Quality Manager

Job Summary

The Quality Manager is responsible for planning, implementing, monitoring, and continuously improving the hospital's Quality Management System (QMS) to ensure compliance with Department of Health (DOH), JCI Accreditation Standards, JAWDA requirements, and other applicable regulatory standards. The role leads quality improvement initiatives, patient safety programs, accreditation activities, performance measurement, and organizational compliance to promote excellence in patient care.

Key Responsibilities

Quality Management

• Develop, implement, and maintain the hospital's Quality Management System (QMS).
• Lead organization-wide quality improvement and patient safety initiatives.
• Establish quality policies, procedures, and clinical governance frameworks.
• Monitor compliance with regulatory authorities, accreditation standards, and hospital policies.
• Conduct quality assessments, gap analyses, and process improvement initiatives.
• Coordinate internal and external quality audits.
  
  

Accreditation & Regulatory Compliance

• Lead hospital readiness for JCI, DOH, CAP, and other accreditation programs.
• Ensure continuous compliance with accreditation standards.
• Coordinate corrective and preventive action (CAPA) plans following audits.
• Monitor implementation of quality improvement recommendations.
  
  

Performance Management

• Develop, monitor, and analyze hospital Key Performance Indicators (KPIs).
• Lead JAWDA KPI data collection, validation, certification, and reporting.
• Prepare monthly quality dashboards and trend analysis reports.
• Present quality performance reports to leadership committees and department heads.
• Recommend action plans based on quality performance outcomes.
  
  

Patient Safety

• Lead patient safety initiatives across all departments.
• Monitor incident reporting systems and root cause analyses.
• Facilitate implementation of corrective and preventive actions.
• Promote a culture of safety and continuous improvement.
  
  

Quality Audits

• Plan and conduct internal quality audits.
• Coordinate external regulatory inspections and accreditation surveys.
• Monitor audit findings and ensure timely closure of corrective actions.
  
  

Documentation & Policy Management

• Develop and review hospital-wide policies and procedures.
• Ensure document control and compliance with QMS requirements.
• Maintain quality documentation and records.
  
  

Training & Staff Development

• Conduct quality awareness and patient safety training programs.
• Educate staff on quality standards, JCI requirements, and QMS processes.
• Support competency development related to quality management.
  
  

Leadership Responsibilities

• Promote the hospital's vision, mission, and quality objectives.
• Collaborate with department heads to improve operational performance.
• Participate in strategic planning for quality and patient safety.
• Foster multidisciplinary collaboration and effective communication.
• Support staff recruitment, retention, and professional development initiatives.
  
  

Education

• Bachelor's Degree in Healthcare Administration, Hospital Administration, Nursing, Business Administration, or a related healthcare field.
• Master's Degree is preferred.
  
  

Certifications

• Certified Professional in Healthcare Quality (CPHQ) preferred.
• Certified Internal Auditor or Lead Auditor qualification is an advantage.
• JCI Accreditation training is preferred.
  
  

Experience

• Minimum 5–8 years of experience in healthcare quality management.
• At least 3–5 years in a leadership role within an accredited healthcare facility.
• Experience with DOH Abu Dhabi regulations, JCI Accreditation, and JAWDA KPIs is mandatory.
  
  

Knowledge & Skills

• Quality Management Systems (QMS)
• JCI Accreditation Standards
• DOH Regulations
• JAWDA KPI Management
• Clinical Governance
• Patient Safety Programs
• Risk Management
• Root Cause Analysis (RCA)
• Performance Improvement (PI)
• Internal & External Auditing
• Policy Development
• Data Analysis & Reporting
• Microsoft Office Suite (Advanced Excel & PowerPoint)
• Strong communication and presentation skills
• Leadership and team management
  
  

Physical Requirements

• Primarily office-based within the hospital environment.
• May require movement between departments and hospital facilities.
• Prolonged computer use and participation in audits, meetings, and inspections.
  
  

Key Performance Indicators (KPIs)

• JCI Accreditation Compliance
• DOH Regulatory Compliance
• JAWDA KPI Performance
• Audit Completion Rate
• Corrective Action Closure Rate
• Incident Reporting & RCA Completion
• Policy Review Compliance
• Staff Quality Training Completion
• Patient Safety Indicator Performance
• Departmental Quality Improvement Project Completion

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