Quality and Risk Staff

•Responsible for supervising the entire Hospital Quality Improvement and Patient Safety (PMKP) program which includes quality improvement, patient safety and risk management, through various clinical service audit processes, auditing compliance with policies and procedures in all divisions and departments in the hospital, carrying out process improvement based on incidents and risks, as well as ensuring the proper functioning of the Quality Management System (Medblaze) as a means of supporting quality improvement efforts.

•Conduct audits of clinical and non-clinical services in accordance with hospital accreditation standards and various hospital policies & procedures, together with Patient Safety Officers in each department / service unit.

•Carrying out quality data collection (various quality indicators) from all departments, validating data according to data validation policy, aggregating and analyzing data at the hospital level.

•Manage hospital documents, starting from developing new documents, reviewing and revising old documents, ratifying, to distributing and communicating documents throughout the hospital.

•Receive and carry out grading of incident reports, appoint incident owners, investigation owners, and action owners in accordance with the escalation grading matrix to superiors based on incident levels.

•Carry out pro-active risk reduction strategies in the form of Failure Mode & Effect Analysis (FMEA) in at least 1 clinical process every year.

•Responsible for managing the hospital level Quality Management System (Medblaze), including the document module, incident & risk, audit module, including managing users and access for all staff in the hospital.

•Acting as a Subject Matter Expert in the fields of Quality Improvement, Patient Safety and Risk Management in the Hospital, and conducting teaching (as a trainer / resource person) on the above topics to all employees in various training programs organized both by Human Capital and by Quality & Risk dept.

•Assist the Quality & Risk department head in preparing reports to the director, chairman of the hospital quality committee, and external parties (accreditation agencies, health services, ministry of health).

•Assist the Quality & Risk department head in preparing for accreditation, especially internally by carrying out self-assessments with the accreditation Working Group, Working Group and reporting the results of the self-assessment to the QR Dept Head, Chair of the Quality Committee and Director.