Quality, Risk & Continuous Improvement Manager

Overview of the Role

The Quality, Risk & Continuous Improvement Manager is responsible for leading the organisation's quality, patient safety, risk management, and continuous improvement agenda. The postholder will ensure compliance with relevant national and international standards, drive quality improvement initiatives, support accreditation processes, and strengthen risk management practices across the hospital.

Key Duties and Responsibilities

Quality Management

• Collaborate with the General Manager, Director of Nursing, Chief Quality and Compliance Officer, Medical Director, and senior leadership team to develop and implement the hospital’s quality improvement strategy and programme.

• Develop, implement, and maintain the Quality Management System (QMS).

• Ensure compliance with relevant healthcare standards and regulatory requirements, including HIQA, JCI, ISO, CHKS, JAG, and HSA standards.

• Lead quality audits, coordinate corrective action plans, and monitor improvement outcomes.

• Analyse quality performance data, develop dashboards, and present reports to senior management.

• Support clinical and non-clinical teams in the development, review, and implementation of policies and procedures.

Risk Management

• Oversee the hospital’s Risk Management Framework, including risk identification, assessment, mitigation, and monitoring.

• Lead incident management processes, including investigations, root cause analyses (RCA), and implementation of corrective actions.

• Foster a culture of open disclosure and support staff involved in incidents and adverse events.

• Ensure statutory reporting requirements for incidents and risks are met.

Patient Safety

• Lead and enhance patient safety initiatives, including falls prevention, medication safety, infection prevention and control, and other safety programmes.

• Monitor patient safety indicators and clinical outcomes, identifying trends and implementing improvement strategies.

• Facilitate multidisciplinary patient safety committees and working groups.

• Support compliance with safeguarding requirements, patient rights standards, and safe-care practices.

Continuous Improvement

• Lead continuous improvement initiatives using methodologies such as Lean, Six Sigma, PDSA cycles, and process mapping.

• Train, mentor, and support staff in the use of quality improvement tools and techniques.

• Facilitate cross-functional improvement projects and evaluate their effectiveness.

• Develop and monitor key performance indicators (KPIs) to measure and sustain improvements.

Accreditation and Compliance

• Lead preparation activities for internal and external inspections, reviews, and accreditation assessments.

• Ensure policies, procedures, and documentation comply with required standards.

• Act as a key liaison with regulatory and accreditation bodies.

• Support service development and organisational change initiatives.

Data, Reporting and Governance

• Prepare and present regular reports on quality, risk, and patient safety performance to the General Manager, Director of Nursing, and governance committees.

• Maintain accurate records and ensure timely submission of compliance and regulatory reports.

• Support clinical audit programmes and monitor implementation of audit action plans.

• Contribute to governance structures and promote evidence-based decision-making.

Education and Staff Engagement

• Deliver training programmes on risk management, incident reporting, quality improvement methodologies, and patient safety.

• Promote a culture of safety, accountability, continuous learning, and improvement.

• Engage and motivate teams through effective communication, feedback, and recognition of achievements.

Professional Development

• Contribute to service development through continuous professional education, research activities, and awareness of emerging developments in healthcare quality, governance, and leadership.

• Support staff undertaking continuous professional development within their areas of responsibility.

• Participate in the development and delivery of induction, education, training, and development programmes for clinical and non-clinical staff.

• Contribute to orientation programmes, performance appraisals, and staff development initiatives.

• Provide professional support, supervision, coaching, and development opportunities for relevant staff members.

• Participate in performance review processes, including objective setting, personal development planning, and constructive feedback.

Qualifications and Experience

Essential Qualifications

• Bachelor's degree in Nursing, Healthcare Management, Quality Management, or a related discipline.

• Master's degree in a relevant field is desirable.

• Formal training in Lean, Six Sigma, or Quality Improvement methodologies (Green Belt or Black Belt certification desirable).

Essential Experience

• Significant experience in healthcare quality, patient safety, and/or risk management.

• Minimum of five years’ experience in healthcare administration or a related leadership role.

• Demonstrated experience supporting or leading hospital accreditation processes, including CHKS or JCI accreditation.

• Strong knowledge of healthcare quality standards, governance frameworks, and regulatory requirements.

• Proven experience in quality improvement methodologies and their application in healthcare settings.

• Experience implementing standardised processes and quality assurance systems.

• Excellent IT skills, including Microsoft Office applications (Word, Excel, PowerPoint, Outlook, and Microsoft Teams).

Core Competencies

• Leadership and people management

• Quality-focused decision-making

• Strategic thinking and planning

• Project and programme management

• Stakeholder engagement and influencing skills

• Problem-solving and root cause analysis

• Data analysis and report writing

• Continuous improvement mindset

• Excellent communication and interpersonal skills

• Strong organisational and prioritisation abilities