Clinical Quality Assurance Coordinator Mary Begg Health Services

PURPOSE OF THE ROLE:

The Clinical Quality Assurance Coordinator in a hospital plays a crucial role in ensuring high standards of patient care and safety. They work with a multidisciplinary team to establish and implement quality standards, conduct audits, and monitor clinical processes. They lead patient safety initiatives, analyse data to identify improvement opportunities, collaborate with healthcare providers for education and training, manage incidents and perform root cause analysis, ensure regulatory compliance, initiate performance improvement projects, and engage patients and families in quality improvement efforts. Through these responsibilities, they contribute to enhancing overall clinical care quality, patient outcomes, and safety within the hospital.

• Developing and Implementing Quality Standards: The Coordinator works with the multidisciplinary team to establish and implement quality standards for clinical care. This involves creating protocols, guidelines, and best practices based on evidence-based medicine and industry standards.
• Monitoring and Auditing Clinical Processes: The Coordinator conducts regular audits and reviews of clinical processes to identify areas for improvement. They analyze data, evaluate compliance with established standards, and provide feedback to healthcare providers to ensure adherence to best practices.
• Patient Safety Initiatives: The Coordinator leads patient safety initiatives, such as developing and implementing protocols for medication management, infection control, and patient identification. They work closely with healthcare teams to promote a culture of safety, identify potential risks, and implement preventive measures.
• Quality Data Analysis: The Coordinator collects, analyzes, and interprets data related to clinical outcomes, adverse events, and patient satisfaction. They identify trends, patterns, and opportunities for improvement, and provide reports and recommendations to hospital leadership and clinical staff.
• Collaboration and Education: The Coordinator collaborates with healthcare providers to educate and train them on quality improvement methodologies and clinical best practices. They provide guidance on quality-related issues, conduct educational sessions, and foster a culture of continuous learning and improvement.
• Incident Management and Root Cause Analysis: In the event of adverse events or incidents, the Coordinator leads or participates in the investigation process. They facilitate root cause analysis, develop corrective action plans, and monitor their implementation to prevent recurrence.
• Regulatory Compliance: The Coordinator ensures compliance with regulatory requirements and accreditation standards related to clinical care. They stay updated on changes in regulations, assist in preparing for audits or inspections, and work with teams to address any areas of non-compliance.
• Performance Improvement Projects: The Coordinator initiates and leads performance improvement projects aimed at enhancing clinical care outcomes and patient experience. They collaborate with stakeholders, set goals, track progress, and implement sustainable improvements.
• Patient and Family Engagement: The Coordinator promotes patient and family engagement in quality improvement efforts. They develop strategies to gather feedback, involve patients and families in care planning, and communicate initiatives and outcomes effectively.

By fulfilling these responsibilities, the Clinical Quality Assurance Coordinator contributes to enhancing the overall quality of clinical care, patient outcomes, and safety within the hospital setting.

KEY RESPONSIBILITIES:

Clinical Services:

• Competence in the demonstration and assessment of all relevant clinical procedures and management of risks.
• Achieves clinical quality standards according to set policies and procedures.
• Ensures continuation of patient care through effective supervision.
• Ensures continued patient education programmes within the facilities
• Maintains a customer-focused mindset that acknowledges the value of the customer and sets high standards for quality.
• Oversee the patient care provided in inpatient, OPD, triage, labour and delivery and MCH, and where gaps or poor care are identified, address the issue with the nursing team / HM.
• Encourages discussion with the multidisciplinary team to ensure goal-directed treatment plans are implemented and adhered to. Discuss treatment with medical doctors and pharmacists in critical cases.
• Attend ward rounds and clinic meetings and participate in the discussion and mandatory role-specific training.
• Attend random nursing medication rounds and use these opportunities to address any areas of competence, nursing technique, learning opportunities, etc. Review medication charts, and DDA registers to ensure all information and counts are properly done.
• Review the ER, Labour and Delivery and Inpatient checklists to ensure clinical staff are conducting proper equipment checks and medication/ consumable counts. Properly document and report to the Clinic/Hospital Manager where equipment needs to be repaired or replaced.
• Monitor all nursing assessments, examinations and routine patient vitals observations and ensure they are documented according to the clinic’s SOP.

Quality

• Implement MBHS Standards.
• Implement quality Management systems.
• Monitor clinical quality indicators.
• Promote quality of patient services through the implementation of best practice guidelines, standard operating procedures and policies.
• Maintain a catalogue of all MBHS SOPs/ Documents/Forms and ensure that correct, most updated versions are implemented.
• Implement an internal audit programme that assesses the quality of services, adherence to the MBHS Standards and the productivity and effectiveness of various departments.
• I’d like you to please develop and implement P.O.A (the plan of action) after the audit (internal and external) with Hospital Manager and CMO and submit progress reports to the Quality and Training Manager.
• Identify, report, investigate and address near-misses and adverse events.
• Sound knowledge of the Scientific Nursing Process and BCA bundles.
• Develop quality improvement strategies to achieve excellence.
• Support clinical audit activities for external audits,
• Guide and Monitor infection control activities at the hospital.
• Work closely with the infection control representatives to implement all infection prevention measures and ensure a safe patient environment.
• Ensure compliance with weekly quality departmental meetings.
• Timely completion of Monthly quality and IPC reports.

Safety, Health & Environmental (SHE)- Focal Person

• Responsible for the effective implementation of the Company HSE Policy.
• Is responsible for the provision and review of facilities and working environment.
• To act quickly on QHSE problems, ideas and recommendations emanating from the activities.
• Ensure that the emergency response plan has been communicated to all staff at MBHS
• Ensure that emergency contact numbers have been displayed at all relevant areas within MBHS premises.
• Ensure that an emergency evacuation plan has been displayed in relevant areas.
• Ensure that the appropriate notifications shall be made during emergencies.
• Assist external agencies during emergencies in coordination with the HSE team.
• Prepare the HSE report and submit it to the Quality Manager.

Infection Prevention and Control

• Developing and implementing infection prevention and control policies and procedures.
• Ensuring compliance with regulatory standards and guidelines related to infection control.
• Conducting risk assessments and identifying potential infection risks within the healthcare facility.
• Collaborating with healthcare teams to develop and implement infection prevention and control strategies.
• Monitoring and auditing infection control practices and processes to identify areas for improvement.
• Analyzing data on healthcare-associated infections and implementing measures to reduce infection rates.
• Providing education and training to healthcare staff on infection control protocols and best practices.
• Overseeing the investigation of outbreaks or incidents related to healthcare-associated infections.
• Implementing and monitoring appropriate cleaning and disinfection practices.
• Collaborating with other departments to develop and implement strategies to prevent the spread of infectious diseases.
• Participating in infection control committees and providing reports on infection control activities.
• Keeping up-to-date with emerging trends and research in infection prevention and control.
• Liaising with public health agencies and other healthcare organisations to exchange information and best practices.
• Promoting a culture of infection prevention and control among staff and patients.

REQUIRED TECHNICAL SKILLS, TRAINING & EXPERIENCE

• An RN Qualification (essential): Bachelor’s degree in nursing
• A current license to practice nursing in Zambia from the General
• Nursing Council of Zambia or equivalent registration in the country of employment.
• BLS training (desirable).
• ISO 9001 courses – Implementation, internal auditor desirable

EXPERIENCE REQUIREMENTS

• Minimum six years’ general nursing experience.
• Experience in clinical audits and quality management projects
• Experience in the national or international accreditation process
• Minimum three years experience in leadership/ Management.