Job Description Card

Job Title:

Quality Manager

Reports To:

Chief Medical Officer/Chief Quality Officer

Objective(s):

To lead and oversee the hospital's quality improvement initiatives, ensure compliance with regulatory requirements, and promote a culture of patient safety and zero harm vision. This position works closely with hospital leadership, medical staff, and various departments to develop and implement quality improvement strategies and programs.

Responsibilities:

· Develop, implement, and monitor quality improvement initiatives aligned with the hospital's strategic goals and objectives. Provide leadership and guidance to the quality improvement team and engage stakeholders across the organization in the development and implementation of quality initiatives.

· Set measurable goals and objectives for quality improvement initiatives and develop a roadmap for achieving these goals, including timelines, resource requirements, and key milestones.

· Oversee the hospital's compliance with local (Jordanian) regulators, as well as accreditation standards (e.g., Joint Commission International).

· Collaborate with medical staff, nursing leadership, and other departments to identify areas for improvement and develop action plans to address quality and safety concerns.

· Analyze and report on quality metrics, including patient outcomes, patient satisfaction, and process measures, to identify trends and opportunities for improvement.

· Lead root cause analysis investigations and implement corrective actions for adverse events and near misses.

· Facilitate the development and implementation of evidence-based clinical practice guidelines and protocols.

· Oversee the hospital's patient safety program, including incident reporting, risk assessment, and proactive risk reduction strategies.

· Provide education and training to staff on quality improvement methodologies, patient safety, and regulatory requirements.

· Chair or participate in various quality-related committees, such as the Quality Improvement Committee, Patient Safety Committee, and Infection Control Committee.

· Serve as a liaison between the hospital and external regulatory agencies, accrediting bodies, and community stakeholders.

· Engage stakeholders, including physicians, nurses, and other healthcare providers, in the development and implementation of quality initiatives. Foster a culture of collaboration and continuous improvement.

· Promote transparency and accountability for quality performance at all levels of the organization.

· Recognize and reward individuals and teams for their contributions to quality improvement.

· Partner with academic institutions and research organizations to stay up to date on the latest evidence-based practices and innovative quality improvement programs.

· Collaborate with other hospitals and community organizations to share best practices and resources.

· Engage with patient advocacy groups and community leaders to understand their perspectives and incorporate their feedback into quality improvement initiatives.

· Demonstrate knowledge of Governance, Risk, and Compliance (GRC) activities across the organization.

· Oversee documentation control, ensuring alignment with organizational policies and external regulatory requirements.

· Develop and monitor Key Performance Indicators (KPIs) for non-clinical departments to track performance and efficiency.

· Manage risk assessments for non-medical operations (e.g., vendor compliance, facility services, and administrative processes).

· Coordinate accreditation readiness activities for support services to maintain continuous compliance.

Qualifications & Skills requirements:

Master's degree in healthcare administration, public health, nursing, or a related field.
A Registered Nurse is a must.
Minimum of 10+ years of experience in healthcare quality improvement, patient safety, or a related field, with at least 3 years in a leadership role.
Certification in healthcare quality (e.g., CPHQ) or patient safety (e.g., CPPS) preferred.
Strong knowledge of healthcare quality improvement methodologies, patient safety principles, and regulatory requirements.
Excellent leadership, communication, and interpersonal skills, with the ability to collaborate effectively with diverse stakeholders.
Strong analytical and problem-solving skills, with the ability to interpret complex data and develop actionable insights.
MAGNET experience is a plus.
Proficient in using data analytics tools and software (e.g., Excel, Tableau).
Preferably possesses Project Management Office (PMO) experience, including the use of PMO tools and methodologies to support organizational projects and initiatives.
Demonstrated project management skills, with the ability to lead multiple initiatives simultaneously.
Ability to serve as a trusted advisor and build strong relationships with all levels of an organization.

Competencies:

Knowledge of Quality Standards: Understanding of healthcare quality standards and regulations (e.g., HCAC standards, Joint Commission standards).
Quality Improvement Methodologies: Proficiency in quality improvement methodologies such as Lean, Six Sigma, or PDCA (Plan-Do-Check-Act).
Data Analysis Skills: Ability to analyze healthcare data, including patient outcomes, process metrics, and quality indicators.
Risk Management: Knowledge of risk management principles and practices within a healthcare setting.
Clinical Knowledge: Familiarity with clinical processes and terminology to effectively assess and improve the quality of care.
Interpersonal and Communication Skills: Strong communication skills to collaborate with healthcare professionals at all levels and effectively communicate quality initiatives and findings.
Project Management: Experience in managing projects related to quality improvement, including planning, implementation, and evaluation.
Problem-Solving Skills: Ability to identify quality-related problems, conduct root cause analysis, and develop and implement effective solutions.
Team Leadership: Experience leading multidisciplinary teams in quality improvement initiatives, fostering a culture of continuous improvement.
Audit and Compliance: Conducting audits to assess compliance with quality standards and regulatory requirements.
Training and Education: Providing training to staff on quality improvement methodologies and initiatives.
Ethical Standards: Upholding ethical standards and promoting patient safety and quality of care.
IT Skills: Proficiency in using healthcare information systems, quality management software, and contemporary AI empowered approaches.

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Quality Manager

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