Quality & Clinical Risk Manager

Overview

Key Responsibilitiesquality Leadership And Strategic Oversight

• Lead the hospital’s Quality, Safety, Risk, and Compliance functions with a strategic, organization-wide perspective.
• Set the strategic direction for all quality improvement and patient safety initiatives.
• Develop, implement, and manage a hospital-wide Quality Plan.
• Maintain continuous readiness for **JCI accreditation**, **DHA inspections**, and other regulatory body evaluations.
• Represent the hospital in all external audits, accreditations, and quality forums.

Clinical Governance & Risk Management

• Act as the primary liaison for regulatory bodies, ensuring timely and complete compliance with laws, licensing, and accreditation standards.
• Identify, evaluate, and mitigate clinical and operational risks through a robust hospital-wide Risk Management System.
• Coordinate root cause analyses (RCA) for adverse events and follow up on the implementation of corrective actions.

Regulatory & Accreditation Compliance

• Ensure compliance with **DHA, JCI, MOH**, and other relevant health authorities.
• Develop regulatory reports, manage all audit responses, and monitor legislative updates.
• Ensure that policies and procedures are consistently updated and align with evolving standards.

Infection Control & Environmental Safety

• Supervise the Infection Prevention and Control (IPC) program, including surveillance, policy implementation, training, and outbreak response.
• Oversee Environmental, Health and Safety (EHS) practices and protocols across all departments.
• Conduct routine hospital-wide safety inspections, fire drills, and emergency preparedness programs.

Medical Records And Documentation

• Audit clinical documentation and medical records to ensure regulatory compliance and internal standards.
• Provide training and feedback to clinical staff on proper documentation practices.
• Ensure privacy, accuracy, and completeness in all patient-related records.

Facility Management Collaboration

• Work closely with Facilities and Engineering teams to ensure safety, maintenance, and functionality of the hospital infrastructure.
• Monitor equipment readiness, maintenance schedules, and facility preparedness for inspections.

Patient Experience & Service Quality

• Lead initiatives aimed at enhancing patient satisfaction, service quality, and operational efficiency.
• Track and respond to patient complaints, safety reports, and incident variances.
• Analyze patient feedback and implement continuous improvement plans.

Training & Capacity Building

• Design and implement hospital-wide training programs on quality, risk, safety, infection control, and fire safety.
• Conduct orientations and ongoing workshops to promote a culture of continuous improvement and compliance.
• Support clinical and non-clinical teams with capacity building in accreditation and audit readiness.

Committees And Multidisciplinary Coordination

• Lead or actively participate in hospital-wide committees including:

• Mortality & Morbidity Review Committee

• Fire and Safety Committee
• Facility and Biomedical Equipment Committee
• Coordinate between departments to unify practices, align objectives, and embed a hospital-wide culture of quality and safety.

Required Qualifications

• **Education:** Bachelor's degree in Healthcare Administration, Nursing, Public Health, or related field; Master's preferred.
• **Certifications:** CPHQ (Certified Professional in Healthcare Quality) or equivalent certification in Quality or Risk Management.
• **Experience:** Minimum 5–7 years in a leadership role in hospital quality, risk, and compliance.
• Proven experience with **JCI and DHA accreditation** processes.
• Strong knowledge of healthcare laws, regulatory standards, and operational policies.
• Excellent communication, leadership, and problem-solving skills.

Job Types: Full-time, Contract

Education

• Bachelor's (Preferred)

Experience

• hospital: 1 year (Preferred)
• JCI : 2 years (Preferred)
• Quality & Clinical Risk Manager: 5 years (Preferred)

Language

• tagalog (Preferred)

License And Certification

• DHA (Preferred)
• CPHQ (Certified Professional in Healthcare Quality) (Preferred)