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Job Purpose

The Quality Manager is responsible for leading and overseeing the hospital's quality management program to ensure compliance with CBAHI, JCI, MOH, and other applicable regulatory and accreditation standards. The role drives continuous quality improvement initiatives, enhances patient safety, monitors key performance indicators, and supports the organization's commitment to delivering high-quality patient-centered care.

Key Responsibilities

Quality Management

• Develop, implement, and monitor the hospital's Quality Management Program in alignment with organizational objectives.
• Establish and maintain quality improvement frameworks, policies, procedures, and standards.
• Lead continuous quality improvement (CQI) initiatives across clinical and non-clinical departments.
• Monitor departmental compliance with established quality standards and best practices.

Accreditation & Regulatory Compliance

• Ensure ongoing compliance with CBAHI, JCI, Ministry of Health, and other regulatory requirements.
• Coordinate accreditation preparation activities, mock surveys, and gap assessments.
• Facilitate hospital readiness for accreditation surveys and regulatory inspections.
• Monitor corrective and preventive action plans arising from audit findings.

Patient Safety

• Promote a culture of patient safety throughout the organization.
• Oversee incident reporting systems, root cause analyses (RCA), and failure mode and effects analyses (FMEA).
• Monitor patient safety indicators and implement improvement initiatives.
• Collaborate with Infection Prevention and Control teams to support patient safety goals.

Performance Measurement & Analytics

• Develop and monitor Key Performance Indicators (KPIs) and quality dashboards.
• Analyze quality metrics, patient outcomes, and trends to identify opportunities for improvement.
• Prepare periodic reports and presentations for senior management, committees, and governing bodies.
• Benchmark organizational performance against national and international standards.

Education & Training

• Conduct quality awareness programs, workshops, and staff training sessions.
• Support departments in implementing evidence-based practices and quality methodologies.
• Mentor departmental quality champions and facilitate quality committees.

Audit & Risk Management

• Plan and conduct internal quality audits and tracer activities.
• Support enterprise risk management initiatives related to clinical and operational risks.
• Ensure timely closure of quality findings and follow-up actions.

Leadership & Collaboration

• Collaborate with department heads, physicians, nursing leaders, and support services to drive quality initiatives.
• Chair or participate in quality, patient safety, and accreditation committees.
• Foster a culture of continuous improvement and accountability across the hospital.