Quality Manager

Job Purpose

The Quality Manager will direct and coordinate the hospital’s quality management efforts, ensuring alignment with CBAHI, JCI, Ministry of Health, and other relevant regulatory and accreditation expectations. This position focuses on continuous improvement, patient safety, KPI tracking, and supporting the delivery of patient-centered, high-standard care.

Quality Management

• Create, roll out, and track the hospital-wide quality management program so it supports organizational goals.
• Build and maintain the policies, procedures, standards, and structures used for quality improvement.
• Guide continuous quality improvement work across both clinical and non-clinical areas.
• Review departmental adherence to defined quality standards and good practices.

Accreditation and Regulatory Compliance

• Maintain compliance with CBAHI, JCI, Ministry of Health, and other applicable regulatory requirements.
• Organize preparation for accreditation, including mock surveys and gap analysis activities.
• Help ensure the hospital is ready for accreditation surveys and official inspections.
• Track the completion of corrective and preventive actions resulting from audit observations.

Patient Safety

• Encourage and strengthen a hospital-wide culture focused on patient safety.
• Manage incident reporting processes, root cause analysis (RCA), and failure mode and effects analysis (FMEA).
• Follow patient safety indicators and drive improvement actions where needed.
• Work closely with Infection Prevention and Control teams to advance patient safety targets.

Performance Measurement and Analytics

• Design and monitor KPIs and quality dashboards for the organization.
• Study quality data, patient outcomes, and trend patterns to pinpoint improvement opportunities.
• Prepare recurring reports and presentations for leadership, committees, and governing stakeholders.
• Compare hospital performance with national and international benchmarks.

Education and Training

• Deliver quality awareness sessions, workshops, and employee training programs.
• Assist departments in applying evidence-based practices and quality tools.
• Coach departmental quality champions and support the work of quality committees.

Audit and Risk Management

• Plan and carry out internal quality audits and tracer reviews.
• Support enterprise risk management efforts tied to clinical and operational risks.
• Ensure quality issues are closed on time and follow-up actions are completed.

Leadership and Collaboration

• Partner with department heads, physicians, nursing leaders, and support functions to move quality initiatives forward.
• Lead or contribute to quality, patient safety, and accreditation committee meetings.
• Help build a hospital culture centered on continuous improvement and accountability.