دانشگاه علوم پزشکی ایران
Iran University of Medical Sciences

Clinical Service Excellence Office

 | Post date: 2018/12/1 | 
Head: Elham Mansourian


Management Records
  • Educational supervisor at Shahid Esmaeili Psychiatric Center
  • Instructor at Islamic Azad University of Varamin
  • Author and researcher in various scientific TV shows at IRIB TV2
  • Expert in charge of teaching in Nursing Office
  • Infection control officer at the Vice-Chancellor’s Office for Treatment
  • An Expert in Plan and Program, Substance Abuse and Deputy Supervision Departments
  • Master of National Accreditation
Organizational Email: e.mansourian.iums@gmail.com
Members of the Expert Team: Ahmad Mostafaei, Ms. Shirazi Zadeh, Farzaneh Rajabi

Introduction
Clinical Service Excellence generally refers to improving the quality of clinical services and increasing the accountability of healthcare providers and authorities for the quality of services provided to the public. Clinical service excellence is a set of plans, strategies and actions aimed at clinical service standardization and delivery with the highest effectiveness, and the lowest possible costs and adverse effects.
Clinical Service Excellence consists of two areas:
  • Development of theoretical knowledge (including knowledge management) in the clinical arena
  • Executive and operational planning for quality enhancement of clinical processes and outcomes
Major Tasks and Activities

Management and Leadership
  • Planning and implementation of development and review stages (two stages in compilation of strategic operational plan) in the area of treatment in accordance with available development plans, upstream documents, and university policies.
  • Seasonal and monthly monitoring and evaluation of headquarters’ operational plans
  • Monthly monitoring and evaluation of universities’ joint operational plan
Capacity Building and Training
  • Education management (needs assessment, implementation, evaluation and promotion of specialized knowledge of managers and staff through in-person and distance training)
  • Participation in the preparation of e-learning packages for staff
  • Empowerment of volunteers from academic and non-academic centers
Planning and Implementation
  • Forming the following specialized (scientific/executive) committees in collaboration with representatives from headquarters and relevant centers:
  • Strategic management
  • Patient safety
  • Staff training and empowerment
  • Suggestions
  • Developing executive/operational manuals for plans in specialized committees
  • Promoting the clinical service excellence system using standards and criteria included in the Quality Management Models
  • Setting up patient safety systems in affiliated centers
  • Contributing to strategic plan review
  • Managing errors and unwanted events
  • Holding regular joint meetings with heads, directors and nursing managers of affiliated centers
  
Monitoring and Evaluation
  • Continuous evaluation of relevant centers with the aim of institutionalizing a culture of quality improvement
  • Intervention program design on the basis of needs assessment and evaluation (self-evaluation and organizational evaluation) results
  • Continuous analysis of intervention results
Major Tasks of the Specialized Committee on Receiving and Reviewing Suggestions from the Vice-Chancellor’s Office for Treatment
  • Establishing committee agendas and inviting members
  • Offering suggestions to be addressed in the specialized committee
  • Holding committee meetings in the presence of least 50% + 1 members
  • Analyzing suggestions precisely in technical, scientific, practical, and legal terms
  • Specifying technical reasons for approval or rejection cases
  • Using expert opinions when reviewing specific suggestions
  • Determining the executive consequences and outcomes of each suggestion
  • Preparing committee minutes and sending copies to all members, following the approval of all participants
  • Attending the university’s specialized committee on receiving and reviewing suggestions, whenever deemed necessary
Major Tasks of the Editor of Virtual Journal of Navid-E-Iran (an E-Journal Published by the Vice-Chancellor’s Office for Treatment)
  • Announcing submission and acceptance criteria
  • Collecting and organizing submitted manuscripts, texts, etc.
  • Conducting interviews, taking photos and gathering news
  • Editing in several steps (technical, lingual, structural, and content editing)
  • Sending contents to the Editorial Board for approval
  • Checking the pagination and layout of contents
  • Getting the final approval of the editor-in-chief and uploading contents to the Vice-Chancellor’s Office for Treatment’s website
Major Tasks of the Secretary of the Board Meeting
  • Following up on location preparation
  • Presenting submitted letters
  • Preparing committee minutes
  • Sending copies of minutes, as well as a summary of discussions to all members
  • Sending letters (that require taking action or following up) to relevant departments/units
  • Monitoring the implementation of previous approvals
  • Archiving records
Major Tasks of the Person in Charge of Monitoring the Implementation of Operational Plan
  • Selecting the person in charge of monitoring each activity
  • Coordinating and holding sessions for the development, monitoring and analysis of strategic and operational plans
  • Coordinating all affairs associated with operational plans with the headquarters of the ministry, university and affiliated units to facilitate the establishment of the operational plan and its monitoring system
  • Integrating all operational plans developed by affiliated units in order to develop the Vice-Chancellor’s Office’s operational plan
  • Informing affiliated units about all relevant rules and regulations contained in manuals and instructions
  • Answering questions and solving problems raised by affiliated units regarding operational planning
  • Holding regular joint meetings with monitoring staff on their progress and submitting relevant minutes to the University’s planning headquarters
  • Holding training sessions on development and monitoring of operational plans for affiliated units
  • Preparing and compiling reports on strategic and operational plans
  • Controlling the monitoring system for the accuracy of registration and uploading processes, and recording causes of deviations
  • Informing and engaging in culture-building practices at all levels of the Vice-Chancellor’s Office on the operational plan
  • Attending the University’s monitoring meetings and presenting relevant information and documents
  • Collaborating and interacting with the University’s monitoring manager in a consistent manner
  • Carrying out all tasks assigned by University’s monitoring manager
  • Reviewing the treatment strategic document and plan, in the event of any change in the macro policies in line with development plans and upstream documents
Major Tasks of the Person in Charge of the Hoteling Promotion Program
  • Determining liaisons for proper implementation of hoteling program at each affiliated center/hospital
  • Coordinating all hoteling issues with the University’s Technical Office at Vice-Chancellor’s Office for Development for optimal implementation of the program
  • Collecting and integrating all progress reports submitted by affiliated units to compile a cumulative report
  • Informing affiliated units about all hoteling criteria and standards contained in guidelines, manuals and instructions
  • Answering questions, solving problems and reducing ambiguities raised by affiliated units regarding relevant executive criteria
  • Preparing and compiling reports on hoteling promotion program
  • Controlling the HSE system in terms of the accuracy of registration and uploading processes
  • Monitoring the implementation and progress of the program at affiliated centers and preparing relevant reports
  • Collaborating and interacting with the University’s Secretariat of the Health System Reform System in a consistent manner
Major Tasks of Person in Charge of Patient Safety
  • Informing affiliated units about all patient safety standards contained in relevant manuals and instructions
  • Training and empowering safety experts on patient safety topics
  • Preparing reports on patient safety-friendly hospital programs
  • Answering questions, solving problems and reducing ambiguities raised by affiliated units regarding patient safety standards
  • Collaborating and interacting with the person in charge of national patient safety programs in a consistent manner
  • Evaluating the establishment of patient safety-friendly hospital standards in affiliated centers and hospitals
  • Holding regular patient safety committee meetings and joint meetings with authorities of affiliated centers
  • Implementing the treatment error management program and attending relevant root cause analysis committees
  • Carrying out all tasks assigned by the person in charge of national patient safety programs
Major Tasks of the Person in Charge of Staff Training
  • Developing an annual staff training plan in line with the University and Vice-Chancellor’s Office’s strategic plans
  • Conducting needs assessments and prioritizing staff and line units (once a year)
  • Reviewing and editing lesson plans and educational topics requested by staff and line units in cooperation with relevant agents
  • Coordinating with the University to prioritize and communicate educational needs and topics and to obtain necessary licenses
  • Providing units with approved in-service training licenses
  • Compiling an educational calendar for the Vice-Chancellor’s Office for Treatment
  • Informing affiliated centers about future training courses
  • Holding periodic sessions of the in-service training committee, whenever deemed necessary
  • Inserting relevant data into the Comprehensive Staff Training System
  • Updating instructors’ database
  • Updating the Personnel ID of all staff in the Comprehensive Staff Training System
  • Participating in the preparation of e-learning packages for staff
  • Participating actively in meetings held by the training and empowerment committee
  • Evaluating and monitoring effectiveness in terms of the reaction level (learner satisfaction with training courses)
  • Evaluating and monitoring effectiveness in terms of the learning level (conducting pre-tests and post-tests)
  • Evaluating and monitoring the implementation of the training courses
  • Participating in the management of financial affairs (paying tuition fees, etc.)
  • Summarizing the performance of the staff and line units and submitting relevant reports to the University

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