Quality & Clinical Risk Manager
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Key skills for this role
About the Role
Beverly Hills Specialist Hospital seeks an experienced Quality & Clinical Risk Manager to lead hospital-wide quality, safety, compliance, and risk functions.
Key Skills for This Role
Responsibilities
- 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
- Act as primary liaison for regulatory bodies, ensuring timely and complete compliance
- Identify, evaluate, and mitigate clinical and operational risks through a robust Risk Management System
- Coordinate root cause analyses (RCA) for adverse events and follow up on corrective actions
- Supervise Infection Prevention and Control (IPC) program
- Oversee Environmental, Health and Safety (EHS) practices
- Audit clinical documentation and medical records for regulatory compliance
- Design and implement hospital wide training programs on quality, risk, safety, infection control, and fire safety
Requirements
- Bachelor's degree in Healthcare Administration, Nursing, Public Health, or related field; Master's preferred
- CPHQ (Certified Professional in Healthcare Quality) or equivalent certification in Quality or Risk Management
- 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
- Tagalog language preferred
- DHA license preferred
Full Job Posting
Overview
- We are seeking an experienced and dynamic Quality & Clinical Risk Manager to take full ownership of all hospital wide quality, safety, compliance, and risk related functions.
- This is a strategic leadership role that oversees everything related to hospital operations and clinical governance from quality improvement, regulatory inspections, infection control, fire and facility safety, to patient experience, documentation auditing, and staff training.
Key Responsibilities Quality 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 Quality & Patient Safety Committee, Infection Control Committee, 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.
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