Summary
Overview
Work History
Education
Skills
Certification
Accomplishments
Personal Information
Credentials
Timeline
Generic
AMAL VIMALAN, CPHQ, CLE, LSSGB

AMAL VIMALAN, CPHQ, CLE, LSSGB

Dubai

Summary

Dedicated Quality and Risk Management Professional with over 14 years of experience in healthcare. Proven track record of driving operational excellence and ensuring compliance with international accreditation standards. Expertise in developing and implementing comprehensive quality management systems across diverse healthcare settings. Skilled in providing centralized advocacy and resource support to healthcare organizations.

Overview

17
17
years of professional experience
1
1
Certification

Work History

Senior Clinical Quality Officer -Corporate

Dubai Health
11.2022 - Current
  • Company Overview: Corporate Patient Safety & Quality Department, Dubai Health, Dubai, UAE
  • Led and coordinated the successful preparation and execution of JCI, ACHSI, and ACI surveys across Dubai Health Facilities.
  • Served as Deputy Chairperson for the Dubai Health Facilities Audit Taskforce, contributing to the development and implementation of audit strategies that ensured compliance and identified areas for improvement across the network.
  • Represented Dubai Health on the Post Graduate Medical Education Committee at Mohammed Bin Rashid Medical University, integrating quality and patient safety principles into the training and development of future medical professionals.
  • Strategically directed and ensured organizational compliance with international accreditation (JCI, ACHSI, ACI) and regulatory requirements across a large and diverse network of 57 healthcare facilities, including 6 hospitals, 17 primary health centers, etc.
  • Collaborated with Quality Heads to conduct comprehensive gap analyses against ACHSI and JCI standards at Dubai Health facilities, identifying key areas for improvement and informing strategic action plans
  • Spearheaded the facilitation of DHA regulatory audits across Dubai Health facilities, ensuring timely submission of robust action plans and rigorous verification of their effective implementation.
  • Developed and managed the annual budget for international accreditations and excellence programs across Dubai Health facilities, optimizing resource allocation to support quality and safety initiatives.
  • Led and executed comprehensive mock surveys for all hospitals, primary care centers, and specialty medical centers, generating detailed reports and driving the timely implementation of corrective actions to enhance survey readiness.
  • Drove continuous improvement by analyzing performance indicator results, external audit findings, and feedback surveys to recommend impactful process improvements and corrective/preventive actions in collaboration with process owners.
  • Directed the development, review, and implementation of standardized policies, procedures, and plans across various Dubai Health facilities to ensure consistent quality and safety standards.
  • Developed Comprehensive Annual Quality Reports for the Corporate Office, leadership, and the board, providing critical insights into performance, trends, and areas for strategic focus
  • Led the development and implementation of a Corporate Risk Management Program, conducting thorough risk assessments and maintaining a comprehensive Risk Register for the corporate office and Dubai Health facilities, mitigating potential liabilities..
  • Ensured timely and accurate notification of potential compensable events identified through incidents, sentinel events, and medical complaints to the CEO and Boards, facilitating proactive risk mitigation strategies.
  • Developing Business Continuity Plans in coordination with Department Heads.
  • Performing disaster drills and tabletop exercises to assess the preparedness level of Dubai Health facilities.
  • Led and conducted thorough investigations of incidents and sentinel events utilizing appropriate quality tools, providing insightful feedback and recommendations to prevent recurrence and improve patient safety
  • Strategically developed, reviewed, and monitored a comprehensive suite of performance indicators and key performance indicators (KPIs) across clinical, managerial, and outsourced areas to drive performance improvement and accountability
  • Administered patient safety culture surveys and diligently monitored the implementation of targeted action plans at facility levels to foster a culture of safety and continuous improvement.
  • Served as a key project coordinator for the successful initiation of new facilities within DAHC, ensuring seamless integration of quality and safety standards from inception.
  • Developing reports and dashboards in Epic System to monitor patient load, budget forecast, and estimated revenue, providing feedback to center heads.

International Healthcare Surveyor (Part Time)

Accreditation Canada International & Global Healthcare Accreditation
12.2017 - Current
  • Conducting on-site surveys of healthcare facilities to assess compliance with Accreditation Canada standards and policies.
  • Reviewing and analyzing healthcare facility documentation, including policies, procedures, and quality improvement initiatives.
  • Interviewing healthcare facility staff at all levels to gather information and assess compliance with standards.
  • Identifying areas of non-compliance and providing recommendations for improvement.
  • Writing comprehensive reports detailing findings, recommendations, and actions taken by the healthcare facility.
  • Participating in meetings and discussions with healthcare facility leadership to communicate survey findings and recommendations.
  • Providing guidance and support to healthcare facilities throughout the accreditation process.
  • Collaborating with other surveyors and accreditation professionals to share knowledge and enhance the accreditation process.

Senior Clinical Quality Officer (Facility Level )

Dubai Health
07.2015 - 11.2022


  • Accreditation Coordinator for JCI, ACHSI & ACI Survey's at Dubai Health.
  • Ensuring Organization Compliance for International accreditation/reaccreditation process and regulatory compliance (5 Hospitals, 17 Primary Health Centers, 4 Ambulatory, 1 Long Term Facility and 20 Medical Fitness centers).
  • Conducted Gap Analysis in collaboration with Quality Heads for ACHSI standards at Dubai Academic Health Corporation facilities.
  • Facilitating DHA regulatory section audits and timely submission of action plans and verification of its implementation at Dubai Health facilities.
  • Annual budget planning for the International accreditations and excellence programs for the DAHC facilities.
  • Performing Mock surveys for all the Hospitals, Primary Care centers and Specialty Medical centers, preparing reports and ensuring the corrective actions are performed on a timely manner.
  • Suggesting process improvements and/or corrective and preventive actions based on the performance indicator results/ external audits/feedback surveys in coordination with process owner.
  • Developing, Reviewing and implementation of Policies, Procedures and Plans at various facilities under Dubai Health.
  • Preparing Annual Quality reports for the facilities.
  • Developing and Implementing a Corporate Risk Management Program, Performing Risk Assessment and maintaining the Risk register for the corporate office and Dubai Health facilities.
  • Notifying potential compensable events to the CEO which has been identified through Incidents, sentinel events and Medical Complaints.
  • Developing Business Continuity Plans in coordination with Department Heads.
  • Performing disaster drills and tabletop exercises to assess the preparedness level of DAHC facilities.
  • Performing incident/sentinel events investigations using quality tools based on incident severity and providing feedback.
  • Developing, reviewing, and monitoring performance indicators and key performance indicators for clinical, managerial, and outsourced areas.
  • Performing patient safety culture survey and monitoring the implementation of action plans at facility levels.
  • Providing consultation to facility heads and department heads to create annual operational plans aligned with DAHC strategic plan.
  • Monitoring and analyzing facilities' achievement of operational plans and providing feedback to governance.
  • Monitoring and analyzing facilities' budget utilization and providing feedback to center medical directors, reporting to the CEO.
  • Acting as a project coordinator for starting new facilities within DAHC.
  • Performing feasibility studies before initiating new services and presenting them to the CEO.
  • Conducting utilization studies for high-cost equipment and services.
  • Developing reports and dashboards in Epic System to monitor patient load, budget forecast, and estimated revenue, providing feedback to center heads.
  • Reviewing medical record audit and clinical audit reports and monitoring compliance with policy and guidelines.
  • Monitoring Physician compliance with Clinical Pathways and guidelines implemented.

Quality Executive

NMC Specialty Hospital
10.2011 - 06.2015
  • Company Overview: Abu Dhabi, United Arab Emirates
  • In charge for NMC Day Surgery Centers.
  • Developing, Implementing and Monitoring Risk management activities related to Infection Control, Facility Management and Finance.
  • Monitoring the implementation of JCI standards within the hospital.
  • Conducting Infection control, Facility and Clinical audits within the hospital to check for the noncompliance with JCI and HAAD Standards and introduce corrective measures.
  • Conducted drills for preparing hospital for various Emergencies.
  • Conducted training for hospital staff on aspects of JCIA for the final Survey.
  • Training the hospital staff for various topics like EHSMS, HAAD and JCIA Standards.
  • Conducted JCI Mock Survey for all the group hospitals in order to prepare for the JCI Final Survey.
  • Developing and Facilitation of Policies, Procedures and Plans Hospital wide as per JCI & HAAD Standards.
  • Development and Facilitation of policies and procedures for new facilities under the group.
  • Monthly monitoring of Hospital Key Performance Indicators.
  • Coordinating with Doctors and other paramedical staff for collecting data for the development and implementation of Hospital Information System.
  • Conducting Internal Quality audits related to EHSMS and JCI.
  • Conducting RCA for the Incidents, Hazards and Near Miss reported in the Hospital.
  • Abu Dhabi, United Arab Emirates

Junior Executive

Amrita Institute of Medical Sciences and Research Institute
05.2008 - 05.2010
  • Company Overview: Kochi, India
  • Conducting Cost Analysis studies for various services provided by the Hospital.
  • Conducting Material Utilization studies for all the departments.
  • The mapping of all the consumables and items used for each service.
  • Providing the data for developing the Hospital information system.
  • Assisting the Technical Manager Laboratory in developing lab policies and procedures.
  • Monitoring the Laboratory Quality Assurance Program.
  • Submitting Data for Equipment Utilization Studies to the Purchase and Technical Committee for review.
  • Kochi, India

Education

Master of Science - Hospital Administration

Amrita School of Arts And Science
Kochi, Kerala
08.2011

Bachelor of Science - Medical Microbiology

School of Medical Education
Kottayam, Kerala
04.2007

Skills

  • Risk management
  • Quality Management Systems
  • Performance Improvement Programs
  • Operations Management
  • Accreditation
  • Project Management
  • Key Performance Indicator development
  • Process planning
  • Data Analysis
  • Policy reinforcement
  • Audit and Tracers

Certification

  • Certified Professional in Healthcare Quality, 05/01/18
  • Lean Six Sigma Green Belt, 03/01/17
  • Lead Auditor ISO 14001:2015, 03/01/17
  • Lead Auditor ISO 19001:2015, 03/01/17
  • Lead Auditor 18001:2007, 09/01/13
  • Internal Auditor Training, 05/01/20
  • Total Quality Management Professional, 05/01/15
  • Project Management Certification, 09/01/13
  • HSE Risk Assessment, 07/01/21

Accomplishments

  • Dubai Health Authority, Al Jalila Children's Hospital- JCI Accreditation., 08/01/11
  • Dubai Health Authority, Homecare Network- JCI Accreditation., 05/01/10
  • Dubai Health Authority, Primary Health Care Network - Accreditation Canada International- Diamond Level Accreditation., 01/01/10
  • Dubai Health Authority, Home Care Network - Accreditation Canada International - Diamond level Accreditation., 01/01/10
  • Dubai Health Authority, Primary Health Care Network - JCI Accreditation and Re-accreditation., 01/01/10
  • Zabeel Health Center - New Project Readiness., 01/01/10
  • Umm Suqeim Health Center- New Project Readiness., 01/01/10
  • NMC Day Surgery Centre, Mohammad Bin Zayed City, Abu Dhabi. Operational readiness and developing required documents for the licensing., 01/01/10
  • NBB Workers City Clinic. Operational readiness and developing required documents for the licensing., 01/01/10
  • NMC Specialty Hospital Reaccreditation., 01/01/10
  • International Surveys Conducted., 01/01/10
  • Guven Hospital, Turkey., 01/01/10
  • Elite Medical Center, Kuwait., 01/01/10
  • New Mowasat Hospital, Kuwait., 01/01/10
  • Islamic Hospital, Jordan., 01/01/10
  • Chwapi Tournai Hospital, Belgium., 01/01/10
  • Primary Health Centers, Bahrain., 01/01/10
  • Ministry of Interior health facilities, Bahrain., 01/01/10

Personal Information

Title: Senior Clinical Quality Officer

Credentials

  • MHA
  • CPHQ
  • LSSGB

Timeline

Senior Clinical Quality Officer -Corporate

Dubai Health
11.2022 - Current

International Healthcare Surveyor (Part Time)

Accreditation Canada International & Global Healthcare Accreditation
12.2017 - Current

Senior Clinical Quality Officer (Facility Level )

Dubai Health
07.2015 - 11.2022

Quality Executive

NMC Specialty Hospital
10.2011 - 06.2015

Junior Executive

Amrita Institute of Medical Sciences and Research Institute
05.2008 - 05.2010

Bachelor of Science - Medical Microbiology

School of Medical Education

Master of Science - Hospital Administration

Amrita School of Arts And Science

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AMAL VIMALAN, CPHQ, CLE, LSSGB