Surveyors Directory

Hugo E. Arce
Dr.

Hugo E. Arce
Dr.
Delegate
Expert
IAQS Member
Individual Member
Latin American CoP Member
Surveyor
ORGANISATION
University Institute of Health Sciences, Barceló Foundation. Argentina
INTERESTS:
Health Policy
Health Sector Reform
Standards/Accreditation
Teaching/Trainin
BIO:
Physician, University of Buenos Aires, Master in Public Health, PhD in Health Sciences. Ex President and CEO, Technical Institute for Accreditation of Healthcare Organizations (ITAES*), 1994-2010. Ex President, Argentine Society for Quality in Health Care (SACAS*), 1999-07. Chair of the 18th International Conference, International Society for Quality in Health Care (ISQua) and SACAS*, Buenos Aires, October 2001. Director, Department of Public Health, University Institute of Health Sciences (IUCS*), Barceló Foundation, Buenos Aires, La Rioja and Santo Tomé (Corrientes), from 2006. Author: "The Territory of Health Decisions" (book on Health Policies), Buenos Aires, 1993; “The Quality in the Health territory” (book on Quality in Health Care), supported by ITAES*, Buenos Aires, 2001; “The Health System: where it comes from and where it goes” (book about the history of health systems at international, Argentine and hospital levels), Ed. Prometeo, Buenos Aires, 2010. Author of more than 170 articles and papers about Health Policies, Hospital Management and Quality in Health Care, from 1982 (most of them in Spanish, about 10 in English)

Hashem ALFADEL
International Surveyor and Consultant for Healthcare quality, accreditation and technology

Hashem ALFADEL
International Surveyor and Consultant for Healthcare quality, accreditation and technology
Fundamentals of Surveying Specialist Certificate User
Individual Member
Surveyor
ORGANISATION
Independent
INTERESTS:
Health Policy
Quality Management
Standards/Accreditation
Patient Safety
External Evaluation
Leadership
Digital Health
BIO:
Extensive experience in healthcare leadership, quality management and healthcare assessments, commissioning and development of hospitals in both public and private sectors. Responsibilities included member, vice chairman and chairman of corporate board of directors as well as Vice president and Managing director of hospitals and medical services companies.
Supervised the implementation of governance codes according to international standards and ministries guidelines including compliance, disclosure and transparency reporting. In addition, served as a member of the corporate audit and governance committees for public shareholding medical services companies for hospitals, biomedical Engineering services, financial operation, and human resources capacity building. Developed proposals and directed programs in procurement services, budgeting, financial and quality audit management. Assessed and surveyed more than 50 hospitals world-wide up to date for performance against standards and reported status, identifying gaps and recommended solutions. Effective skills in preparing reports for action plans requirements, recommendations for gaps based on the compliance found and assessments. Over 35 years of leading experience in USA, China, Europe, Thailand, Egypt, Saudi Arabia, Gulf Countries, Turkey and Jordan. Familiarity in working with Arab ministries of health, private, public sectors, NGOs and USAID programs. professional certification includes JCI Hospital certified surveyor, Temos Certified Assessor, QHA Trent, green belt Six Sigma and certified clinical Engineer.
Surveyed hospitals through TEMOS and QHA Trent and mock surveys for JCI, HCAC and CBAHI accreditations. In addition, served as member of the national HTA committee, Vice Chairman of Health Sector Board, Arab trainers’ union, Arab League and Chairman of the Jordanian special needs association. Among healthcare major organizations worked for, include Memorial hospital of South bend, IN, USA as a Clinical Engineer, Project Hope, USA, Egypt and China as a program director, King Faisal Specialist Hospital and Research Center in KSA as Director of Clinical Engineering, General Electric Healthcare, USA as Regional Director for Middle East and Africa. Served as the first Chairman of Temos Assessors Advisory Board for10 years until December 31 2021. Currently, regional Director for Temos International for Jordan, KSA, Kuwait, Bahrain and Lebanon. In addition, Chairman of the Board for Middle East Institute for Special Education and member in in different professional organizations and an ISqua EEA surveyor since 2021.
Education includes, Ph.D. and MBA in healthcare management, graduate and undergraduates in Biomedical Engineering from Universities of Illinois, Indiana and Washington, USA.

Atul Mohan Kochhar
Dr.

Atul Mohan Kochhar
Dr.
Expert
Institutional Member
South East Asia CoP
Surveyor
ORGANISATION
National Accreditation Board for Hospitals and Healthcare Providers (NABH)
INTERESTS:
Certification
Clinical Practice
Health Policy
Health Sector Reform
Standards/Accreditation
Admin/Management
BIO:
Dr. Atul Mohan Kochhar obtained his MBBS (UCMS-1990) and MD (MAMC-1996)
from Delhi University. He was awarded the University Gold medal for excellence
in the field of Dermatology, Venereology and Leprology. He is also a Diplomate
of National Board (DNB- Dermatology and Venereology), a Member of the
National Academy of Medical Sciences and a Fellow of the American Academy of
Dermatology. He worked since 2003, as a Professor & Consultant in the Department of
Dermatology & STD, Lok Nayak Hospital and Maulana Azad Medical College and,
New Delhi.Over the years he has held various Organizational
positions viz. the President, Secretary, Vice President, and Executive member
of the IADVL –Delhi State branch and has successfully organized as Organizing
Secretary various conferences of IADVL – at State and National Level. He is the
recipient of various state and national awards including the prestigious Sardari
Lal Memorial Award for the year 2015. He
is the current President – Society for Pediatric Dermatology and Founder
Secretary -Scientific Cosmetological Society. He has More than 70
publications, 4 books and many chapters and multimedia to his credit. An active practicing clinician, with a
passion for quality in healthcare, a Principal Assessor with NABH since 2016,
he has recently taken over as the Chief Executive Officer of the National Accreditation
Board for Hospitals and Healthcare providers of India. Quality, promotion of patient safety and taking Best healthcare
practices to the ‘poorest of the poor ’ are
his mission in life.

Catherine Cummings
Mrs.

Catherine Cummings
Mrs.
Surveyor
Surveyor
Surveyor
ORGANISATION
DAA Group Limited
INTERESTS:
Standards/Accreditation
Review/Audit
Cer
BIO:
Cathy is a Co-Director of The DAA Group, a leading assessment and evaluation agency in New Zealand.
Cathy has extensive assessment and quality management experience in most sectors of health. She has
managed a quality auditing and accreditation agency for more than twenty years and has in-depth expertise
in certification, accreditation, contracts and issues-based assessments. Cathy is acknowledged as being
fair and non-threatening in her approach.
Cathy has wide and in-depth experience in health and disability services, having worked in the health sector
as a registered nurse in New Zealand, Australia and in the United Kingdom.

Elma Heidemann

Elma Heidemann
Expert
IAQS Member
Individual Member
Surveyor
Surveyor
Surveyor
Surveyor
ORGANISATION
Elma Heidemann
BIO:
Ms. Heidemann was the Executive Director of the Canadian Council of Health Services Accreditation (CCHSA) until retiring, a position which she held for eleven years. Prior to that, she held senior positions in health planning and palliative care. She has been Chair of the Boards of the Ottawa Regional District Health Council, the Ontario Hospital Association, the Canadian Healthcare Association and the International Society for Quality in Health Care (ISQua). Ms. Heidemann has also held board positions with the national accreditation agencies in France and Ireland. Most recently Ms. Heidemann has also worked as an International Consultant for the World Health Organization (WHO) and the World Bank in the areas of Health Care Accreditation, Quality and Evaluation. Ms. Heidemann served on the Canadian Patient Safety Institute Initiative and was a founding steering committee member representing the CCHSA. Currently, Ms. Heidemann is the Co-Chair of CHLNet.

Brian Johnston
Principal

Brian Johnston
Principal
Expert
IAQS Member
Individual Member
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
ORGANISATION
Brian Johnston Consulting
INTERESTS:
Policy Development /Planning
Standards/A
BIO:
Brian provides senior counsel to boards and management on governance practices, strategic planning, performance monitoring, and stakeholder relationships with his particular expertise in health services accreditation programs both nationally and internationally. His professional career has been in the health industry and has included positions at both government department and senior health service management levels. His roles have encompassed operational management of health services and facilities, particularly teaching and referral centres. As Chief Executive he led the Australian Council on Healthcare Standards (ACHS) from 2000 to 2013. During his tenure the organisation successfully expanded both the range and nature of its services, initiated its collaborative research agenda and commenced its international business are. He was appointed a Life Member of the International Society for Quality in Health Care (ISQua) in 2010 in recognition of his contribution to the promotion of quality and safety through the society’s international accreditation program.

Maria Carolina Moreno
Mrs.

Maria Carolina Moreno
Mrs.
Delegate
Expert
Individual Member
Surveyor
Surveyor
Surveyor
Surveyor
ORGANISATION
Guarulhos' Secretary of Health
INTERESTS:
Policy Development /Planning
Standards/Accreditation
Review/Audit
Health Sector Reform
Admin/Management
Certification
Quality Management
Health Policy
BIO:
She is a Medical Doctor with obstetrics and gynecology medical residency. She has a master degree in collective health from the Social Medicine Department - College of Medical Sciences at Santa Casa de São Paulo and specialization in hospital and health services management at Fundação Getúlio Vargas. São Paulo 's Business School. She is the former CEO of brazilian accreditation system - ONA, where she conducted the update of ONA’s accreditation process, defined the institutional communication strategy and led the change in ONA's educational model. She was also responsible for restructuring the Quality Management System and Institutional Risk Management. She performed more than 25 healthcare organizations' surveys, including hospitals, home cares, blood services and clinics, as a surveyor and as an ONA’s observer. Since 2015 she is an ISQua fellow and surveyor and has performed more than 10 surveys under ISQua Accreditation Program.
She worked for the private and public health sector in Guarulhos -SP, implementing quality improvement and patient safety strategies, as a consultant and as part of the staff.
Carol is a guest lecturer at Fundação Getúlio Vargas – IDE FGV Management, teaching quality improvement, patient safety and accreditation in healthcare at Healthcare Management MBA, and she is the founding partner of the portal web Portal Qualificação, designed to spread Patient Safety and Quality Improvement practical content to public and private healthcare providers in Brazil through social media strategies.
She is an international speaker with more than a hundred lectures about accreditation programs, quality improvements and patient safety initiatives.
Her interests are external evaluation processes, quality improvement initiatives, patient safety, communication strategies, staff engagement on patient safety and quality improvement initiatives and governance.

Rabab Diab
Deputy CEO, Director Education and Consultation

Rabab Diab
Deputy CEO, Director Education and Consultation
Surveyor
ORGANISATION
Health Care Accreditation Council
INTERESTS:
Policy Development /Planning
Standards/A
BIO:
Rabab Diab is the Deputy Chief Executive Officer of the Health Care Accreditation Council and the Director of
the Education and Consultation Department. She has been with HCAC for more than 7 years to date and has a
life time focus on quality improvement and patient safety issues. Ms. Diab has been leading the Education
and Consultation arm of HCAC in developing and administering products needed for the improvement of
quality in health care settings at all levels. She designs, develops and administers trainings as well as plans and
executes strategies for quality improvement. She has been instrumental in designing and improving the HCAC
flagship courses and reaped successes in advancing the health care workforce buy in and skills for
accreditation compliance. Ms Diab is also a certified consultant and certified surveyor with HCAC.
Prior to joining HCAC, Ms. Diab was a freelance healthcare quality consultant, where she provided services in
Jordan and the Arab region for healthcare institutions to build quality management systems, prepare for
accreditation, and develop the capacity of the healthcare professionals in quality management and
performance improvement.
Ms. Diab has a Master’s Degree in Nursing Education and a Bachelor of Science degree in Nursing from the
University of Jordan. She is a member of the Jordan Society of Quality and • Jordan Syndicate for Nurses and
Midwives. She has several certifications from institutions such as CPHQ from NAHQ, and ISQua fellowship.

Syed Sajid Ahmed
Dr.

Syed Sajid Ahmed
Dr.
Delegate
Fellow
Individual Member
Surveyor
ORGANISATION
Aspetar
INTERESTS:
Policy Development /Planning
Standards/Accreditation
Review/Audit
Teaching/Training (education)
Health Sector Reform
Admin/Management
Research
Clinical Practice
Certification
Quality Management
Health Policy
BIO:
Dr. Syed Sajid Ahmed is currently
working as Head of Quality Management at Aspetar Orthopedics and Sports
Medicine Hospital in Doha, Qatar. Aspetar is a global leader in sports medicine
and exercise science. He has previously worked with Accreditation Canada
International as Advisor, Healthcare Improvement and has over twenty years of leadership,
medical, healthcare management experience in varied healthcare settings
including acute, primary care and family practice. He has worked as a physician
in family medicine and acute care settings. His work experience includes
assignments in Canada, Middle East, Brazil, Caribbean, Europe and India. He is
currently a surveyor for Accreditation Canada and ISQua (International Society
for Quality in Healthcare). He has successfully delivered several surveys, training
sessions, advisory and consulting assignments in healthcare quality and patient
safety globally. He has also participated and presented papers on healthcare
quality at national and international conferences. Sajid holds a Masters in Health
Management from McMaster University, Hamilton, Canada. He also holds a medical
degree (MD). In 2014, he got the prestigious Fellowship in International
Society for Quality in Healthcare (FISQua) credential.Sajid is a Certified Healthcare
Executive (CHE) and member of the Canadian College of Health Leaders (CCHL). He
is also a Certified Professional in Healthcare Quality (CPHQ) from the
Healthcare Quality Certification Board, USA. As well, he holds certifications
in patient safety and risk management. In 2020, he completed the Professional
Diploma in Sports Management with distinction, from Jasoor Institute, Qatar that
runs the program in partnership with SDA Bocconi School of Management, Italy.
In 2021, under his leadership Aspetar became the first healthcare organization
in the world to achieve 100% compliance to Accreditation Canada’s Qmentum
International standards of excellence (Version 4) during its accreditation survey. In 2023, Sajid successfully completed the Lean Six Sigma Green Belt Certification in Healthcare issued by the internationally-recognized Council for Six Sigma Certification.

Mihaela Luncan
Mrs

Mihaela Luncan
Mrs
Fellow
Individual Member
Surveyor
ORGANISATION
Mihaela Luncan PFA/MediQua
BIO:

Linda O'Connor
Ms

Linda O'Connor
Ms
Surveyor
ORGANISATION
Australian Council on Healthcare Standards (ACHS)
BIO:
Linda O’Connor is the Executive Director of Customer Services and Development at the Australian Council on Healthcare Standards (ACHS). This role is responsible for standards and product development, customer services, contract management and the clinical indicator program. Linda has worked in healthcare for 25 years, and is a Board Certified Professional in Healthcare Quality (CPHQ). Linda has both national and international experience. In the senior management team of Harvard Medical International, the international consulting arm of Harvard Medical School, she worked between Boston and Dubai to establish the Center for Healthcare Planning and Quality, Dubai Healthcare City. As Director of Quality, she led numerous healthcare education and quality improvement initiatives, including development of healthcare policy and quality standards, establishment of the healthcare accreditation program, and coordination of an international Quality Council. Linda has collaborated on projects with the Joint Commission, ISO and Accreditation Canada. Her clinical specialties include high risk obstetric ultrasound and diagnostic medical imaging, and she previously worked at the Mater Private Hospital Sydney. Linda was a member of the Commonwealth BreastScreen Australia Accreditation Review Committee. She holds a Masters Degree in Organisational Communication, is a graduate of the Australian Institute of Company Directors (GAICD), and is a member of the Harvard Club of Australia.

Loretta Yam
Dr.

Loretta Yam
Dr.
Individual Member
Surveyor
ORGANISATION
Pamela Youde Nethersole Eastern Hospital
INTERESTS:
Standards/Accreditation
Teaching/Training (education)
Admin/Management
Clinical Practice
BIO:
I was consultant physician and Chief of medicine in Alice Ho Miu Ling Nethersole Hospital (AHMLNH) in 1988 which became one of the Hospital Authority (HA) hospitals when HA was established in 1991. I led the relocation of the AHMLNH Department of Medicine to Pamela Youde Nethersole Eastern Hospital (PYNEH) and its subsequent development (1993-2005) to serve the 0.6 million population of the Hong Kong East District. I assumed a second role as clinical coordinator in hospital and cluster management (2000-2005). I was also appointed a member of the HA Board (2003-2005), through which I was initiated into the multidimensional nature of healthcare risk management and the crucial role of team-optimality in the planning and implementation of healthcare delivery systems.
I was Hospital Chief Executive (HCE) of Pamela Youde Nethersole Eastern Hospital (PYNEH) and Cluster Chief Executive (CCE) of the Hong Kong East Cluster (HKEC) of six hospitals from June 2005 to April 2011. I led my hospital and cluster in piloting numerous initiatives in quality and safety and demand management, a number of which have since been adopted by the whole of HA.
In 2008, I actively contributed to the establishment of the Pilot Accreditation Scheme for public and private hospitals under the auspices of the Food & Health Bureau, Hong Kong SAR Government, and PYNEH was also the first HA hospital to obtain full accreditation from the Australian Council on Healthcare Standards (ACHS) in September 2010.
Since my retirement in 2011 I have resumed part-time clinical practice and I am also adjunct professor of The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong.

Carlos Hiran Goes de Souza
Dr.

Carlos Hiran Goes de Souza
Dr.
Delegate
Expert
IAQS Member
Individual Member
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
ORGANISATION
AACI
INTERESTS:
Health Sector Reform
Quality Management
Standards/Accreditation
Teaching/Training (education)
Admin/Management
BIO:
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Carlos Hiran Goes de Souza
MD, MPH, MBA
VP, CEO AACI Portugal & Brazil
Carlos Hiran Goes de Souza is a physician, Master of Public Health, Master of Business Administration, Specialist in Planning and Management of Health Care Systems and Hospital management. Carlos has worked on quality improvement in healthcare since 1990 on the start-up of accreditation schemes in Brazil. Since then, he was trained in Brazil, USA, France and UK in quality management, quality assessment, ISO and accreditation processes. His professional life has been focused on clinical governance, and hospital management always involved in quality management. As a former member of Public Health Organisations, he brings experience as a policy developer of government programs. Over his career, he held positions as CEO in several hospitals and home healthcare services. He has been a member of the Brazilian Medical Society of Healthcare Administration and the Brazilian Academy of Hospital Administration since 1990 and member of the Portuguese Society for Quality in Health Care since 2010. Over the last 20 years, his professional and academic experience has broadened considerably through his international work and understanding of healthcare systems in different cultural contexts. Carlos worked for CHKS, UK from 2008 until February 2020, as a Client Manager for the international accreditation process of several hospitals in Portugal. In 2017, he founded an independent education and research institution - the Accreditation Pathways Institute - with the purpose of the development of pathways for supporting organisations on the accreditation and certification preparation cycles. Since April 2020, he is part of AACI Group as VP, CEO of AACI Portugal & Brazil. Over his academic and cultural life, Carlos has been involved in several teaching programs. He has also published book chapters on the accreditation subject area as well as three fiction books. His involvement with ISQua commenced in 2010 as Individual Member, Surveyor, Expert and a former ISQua IAP Council member. In June 2018, Carlos was elected one of the 35 founding members of the International Academy of Quality and Safety in Health Care (IAQS).

Sanjeev Singh
Dr.

Sanjeev Singh
Dr.
South East Asia CoP
Surveyor
Surveyor
Surveyor
Surveyor
ORGANISATION
Amrita Institute of Medicine Sciences
INTERESTS:
Quality Management
BIO:
I am presently Medical Superintendent of the 1350 bed university teaching super specialty hospital in South India. I look after the Medical Administration of the hospital and the educational wing, since this hospital has a medical college other than the hospital campus. I am Director of Quality & Standards in the hospital and am responsible for all accreditations (Hospital, laboratory, academics and research wing). I am also Director of Infection Prevention. All clinical departments heads report to me and I am responsible for their clinical growth, volumes, patient care and outcomes. I am legal cell and takes care of regulatory and licensing part for the institute I am also Co-Chair of Research Committee at National Accreditation Board for Hospitals (NABH) and am Lead Assessor for NABH for the past 9 years. I am also Chairman Technical Committee of Association of Healthcare Providers of India (AHPI) and have drafted Entry level. Advanced level and Green Hospital Standards. I was part of technical Committee in NABH who drafted 3rd edition. I am national faculty for CQI and Clinical Audit workshop run by NABH. I am Ambassador from India to Society of Healthcare Epidemiology of America (SHEA) and have been awarded of Infection Control from Association of Professionals in Infection Control. I am also President of APIC-India chapter. I am an improvement Advisor from Institute of Healthcare Improvement (IHI) and have been guiding QI projects. I am technical experts to State govt projects on E Health, Antibiotic; Infection Control; IMR. I am technical expert to WHO on regulatory; licensing and am doing a project on Quality interventions in India. I am a member of Drug Safety Council (Govt of India) and Advisor on Injection Safety Board of India. I am country coordinator on Point Prevalence Surveillance and HAI Collaborative.

Jacqui Stewart

Jacqui Stewart
African CoP Member
Delegate
Expert
IAQS Member
Institutional Member
Institutional Sub-Member
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
ORGANISATION
The Council for Health Service Accreditation of Southern Africa NPC (COHSASA)
INTERESTS:
Health Sector Reform
Policy Development/Planning
Quality Management
Review/Audit
Standards/Accreditation
External Evaluation
Leadership
BIO:
Jacqui Stewart is the Chief Executive Officer of The Council for Health Service Accreditation of Southern Africa NPC (COHSASA). She has worked in the public and private health care sectors in South Africa and England. Having qualified as a registered nurse in Cape Town she went on to specialise in Cardio-Thoracic nursing in London. She ran the Heart Transplant Unit at Harefield Hospital, Middlesex for five years. From there she moved into a variety of managerial roles in quality, capital and service planning in the National Health Service. Between 1996 and 2002, she held director posts at the Family Health Services Authority (FHSA) in Kent and East Kent Health Authority, responsible for primary health care, service development and integration. She moved to a regional role and then became the Director of Career Development and Succession Planning at the NHS Modernisation Agency, Leadership Centre.
In 2005 Jacqui returned to South Africa and joined COHSASA as Chief Operations Manager. She was appointed CEO in 2016. She has experience in standards development, external evaluation and accreditation. As COHSASA works in low- and middle-income countries there is a strong focus on capacity building and quality improvement in all the programmes.
Jacqui has a Master of Professional Studies, Health from Middlesex University, London. She was a member of the South African Lancet Commission on High Quality Health Systems. In 2019 Jacqui was elected to the International Academy of Quality & Safety in Health Care (IAQS). She is a Board member of the International Society for Quality in Health Care (ISQua), an ISQua Expert and serves on the Board and Accreditation Council of the ISQua External Evaluation Association.

Thaira Madi
Ms.

Thaira Madi
Ms.
Fellow
Individual Member
Surveyor
ORGANISATION
Health Care Accreditation Council
INTERESTS:
Policy Development /Planning
Standards/Accreditation
Health Sector Reform
Admin/Management
Research
Clinical Practice
Certification
Quality Management
Health Policy
BIO:
Thaira is the Director, Accreditation Department in the Health Care Accreditation Council as of June
2011, the Arab region’s only independent not-for-profit organization that aims at improving the quality of
health care services across the spectrum. Ms. Madi is responsible for overall management of HCAC
accreditation and certification survey processes and surveyors, management of HCAC surveyor
certification, and oversight of the planning, organizing, and improving the HCAC standards
development. Ms. Madi is a surveyor with Accreditation Canada.
Ms. Madi has over 25 years’ experience in health care industry with special expertise in management,
staff development, and performance improvement. Since 2004, she has been extensively involved in
healthcare quality and accreditation. She has brought her strong self-motivation and dynamic approach
to surveys and standards development. She is skillful in coaching, teaching, counselling and building
confidence in others. She has extensive experience in accreditation, standards, and surveyor methods
that lends to her supportive and supervisory role towards HCAC surveyors.Prior to Joining the HCAC Ms. Madi led the quality improvement process at Jordan University Hospital.
In that role, she had gained experience in developing and implementing quality programs, as well as in
leading the performance improvement process and Patient Safety program. Ms. Madi was responsible
for planning, directing, and administering internal operations to ensure the realization of quality, her
consulting expertise includes operational assessment; patient safety assessment; medication
management; infection prevention and control; environment of care; executive leadership and
governing bodies; medical staff and senior executive dialogue; performance improvement; and the
periodic performance review as management tool. Ms. Madi was also responsible for communicating,
interpreting and led the implementation of JCI, HCAC, HACCP and ISO standards in the hospital.
From early 2001 until the end of 2003, Ms. Madi had been assigned as Hospital Nursing Supervisor C
shift. As the Hospital Nursing Supervisor, she was responsible for planning, directing, and administering
internal operations to ensure providing high quality of nursing care during the night, and to tackle all
issues arise pertinent nursing practice.
From late 1991 until the end of 2002, Ms. Madi worked as a registered nurse (from junior to in charge)in
medical ward, where she was responsible to provide care for different types of patients (oncology,
nephrology, neurology and general medicine).

FABIENNE MENOT
Mrs.

FABIENNE MENOT
Mrs.
Individual Member
Surveyor
ORGANISATION
HAUTE AUTORITE DE SANTE
INTERESTS:
Policy Development /Planning
Standards/Accreditation
Admin/Management
Quality Management
BIO:
Fabienne Menot, Technical Advisor to the Director for the Improvement of Quality and Safety of Healthcare, joined HAS in 2005.
Her business portfolio covers numerous aspects of improving the quality of healthcare in France; these include helping to develop the strategy and reference standards for certification in France, international cooperation outside Europe, and the certification of health websites. Fabienne is also in charge of the certification aspects of HAS’ accreditation by ISQUA.
Before joining HAS, Fabienne Menot spent 10 years in the marketing departments of international groups specialising in food products, before she became interested in health and ran a private hospital for 12 years. She then set up a consultancy specialising in healthcare organisation mergers and restructuring.
Fabienne Menot is also a management coach certified by Paris 8 University and, at HAS, trains French surveyors in team dynamics.

Steven Wilson
Mr.

Steven Wilson
Mr.
Individual Member
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
ORGANISATION
Healthcare Improvement Scotland
INTERESTS:
Standards/Accreditation
Review/Audit
Admin/Management
Research
Quality Management
BIO:
Steven is a Senior Programme Manager with Healthcare Improvement Scotland, leading the planning, management and delivery of national quality improvement programmes across the health sector in Scotland. Prior to this he was Head of Clinical Governance for South Glasgow University Hospitals for 10 years.
Steven has a Master’s degree in Leadership for Health Quality Improvement from Birmingham University and an honorary research fellowship with Dundee University. He was awarded a Churchill Fellowship in 2015 to study how health information technology can be used to engage & empower patients. Steven is a Member of the Chartered Management Institute.

Elizabeth Pringle
Ms.

Elizabeth Pringle
Ms.
Individual Member
Surveyor
ORGANISATION
Improvement Matters Pty Ltd
INTERESTS:
Policy Development /Planning
Standards/A
BIO:

Ingrid Fairlie
Mrs.

Ingrid Fairlie
Mrs.
Individual Member
Surveyor
ORGANISATION
National Disability Insurance Scheme Quality and Safeguards Commission
INTERESTS:
Policy Development /Planning
Standards/Accreditation
Review/Audit
Health Sector Reform
Admin/Management
Research
Certification
Quality Management
Health Policy
BIO:

Kirsten Peddie
Ms.

Kirsten Peddie
Ms.
Individual Member
Surveyor
Surveyor
Surveyor
Surveyor
ORGANISATION
Australian Aged Care Quality Agency
INTERESTS:
Standards/Accreditation
Health Sector Reform
Admin/Management
Clinical Practice
Quality Management
Nursing Practice
BIO:
Kirsten’s role is to manage the surveyor workforce, the NSW/ACT State office’s accreditation program and quality assurance processes to ensure that strategic objectives are met. Kirsten manages the State office’s program of assessments of the performance of residential aged care homes and home care services. Kirsten leads and manages the recruitment, performance and development of the surveyor workforce. Kirsten makes decisions on compliance for residential aged care homes and home care services. This includes decisions about accreditation and the period of accreditation, monitoring services who have failed to meet the standards, reviewing visit programs to residential homes and home care services, making decisions about future visits and providing advice about case management. As a registered quality assessor Kirsten undertakes accreditation audits, announced and unannounced visits to aged care homes. Kirsten also undertakes quality review visits to home care services. Originally from New Zealand, Kirsten has a background in nursing and law. Kirsten has previously worked in acute care in secondary and tertiary care hospitals. She has worked in private practice for two large law firms in the areas of public and environmental law and has also spent time working with the New Zealand Health and Disability Commissioner. For 6 months in 2009 Kirsten was seconded to the Australian Commission on Safety and Quality in HealthCare where she supported the development of new health standards.

Hein Muller
Dr.

Hein Muller
Dr.
Delegate
Individual Member
Surveyor
ORGANISATION
consultant
INTERESTS:
Clinical Practice
Quality Management
Standards/Accreditation
External Evaluation
BIO:
I have worked for 30 years in a university affiliated hospital near Amsterdam ( 1981-2009) as a haematologist and for the last 2 and a half years of that period, as a manager for patient safety and quality of care.
During my clinical work I was president of the Dutch Society of Internists (NIV) and a board member of the executive council of the European Federation of Internal Medicine (EFIM).
As a board member of the Dutch Society of Medical Specialists I was responsible for the portfolio of quality, education and research. During this time (2000-2003) I was a board member of the executive council of NIAZ ( the Netherlands Institute of Accreditation for Care and Cure Institutions)
From 2007 onwards I am working as a consultant in Healthcare with projects in several hospitals in the Netherlands. Since that time I am also a member of the boards of trustees of two hospitals in the Netherlands
( Maasstad Hospital in Rotterdam and the St Jans Gasthuis in Weert).
I was send by the Dutch Government ( PUM) on missions to Bangladesh, Cameroon and Tanzania to advise Hospitals and primary care institutions.

Ali Hojjati
Dr.

Ali Hojjati
Dr.
Surveyor
ORGANISATION
Accreditation Canada International
INTERESTS:
Policy Development /Planning
Standards/Accreditation
Teaching/Training (education)
Admin/Management
Quality Management
BIO:

Anne Chenoweth

Anne Chenoweth
Individual Member
Surveyor
ORGANISATION
United States Veterans Health Administration
INTERESTS:
Health Sector Reform
Quality Management
Standards/Accreditation
BIO:
Anne Chenoweth is currently the National Enforcement Officer for the United States Veterans Health Administration. In that role she is responsible to ensuring the quality of the clinical laboratory services for all US veterans.
Anne Chenoweth was the Senior Director of the Accreditation and Quality Department for the AABB (formerly known as the American Association of Blood Banks), the global leader in accreditation of transfusion, donor and cellular therapies from 2008 until 2021
She obtained her Masters from Johns Hopkins University and her certification as a quality auditor from the American Society for Quality.
Anne took her first steps toward a career in blood banking and transfusion medicine at the University of Virginia, where she received her bachelor of science/medical technology degree. She has worked as a medical technologist at Johns Hopkins Hospital and as a sale representative for Curtin Mathison Scientific.
Anne was the manager of the transfusion service at Montgomery General Hospital for 20 years. In that capacity, she took a leadership role in numerous redesigns, both operational and organizational.
Anne has worked closely with the African Society for Safety in Blood Transfusion and the Brazilian Association of Hematology and Hemotherapy.
In her capacity as a certified quality auditor, she has been a judge in the International Team Excellence awards. These awards are given to companies that showcase projects Anne Chenoweth is currently the National Enforcement Officer for the United States Veterans Health Administration. In that role she is responsible to ensuring the quality of the clinical laboratory services for all US veterans.Anne Chenoweth was the Senior Director of the Accreditation and Quality Department for the AABB (formerly known as the American Association of Blood Banks), the global leader in accreditation of transfusion, donor and cellular therapies from 2008 until 2021 She obtained her Masters from Johns Hopkins University and her certification as a quality auditor from the American Society for Quality. Anne took her first steps toward a career in blood banking and transfusion medicine at the University of Virginia, where she received her bachelor of science/medical technology degree. She has worked as a medical technologist at Johns Hopkins Hospital and as a sale representative for Curtin Mathison Scientific. Anne was the manager of the transfusion service at Montgomery General Hospital for 20 years. In that capacity, she took a leadership role in numerous redesigns, both operational and organizational. Anne has worked closely with the African Society for Safety in Blood Transfusion and the Brazilian Association of Hematology and Hemotherapy. In her capacity as a certified quality auditor, she has been a judge in the International Team Excellence awards. These awards are given to companies that showcase projects and processes that highlight Lean as well as Six Sigma that have saved millions In 2008 Anne become a surveyor for the International Society for Quality in Healthcare. She has also spoken to numerous societies and associations about quality and performance improvement topics.

Paul van Ostenberg
Dr.

Paul van Ostenberg
Dr.
Expert
Individual Member
Surveyor
Surveyor
Surveyor
Surveyor
ORGANISATION
Retired From Joint Commission International
INTERESTS:
Standards/Accreditation
Certification
Quality Management
Health Policy
BIO:
Paul vanOstenberg has over 30 years of international leadership in health care quality, patient safety, health care accreditation and standards development. Most recently he held senior management positions at Joint Commission International (JCI) including Senior Advisor, Global Growth and Innovation and Vice President for International Accreditation, Standards, and Measurement and was the first Managing Director for the JCI Asia Pacific Office in Singapore, and the first Managing Director for the JCI European office. In addition to his international leadership for JCI, he worked on special projects for WHO, the US Treasury in Saudi Arabia, USAID in several Eastern European countries and in Africa, most notably Eritrea. Along with the Pharmaccess foundation in the Netherlands and the Council on Health Services Accreditation of Southern Africa he helped develop the SafeCare program in resource poor countries in Sub Saharan Africa. Paul is an exceptional educator and standards developer and has been recognized as such around the world including the 2015 Distinguished Service Award from the ISQua for this international standards work. Paul’s leadership has been synonymous with innovative strategic thinking, mentoring and compassionate team building. Dr. vanOstenberg earned a BA (Bachelor of Arts) from the University of South Florida, Tampa, Florida. He also received a DDS (Doctor of Dental Surgery) from the Medical College of Virginia, Richmond, Virginia and an MS (Masters in Gerontology and Health Administration) from the Virginia Commonwealth University, Richmond, Virginia.

Edward Chappy
Mr.

Edward Chappy
Mr.
Expert
Fellow
Individual Member
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
ORGANISATION
Selfemployed Consultant
INTERESTS:
Policy Development /Planning
Standards/Accreditation
Teaching/Training (education)
Health Sector Reform
Admin/Management
Research
Quality Management
Health Policy
BIO:
Edward Chappy is healthcare quality and accreditation consultant living in Jordan. During 2014, he helped Rwanda and Afghanistan develop their national five-year quality and accreditation policy and strategy and advised the Central Board for Accreditation of Healthcare Institutions (CBAHI), the national accreditation agency in Saudi Arabia, with strategic planning and developing a strategy to link health facility licensure and accreditation. From 2005 to 2013 Ed was the head of the Jordan Healthcare Accreditation Project (JHAP) and was instrumental in establishing the national healthcare accreditation agency in Jordan. Prior to coming to Jordan Ed worked in several countries implementing quality systems in private hospitals in Eritrea, Indonesia, Pakistan, Turkey, and Saudi Arabia. Ed was the Chief Executive Officer (CEO) at private hospitals in Pakistan, Indonesia, & Turkey and was responsible for commissioning 5 hospitals from the construction phase through operations.

Bruno Lucet
Mr.

Bruno Lucet
Mr.
Delegate
Expert
Individual Member
Surveyor
Surveyor
Surveyor
Surveyor
ORGANISATION
Retired
INTERESTS:
Standards/Accreditation
Review/Audit
Teaching/Training (education)
Admin/Management
Research
Quality Management
BIO:

Claudia Jorgenson
Ms.

Claudia Jorgenson
Ms.
Delegate
Individual Member
Surveyor
Surveyor
Surveyor
Surveyor
ORGANISATION
CJJ HealthCare Consulting
INTERESTS:
Standards/Accreditation
BIO:
As a Senior Healthcare Consultant, my passion is to refine strategic operations for accreditation and certifications, survey processes, international standards development and interpretation, risk reduction, and quality improvement for Global Healthcare organizations. Combining expertise as Director of Clinical Operations at Joint Commission International, with nonprofit association and for-profit hospital experience, has also enhanced my skills in consulting for the industry’s quality and safety improvements.
I have led and cultivated, as a project manager and director, collaborative relationships with U.S. and International government agencies, and Ministries of Health (MOH) to guide strategy, innovation, and quality solution/outcome focused achievements. Here is how I assess organizational processes and implement ideas for cost efficient and budgeting solutions to attain the results.
Being an International Surveyor for healthcare organization accreditation and the International Society for Quality in Healthcare (ISQua), along with mastery in standards development, interpretation, and survey process for compliance, as well as proficiency as a public speaker lecturing on standards and survey preparedness; patient safety; and quality improvement has enhanced my expertise.
As a Healthcare consultant, I welcome your partnership in learning about your projects to:
a) recommend ideas and solutions for organizational improvements to facilitate change dynamics; and
b) offer any refocus, focus and or redesign to your operations at healthcare organizations.
Specialties include: International and North American healthcare quality, safety, process improvement, risk reduction, patient safety, survey and accreditation across diverse cultures and healthcare systems, Nursing Operations, management, standards development, certified yellow belt, project management, work group management, presenter, speaker, and trainer.

Jan Mackereth-Hill
Mrs.

Jan Mackereth-Hill
Mrs.
Delegate
Expert
Fellow
Individual Member
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
ORGANISATION
Jan Mackereth-Hill
INTERESTS:
Policy Development /Planning
Standards/Accreditation
Review/Audit
Admin/Management
Certification
Quality Management
BIO:
A Quality Management Systems Lead Auditor I worked for 11 years for a UK based Healthcare Accreditation Organisation. Duties involved leading teams of up to 11 peer review surveyors in surveys which lasted from 3 -6 days both in the UK and Europe. I was also responsible for: running surveyor training sessions; development of the Standards Programmes; co-design and testing of an online accreditation tool. During this time I was the acting Accreditation Manager for ISQua during the transition from Australia to Dublin.
Prior to that I implemented ISO9001 in a UK hospital and maintained the ongoing certification for 4 years.
Other recent work includes 5 years as an Accreditation Manager at ISQua, representing the British Standards Institute as a UK expert for ISO9001 quality management systems (in healthcare) on a CEN (European Committee for Standardization) task force of clinical representatives of EU countries with the remit of integrating risk management and quality into a standard for healthcare organisations EN15224. My role was to give technical advice and interpret the standard and ultimately act as editor. Following on from this I was the technical author for the BSI Publication PAS 1616:2016 Healthcare – Provision of clinical services – Specification. More recently I am advising organisations in setting up accred, writing standards and training surveyors.

Triona Fortune
Mrs.

Triona Fortune
Mrs.
Delegate
Expert
Individual Member
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
ORGANISATION
Fortune Quality Accreditation Services
INTERESTS:
Standards/Accreditation
Review/Audit
Admin/Management
Research
Certification
Quality Management
Nursing Practice
BIO:
Triona works as an expert in the development of health and social care external evaluation systems with Fortune Quality Accreditation Services (FQAS). Her expertise is in the development of international health and social care standards and external evaluation systems, especially accreditation. Triona has advised several governments on best practices for developing their National Accreditation schemes, including South Africa, Nigeria, Indonesia, Lebanon and New Zealand to name a few. She also has over 20 years’ Senior Management experience specialising in Corporate Governance and Human Resource management. Before setting up FQAS Triona was the Deputy Chief Executive Officer of the International Society for Quality in Health Care (ISQua) where she led a number of their strategic goals including the International Accreditation and Events Programmes. Triona also continues to work with the World Health Organisation as an Expert Advisor on various Patient Safety initiatives - including EMRO’s Patient Safety Friendly Hospital Initiative and the National Quality Policy and Strategy Programme. As Director of Client Services with the Irish Health Services Accreditation Board, Triona was part of the senior executive to set up the Irish National Accreditation Programme. She was directly responsible for implementing accreditation in 90% of acute care hospitals in Ireland. This was followed by a senior position in HIQA were she led Irelands first national investigation into cancer misdiagnosis. She has held senior healthcare management positions in Ireland and internationally. Triona has taught on numerous Masters Programmes, specialising in healthcare quality and is currently working with Trinity College Dublin as a mentor to their MSc Nursing Students. She also works with the Sultan Qaboos University, Oman. She is an international speaker at numerous international conferences on all aspects of healthcare accreditation, patient safety and leadership. She is also the author of several peer reviewed articles published on health care standards, accreditation systems and patient centered care. Triona commenced her healthcare career as a nurse and midwife, specialising in emergency care and obtained her academic qualifications from Trinity College Dublin. When not travelling, she lives in Dublin.

Philomena Mitolo
Ms.

Philomena Mitolo
Ms.
Individual Member
Surveyor
Surveyor
Surveyor
Surveyor
ORGANISATION
QCI Consulting
INTERESTS:
Standards/Accreditation
BIO:

Virginia Matthews
Ms.

Virginia Matthews
Ms.
Individual Member
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
ORGANISATION
Independent Consultant
INTERESTS:
Standards/Accreditation
Research
BIO:
Appointment member of SA Allied Health Practitioners Tribunal for 3 year period commencing 7 July 2016.
Commenced own consultancy business in May 2018, Quality Compliance and Innovation Pty Ltd. The types of services performed include:
Assisting residential and community based aged care services with identified non-compliance to achieve compliance
Assisting services with self-assessment and gap analysis prior to re-accreditation site audits or quality reviews
Surveying consumers to gauge their level of satisfaction with care and services provided by service providers, to identify any gaps or areas for improvement
Assessing service providers current systems and processes against the new Aged Care Quality Standards and developing Action Plans to assist services in readiness for assessment against the new standards from July 2019.
Employed at UnitingSA as Clinical Quality and Education Manager, from December 2017 to May 2018. Responsible for the management and leadership of the clinical quality system including; achieving all aged care accreditation requirements and ensuring a highly functioning clinical IT system (Platinum5) exists for the organisation. This included working collaboratively with internal and external stakeholders to identify requirements, benchmarking best practice, developing solutions and plan implementation including the training of clinical and non-clinical staff in the new ways of working.
Joined the Accreditation Agency in 2000 and have held the positions of Quality Assessor, Principal Assessor and Assistant Director, and relief State Director until December 2017. Assistant Director for nine years from 2008 to 2017. The Assistant Director position was the senior of the team managers in the state office and is responsible for assessing and reporting the performance of aged care services, accreditation and related decisions, case management of aged care homes’ compliance, ensuring that compliance objectives are met, and effective management of the assessor workforce and implementation of quality processes.
Commenced with the Aged Care Industry in 1994 as director of nursing of a small private nursing home and then as residential care manager of a co-located high and low care facility for a large not for profit aged care provider.
Prior technical and clinical roles in acute care, mental health, and water quality.
Previous roles in quality assurance and quality management in aged care and water quality.
Master of Nursing – Business Management and Organisational Development / Aged Care Nursing (University of SA);
Bachelor of Nursing (University of SA)
Graduate Certificate in Aboriginal Studies (University of SA).
Diploma of management (Upskilled)

Margarida Madalena Martins Franca
Dr.

Margarida Madalena Martins Franca
Dr.
Surveyor
ORGANISATION
Porto Oncologic Institute
BIO:
I started my professional activity as hospital administrator in the NHS in 1989 and have experienced several senior hospital management positions. Deputy Director and Director of the National Institute for Quality in Health (IQS) (2000-2006). National coordinator of the Hospital Accreditation National Program launched in 1999 within the joint with King’s Fund/HQS/CHKS till 2006. Member of the CHKS Accreditation Council and Awards Panel since 2006 and surveyor of the CHKS Accreditation Programme. National coordinator of the European research project DUQuE – Deepening our Understanding of Quality Improvement in Europe (2010-2013). Adviser of the General Directorate of Health, Ministry of Health since 2008. National representative on the OECD HCQI and member of the Patient Safety Expert Group, years 2003 to 2011. Invited Professor at Portuguese Catholic University, Porto, since 2002. Cofounder and Chair of the Portuguese Society for Health Quality since 2010 (IQS) Member of the governance bodies of Portuguese Hospital Administrators Association (APAH) since 2013. Distinguished Service Medal “Gold” from Ministry of Health, assigned by Health Ministry on the 25th May 2009.

Peter Frendin
Mr.

Peter Frendin
Mr.
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
ORGANISATION
Peter Frendin
INTERESTS:
Management
BIO:
Having qualifications in Nursing and midwifery Peter holds post graduate qualifications in Health Services Management and is a graduate of the Australian Institute of Company Directors. Peter is currently a Consumer and Community Advisor with the Cancer Institute of New South Wales (NSW) a member of the Aboriginal Health Council for Western NSW Primary Health Network, a Justice of the Peace for NSW and a member of the local Volunteer Coastguard. Peter has worked in Indigenous Health in many of the remote areas of Australia including the deserts of South Australia, Western Australia and the Northern Territory. He has managed hospitals, regional health services and Community based organisations across Australia, and lived and worked in Dubai and India as a health management consultant. More recently he headed remote health services for the Northern Territory Government in Central Australia and subsequently oversaw the Territories Prison health services. In his current role Peter heads the National Development team for the AGPAL group of companies, Australia’s most comprehensive quality and accreditation agency in the health and human services sector. Peter is married to his long suffering wife Jenn (24 moves in 35 years would try anyone’s patience!) and they have two (nearing) middle aged boys and a wonderful granddaughter (not that Peter is biased…)

Jim DuRose
Mr.

Jim DuRose
Mr.
Surveyor
Surveyor
Surveyor
Surveyor
ORGANISATION
Health and Disability Auditing New Zealand
BIO:

Anand R
Prof.

Anand R
Prof.
Expert
Individual Member
Surveyor
Surveyor
Surveyor
Surveyor
ORGANISATION
Kasturba Medical College
INTERESTS:
Other
BIO:
Dr Anand R is a Pulmonologist practicing in a 600 bed ry care hospital in India. He currently is the Professor in the Department of Pulmonary Medicine at Kasturba Medical College, Mangalore, India which is one of the medical colleges in India. Anand has been involved in the implementation of quality management system in his organization. Currently he is a member of the Assessor Management Committee of National Accreditation Board for Hospital and Healthcare Providers [NABH]. He was also a member of the Technical Committee of NABH and a Technical Expert for National Accreditation Board for Certifying Bodies of India which is the accrediting body for various certifying bodies in India. Anand has been Assessor and Principal Assessor for NABH since 2007 and in these capacities has performed about 50 assessments. Anand has participated as faculty in various training programmes and delivered guest talks on various quality related topics.

Pawan Kapoor
Dr.

Pawan Kapoor
Dr.
Expert
Individual Member
Surveyor
Surveyor
Surveyor
Surveyor
ORGANISATION
National Accreditation Board for Hospitals & Health care Providers (NABH)
INTERESTS:
Other
BIO:
Served in the Indian Armed Forces from October 1979 to December 2017. Served in the Indian Army in various appointments and finally superannuated as Director General of Medical Services (Air Force). One of the founder members and Chairman of the Technical Committee and Chairman of the Accreditation Committee of National Accreditation Board for Hospitals and Health Care Providers. Principal Assessor for NABH since inception and an Assessor for ISQUA since 2012. Provided training to several medical and nursing professionals across India on patient safety, Quality in health care and Accreditation process and standards.

Parvez Ahmad
Dr.

Parvez Ahmad
Dr.
Individual Member
Surveyor
ORGANISATION
Subharti Hospital & Medical College, Nanda Ki Chowki, Prem Nagar, Dehradun
INTERESTS:
Policy Development /Planning
Standards/Accreditation
Review/Audit
Teaching/Training (education)
Health Sector Reform
Admin/Management
Clinical Practice
Certification
Quality Management
Nursing Practice
Health Policy
Other
BIO:

Neeraj Lal
Mr.

Neeraj Lal
Mr.
Individual Member
Surveyor
ORGANISATION
Apollo Hospitals Ahmedabad
BIO:
Neeraj Lal (Group Senior Vice President - Medicover Hospitals India ) A post-graduate in Hospital Administration from the renowned Institute of Social Sciences (TISS), Mumbai, degree
in Medical Sciences from PGI Chandigarh. Young and dynamic healthcare leader with eye for quality detailing. He is one among the four Indian individual members of the International Society for Quality in Healthcare (ISQua) based out of Dublin. He is also an approved Surveyor for ISQua’s International Accreditation Programme and was previously Cluster Head and Vice President at Rainbow Children's Hospitals Bangalore and Karnataka Region and Group Chief Operating Officer of the Sunshine Global Group of Hospital based out of South Gujarat. He have held senior positions in various Indian Hospitals for a number of years. He has won various awards and prestigious positions to his credit-
Received the Award of Excellence for “Outstanding Contribution in Healthcare Sector” by North Gujarat University, Patan (2011).
the Prestigious Aikat Memorial Gold Memorial Gold Medal" for the Best Outgoing Student of P.G.I.Chandigarh (1996). Healthcare expert with New York based On Frontiers operations, business and management of hospitals and medical institutions Guest faculty with many Indian Universities and Business schools for teaching
programs in Hospital Administration & healthcare quality. mentoring start-ups and help them understand the detailing of healthcare http://www.healthpodindia.com/mentors.html"

Tricia Dore
Ms.

Tricia Dore
Ms.
Individual Member
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
ORGANISATION
Q-Xcel Ltd
BIO:
Tricia has a background that includes management roles in quality, projects, operations, manager of
intensive community mental health teams and senior lecturer at university. She is a registered nurse with a current practicing certificate and is also a qualified teacher.
Tricia manages her own company which has been operating for over 12 years. Work includes consulting around strategic, business, quality and risk management; workforce development; project
management; auditing of a range of health services (primary, secondary and tertiary services). Tricia completes over 150 days audit per year with examples of works in auditing and surveying as follows:
• International surveyor for ISQua since 2010 with completion of desk-top surveys; validation of surveys; on site surveys. Tricia has been identified as the team leader on some surveys and provided leadership and mentoring.
• Extensive audits against contracts and as part of the designated auditing programme in New Zealand.
• Development and implementation of training packages for auditors/surveyors including training of auditors against approved New Zealand Qualifications Authority standards. Examples of other recent work completed includes the following:
• Implementation of new social housing contracts to house chronically homeless people and sustain housing for people identified as having significant issues with housing.
• Review of business intelligence tools for proposed implementation.
• Leadership of mental health teams;
• Development and course facilitation of training packages for the University of Auckland (NZ)).
• Development of policies and procedures for health services.
• Evaluation of pilot programmes, and
• Development of clinical pathways.
Tricia is part of a large international multicultural family. She loves the diversity and enjoys working with people from other nations to support growth and development. She is passionate about making a
difference in healthcare and believes in supporting organisations to be innovative, strive for quality improvement within a philosophy of striving for excellence together.

Gary Smith
Mr.

Gary Smith
Mr.
Delegate
Expert
Individual Member
Surveyor
ORGANISATION
Australian General Practice & Accreditation Ltd (AGPAL) and Quality Innovation Performance P/l/(QIP)
INTERESTS:
Health Sector Reform
Quality Management
Review/Audit
Standards/Accreditation
BIO:
I have been a Surveyor in Australia for some 16 years specialising in General Practice Accreditation, but extending to health services in correctional centres, immigration detention centres and women health clinics. I have extensive experience in the writing of Standards, with the Royal Australian College of General Practitioners (RACGP) Standards for General Practice, After Hours Medical Deputising Services, Health Centres in Immigration Detention Centres. I carried out the piloting of all the Standards for the RACGP/AGPAL. I was appointed an Australian Expert on the implementation of Accreditation in General Practice with the Royal New Zealand College of General Practitioners (RNZGP PAAC). I have had extensive experience in the education, training, and presenting on Standards at conferences, seminars along with the training of Surveyors. In 2012 I led the merger (as Chair of QIP) between Australia’s four major primary care accreditation bodies: Quality In Practice; The Quality Improvement Council (QIC); Quality Improvement and Community Services Accreditation Inc. (QICSA); Quality Management Services (QMS). QIP’s establishment resulted in Australia’s most comprehensive accreditation business of which I am the inaugural Chair.

Susan Yates
Ms.

Susan Yates
Ms.
Fellow
Individual Member
PCC: Building Health Care for People Specialist Certificate User
Surveyor
ORGANISATION
Leeds, Grenville, and Lanark Health Unit
INTERESTS:
Clinical Practice
Health Policy
Health Sector Reform
Nursing Practice
Quality Management
Review/Audit
Standards/Accreditation
Teaching/Training (education)
Admin/Management
BIO:

Danielle Dorschner
Ms.

Danielle Dorschner
Ms.
Expert
Individual Member
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
Surveyor
ORGANISATION
Accreditation Canada
INTERESTS:
Standards/Accreditation
Nursing Practice
Health Policy
BIO:
Danielle Dorschner is an executive healthcare professional with more than 30 years’ experience in
health care at the local, national and international level. She has recently retired from her position as Executive
Director of OHSNI – Ottawa-Baffin Nunavut Health Services, a not for profit organisation that
coordinates specialist and tertiary health care for the residents of the Baffin Region of Nunavut referred
to Ottawa for treatment. Before that, she was Executive Director at Accreditation Canada where she
oversaw the implementation of the accreditation program and services for Canada. During her 16 years
tenure at Accreditation Canada she has spoken at many conferences, events and participated on expert
panels regarding accreditation. Danielle was with Accreditation Canada since September 2001 where
she has worked as an accreditation specialist, an accounts specialist and Director of Client Services,
Senior Director of Programs and Client Engagement and Executive Director, Canadian Accreditation.
Danielle is a certified Surveyor with the International Society for Quality in Health Care (ISQua).
She is a Registered Nurse that obtained her Masters of Science in Nursing at l’Université de Montréal
in 1992 and her Bachelor of Science in Nursing at Laurentian University in Sudbury in 1985. She is also
an active volunteer with several national and local boards and is a public member of the Committee on Accreditation of Canadian Schools of Medicine where she sits on the standards sub-committee and participates in accreditation surveys.

Anita Harris
Owner & Principal Consultant

Anita Harris
Owner & Principal Consultant
Individual Member
Surveyor
Surveyor
Surveyor
Surveyor
ORGANISATION
Anita Harris
BIO:
Anita Harris has retired from her position as Vice-President of Clinical Affairs and Chief Privacy Officer at Hotel-Dieu Grace Hospital in Windsor, Ontario. She was responsible for overseeing the Hospital’s Risk Management Program, Infection Control, Patient Advocacy, Medical Affairs, Legal Affairs, Professional Services, and all matters related to Privacy. Currently Anita is the Managing Partner in "Workplace Dispute Investigations", does medical/legal consulting for a number of law firms and hospitals and is a surveyor with Accreditation Canada and Accreditation Canada International.
Anita graduated from the University of Windsor’s Faculty of Law in 1997 and was admitted to the Law Society of Upper Canada, Ontario Bar in 1999. She is a Registered Nurse and had worked in Critical Care for 23 years, prior to obtaining her law degree. She is a graduate of the Advanced Health Leadership Program from the University of Toronto, Rotman School of Management and has recently obtained her Long term care Administrator certification.
Besides her extensive career in Acute Care, Anita has extensive experience in Primary Care. She served as Interim Executive Director for a Family Health Team. In addition, she was one of the founding Board members for a Primary Care Health Team in Windsor and has remained on the Board for 9 years. She currently holds the title of President and Chairperson of the Board of Directors, and Chairs various committees of the Board.
Throughout her career, Anita has been a frequent guest lecturer at the University of Windsor and St. Clair College in the Faculty of Nursing and Law, and is a conference presenter on a variety of health law topics.
Anita is a "Do Good Diva" and is the recipient of St. Clair College’s 2009 Alumni Award of Distinction in Health Sciences.

Al Alassaf
Prof.

Al Alassaf
Prof.
Individual Member
Surveyor
ORGANISATION
University of Oklahoma
INTERESTS:
Quality Management
Standards/Accreditation
BIO:
Professor A. F. ALASSAF, M.D., M.P.H.; Executive Director, American Institute for Healthcare Quality, USA Chief Administrative Officer for AGI Consulting, USA; Professor Emeritus, University of Oklahoma, U.S.A.
Professor Alassaf is an international consultant in healthcare quality and hospital management for the last 35 plus years. He provides advice on systems strengthening and accreditation in the U.S. and other countries worldwide. His consultation extends to such organizations as U.S. Air Force, U.S. Veterans Affairs Health System, US Agency for International Development (USAID), Hospital Corporation of America, Selected Professional Associations, World Bank, UNDP, UNICEF, World Health Organization (WHO), and the American Association for World Health. He has also provided advice on system development and analysis including clinical improvement, leadership and capacity building to a number of organizations in countries in the North America, MENA region countries, South East and Central Asia as well as Eastern Europe. As a researcher and public speaker, he served as an Associate Dean and Professor of Health Administration and Policy for the University of Oklahoma for more than 28 years. He also had several adjunct and visiting professor appointment at Universities in Oklahoma, Alabama, Arizona State, Missouri, Malaysia, Cyprus, Turkey, UAE, Iraq, Tunisia, Lebanon, Saudi Arabia, Jordan, Bahrain and Egypt.
Prof. Alassaf has published 17 books, eight book chapters, and over 170 scientific and professional publications in national and international journals, and presented lectures, seminars, or workshops to about 300 groups and organizations both nationally and internationally. He is a reviewer for several international journals on healthcare administration and is a member of the editorial board of several American healthcare journals. He has also served as principal investigator on several grants and contracts and has authored a considerable number of technical reports and abstracts. At the American Institute for Healthcare Quality and since September 2013, he serves as the Executive Director and has delivered numerous courses in quality, patient safety, infection control, health and hospital administration, Healthcare Finance, and risk management among several other topics to healthcare professionals world-wide. The Institute is a licensed vocational school in the State of Oklahoma with representations in 5 different countries and maintains physical presence in many others worldwide.
Prof. Alassaf is a physician (MD) with a Masters degree (MS) and a Diploma in Cardio-thoracic Medicine (DCTM) from the University of London. He also holds a Masters of Public Health Administration degree (MPH) from the University of Oklahoma. He is a Member of the American College of Cardiology (MACC), Fellow of the Royal Society of Health (FRSH), Fellow and a Diplomate of the American Academy of Medical Administrators (FAAMA), Fellow of the American Institute for Healthcare Quality (FAIHQ), Fellow of the American College of Managed Care Administrators (FACMCA), Member of the American College of Cardiology, Board Certified as a Quality Analyst (CQA) and a certified international surveyor for ISQua.. He also holds certifications in infection control, risk management, and patient safety. He is a member of the speakers' bureau of the American Association for World Health and belongs to several professional associations in Healthcare Quality and Medicine.
Dr. Alassaf is a recipient of more than 100 awards and recognition including Who’s Who in America and the World.

Ahmad Shatat
Mr.

Ahmad Shatat
Mr.
Surveyor
ORGANISATION
Health Care Accreditation Council- Jordan
INTERESTS:
Standards/Accreditation
Teaching/Training (education)
Certification
Quality Management
BIO:
Ahmad Shatat is a health care professional, has more than 10 years of experiences in healthcare and quality. Mr. Shatat is currently works as an Accreditation Specialist in the Survey and Standards Development Department at Health Care Accreditation Council (HCAC) in Jordan. The Health Care Accreditation Council (HCAC) is the only independent ISQua-accredited institution in the Arab World dedicated to improving the quality of health care and patient safety.Mr. Shatat work mainly in overall management of accreditation and certification surveys and management of surveyors related activities including hiring and training, and he is a certified surveyor. Additionally, Ahmad participates in the developing, testing, disseminating, and communicating new and revised HCAC accreditation/certification standards. He also participates in the conducting of training and education courses and workshops for health care professions such as quality management and risk management courses and workshops that conducted by HCAC. Mr. Shatat responsible for developing the national quality and safety goals in Jordan every other year. He is also expert in developing accreditation recognition programs, accreditation programs’ survey guidelines, accreditation standards’ implementation packages.
Prior to joining the HCAC, Mr. Shatat worked as an ICU In-charge Nurse and Registered Nurse at King Hussein Cancer Center. Mr. Shatat holds a Master’s Degree in Health Services Management from the adjoin program between the Royal College of Surgeons Ireland (RCSI) & the Yarmouk University of Jordan, and a Bachelor’s Degree in Nursing from the Al-albayt University.
He also HCAC Certified Surveyor for Hospitals, Primary Healthcare Centers, Ambulatory Centers and Medical Laboratories, Certified Surveyor,
Accreditation Canada International Accreditation (ACI), Healthcare Certified Quality Practitioner and ISQua fellow. In addition, he is participating now in many researched related to quality and patient safety and participated in many conferences as a speaker.

Julia Hsu
Ms.

Julia Hsu
Ms.
Delegate
Fellow
Individual Member
JCT Fellow
Surveyor
ORGANISATION
Joint Commission of Taiwan
BIO:

Ann Wunsch

Ann Wunsch
Surveyor
ORGANISATION
Aged Care Quality and Safety Commission
INTERESTS:
Policy Development /Planning
Standards/A
BIO:
Ann is currently the Executive Director of Operations at the Australian Aged Care Quality Agency. Ann manages the accreditation program for residential aged care facilities and the quality review program for home care services across Australia. Ann has also managed the education division which develops and delivers education to the aged care sector and manages the assessor training course and the quality reviewer course. Prior to holding this position, she was the State Manager for NSW/ACT responsible for managing the accreditation arrangements and education program for over 800 aged care facilities. Before joining the Aged Care Standards and Accreditation Agency in 2005, Ann managed a number of programs in the disability services sector including deinstitutionalisation projects and the establishment of community accommodation services for adults with developmental disability. Ann has also worked in regulatory agencies and in policy and advisory roles in government agencies and has served on a number of boards of organisations in the disability services sector. From 2004 – 2014, Ann served as a part-time member of the NSW Administrative Appeals Tribunal, in the Guardianship and Protected Estates division.

Bhupendra Rana
Dr.

Bhupendra Rana
Dr.
Expert
IAQS Member
Individual Member
South East Asia CoP
Surveyor
ORGANISATION
Quality and Accreditation Institute (QAI)
INTERESTS:
Standards/Accreditation
Review/Audit
Teaching/Training (education)
Admin/Management
Certification
Quality Management
BIO:
Dr. B.K. Rana is the Founding CEO of Quality and Accreditation Institute (QAI) and former Director of NABH, Quality Council of India. He served International Society for Quality in Health Care (ISQua) as elected Vice-Chairman- Accreditation Council (2008-2014) and Chairman- Accreditation Council (2014-2016). He was appointed Director on ISQua Board from 2014 to 2016. Concurrently, he served as President of Asian Society for Quality in Healthcare (ASQua) in 2011 and 12 and now serving as Director on its Board and Chairman- Technical Committee. He has many honours to his credit including an appointment as ‘ISQua Expert’. Because of his unparalleled mastery and knowledge, he took part in WHO’s International Steering Committee for Patient Safety and served also as External Consultant of World Health Organization (WHO) on setting hospital accreditation program. Alongside, he achieved rare distinction by becoming part of United Nations Framework Convention on Climate Change (UNFCCC) as an Expert/Assessor for Clean Development Mechanism (CDM). He sits on many national and international committees including ISO/ TC 210 WG1. His expertise on Standardisation, Quality, and Accreditation include establishing accreditation bodies [Laboratory (ISO/IEC 17011) and Healthcare Providers (ISQua)], External Quality Assessment Schemes (ISO/IEC 17043), Standard Development, Training Program Development, Implementation of the Requirements of ISO/IEC 17025, ISO 15189 and ISO/IEC 17043. He is sought-after as a speaker and is published in several magazines on accreditation, quality improvement, patient safety, standards etc. Dr. Rana holds Ph.D in Biochemistry and Diploma in German. He also received Post Graduate Diploma in Hospital and Health Management. He has published nine research papers in international journals, contributed chapters in books and presented in several national and international conferences.

Kadar Marikar
Dr.

Kadar Marikar
Dr.
Expert
Individual Member
Surveyor
ORGANISATION
Malaysian Society for Quality in Health (MSQH)
INTERESTS:
Management
Certification
Policy Development/Planning
Quality Management
Standards/Accreditation
Patient Safety
External Evaluation
Leadership
Education
Knowledge and Research
BIO:

Lena Low
Dr.

Lena Low
Dr.
Delegate
Expert
Expert
Expert
Expert
Individual Member
Surveyor
ORGANISATION
Lena Low
BIO:
Dr Low has been involved in the health care industry since 1995 with involvement in strategic development and operationalising health care accreditation systems. As Executive Director of the Australian Council on Healthcare Standards which accredits more than 1,600 healthcare organisations nationally in Australia and in 18 countries internationally , she has responsibility for management of national and international corporate services. This involves financial and information technology management for the national and international organisations, human resource management , surveyor workforce logistics and performance management. Dr Low also has previous experiences in the health care industry as interim Chief Executive Officer and Company Secretary and presents at national and international forums and conferences on safety, quality and accreditation.
Dr Low's qualifications include: Doctor of Philosophy (PhD in public health and community medicine UNSW}, Master of Business Administration , Diploma Austral ian Institute of Company Directors and Graduate Diploma in Management. Dr Low is also an Adjunct Fellow at Macquarie University, Fellow of the Australian Institute of Company Directors, and an Accreditation Council member of the International Society for Quality in Health Care (ISQua). Dr Low is an ISQua surveyor who has led survey teams for ISQua in France, India, New Zealand, Indonesia and Canada and is also a member of the "ISQua Experts" panel presenting at Expert Webinars and Fellowship Forums. Dr Low is also a Board Director of one of Sydney's leading private golf clubs.

Daniyar Ospanov

Daniyar Ospanov
Institutional Member
Surveyor
ORGANISATION
Public Association of surveyors and consultants in the field of healthcare accreditation, Kazakhstan
BIO:

Nisreen Abada
Service Line Leader

Nisreen Abada
Service Line Leader
Fellow
Individual Member
Surveyor
ORGANISATION
Dubai Healthcare Corporation, Head Quarters Dubai Health Authority
INTERESTS:
Policy Development/Planning
Quality Management
Review/Audit
Standards/Accreditation
Teaching/Training (education)
BIO:
Nisreen Abada has an extensive expertise in Healthcare Quality Improvement Operations, Infection Prevention and Control, and Environment Health & Safety Management systems and has a vast experience in international accreditation operations and regulatory requirements. Nisreen is currently working for Dubai Healthcare Corporation Head Quarters as a Specialist at the Centers of Excellence Office. Her main role is to establish Service lines and Centers of Excellence across the healthcare operators with the public sector of the Emirate of Dubai.She has been a core member in steering the ISQua Organization Accreditation at Dubai Healthcare City Authority- Regulatory and has been the Survey Manager at Dubai Healthcare City for three and a half years. Nisreen has been a focal member in establishing the Dubai Healthcare City Authority Excellence Awards Program. She has led the Prime Healthcare Group quality operations and headed the commissioning of Prime Hospital. In addition to her long and diverse experience at the fast-paced Sheikh Khalifa Medical City Abu Dhabi under SEHA. She holds a Bachelor’s Degree in Pharmaceutical Sciences and Pharmacy from the University of Alexandria, Egypt, and is a Certified Professional in Healthcare Quality (CPHQ) and a Certified Six Sigma Green Belt (CSSGB). On a personal level Nisreen believes in instituting excellence in day to day operations and maintaining a high quality and safe healthcare environment for the community. She is compassionate and focused on developing and delivering high standards of quality, enhancing excellence, patient safety, performance and outcome.

Chin-Pao Cheng

Chin-Pao Cheng
African CoP Member
Surveyor
ORGANISATION
JCT
BIO:

Scott Phipps

Scott Phipps
Individual Member
Surveyor
ORGANISATION
Scott Phipps
BIO:
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