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The document provides a summary of Dr. Ahmed Kassem Ghoneem's qualifications and experience in healthcare quality management. It lists his education and certifications in fields including management, healthcare utilization, data analysis, and quality management. It then describes his work experience in quality management roles for various hospitals in Saudi Arabia and Egypt from 2008 to present. Finally, it outlines his core skills and achievements in areas such as quality improvement, accreditation, clinical guidelines, data analysis, and leading quality projects.

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2013 Certified in Management applications, healthcare utilization and strategic planning ICDM, Saudi Arabia 2012 Certified in Business Process Management ICDM, Saudi Arabia 2011 Certified in Advanced Data Analysis ICDM, Saudi Arabia 2008 Certified in Advanced Healthcare Communication Johns Hopkins University Bloomberg School of Public Health in Cooperation with the American University of Cairo, 2007 Certified in training of trainers Ain Shams University, Cairo Egypt 2007 Six sigma Green built, American university of Cairo, Cairo Egypt 2007 Lean Green built American university of Cairo, Cairo Egypt 2006 Diploma in Total Quality Management, American University of Cairo, Cairo Egypt 2002 Baccalaureate of Medicine and Surgery, Faculty of Medicine, Al-Azhar University, Cairo Egypt Q Dr. Ahmed Kassem Ghoneem HEALTHCARE QUALITY AND UTILIZATION MANAGEMENT CONSULTANT EDUCATION AND CERTIFICATIONS
April 2016-present Quality manager Saudi German Hospital Cairo 2015-2016 Freelance consultant for in gulf area 2011-2015 Head of performance excellence King Fahd Specialist Hospital Dammam KSA (350 bed Tertiary hospital with core Competency in oncology, transplant, neuroscience and Genetics accredited for - JCI - ISO 9001 - IAEA - HACCP - CAP - ASHI - AAHRPP for clinical research 2008-2011 Quality Manager -Mouwasat hospital KSA (Group of sex hospitals all accredited For JCI, CBAHI AND CAP) 2007-2008 Director of Quality at El Haram Health Administration, MOH GIZA 2007-2008 Head of Health Education Department at El Haram Health Administration, MOH GIZA WORK EXPERIENCE
2006-2007 Chairman of Quality Council at Kafr El-Gabal Health Center, MOH - GIZA 2005-2006 Family Medicine Physician at Kafr El-Gabal Health Center, MOH -GIZA STRATEGIC PLANNING - Expert in facilitating the process of organization wide strategic planning using SWOT analysis , - Expert in facilitating the process of translation of hospital strategic goals into operational plans using Balanced scorecard and mapping there implementation using (PERT) methodology as well as monitoring of the achievements using KPIs (Key performance indicators UTILIZATION MANAGEMENT - Expert in the process of planning for future organization resource expansion and subsequent appropriate budget allocation using forecasting and queuing - Expert in leading the process of planning for new beds as well as analysis of current beds utilization using new advanced methodologies including electronic bed board , DRG , Clinical practice guidelines forecasting models, queuing theory and simulation models - Expert in conducting and training for initiating feasibility studies for any newly proposed healthcare related projects - Expert in building an organization wide utilization analysis system using a network of KPIs monitored overtime using SPC (Statistical process control) analysis tools CORE SKILLS & AREAS OF STRENGTH
QUALITY IMPROVEMENT, SAFETY AND PERFORMANCE EXCELLENCE - Expert in leading the Development, implementation, coordination and monitoring of hospital wide performance improvement and safety programs - Expert in the process of monitoring performance using Key performance indicators with long experience in all KPI process roadmap including selection , collection , validation , analysis , and reporting - - Expert in initiating a standardized framework for the quality improvement projects road map as part of the quality program scope , this road map includes Identify sources for proposing improvement project areas Selection and prioritization criteria of the project area Selection of appropriate methodology (FOCUS-PDCA/LEAN/SIX- SIGMA) Project planning and charter Project monitoring completion and evaluation. - CLINICAL PRACTICE GUIDELINES AND PATHWAYS - Expert in leading and coordinating the process of evidence base standardization of clinical care through initiation, monitoring of compliance as well as effectiveness evaluation of clinical practice guidelines and clinical pathways. - Expert in improving hospital utilization of clinical practice guidelines and pathways implementation through Improving average length of stay (Non profit making hospital) Reduce the cost of non indicated procedures and investigations (Non profit making hospitals) Reduce insurance rejection rate (profit making organization) Improve revenue through increase the number of evidence based requested investigations and consultations (not to miss evidence based requested investigations)
BUSSINESS PROCESS REENGINEERING - Expert in conducting and training for BPR methodology that include the following Select the end to end process to be redesigned Prepare ,Involve and ensure buy-in by the concerned frontlines and managers across the whole BPR lifecycle Identify process architecture (e.g. related laws and regulations , fixed and flexible roles to be considered in the redesign phase) Mapping the current AS IS process flow and identifying all related barriers and bottle necks Data collection for each process step that include but not limited to ,step turnaround time and its distribution , number of transactions , Number of resources and their availability time distribution , added value and non added value steps , and areas of interactions with other processes in the same or in deferent areas/departments (sound of integration) Redesign the process to achieve the maximum efficiency and quality within the predefined process architecture FMEA for new process Expert in simulating the old and the new processes using simulation software e.g. ARENA Pilot implementation Full implementation , feedback and monitoring of the redesigned process PROJECT MANAGEMENT - Expert in project planning and management - expert in project output data collection planing analysis interpretation and reporting - Expert in using project planning tools that includes and not limited to Gaunt chart
PERT (Project evaluation and review technique) methodology Identifying the critical path and subsequent critique for crushing the project timeline Human recourse distribution ORGANIZATION DEVELOPMENT - Expert in assisting the process of formulation/revision of philosophy, objectives and contents of organization policies - Expert in formulating reviewing and improving Organization structures and organization charts aiming to serve organization vision , mission and strategic goals QUALITY ACCREDITATIONS - Expert in JCI standards , their interpretation and monitoring with full knowledge about history of standards changes over the last three editions (3rd , 4th ,and 5th editions) - Expert in CBAHI standards , their interpretation and monitoring - Expert in preparing hospitals and other healthcare organizations for both above mentioned accreditation systems - Expert in Egyptian national accreditation standards RISK MANAGEMENT - Expert in helping hospitals and other healthcare facilities to initiate an organization wide (clinical and non clinical) risk management program that incorporates risk identification and assessment , reporting , prioritization ,prevention and control - Expert in utilizing and educating risk management tools both proactive and
reactive risk management tools that include but not limited to root cause analysis (RCA) , failure mode and effect analysis (FMEA) ,and risk grading matrix. - Expert in assessing and measuring hospital/healthcare organization safety culture (Safety culture AHRQ) TRAINING, EDUCATION, AND CONSULTATIONS - Expert in assessing healthcare quality training needs , Planning and co- ordination of these training activities - Expert in designing and conducting different healthcare quality , management and utilization training courses and consultations ,this includes and not limited to the following training and consultation activities Bed planning and utilization using Forecasting , queuing model and diagnosis related groups (DRG) JCI Accreditation in 12 months CBAHI accreditation Staffing plan Hospitals utilization analysis Management tools (Strategic-Tactical-Operational-Supply chain) Advanced statistical analysis Six sigma breakthrough improvement PDCA and FOCUS-PDCA improvement methodology Clinical practice guidelines and clinical pathways roadmap Statistical process control (SPC) Strategic planning using Key performance indicators (KPI) roadmap and Balanced Score Card Data Management Data analysis using SPSS Business Process management in healthcare
DATA MANAGEMENT - Expert in all data management roadmap steps including collection ,sampling , validation , analysis , Reporting , and Benchmarking - Expert in using all advanced data analysis tools (either Quantitative or Qualitative) to support data based decision making - Expert in using and training for most of the quantitative and qualitative data analysis software (e.g. SPSS , Minitap , Pathmaker , N-Vivo ) - Expert in using SPC (statistical process control ) concept and methodology CHARTS REVIEW AND TRACER METHODOLOGY - Expert in leading and teaching and training of organization staff to conduct organization wide tracer methodology for the following areas aiming to improve continuity of care ,patient centered care , system integration as well as a preparedness tool for JCI accreditation. Clinical tracer Maintenance and equipment tracer Infection control tracer Facility management and safety tracer - Expert in the process of Closed and Open patient chart review based on both JCI and CBAHI accreditation standards , this process include the following How often Sampling JCI/CBAHI required documentation formats (Validating current hospital formats) Audit method (How and when to audit) Data aggregation formats and database
Data Validation Data analysis Reporting formats PATIENT EXPERIENCE CENTERED AND INTEGRATED CARE: - Expert in designing tools to collect patient needs - Expert in analyzing and interpreting patient needs data in terms of new strategic objectives as well as new process of care redesign requirements - Expert in designing and redesigning integrated care programs that tackle the patient needs and ensure removing inter-disciplines silos ANALYSIS SOFTWARE - Expert in utilizing and training for the following analysis software SPSS (Quantitative data analysis software) Pathmaker (Quantitative data analysis software) Minitab (Quantitative data analysis software) N-vivo (Qualitative data analysis software) Arena (Process simulation software) - Prepared and Assist 3 hospitals (Mouwasat Jubail , Mouwasat Qatif , King Fahd specialist hospital) to get 3 JCI accreditation and 3 reaccreditation (3rd and 4th edition JCI standards) - Conducted and assist in 4 JCI mock surveys which was held by AGI group (Prof. Assaf El-Assaf Prof. of Quality and Safety in Oklahoma University / Prof. Seval Aqugnum).and JCI consultants (Dr.Derick Pasternak) ACHIEVEMENTS
- Prepared and assist Mouwasat hospital Madinah for Central Board of Accreditation for Healthcare Institutes (CBAHI) accreditation. - Shared in 3 facility safety mock surveys which was held by Prof. Azimi Mehedy, Oklahoma USA) - Led and supervised the preparation of different hospitals and healthcare centers for National Egyptian accreditation - Supervised the process of implementation of Business process Management to improve clinical and administrative processes in King Fahd specialist hospital as the project manager with PWC company (Pricewaterhouse cooper) - lproject manager for implementation of ERP system in king fahd specialist hospital ,Saudi arabia - Led and Supervised the process of initiation and implementation of Ongoing professional practice evaluation program (OPPE) in king Fahd specialist hospital- Dammam - Supervised the process of KPIs (Key performance indicators) initiation roadmap in King Fahd Specialist hospital , Mowasata hospital Jubail , Mouwasat hospital Qatif and Mouwasat hospital Madinah - Supervised the process of clinical practice guidelines and pathway initiation, monitoring of implementation and effectiveness evaluation together with linking the implementation to improve hospital utilization e.g. A.L.O (average length of stay ) , radiology and lab utilization. In the above mentioned 4 hospitals
- Coordinated and supervised many improvement projects that include but not limited to : Six Sigma Projects: Reduce the Surgical Site Infection Rate In Clean Operative Procedures Reducing Ventilator Associated Pneumonia (VAP) In ICU Reducing The Rate of Catheter Associated Urinary Tract Infection (CAUTI) Reducing Central Line Catheter Blood Stream Infection (CLABCI) In ICU Reducing Unit Acquired / Hospital Acquired Pressure Ulcer Rates Reduce Admission Process Turnaround Time (TAT) Reducing Percent of Pending Referral Cases Reducing the Percentage of False Positive Blood Culture Results Due To Contamination Reducing Lab Specimens Rejection Due To Clotting Reducing Lab Specimens Rejection Due To Hemolysis Reducing Response Time For Isolation Room Terminal Cleaning Reducing Actual Time of Isolation Room Terminal Cleaning Lean Projects: Communicating Laboratory Critical Results Live Kidney Donor Evaluation Use of Emergency Drugs In ICU Improving The Process For Dispensing Discharge Medication Improve the In Patient Admission Process Improve The In-patient Discharge Process
Organizing the Operating Room Booking In Neurosurgery Department Reducing the Turnaround Time (TAT) Between Cases in The Operating Room (OR) Improving Patient Flow In Emergency Department (ED) Improving Admission Criteria to Pediatric Department To Meet The Scope of Service of A Tertiary Care Improving The Admission Process To The Day Procedure Unit (DPU) Reducing Waiting Time from Arrival To Administration of Chemotherapy Improve The Out Patient Department (OPD) Booking in Rheumatology Clinic Reducing MRI Access Time Improve TAT In ER Samples Elimination of Redundancies In Interventional Radiology (IR) Pre-Procedure Workup Improving the Recruitment Process Cycle Time Improving The Nursing Overtime Process Improve the Call Center Process Streamlining the Direct Purchasing Process Management process of lab reagents FOCUS-PDCA Reducing Medication Error Improving Hand Hygiene Improving Waste Segregation Improving Patient involvement in Care Process Reducing Hospital acquired pressure ulcers Reducing Chemo contamination Improving Response to call bell
Improving the process of High alert medications management CUTI infection Improve volume of blood extraction in Pediatric ICU - Coordinated and supervised initiation of hospital departmental manuals in Mouwasat hospital group - Put a standardized strategy for hospital utilization analysis to improve income and reduce costs using up-to-date quality tools (software proposal for utilization analysis approved as feasible project by many of international healthcare software companies) Mouwasat hospital group - Initiated a forecasting model for all utilization KPI in King Fahd Specialist Hospital Dammam - Supervised the preparation of implementation of schedule B Quality standards of ARAMCO contract in Mouwasat hospital group - Led the initiation , execution , and monitoring of strategic plans in Mouwasat hospital Jubail , Qatif , Madinah ,King Fahd specialist hospital - Led and supervised the initiation , implementation of corporate risk management program for Mouwasat hospital group after they decided to share in the stock market - Supported Mouwasat hospital Jubail operation through the following : Initiated a statistical based software program for stock control (analytical rather than operational i.e. tool for auditing stock control processes by top management) in cooperation with IT department
Business planning for a lot of IT projects including SABIC center communication project and online approval center Initiated a statistical based program for evaluation of effectiveness of marketing department tools and their impact on hospital services growth etc using curve estimation tools Initiated data analysis support for the following feasibility studies in Mouwasat group ; Outpatient clinics expansion Physiotherapy department expansion Inpatient capacity expansion Best way to utilize the Space near Mowasat Jubail hospital - Worked with top management in Mouwasat Jubail to initiate a statistical based artificial intelligence software program to support decision making - Initiated bed utilization analysis model in King Fahd Specialist Hospital Dammam using the following tools Electronic bed board Forecasting Model Queuing model DRG (Diagnosis related groups) CPG (Clinical practice guidelines and pathways) - Speaker in many events including but not limited to Babtain hospital symposium for healthcare quality and patient safety Dammam university HIM (Health Information Management) annual symposium Quality and safety event King Faisal Specialist hospital Riyadh Quality and safety events KFSH-D
Quality and safety events Mouwasat Group Oncology nursing Club

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DOC-20160808-WA0000

  • 1. 2013 Certified in Management applications, healthcare utilization and strategic planning ICDM, Saudi Arabia 2012 Certified in Business Process Management ICDM, Saudi Arabia 2011 Certified in Advanced Data Analysis ICDM, Saudi Arabia 2008 Certified in Advanced Healthcare Communication Johns Hopkins University Bloomberg School of Public Health in Cooperation with the American University of Cairo, 2007 Certified in training of trainers Ain Shams University, Cairo Egypt 2007 Six sigma Green built, American university of Cairo, Cairo Egypt 2007 Lean Green built American university of Cairo, Cairo Egypt 2006 Diploma in Total Quality Management, American University of Cairo, Cairo Egypt 2002 Baccalaureate of Medicine and Surgery, Faculty of Medicine, Al-Azhar University, Cairo Egypt Q Dr. Ahmed Kassem Ghoneem HEALTHCARE QUALITY AND UTILIZATION MANAGEMENT CONSULTANT EDUCATION AND CERTIFICATIONS
  • 2. April 2016-present Quality manager Saudi German Hospital Cairo 2015-2016 Freelance consultant for in gulf area 2011-2015 Head of performance excellence King Fahd Specialist Hospital Dammam KSA (350 bed Tertiary hospital with core Competency in oncology, transplant, neuroscience and Genetics accredited for - JCI - ISO 9001 - IAEA - HACCP - CAP - ASHI - AAHRPP for clinical research 2008-2011 Quality Manager -Mouwasat hospital KSA (Group of sex hospitals all accredited For JCI, CBAHI AND CAP) 2007-2008 Director of Quality at El Haram Health Administration, MOH GIZA 2007-2008 Head of Health Education Department at El Haram Health Administration, MOH GIZA WORK EXPERIENCE
  • 3. 2006-2007 Chairman of Quality Council at Kafr El-Gabal Health Center, MOH - GIZA 2005-2006 Family Medicine Physician at Kafr El-Gabal Health Center, MOH -GIZA STRATEGIC PLANNING - Expert in facilitating the process of organization wide strategic planning using SWOT analysis , - Expert in facilitating the process of translation of hospital strategic goals into operational plans using Balanced scorecard and mapping there implementation using (PERT) methodology as well as monitoring of the achievements using KPIs (Key performance indicators UTILIZATION MANAGEMENT - Expert in the process of planning for future organization resource expansion and subsequent appropriate budget allocation using forecasting and queuing - Expert in leading the process of planning for new beds as well as analysis of current beds utilization using new advanced methodologies including electronic bed board , DRG , Clinical practice guidelines forecasting models, queuing theory and simulation models - Expert in conducting and training for initiating feasibility studies for any newly proposed healthcare related projects - Expert in building an organization wide utilization analysis system using a network of KPIs monitored overtime using SPC (Statistical process control) analysis tools CORE SKILLS & AREAS OF STRENGTH
  • 4. QUALITY IMPROVEMENT, SAFETY AND PERFORMANCE EXCELLENCE - Expert in leading the Development, implementation, coordination and monitoring of hospital wide performance improvement and safety programs - Expert in the process of monitoring performance using Key performance indicators with long experience in all KPI process roadmap including selection , collection , validation , analysis , and reporting - - Expert in initiating a standardized framework for the quality improvement projects road map as part of the quality program scope , this road map includes Identify sources for proposing improvement project areas Selection and prioritization criteria of the project area Selection of appropriate methodology (FOCUS-PDCA/LEAN/SIX- SIGMA) Project planning and charter Project monitoring completion and evaluation. - CLINICAL PRACTICE GUIDELINES AND PATHWAYS - Expert in leading and coordinating the process of evidence base standardization of clinical care through initiation, monitoring of compliance as well as effectiveness evaluation of clinical practice guidelines and clinical pathways. - Expert in improving hospital utilization of clinical practice guidelines and pathways implementation through Improving average length of stay (Non profit making hospital) Reduce the cost of non indicated procedures and investigations (Non profit making hospitals) Reduce insurance rejection rate (profit making organization) Improve revenue through increase the number of evidence based requested investigations and consultations (not to miss evidence based requested investigations)
  • 5. BUSSINESS PROCESS REENGINEERING - Expert in conducting and training for BPR methodology that include the following Select the end to end process to be redesigned Prepare ,Involve and ensure buy-in by the concerned frontlines and managers across the whole BPR lifecycle Identify process architecture (e.g. related laws and regulations , fixed and flexible roles to be considered in the redesign phase) Mapping the current AS IS process flow and identifying all related barriers and bottle necks Data collection for each process step that include but not limited to ,step turnaround time and its distribution , number of transactions , Number of resources and their availability time distribution , added value and non added value steps , and areas of interactions with other processes in the same or in deferent areas/departments (sound of integration) Redesign the process to achieve the maximum efficiency and quality within the predefined process architecture FMEA for new process Expert in simulating the old and the new processes using simulation software e.g. ARENA Pilot implementation Full implementation , feedback and monitoring of the redesigned process PROJECT MANAGEMENT - Expert in project planning and management - expert in project output data collection planing analysis interpretation and reporting - Expert in using project planning tools that includes and not limited to Gaunt chart
  • 6. PERT (Project evaluation and review technique) methodology Identifying the critical path and subsequent critique for crushing the project timeline Human recourse distribution ORGANIZATION DEVELOPMENT - Expert in assisting the process of formulation/revision of philosophy, objectives and contents of organization policies - Expert in formulating reviewing and improving Organization structures and organization charts aiming to serve organization vision , mission and strategic goals QUALITY ACCREDITATIONS - Expert in JCI standards , their interpretation and monitoring with full knowledge about history of standards changes over the last three editions (3rd , 4th ,and 5th editions) - Expert in CBAHI standards , their interpretation and monitoring - Expert in preparing hospitals and other healthcare organizations for both above mentioned accreditation systems - Expert in Egyptian national accreditation standards RISK MANAGEMENT - Expert in helping hospitals and other healthcare facilities to initiate an organization wide (clinical and non clinical) risk management program that incorporates risk identification and assessment , reporting , prioritization ,prevention and control - Expert in utilizing and educating risk management tools both proactive and
  • 7. reactive risk management tools that include but not limited to root cause analysis (RCA) , failure mode and effect analysis (FMEA) ,and risk grading matrix. - Expert in assessing and measuring hospital/healthcare organization safety culture (Safety culture AHRQ) TRAINING, EDUCATION, AND CONSULTATIONS - Expert in assessing healthcare quality training needs , Planning and co- ordination of these training activities - Expert in designing and conducting different healthcare quality , management and utilization training courses and consultations ,this includes and not limited to the following training and consultation activities Bed planning and utilization using Forecasting , queuing model and diagnosis related groups (DRG) JCI Accreditation in 12 months CBAHI accreditation Staffing plan Hospitals utilization analysis Management tools (Strategic-Tactical-Operational-Supply chain) Advanced statistical analysis Six sigma breakthrough improvement PDCA and FOCUS-PDCA improvement methodology Clinical practice guidelines and clinical pathways roadmap Statistical process control (SPC) Strategic planning using Key performance indicators (KPI) roadmap and Balanced Score Card Data Management Data analysis using SPSS Business Process management in healthcare
  • 8. DATA MANAGEMENT - Expert in all data management roadmap steps including collection ,sampling , validation , analysis , Reporting , and Benchmarking - Expert in using all advanced data analysis tools (either Quantitative or Qualitative) to support data based decision making - Expert in using and training for most of the quantitative and qualitative data analysis software (e.g. SPSS , Minitap , Pathmaker , N-Vivo ) - Expert in using SPC (statistical process control ) concept and methodology CHARTS REVIEW AND TRACER METHODOLOGY - Expert in leading and teaching and training of organization staff to conduct organization wide tracer methodology for the following areas aiming to improve continuity of care ,patient centered care , system integration as well as a preparedness tool for JCI accreditation. Clinical tracer Maintenance and equipment tracer Infection control tracer Facility management and safety tracer - Expert in the process of Closed and Open patient chart review based on both JCI and CBAHI accreditation standards , this process include the following How often Sampling JCI/CBAHI required documentation formats (Validating current hospital formats) Audit method (How and when to audit) Data aggregation formats and database
  • 9. Data Validation Data analysis Reporting formats PATIENT EXPERIENCE CENTERED AND INTEGRATED CARE: - Expert in designing tools to collect patient needs - Expert in analyzing and interpreting patient needs data in terms of new strategic objectives as well as new process of care redesign requirements - Expert in designing and redesigning integrated care programs that tackle the patient needs and ensure removing inter-disciplines silos ANALYSIS SOFTWARE - Expert in utilizing and training for the following analysis software SPSS (Quantitative data analysis software) Pathmaker (Quantitative data analysis software) Minitab (Quantitative data analysis software) N-vivo (Qualitative data analysis software) Arena (Process simulation software) - Prepared and Assist 3 hospitals (Mouwasat Jubail , Mouwasat Qatif , King Fahd specialist hospital) to get 3 JCI accreditation and 3 reaccreditation (3rd and 4th edition JCI standards) - Conducted and assist in 4 JCI mock surveys which was held by AGI group (Prof. Assaf El-Assaf Prof. of Quality and Safety in Oklahoma University / Prof. Seval Aqugnum).and JCI consultants (Dr.Derick Pasternak) ACHIEVEMENTS
  • 10. - Prepared and assist Mouwasat hospital Madinah for Central Board of Accreditation for Healthcare Institutes (CBAHI) accreditation. - Shared in 3 facility safety mock surveys which was held by Prof. Azimi Mehedy, Oklahoma USA) - Led and supervised the preparation of different hospitals and healthcare centers for National Egyptian accreditation - Supervised the process of implementation of Business process Management to improve clinical and administrative processes in King Fahd specialist hospital as the project manager with PWC company (Pricewaterhouse cooper) - lproject manager for implementation of ERP system in king fahd specialist hospital ,Saudi arabia - Led and Supervised the process of initiation and implementation of Ongoing professional practice evaluation program (OPPE) in king Fahd specialist hospital- Dammam - Supervised the process of KPIs (Key performance indicators) initiation roadmap in King Fahd Specialist hospital , Mowasata hospital Jubail , Mouwasat hospital Qatif and Mouwasat hospital Madinah - Supervised the process of clinical practice guidelines and pathway initiation, monitoring of implementation and effectiveness evaluation together with linking the implementation to improve hospital utilization e.g. A.L.O (average length of stay ) , radiology and lab utilization. In the above mentioned 4 hospitals
  • 11. - Coordinated and supervised many improvement projects that include but not limited to : Six Sigma Projects: Reduce the Surgical Site Infection Rate In Clean Operative Procedures Reducing Ventilator Associated Pneumonia (VAP) In ICU Reducing The Rate of Catheter Associated Urinary Tract Infection (CAUTI) Reducing Central Line Catheter Blood Stream Infection (CLABCI) In ICU Reducing Unit Acquired / Hospital Acquired Pressure Ulcer Rates Reduce Admission Process Turnaround Time (TAT) Reducing Percent of Pending Referral Cases Reducing the Percentage of False Positive Blood Culture Results Due To Contamination Reducing Lab Specimens Rejection Due To Clotting Reducing Lab Specimens Rejection Due To Hemolysis Reducing Response Time For Isolation Room Terminal Cleaning Reducing Actual Time of Isolation Room Terminal Cleaning Lean Projects: Communicating Laboratory Critical Results Live Kidney Donor Evaluation Use of Emergency Drugs In ICU Improving The Process For Dispensing Discharge Medication Improve the In Patient Admission Process Improve The In-patient Discharge Process
  • 12. Organizing the Operating Room Booking In Neurosurgery Department Reducing the Turnaround Time (TAT) Between Cases in The Operating Room (OR) Improving Patient Flow In Emergency Department (ED) Improving Admission Criteria to Pediatric Department To Meet The Scope of Service of A Tertiary Care Improving The Admission Process To The Day Procedure Unit (DPU) Reducing Waiting Time from Arrival To Administration of Chemotherapy Improve The Out Patient Department (OPD) Booking in Rheumatology Clinic Reducing MRI Access Time Improve TAT In ER Samples Elimination of Redundancies In Interventional Radiology (IR) Pre-Procedure Workup Improving the Recruitment Process Cycle Time Improving The Nursing Overtime Process Improve the Call Center Process Streamlining the Direct Purchasing Process Management process of lab reagents FOCUS-PDCA Reducing Medication Error Improving Hand Hygiene Improving Waste Segregation Improving Patient involvement in Care Process Reducing Hospital acquired pressure ulcers Reducing Chemo contamination Improving Response to call bell
  • 13. Improving the process of High alert medications management CUTI infection Improve volume of blood extraction in Pediatric ICU - Coordinated and supervised initiation of hospital departmental manuals in Mouwasat hospital group - Put a standardized strategy for hospital utilization analysis to improve income and reduce costs using up-to-date quality tools (software proposal for utilization analysis approved as feasible project by many of international healthcare software companies) Mouwasat hospital group - Initiated a forecasting model for all utilization KPI in King Fahd Specialist Hospital Dammam - Supervised the preparation of implementation of schedule B Quality standards of ARAMCO contract in Mouwasat hospital group - Led the initiation , execution , and monitoring of strategic plans in Mouwasat hospital Jubail , Qatif , Madinah ,King Fahd specialist hospital - Led and supervised the initiation , implementation of corporate risk management program for Mouwasat hospital group after they decided to share in the stock market - Supported Mouwasat hospital Jubail operation through the following : Initiated a statistical based software program for stock control (analytical rather than operational i.e. tool for auditing stock control processes by top management) in cooperation with IT department
  • 14. Business planning for a lot of IT projects including SABIC center communication project and online approval center Initiated a statistical based program for evaluation of effectiveness of marketing department tools and their impact on hospital services growth etc using curve estimation tools Initiated data analysis support for the following feasibility studies in Mouwasat group ; Outpatient clinics expansion Physiotherapy department expansion Inpatient capacity expansion Best way to utilize the Space near Mowasat Jubail hospital - Worked with top management in Mouwasat Jubail to initiate a statistical based artificial intelligence software program to support decision making - Initiated bed utilization analysis model in King Fahd Specialist Hospital Dammam using the following tools Electronic bed board Forecasting Model Queuing model DRG (Diagnosis related groups) CPG (Clinical practice guidelines and pathways) - Speaker in many events including but not limited to Babtain hospital symposium for healthcare quality and patient safety Dammam university HIM (Health Information Management) annual symposium Quality and safety event King Faisal Specialist hospital Riyadh Quality and safety events KFSH-D
  • 15. Quality and safety events Mouwasat Group Oncology nursing Club