CLINICAL SURVEY OFFICER, CLINICAL SURVEY

Job Description:

Quality System Management:  

The CSO must plan and implement the hospital’s quality system to meet MSQH and JCI Accreditation Standards. This includes developing annual Clinical Compliance Gantt Charts and assisting Quality Improvement Committees in updating the Quality Management System. 

Surveys and Auditing:  

Responsibilities include scheduling quarterly clinical compliance surveys and organizing periodic patient tracer surveys. The CSO also coordinates audits for the completeness of medical records and participates in internal surveys as required. 

Clinical Risk and Incident Reporting:  

The CSO monitors morbidity and adverse event statistics. They must report any adverse clinical incidents to the CEO immediately and inform KPJ Clinical & Quality services of sentinel incidents within 24 hours. They also facilitate Root Cause Analysis (RCA) for clinical incidents. 

Committee Participation:  

As a member of the Clinical & Quality Committee, the CSO is expected to attend 80% of meetings, present compliance status reports, and follow through on committee resolutions. 

Reporting:  

The role requires compiling monthly clinical indicators, incident reports, and clinical data. These reports are submitted to various bodies, including the Board of Management (BOM) and the Board of Directors (BOD) on a quarterly basis. 

Safety and Infection Control:  

The CSO ensures compliance with International Patient Safety Goals (IPSG) and works closely with the Infection Control team on audits such as hand hygiene compliance and waste management. They are also responsible for ensuring adherence to ISO standards (9001:2015, 14001:2015, 45001:2018) and the Occupational Safety and Health Act. 

Requirements:

Education: 

• Minimum hold Diploma/Degree in Nursing/ Pharmacy/ Clinical Support Certification or Post Graduation Qualification in Management. 

• Master Certification is optional. 

• Preferred: Degree in any clinical related profession. 

Knowledge and Experiences: 

• Registered Nurse with at least 3 years of clinical experience and diversity in clinical experience.   

Skills & Competencies: 

• Possess certifications in BLS, ACLS, MTLS, PALS and NRP (according to the specialties)   

Special skills required 

• Proficient in writing and conversing in English and Bahasa Malaysia.  

• Caring, honest, and responsible workers and team player  

• Microsoft Office literacy 

Personal attributes  

• Good leadership, good interpersonal and communication skills. 

• Team work and good time management 

• Willing to work extra miles for company’s achievement.