Responsible for overseeing all aspects of the department’s quality management system, including compliance with regulatory standards, accreditation requirements, and internal policies and procedures.
Shaping the culture of the department by setting expectations for staff members and encouraging them to take ownership of their work.
Participating on committees focused on quality improvement projects such as morbidity & mortality and clinical pathways.
Reviewing incident reports (Self Reporting System-SRS) and assessing risk factors to determine the cause of any problems that occur.
Developing hospital policies regarding clinical pathways, optimizing OR utilization, patient safety, and other relevant topics.