Manager Quality

IBRAHIM HAMED ROSHDY ELLAKANY, RPH, CPHQ

Address: Saudi German Hospital Aseer, King Fahd Road, Khamis Mychait, KSA.

Cell phone # 096*-***-***-***

E-mail Address: "***************@*****.***"

I'm a highly Qualified & Certified Healthcare Quality Professional

seeking for the job as QPS Manager or Clinical Risk Manager.

PERSONAL DATA:

Nationality : Egyptian

Religion : Muslim

: Saudi German Hospital – Aseer

Address (KSA)

Address (Egypt) : Gawharet Al Obour Building – Al Obour City, Cairo

Gender : Male

Date of Birth : 6/1/1981

Marital Status : Married & have two children

Military Status : Finished

Mobile : Saudi Arabia 096*-***-***-***

Tel. Home : Saudi Arabia 096*-*-******* ext. 6411

: Egypt (02) 2970649

Tel. Work : Saudi Arabia 096*-*-******* ext. 6411

Fax. Work : Saudi Arabia 096*-*-*******

E-mail : ***************@*****.***.

: ***************@*****.***.

: ****.***@********.***.

QUALIFICATION:

University degree : Bachelor of Pharmaceutical Sciences.

Graduation place : Tanta University.

Graduation degree : Very Good.

Graduation date : May 2003.

Registration No : (Egypt) 6535 (19/8/2003).

: (KSA) 07-R-P-0015285.

CERTIFICATION:

CPHQ: Re-certified as Certified Professional In Healthcare Quality From

1.

American Health Care Quality Certification Board Effectively Jan, 1. 2013.

2.

CPHQ: Certified as Certified Professional In Healthcare Quality From

3.

American Health Care Quality Certification Board Effectively April, 24.

2010.

4. Certified as Basic Life Support Provider from Saudi Heart Association

which is affiliated with American Heart Association.

FAIHQ: Certified as Fellow of American Institute of Health Care Quality

5.

effectively September, 11. 2009.

HAS/AIHQ: Certified as Primary Hospital Accredited Surveyor from

6.

American Institute of Health Care Quality effectively February, 1. 2009.

EXPERIENCE

Saudi German Hospital Group – ASEER (KSA)

Position : Quality Improvement & Patient Safety Manager.

Period : From 1-2-2012 till Now

Saudi German Hospital Group – MADINAH (KSA)

Position : Clinical Risk Manager.

Period : From 1-10-2009 to 31-1-2012

Saudi German Hospital Group – MADINAH (KSA)

Position : Acting Quality Improvement & Patient Safety Manager

Period : From 1-11-2009 to 1-5-2010.

Saudi German Hospital Group – MADINAH (KSA)

Position : Acting Infection Control Officer

Period : From 1-1-2010 to 23-10-2011.

Saudi German Hospital Group – MADINAH (KSA)

Position : Quality Improvement Pharmacist.

Period : From 1-4-2008 to 1-11-2009.

Saudi German Hospital Group – MADINAH (KSA)

Position : Pharmacist.

Period : From 13-5-2007 to 26-3-2008.

AL ABASIA PSYCHIATRIC HOSPITAL (EGYPT)

Position : Pharmacist.

Period : From 4-5-2004 to 8-5-2007.

PRIVATE PHARMACIES (EGYPT)

Position : Pharmacist.

Period : From 1-7-2004 to 8-5-2007.

CONFERENCES & SYMPOSIUMS & Events:

1. Selected by National Association of Healthcare Quality (NAHQ) as Poster

Presenter for the 38 NAHQ annual coference (Triple Crown of Quality) which

will be conducted in Louisville, KY, USA from 6 – 9 October 2013.

2. Attending Prepartion Course for Certified Profesional in Health care Quality

(CPHQ) Held in Saudi German Hospital Aseer for 6 days from 5 / 5 / 2012 to

10 / 5 / 2012 & was the only instructor of the course for 3 days in the course

from 5 / 5 / 2012 till 7 / 5 / 2012.

3. Attending Certified Profesional In Healthcare Hospital Administration held in

Mashary Hospital – Ryiadh, KSA between 11 / 4 / 2012 to 15 / 4 / 2012 for

Five days.

4. Attending the JCIA Reaccreditation for Saudi German Hospital Madinah as

Medical Risk Manager & IPSGs Chapter Leader.

5. Attending the Mock Survey done by AGI Consultation Company for the

preparation of the hospital for JCIA Reaccreditation.

6. Attendance of Quality Conference held in 27 & 28 May 2010 in Obroi Hotel

Under the name of Quality & News in medical Practice.

7. Attendance of training Program conducted in SGH Medina from 17 to 22

March 2009 in developing business problem solving & executive decision

making.

8. Attending JCIA Accreditation for Saudi German Hospital Madinah as QI

Pharmacist, Medical Risk Manager & MMU Co-chapter Leader.

9. Attending two mock Surveyes done by AGI Consultation Company for the

preparation of the hospital for the JCIA Accreditation.

10. Attendance of quality symposium under the name of leadership commitment

on quality & patient safety in 28, 29. October. 2008.

11. Attendance of Manay Clinical Symposiums from 13, May 2007 Unti Now.

DUTIES AND RESPONSIBILITIES:

As Quality Improvement & Patient Safety (QPS) Manager:

1. Performs all managerial functions as established by Job Description.

2. Supervises proper maintenance of records; allocation and appropriate utilization of

manpower and other resources to its optimum effectiveness within QPS Department.

3. Participates in Risk Management Programs in collaboration with Safety and Risk

Management and Maintenance Departments:

3.1. Receive and organize data from risk identification sources in summary form for

review by Executive Medical Director and the Medical Management Committee on a

quarterly basis. Share information, as directed, with Quality Improvement & Patient

Safety Committee, Environment of Care Committee or others, as necessary.

3.2. Report and discuss adverse events or trends regarding potential risk management/loss

prevention and control issues with the Hospital Director, Clinical Services. Take

appropriate action and report results.

3.3. When a Critical Event is identified, coordinate with the Executive Medical Director

to sequester equipment, containers, medications, documents, and medical records,

and secure in locked file or area.

3.4. Assist in the facilitation and completion of the investigation of a Critical Event,

assuring that findings are submitted in a timely manner. Address the root causes of

the Critical Event, and that an appropriate action is identified and implemented, as

directed, by the Executive Medical Director.

3.5. Organize and submit a quarterly summary Risk Management/Loss

Prevention/Control report to the Executive Medical Director.

3.6. Organize and present an annual educational review of the staff responsibilities related

to the Risk Management Program. Address related interim educational needs when

identified.

3.7. Act as a resource to assist in incorporating Risk Management/Loss

Prevention/Control components during the review of established policies and

processes, and the development of new ones.

3.8. Be responsible for maintaining the pertinence and current status of the Risk

Management Plan.

4. Develops quality management plans & The plans shall include but not limited to the

following:

4.1. Shared mission, vision, goals and objectives of QPS identifying all levels of staff

roles and responsibilities in quality programs.

4.2. Quality-related educational activities in collaboration with Academic Affairs

benchmarked from incident reports and monitored results to focus on staff

weaknesses.

4.3. How to implement uniform standard practices from JCIA to other organization

affiliations for compliance.

4.4. Quality Management processes and learning cycle such as method for data collection

and measurements, analysis, approval and implementation of improvements.

4.5. Managing & Facilitating Quality Improvement future projects.

5. Manages daily operations by distributing workloads to assigned employees; assuring

manpower and utilities are fully provided according to department needs in timely

manner.

6. Provides administrative supervision to all levels of staff assigned in the department.

7. Implements quality improvement programs through the hospital-wide committees.

8. Implementation quality improvement educational programs in collaboration with

Academic Affairs.

9. Collaborates with Human Resources Department for pre-selection of applicants to be

recruited and deployed to the department.

10. Receives monthly reports from the teams of hospital-wide committees, department

heads, and Quality Management Coordinators compiling it in QPS office to be

forwarded to the higher management. Reports shall include all the quality

improvement efforts done during the period.

11. Identifies problems on the basis of incident reports received, calls for meeting with

concerned department head (that may include staff involved in the incident) to take

appropriate decision and action (including correction of errors identified in the

meeting process).

12. Communicates quality improvement activities to employees’ hospital-wide (thru

appropriate channel) as approved by the committees.

13. Reviews semi-annually and annually all the plans under .4. To monitor status and

decide the need for any revision.

14. Schedules staff attendance in collaboration with Academic Affairs and Research

Center and Department Heads on the planned quality-related educational activities.

15. Develops and implements set of measurements / Indicators as determined by the

hospital and in consonance with the T.Q.M. mission/vision including structures,

processes, and outcome.

16. Attends to scheduled or unscheduled meetings to discuss and resolve problems

including the hospital-wide committee meetings where my attendance is necessary.

16.1.Performs other related duties necessary to effect service efficiency.

As Clinical Risk Manager

1. Administrative functions

1.1. Develops and maintains a centralized RM program.

1.2. Provides hospital-wide education on risk and potential risk

identification/prevention/control.

1.3. Establishes and maintains effective communication with all levels of staff,

all departments and services.

1.4. Effectively manages fiscal resources.

1.5. Continuously develops personal and professional skills and knowledge to

improve performance.

1.6. Plans, develops, and maintains the internal Safety Management program for

risk identification, loss prevention and safety measures, and claims control.

Advises management of potential sources of loss and liability and

recommends methods of minimizing, and/or eliminating these risks.

Coordinates and communicates safety and security concerns with other

departments, committees, and individuals at all levels to minimize and/or

eliminate risks.

1.7. Develops centralized safety management goals, objectives, and programs

consistent to the hospital mission, vision, philosophy, and strategic plan in

consultation with QPS and Safety Officer to prevent adverse events that

could result in claims, liability, and/or financial and credibility loss against

the hospital.

1.8. Recognizes and responds to accidents, incidents, and sentinel events at all

times.

1.9. Logs, tracks, and trend an occurrence/variance report (OVR) in collaboration

with QPS and Safety Officer for the purpose of conducting cost-effective

root-cause analysis; and month and year-to-date experience comparison with

similar periods in the past.

1.10.Routine periodic distribution of pertinent risk-related data including hospital-

wide monitoring and reporting systems to departments, Environment and

Safety Committee (ESC), and administration.

1.11.Establishes various trending reports such as an open claims list, facility and

safety management problem log, and related communication file under

maintenance.

2. Performance Standards

2.1. Develops and maintains a claims management process that:

2.1.1. Identifies and investigates all potential and real claims.

2.1.2. Coordinates activities of occurrence variance report (OVR) system by:

2.1.2.1. Reviewing and evaluating all variance reports to determine severity and

appropriate follow-up

2.1.2.2. Analyzing data for patterns or trends reporting data, at least monthly, to

departments and appropriate committees

2.1.2.3. Recommending action such as change in practice, policy, procedure, staffing to

correct identified problems

2.1.2.4. Notifying legal counsel as necessary

2.1.2.5. Reporting immediately to administration any serious incident/injury/complaint

2.1.3. Coordinates claims management and defense with legal counsel.

2.2. Makes recommendations for reduction or write-off of patient bills associated with

complaints/claims.

2.3. Manages a Safe Medical Device Reporting Program.

2.4. Reviews comments, contracts, and agreements for risk and insurance implications.

Requests advice from legal counsel when needed.

2.5. Develops and maintains RM policies and procedures.

2.6. Insures compliance with JCI, MOH, and other regulatory or National Accrediting

agencies.

2.7. Develops goals and objectives consistent with hospital philosophy, culture, and

strategic plan.

2.8. Conducts RM education at least annually for nursing, medical and ancillary staff.

2.9. Provides unit/department specific education as needed.

2.10. Serves as a resource to all departments and services.

2.11. Counsels and advises departments and professional staff regarding sensitive

situations involving actual or potential claims.

2.12. Participates in the hospital-wide orientation program.

2.13. Establishes agendas and conducts all meetings regarding claims and liability.

2.14. Serves as a member of the organization Claims Board, Safety Committee,

Performance Improvement Committee, and other committees/teams as assigned.

2.15. Establishes and maintains a collaborative relationship with Performance

Improvement staff and regularly communicates RM concerns.

2.16. Communicates changes in regulation/law to appropriate parties.

2.17. Prepares regular reports on RM issues and trends and presents to the organization’s

Quality and Safety Committee, and Governing Board.

2.18. Intervenes as necessary to resolve customer complaints.

2.19. Provides data for improvement studies.

2.20. Manages reimbursement for patient losses.

2.21. Participates in local, regional, and national organizations that are concerned with

RM issues.

2.22. Maintains in-depth knowledge of local regulations and laws that impact RM.

2.23. Maintains current knowledge of “state of the art” risk prevention/ management

programs.

2.24. Takes responsibility for personal and leadership development.

2.25. Attends ongoing Performance Improvement training and effectively participates on

improvement teams.

2.26. Attends to scheduled or unscheduled management and hospital-wide committee

meetings to discuss and resolve risks and safety related issues.

2.27. Performs other duties necessary as requested by the higher management.

SPECIAL QUALITY EXPERIENCES:

1. Getting JCIA Reaccreditation in Saudi German Hospital Aseer in 26 – 30

may 2012 as QPS Manager & Survey Coordinator.

2. Preparing & Instructor of the course of preparation of CPHQ held in SGH

Aseer for 6 days

3. Attending CPHHA Course in Mashary Hospital in Ryiadh, KSA

4. Leading the team of Saudi German Aseer Hospital (400 Beds) for the

preparation of JCI Reaccreditation in 26 – 30 may 2012 as Quality

Improvement & Patient Safety Director.

5. Sharing in JCI Reaccreditation survey for Saudi German Hospital Group –

Madinah (300 beds) which was conducted in January 2012 as Clinical Risk

Manager & Chapter leader of International Patient Safety Goals which was

scored 100%.

6. Sharing in Mock survey conducted by AGI Company for the preparation of

Saudi German Hospital Group – Madinah as Chapter leader for International

Patient Safety Goals & also as chapter leader for Prevention & Control of

Infection.

7. Working as acting infection control officer in Saudi German Hospital Group

– Madinah for almost two years doing the daily surveillance & managing the

infection control unit & dealing with official authorities like MOH through

weekly & monthly reporting.

8. Conducting complete patient safety survey of AHRQ with full statistics in

Saudi German Hospital Group – Madinah.

9. Certified as Certified Professional in Healthcare Quality (CPHQ).

10. Sharing in the strategic Planning of SGH Madinah for 2010 – 2013.

11. Certified as Fellow of American Institute of Healthcare Quality (FAIHQ).

12. Sharing in the final JCI Accreditation Survey which was conducted from 22

to 25 February 2009 & assigned as escort for the physician surveyor.

13. My Certification as Hospital Accredited Surveyor from American Institute of

Health Care Quality give me chance to share as a surveyor during internal

hospital self assessment one week before the final Survey.

14. Sharing in TWO mock Surveys conducted by American Gulf Institute (AGI)

the company which was contracted by the hospital for JCI Preparation.

15. Sharing in many Improvement Projects during the preparation of JCI

accreditation including online prescription improvement Project & Pain

Management Improvement Project.

16. Working as Medical Risk Manager Give me the chance to deal with all kinds

of incidents from normal events till sentinel events & having very good

experience in Root Cause Analysis (RCA).

17. Working as QI Pharmacist gives me chance to share in the preparation of the

hospital for JCI Accreditation & to be responsible for Medication

Management & Use (MMU) chapter & giving a lot of lectures & training to

both nursing & doctors’ staff regarding medication management & use.

18. My experience in medications helps me to be professional in risk

management & dealing with medication errors from all aspects including

assessment, analysis & prevention.

19. Qualification as a pharmacist gives me very good clinical, pharmaceutical &

statistical back ground which helps me too much in the quality & Risk

Management work.

SPECIAL SKILLS:

Leadership Skills.

Decision Maker.

Communication Skills.

Training & Presentation Skills.

Computer Skills (Word, Excel, PowerPoint) – Internet.

Clinical, Pharmaceutical, Statistical Back Ground.

Skills in making & analyzing all kind of Graphs including Par, Pie, Pareto,

Histogram, Control chart & Run chart.

Expert in all Performance Improvement & Risk Management Tools like

Brainstorming, Affinity Diagram, Cause & Effect Diagram ….etc.

Expert in Strategic Planning & SWOT Analysis.

LANGUAGES SKILLS

Arabic is my native language written & speaking.

English Very Good written & speaking.

REFERENCES:

• Saudi German Hospital Aseer (KSA) Tel (009**-*-******)

• Saudi German Hospital Madinah (KSA) Tel (009**-*-*******)

• Al Abasia Psychiatric Hospital

• American Institute of Healthcare Quality.

• American Board of Heathcare Quality.

Contact this candidate