Clinical Audit and Compliance Specialist

Job Description

Policies, Systems, Processes & Procedures:

• Supervise the implementation of sectional policies, systems, processes, procedures, and internal controls covering the assigned areas of the division so that all relevant procedural /legislative requirements are fulfilled while delivering a quality, cost-effective service in a consistent manner
• Identify potential areas of improvement, to support an efficient and effective operation and contribute towards the continuous improvement of existing policies, processes, and procedures by collating inputs from team, and identifying and recommending improvements.
• Ensure compliance with laws, rules, and regulations from the United Arab Emirates and relevant authorities.

Quality Audit and Compliance

• Establish and implement quality audit and compliance program covering all essential clinical governance pillars and continuous readiness towards accreditation programs.
• Oversee clinical and quality review activities within the hospital variance and misconducts are revealed, and action plans are implemented to enhance quality and service and contribute to the overall development of organization.
• Support clinical teams to prioritize develop and/or adopt evidence-based clinical practice guidelines, clinical pathways, or protocols.
• Coordinate with Dubai Health Authority, Ministry of Health, or other regulatory authorities on areas related to Clinical Governance to implement and maintain a safer and healthier work environment, aligned with generated frameworks.

Establish and implement the following audits and reviews:

• Clinical audits and patient tracers
• Clinical guidelines and pathways reviews
• Medical records reviews
• Medication management reviews
• Blood utilization reviews
• Credentialing and privileging reviews
• Surgical care reviews
• Anesthesia and sedation practices reviews
• IHI trigger tools reviews
• Morbidity and mortality reviews
• Patients’ clinical complaints reviews
• Committee management reviews
• Utilization management review

General

• Develop a continuous readiness program to ensure that all national and international standards are implemented into day-to-day operations.
• Work towards the implementation of all the accreditation requirements and ensure that all the related stakeholders are involved in the process.
• Develop and execute training programs to all levels on quality audits and compliance tools and processes.

Safety, Quality & Environment

• Ensure the application of patient safety, quality and environmental management policies, patient and family right policies, procedures, and controls to ensure patient safety, legislative compliance, delivery of high-quality products/services and a responsible environmental attitude.
• Enhance and manage person-centered care behavioral expectations to comply with organizational values.
• Abide by CARE+ communication and service standards when interacting with other staff members or with patients and families.
• Ensure the preparation of reports in a timely and accurate manner to meet the departmental requirements, policies, and standards.

Related Assignment

• Perform other related duties or assignments as directed by the group.
• Perform other related duties or assignments as directed by the department manager.
• Participate in hospital committees, task-force meetings and other meetings as required.

QUALIFICATION REQUIREMENTS:

Education

• Bachelor’s degree in healthcare (Medical, Nursing, Pharmacy, Laboratory, etc.) plus Postgraduate Diploma in Healthcare Management, Quality Management, Hospital Administration, or Business Administration, and
• Certification in Healthcare Quality, Patient Safety, or Risk Management 

Experience

• Working experience of Six (6) years in hospitals or other recognized healthcare institutions
• Four (4) years-experience as a health professional in hospital setting
• Two (2) years-experience in a position in quality management or risk management.