OverviewThe Director, Clinical Governance and Innovation ensures high quality, patient centered care by providing professional leadership and governance to the quality and patient safety program. The Director works closely with facility leadership to optimize and meet hospital strategic goals and objectives; measures outcomes and provides supervision for robust process improvement projects ensuring high reliability methods in order to eliminate factors and practices which waste time, effort and monetary resources and measurement; facilitates the development and implementation of clinical practice guidelines/policies according to international best practice; fosters team work and champions service excellence throughout the facility; ensures compliance with corporate objectives, applicable laws, regulations, and other governmental requirements.The core components of the role includes:

• Accreditation and regulatory compliance
• Clinical effectiveness and research
• Clinical outcomes
• Clinical quality and process improvement
• Clinical Risk Management
• Infection Control and Prevention
• Learning and Effectiveness

ResponsibilitiesKEY DECISIONS THE ROLE MAKES AND THE EXTENT OF THE IMPACT OF THE DECISION

• Takes decisions on areas including but not limited to managing, executing, and administrating the operational

aspects of budgets, people, financial and other resources in alignment with the established Delegation of
Authority (DoA). * Makes decisions where relevant on areas including but not limited to Quality Assurance strategies, frameworks,and policiesKEY ACCOUNTABILITIES AND ACTIVITIESBusiness Strategy

• Strong organizational and systems thinking skills with attention to detail and a demonstrated ability to manage competing demands, meet deadlines, and effectively manage change.
• Pro-actively participates in collaboration with Facility Leadership and the Corporate Office to meet the function's strategic and operational goals.
• Develops and manages the implementation of the divisions strategic and operational goals and continuously monitor progress towards their achievement.
• Ensures people, financial and technological resources within the division are utilized effectively.
• Promotes a culture of improvement and enhance workforce capability to optimize safe and high-quality care through the identification and mitigation of risk, rigorous monitoring and reporting systems, and comprehensive review and oversight of activities to improve performance

People Management

• Promotes and provides continuous constructive feedback and coaching to employees and takes prompt action where necessary to ensure progressive development.
• Establishes clear directions, assigns and delegates responsibilities effectively to ensure smooth operational flow.
• Supports in setting caregivers individual objectives, manages their performance and development, as well as motivates them to achieve their individual goals.
• Provides continuous constructive feedback and coaching to caregivers and takes prompt action where necessary to ensure progressive development.
• Assigns responsibilities effectively in adherence with the organizational DoA and monitors the workflow of the function while maintaining high caregiver engagement and a motivated work environment.
• Drives opportunities for caregivers to suggest, participate and contribute to improvement, innovation and knowledge sharing initiatives.
• Provides input in areas of manpower planning including recruitment, training, capability enhancement and drives a high level of caregiver engagement.
• Actively participates in organizational training programs and on the job learning to continuously enhance skillset required to perform the job.
• Provides leadership in support of contemporary, evidence-based practice and quality initiatives.
• Develops implements and evaluates succession planning processes aimed at promoting quality & clinical leadership.

Accreditation and Regulatory Compliance

• Ensures all regulatory requirements and organizational accreditation related standards are effectively monitored and adhered to.
• Ensures a coordinated approach to accreditation by leading the quality team in the preparation and participation of regulatory audits.
• Delivers resultant action plans.

Clinical Effectiveness / Research / Innovation

• Searches for adopts and evaluates contemporary, a best practice implemented elsewhere.
• Coordinates electronic literature searches, evaluates and appraises research evidence, and synthesizes evidence into summaries for review by multidisciplinary teams of content experts from across organization.

• Facilitates content expert team meetings to develop care standards, clinical practice recommendations and evidence-based guidelines for the organization; as well as outlining process measures and outcome measures which evaluate variation production and increased patient value.
• Facilitates transition of evidence-based clinical decision support tools (i.e. order sets) into electronic health records (EHRs), and coordinates with analytics to develop reports/scorecards which track the defined process and outcome measures to ensure the financial and clinical impact of projects.
• Acts as a change agent by promoting a culture of value-based care and evidence-based practice through educational endeavors.
• Champions new ideas and supports others to plan and implement change initiatives.
• Proposes and implements change initiatives and new projects that bring about innovation.

Clinical Outcomes

• Advocates for benchmarking the organizations quality services against nationals and international standards.
• Coordinates and assist departments with quality measure selection and in the development of quality assurance programs.
• Oversee evaluation, analysis, reporting, and improving patient safety and quality systems and outcomes.

Clinical Quality and Process Improvement

• Contributes to the development and communication of quality and safety plan and strategic aims aligned with corporate objectives.
• Conducts periodic internal audits to evaluate effectiveness of the Quality and Safety Plan.
• Leads the implementation of quality improvement projects based on retrospective and prospective risks identified.
• Analyses retrospective and prospective issues using tools such as root causes analyses and Failure Modes Effects Analysis (FMEA).
• Reviews policies, procedures and processes so as to ensure its continual suitability, effectiveness and appropriateness.
• Participates in and leads the quality and patient safety committees.
• Reports QPS data to Mubadala Health Quality, Patient Safety and Experience Committee.

Clinical Risk Management

• Develops, implement and monitor/evaluate a Culture of Safety Program.
• Oversees the clinical incident management system including review of morbidity, mortality and clinical audit outcomes.
• Ensures events (incidents) are appropriately responded to, fully investigated and actions taken to minimize recurrence.
• Leads the development of risk identification throughout the organization by producing a risk register.
• Ensures the risk register is maintained to ensure it is updated and showing increased mitigation of identified risks

Infection Control and Prevention

• Supports the goals and objectives for infection control and prevention; ensure technological advances in infection control and prevention are incorporated in a safe and cost-effective manner

Learning and Effectiveness

• Educates caregivers at all levels on high reliability methodologies in support of evidence-based practices, the reduction of medical/health care errors and other factors that contribute to unintended adverse outcomes.
• Performs systematic evaluation of quality initiatives/education programs to determine if they meet the organizations needs.

Enganging with Stakeholders

• Liaises with external parties such as DOH/DHA, JCI, and other relevant accreditation and Government bodies on all matters related to the external audit and accreditation process.

• Develops relationships with key stakeholders across MH to ensure Caregivers are supported by consistent safety and quality systems to continually improve clinical outcomes.

• Oversees the implementation of High Reliability and Safety within the facility. Facilitates consistency in facility policies and practices.

• Champions a proactive patient safety, quality improvement and risk management culture that reflects best practice.

• Develops and proactively uses networks, both inside and outside the organization, to build relationships.

QualificationsEducation

• Bachelors Degree in nursing, Healthcare Management or equivalent field
• Certified Professional in Health Care Quality (CPHQ) or equivalent required

Experience

• 10+ years of progressive career experience inclusive of 5-7 years management experience or the equivalent

in a progressive professional experience developed through an internal succession planning processJob Specific Skills and Abilities

• Knowledge of leading practice quality assurance and patient safety methods
• Strong ability to use tools for continuous quality and safety improvement
• Strong knowledge of key quality assurance processes and current best

practices * Excellent presentation skills and the ability to clearly convey information andinstructions * Strong analytical and problem-solving skills

• Proficiency with Microsoft Office suite
• Fluency in written and spoken English

National Reference Laboratory