1.Review medical records to collect raw data for the development of assigned quality indicators, including:

• Hospital Performance Indicators

• Departmental Performance Indicators

• Benchmark Indicators

2.Review, monitor, and evaluate clinical practices in accordance with Clinical Practice Guidelines (CPGs), and gather and analyze relevant data to ensure accuracy and up-to-date quality indicator calculations.

3.Implement clinical quality improvement initiatives (Clinical Care Program) by analyzing data to identify evidence-based practices and establish best practices. Support hospital-wide quality improvement programs (QPS Program) related to clinical care processes.

4.Monitor and coordinate incident and abnormal event closure, ensuring that all departments and committees complete the process within the specified timeframe and in a systematic manner.

5.Coordinate Peer Review processes and prepare summary reports of corrective and preventive actions for incidents classified as levels E-I and Sentinel Events within the required deadlines.