Francisca Mapa

Nursing Director

• Improved staffing efficiency by optimizing nurse scheduling, which reduced overtime and ensured adequate coverage.
• Spearheaded implementation of evidence-based nursing practices that enhanced patient safety and care standards.
• Streamlined nursing workflows, reducing patient wait times and increasing overall hospital efficiency.
• Developed and implemented effective training programs that resulted in highly skilled and motivated nursing workforce.
• Initiated mentorship programs for new nurses to foster professional growth and reduce turnover rates.
• Played key role in expanding nursing services, including opening new units and extending service hours to meet patient demand.
• Aligned nursing objectives with hospital’s overall strategic plan, resulting in enhanced organizational performance.
• Created long-term plans for nurse recruitment and retention, ensuring sustainable workforce in competitive healthcare environment.

Quality and Patient Safety Director

• Developed comprehensive Accreditation Readiness Plan by aligning hospital practices with JCI and CBAHI standards across departments.
• Conducted thorough gap analyses, identifying areas of non-compliance and implementing corrective actions to meet stringent requirements of both JCI and CBAHI standards.
• Led hospital to successfully achieve triennial Joint Commission International (JCI) accreditation, meeting global healthcare standards in patient safety, care quality, and organizational management.
• Directed hospital-wide initiative that resulted in achieving triennial CBAHI accreditation, ensuring compliance with national standards set by Saudi Ministry of Health.
• Standardized patient safety reporting process, enhancing hospital’s ability to track, manage, and resolve incidents in line with accreditation guidelines.
• Established sustainable quality monitoring framework that allowed small hospital to track safety and quality metrics over time, maintaining continuous improvement and readiness for reaccreditation and ESR unannounced visit.

Nursing Director

• Successfully restructured staffing plan for Nursing Department in alignment with Ministry of Health (MOH) Recommended Safe Staffing Ratio. This initiative improved nurse-to-patient ratios, ensuring safer patient care and better workload distribution among staff.
• Achieved reduction in nursing department overtime, cutting it by 30% of average monthly approved overtime. This was accomplished through effective staffing strategies, improved scheduling, and optimizing workforce utilization.
• Plays major role in increasing long-term care unit’s capacity, increasing number of patients from 38 to 58. This expansion addressed growing demand for long-term care services and improved patient accommodation.
• Launched comprehensive unit patient safety program that included initiatives such as CAUTI Bundle, Pressure Ulcer Prevention, and Care Planning.
• Implementation of these safety programs led to notable reduction in catheter-associated urinary tract infections (CAUTIs), pressure ulcers, and improved overall patient outcomes.
• Developed and introduced comprehensive unit-specific competency and preceptorship program. This program enhanced skills and knowledge of nursing staff, ensuring high standards of care and effective onboarding of new staff members.
• Achieved High Licensure Rates: Attained remarkable 97% nursing staff licensure rate with Saudi Council for Healthcare Specialties MOH requirements

Quality and Patient Safety Director

• Led hospital to successfully attain triennial CBAHI accreditation, overcoming challenges of limited resources and smaller teams by effectively streamlining processes and maximizing available resources.
• Developed tailored Accreditation Readiness Plan that efficiently used to implement fast, hospital-wide changes in compliance with safety and quality standards.
• Conducted resource-efficient mock surveys and interdisciplinary collaboration to prepare hospital for accreditation, achieving full compliance without need for costly external consultants.
• Introduced monthly interdisciplinary safety huddles, where staff from different departments could share challenges and successes in patient safety, leading to more collaborative and innovative safety solutions.
• Established sustainable quality monitoring framework that allowed hospital to track safety and quality metrics over time, maintaining continuous improvement and readiness for accreditation and ESR unannounced visit.

• Successfully led hospital through initial and triennial surveys for CBAHI, JCI, and ACI accreditations, demonstrating adherence to high standards of patient care and safety on international scale.
• Ensured continuous compliance with accreditation requirements, fostering environment of excellence in patient care and operational standards.
• Led creation of detailed manuals, policies, and procedures tailored to hospital’s specific needs, ensuring they aligned with JCI International Patient Safety Goals (IPSG) and CBAHI requirements.
• Created and implemented comprehensive contract management process, including contract negotiation, compliance monitoring, and renewal procedures, optimizing vendor relationships and ensuring legal and regulatory adherence.
• Launched effective satisfaction programs for both patients and staff, integrating feedback mechanisms, surveys, and performance metrics to enhance service quality and staff engagement.
• Leveraged feedback from satisfaction programs to drive targeted improvements, resulting in increased patient satisfaction and higher staff morale.
• Designed and implemented Patient and Family-Centered Care Program to enhance patient experience by involving patients and families in care decisions, improving communication, and personalizing care delivery.
• Spearheaded EMR Integration: Led transition from manual forms to electronic medical record (EMR) system, streamlining data management, improving accuracy, and enhancing accessibility of patient records.
• Established robust performance measurement and improvement system, focusing on key metrics such as patient outcomes, process efficiency, and adherence to safety standards.
• Oversaw monitoring reporting of metrics related to utilization of services, including number of visits, admissions per department, services, providers, top diagnoses, and procedures.
• Oversaw monitoring of strategic operational plan, ensuring alignment with organizational goals and objectives.
• Regularly assessed effectiveness of strategic plan, coordinates adjustments as needed to address emerging challenges and capitalize on opportunities for improvement.
• Enhanced employee awareness on safety practices through regular workshops, presentations, and demonstrations.
• Developed and implemented safety tracking, training and management programs.
• Streamlined communication channels between departments for reporting potential hazards or unsafe conditions, enabling prompt action and resolution.
• Managed emergency response teams during crisis situations, ensuring timely and efficient resolutions with minimal disruption to operations.
• Coordinated with regulatory agencies such as OSHA to ensure compliance with federal and state safety standards.
• Evaluated effectiveness of current safety measures in place by analyzing data trends related to accidents, injuries, or near misses reported over time periods.

• Successfully led process to initiate Accreditation Canada International (ACI) accreditation, setting stage for achieving high standards in patient safety and quality of care.
• Created comprehensive strategic plan for ACI accreditation that included timelines, resource allocation, and key milestones, ensuring structured and effective approach to meeting ACI standards.
• Established and led cross-functional task force composed of representatives from various departments to oversee and manage accreditation process, ensuring thorough preparation and collaboration.
• Performed detailed gap analysis to identify areas needing improvement relative to ACI standards, and developed targeted action plans to address these gaps.
• Rolled out various quality improvement initiatives across hospital, including enhancing clinical protocols, improving patient safety measures, and refining operational processes to align with ACI requirements.
• Coordinated extensive training programs for all staff members on ACI standards, focusing on areas such as patient safety, quality of care, and risk management to ensure full preparedness for accreditation process.
• Successfully led hospital through ACI accreditation process, achieving full accreditation status, achieved Accreditation Canada Accreditation Certificate (Gold Level).
• Effectively managed and resolved any findings or recommendations from ACI surveyors, implementing corrective actions and process improvements as needed to meet accreditation requirements.
• Established continuous quality improvement program to ensure ongoing compliance with ACI standards, including regular internal audits, performance monitoring, and continuous staff education.

• Successfully led nursing team of 230 members, fostering collaborative and supportive work environment.
• Implemented regular training and development programs, resulting in improvement in staff competency and satisfaction scores.
• Mentored emerging nursing leaders, with 10 team members advancing to higher leadership roles.
• Launched comprehensive hospital wound care program.
• Developed nursing department policies and procedures that aligned with best practices, maintaining high standards of care and legal compliance.
• Core member in expansion of Outpatient Department (OPD) from 35 clinics to 57 clinics by overseeing commissioning of new OPD building. This expansion significantly enhanced patient access and streamlined outpatient services.
• Spearheaded commissioning of Long-Term Care Unit, growing facility’s capacity from initial 26 patients to 180 patients. This expansion to addressed increasing demand for long-term care services and improved patient accommodation.
• Led commissioning of SMCH Tower 2, adding additional 120 beds to hospital’s capacity. This development supported hospital’s growth and improved its ability to meet needs of larger patient population.
• Played crucial role in planning and successful opening of several key services such services are: Blood Bank, Endoscopy Unit: OR Transfer and Home Health Care
• Supervised staff of 220 registered nurses, 30 practical nurses and nursing assistants.
• Promoted positive work environment by recognizing achievements and addressing concerns promptly.
• Participated in community outreach events to promote healthcare awareness and foster strong relationships with local organizations.