HEAD, QUALITY

Job Description:

QUALITY MANAGEMENT, ACCREDITATION AND ORGANIZATIONAL DEVELOPMENT 

• Ensure the hospital's Quality Management System (QMS) is effectively implemented, maintained, and continuously improved in accordance with MSQH Standards, Ministry of Health (MOH) requirements, CKAPS regulations, and other applicable statutory requirements. 

• Lead and coordinate all accreditation activities, including MSQH surveys, self-assessments, mock surveys, gap analyses, and accreditation readiness programs. 

• Monitor compliance with organizational policies, procedures, standards, and quality objectives across all departments. 

• Facilitate the implementation of hospital-wide quality improvement initiatives and support departments in achieving their quality goals and performance indicators. 

• Coordinate quality-related committees, meetings, and activities to ensure effective communication and collaboration throughout the organization. 

• Prepare and present quality performance reports, dashboards, and analyses to Management Committees and relevant stakeholders. 

• Act as the focal person for quality management matters and serve as liaison with regulatory authorities, accreditation bodies, and external auditors. 

• Ensure timely submission of quality reports, indicators, surveys, and compliance documentation as required by internal and external stakeholders. 

• Monitor departmental action plans arising from audits, surveys, incidents, and quality improvement activities to ensure timely closure. 

• Promote a culture of patient safety, quality excellence, and continuous improvement throughout the organization. 

• Any other duties and responsibilities assigned by the Chief Executive Officer (CEO), Head of Services, or designated authority. 

HUMAN RESOURCE AND DEVELOPMENT 

• Take responsibility for personal and professional development by maintaining competency in quality management, patient safety, accreditation standards, and healthcare regulations. 

• Provide guidance, coaching, and support to department heads, managers, and staff on quality improvement methodologies and accreditation requirements. 

• Organize and facilitate training, awareness programs, workshops, and educational activities related to quality, patient safety, risk management, and accreditation standards. 

• Promote staff engagement and participation in quality improvement projects, patient safety initiatives, and organizational excellence programs. 

• Support the development of a learning culture through evidence-based practices and continuous professional development. 

• Foster effective teamwork, communication, and collaboration across multidisciplinary departments. 

FACILITIES, DOCUMENT CONTROL AND RESOURCE MANAGEMENT 

• Oversee the hospital document control system and ensure policies, procedures, guidelines, and forms are reviewed, approved, updated, and distributed according to established requirements. 

• Monitor the availability and accessibility of quality-related documents, records, and evidence required for accreditation and regulatory compliance. 

• Ensure proper maintenance and retention of quality records, audit reports, risk registers, incident reports, and accreditation documentation. 

• Coordinate resource requirements related to quality improvement programs, accreditation activities, and patient safety initiatives. 

• Ensure quality management systems and databases are maintained accurately and effectively. 

SAFETY, RISK MANAGEMENT AND QUALITY IMPROVEMENT ACTIVITIES 

• Lead and coordinate hospital-wide quality improvement, patient safety, risk management, infection prevention and control, and clinical governance activities. 

• Monitor and analyze quality indicators, patient safety indicators, adverse events, near misses, sentinel events, and organizational performance trends. 

• Facilitate Root Cause Analysis (RCA), Failure Mode and Effects Analysis (FMEA), and other quality and risk assessment methodologies as required. 

• Maintain and monitor the organizational risk register and ensure appropriate mitigation plans are implemented and reviewed. 

• Coordinate internal audits, quality audits, compliance reviews, and accreditation assessments to ensure continuous readiness. 

• Collaborate with department heads and stakeholders to implement corrective and preventive actions arising from audits, incidents, complaints, and accreditation findings. 

• Participate in and support hospital-wide surveys, including MSQH, JCI, IMS, CKAPS, and other accreditation or regulatory assessments. 

• Ensure compliance with the Occupational Safety and Health Act 1994, patient safety goals, infection prevention and control standards, risk management requirements, and organizational safety policies. 

• Promote patient-centered care, patient rights, family involvement, and service excellence initiatives throughout the hospital. 

• Monitor and evaluate the effectiveness of quality improvement initiatives and recommend opportunities for further enhancement. 

Requirements:

Education: 

• Bachelor’s degree in healthcare management, Nursing, Allied Health Sciences, Public Health,    

• Quality Management, Hospital Administration, or other related disciplines from a recognized institution. 

 Knowledge and Experiences: 

• Minimum five (5) years of working experience in healthcare quality management, accreditation, clinical governance, patient safety, or risk management within a hospital environment. 

• Exceptional communication and interpersonal skills, with the ability to collaborate effectively across functions. 

• Ability to work collaboratively in a team and interface with various levels of the organization. 

• Experience in coordinating and leading MSQH accreditation surveys and hospital-wide quality improvement initiatives. 

• Experience in healthcare compliance, audit management, policy development, and performance monitoring. 

• Exposure to private healthcare operations and regulatory requirements will be an added advantage. 

• Experience with international accreditation standards such as JCI, ACHSI, or equivalent will be an added advantage. 

Skills & Competencies: 

Special skills required 

• Strong leadership and people management skills. 

• Excellent communication, presentation, and interpersonal skills. 

• Strong analytical, problem-solving, and decision-making abilities. 

• Ability to influence and collaborate effectively across all levels of the organization. 

• Strong project management and organizational skills. 

• Ability to manage multiple priorities and work under pressure to meet deadlines. 

• Proficient in Microsoft Office applications, data analysis tools, and presentation software. 

• Strong report writing, policy development, and documentation management skills. 

• Demonstrated ability to lead change management and continuous improvement initiatives. 

• High level of integrity, professionalism, and attention to detail. 

Personal attributes  

• Patient-focused and quality-driven mindset. 

• Strong commitment to continuous improvement and organizational excellence. 

• Proactive, self-motivated, and result oriented. 

• Ability to work independently and as part of a multidisciplinary team. 

• Demonstrates professionalism, accountability, and ethical conduct at all times. 

• Possesses strong stakeholder engagement and relationship management capabilities.