Ibtsam A.

Registrar Family Medicine/Director Quality & Patient Safety--Additional Charge MRD Manager

Hospital Records • Full-time

Nov 2025 - Present • 6 mos

▸ Lead all quality and patient safety initiatives aligned with international accreditation standards (JCI/CBAHI). ▸ Oversee the Employee Health Program including pre-employment medicals, occupational health surveillance, and staff immunization. ▸ Manage the Medical Records Department, ensuring timely, accurate, and compliant documentation and coding practices. ▸ Drive Root Cause Analysis (RCA), Failure Mode & Effects Analysis (FMEA), and incident reporting systems. ▸ Develop, implement, and monitor Key Performance Indicators (KPIs) for clinical quality and patient safety outcomes. ▸ Lead multidisciplinary committees including Medical Record Review, Patient Safety, and Quality Improvement Committees. ▸ Coordinate with clinical and administrative departments to embed a culture of continuous quality improvement.

Senior Project Manager Technical (Add Charge: Director Health Care Quality Assurance)

Health.gov • Full-time

Jul 2017 - Nov 2025 • 8 yrs 4 mos

▸ Led revamping of district and tehsil headquarter hospitals (secondary healthcare) across Punjab along with contribution to the formulation of health and public policy by rendering expert technical advice to senior management and government authorities. ▸ Led the Planning Wing team in preparing, reviewing, and finalizing Health related PC-I, documentation and project proposals, securing approvals from high-level forums. ▸ Develop multi-year strategic plans, incorporating performance targets, risk assessments, and implementation roadmaps ▸ lead role in up-gradation of regional training institutes in to School of Nursing and Midwifery after merger of Primary & Secondary Healthcare Department and Population Welfare Department. ▸ Spearheaded development and implementation of HMIS in hospitals in collaboration with the IT department. ▸ Developed SOPs, operational manuals and standardized Patient Treatment Charts aligned with MSDS, JCI, and ISO standards. ▸ Achieved MSDS accreditation for 30 hospitals and ISO 9001:2015 & 14001:2015 for 72 secondary hospitals. ▸ Led operationalization and monitoring of Mobile Health Units/Field Hospitals in rural Punjab. ▸ Maintained cost-effectiveness and quality of outsourced diagnostic services (CT scan, MRI, pathology, mammogram). ▸ Provided technical and operational support in the establishment and functionality of Regional Blood Centers (RBCs) and hospital blood banks (HBBs) across Punjab. ▸ Served as focal person for KPI monitoring of doctors, nurses, allied health professionals, and paramedics. ▸ Formulated equipment, civil maps, and HR yardsticks for BHU, RHC, DHQ, and THQ hospitals. ▸ Conducted capacity-building and professional training sessions for Quality Assurance Officers, Administrative Officers, and Procurement Officers on Minimum Service Delivery Standards at the Management and Professional Development Department (MPDD). ▸ Organized skill development courses for doctors, nurses, and paramedics in collaboration with the U

Medical Records Manager

Hospital Records • Full-time

May 2014 - Jul 2017 • 3 yrs 2 mos

▸ Led open and closed in-patient file analysis per JCI standards on monthly, quarterly, and annual cycles. ▸ Served as co-chapter leader of MOI during JCI survey, achieving 100% compliance and successful accreditation. ▸ Championed shift from ICD-9-CM to ICD-10-AM/ACHI coding across clinical departments. ▸ Chaired the Medical Record Review Committee; served on multidisciplinary critical care and Medical Board committees. ▸ Conducted monthly audits of clinical practice guidelines as a JCI quality indicator. ▸ Prepared Aramco patient encounter data and managed medico-legal and rejected insurance claim replies. ▸ Performed KPI-based evaluation of permanent and visiting faculty. ▸ Compiled statistical analyses of hospital output indicators (mortality, morbidity, LAMA).