the quality leadership and the Performance Improvement Committee.
• Assist with monitoring of unusual occurrences.
• Participate in the Performance Improvement Committee and implement its action plans.
• Utilize the appropriate performance improvement tools and techniques to identify problems and design action plans.
• Participate in root-cause analysis teams and other task forces related to quality and patient safety.
• Participate in the selection of specific topics for review, such as problematic procedures, high volume and high risk processes.
• Encourage staff to participate in solving problems.
• Construct and populate appropriate databases to perform statistical analyses.
• Identify unit trends and share findings with Chairman and vice chair for assessment with other data and identification of departmental vs. organizational trends.
• Regularly generate reports of key indicators and performance measures as scheduled.
• Audit charts:
  -Ensure all charts are completely filled
  -Follow up on incomplete charts
  -Submit reports as requested by QARM

Patient Centered Care: 

• Maintain and update the MPOG database and communicate effectively with patients, families and staff through the following steps:
• Identify patients for inclusion in the MPOG registry through the application of strict program inclusion/exclusion criteria and randomization protocol.
• Responsible for the reliable collection of preoperative, operative, and postoperative data components for the program through the effective utilization of the AUBHealth.
• Attend Morbidity and Mortality meetings to ensure reliable data collection of post procedure occurrences.
• Responsible for identifying areas for streamlining and process improvement in the data collection process.
• Demonstrate appropriate utilization of resources necessary to obtain valid, reliable data into the program.
• Utilize software applications at the site for data collection and analysis.
• Ensure accurate and timely entry of data and assuring the transmission of completed data.
• Contact patients and/or families via telephone and/or written communications postoperatively for the purposes of identifying possible occurrences associated with procedures performed at the hospital.
• Serve as an educational resources in the MPOG for internal and external audiences by developing educational material and delivering presentation.
• Attend conferences pertaining to the program as requested.
• Investigate patient care occurrences in coordination with the concerned AUBMC staff.
• Review medical records of patients affected by patient care occurrences.
• Prepare summary reports on patient care occurrences.
• Review AUBMC policies and procedures regarding safety and security of patients and families, and ensure their implementation in coordination with the AUBMC Risk Manager.
• Perform pro-active review of patient safety processes and identify process improvements.
• Propose action plans for prevention of similar occurrences.

Administrative/Miscellaneous:

• Maintain databases and performance improvement documentation that support the structure of the Medical Center for peer review, statistical analysis, process and outcome monitoring.
• Prepare data collection sheets and collect relevant data on the assigned quality reviews.
• Review and analyze departmental morbidity and mortality data to monitor for specific trends and patterns.
• Prepare and coordinate all Mortality and Morbidity review sessions and maintain an updated log of all cases.
• Document and report all performance and quality improvement activities to engage staff in continuous quality improvement.
• Communicate progress on initiatives to all stakeholders in a scheduled and timely manner.
• Compile statistical data and write narrative reports summarizing quality improvement findings.
• Facilitate the coordination of meetings for performance/quality improvement projects.
• Scheduling of meetings and rooms; notifying participants.
• Developing agendas in collaboration with involved leaders.
• Following up after meetings to ensure that work gets done.
• Recommend changes for quality improvement in the departmental Policies and Procedures manual based on findings of reviews and surveys.
• Attend in-service discussion as requested.
• Perform self-development activities.
• Provide educational support, leadership and consultation services.
• Work in concert with the AUBMC medical, nursing, administrative staff and the Medical Board Committees to ensure that goals are set and measured to continuously improve performance.
• Perform other administrative activities and duties as assigned.
• Participate and contribute to successful departmental compliance with the national and international regulatory surveys/accreditation processes through reviewing the standards and intent of the Ministry of Public Health (MOPH) and the Joint Commission International accreditation Standards for Hospitals (JCIA).
• Interpret and implement Medical Center policies and accreditation standards related to quality improvement and patient safety.