3.1 Monitor the implementation and updates of all PPG’s every two years in all departments as per MSD regulations (Medical and Non Medical).
3.2 Monitor the implementation of JCI and CBAHI Standards for Hospitals.
3.3 Adherence to CBAHI/JCI standards for health care instructions.
3.4 Implement the Quality Improvement Program as per MSD regulations.
3.5 Monitor implementation of all MSD By-Laws (Staff and Program By-Laws).
3.6 Monitor implementation and use of standardized MSD Forms.
3.7 Training of all hospital staffs about implementation of JCI Standards.
3.8 Perform self-assessment for JCI Standards compliance annually and send it to CQI Department Southern Region.
3.9 Prepare for internal assessment visits done by MSD Survey Team.
3.10 Prepare for all consulting or evaluating visits arranged by MSD.
3.11 Follow up all QI recommendation in accreditation visit report and send a feedback to CQI & PS Southern Region.
3.1 Participates in CQIPS Systems Improvement activities, Systems Control activities and Staff Development activities.
3.2 Performs other applicable tasks and duties assigned within the realm of his/her knowledge, skills and abilities.