Job Description

The Quality Manager is responsible for overseeing the Quality Improvement and Patient Safety Program within the hospital. This role involves interpreting, defining, implementing, coordinating, monitoring, evaluating, and reporting on quality initiatives. The Quality Manager ensures the organization's adherence to Joint Commission International Accreditation Standards, serving as the authority in this field.



• Serve as the primary contact for Department of Health Abu Dhabi's initiatives on Quality, Patient Safety, and Risk Management.
• Collaborate with hospital leaders, department managers, physicians, and staff to design and implement systems that improve patient care management, clinical outcomes, workflow efficiency, and cost-effectiveness while ensuring high patient satisfaction and alignment with strategic initiatives.
• Contribute to committees such as the Quality Improvement & Patient Safety Committee and the Higher Management Committee.
• Educate leadership and staff on regulatory issues, new guidelines, and safety/quality performance improvement activities.
• Promote a culture of safety, high reliability, patient and staff engagement, and performance excellence.
• Maintain a deep understanding of Joint Commission International (JCI) standards, measurable elements, and intents.
• Stay continuously informed about JCIA functions and standards.
• Develop and implement the NMCRH-KC Quality Improvement Plan and follow up on its activities.
• Lead hospital-wide Quality Improvement Initiatives and activities.
• Serve as a resource for all departments and established committees related to Quality Assurance.
• Promote cost-effective resource utilization related to infection control policies and procedures.
• Prioritize investigation of problem areas based on their potential adverse impact on patient care.
• Develop effective patient care review and evaluation mechanisms and ensure results are achieved.
• Implement and maintain technical guidelines and frameworks for evaluating the quality of care.
• Coordinate with Quality Facilitators for staff education, variance collection, and analysis.
• Establish a system-wide variance database for benchmarking, system improvement opportunities, length of stay, and resource management.
• Provide ongoing support for continuous quality improvement, quality assurance, and risk management for priority programs.
• Identify and plan improvements based on evaluations of patient medical records.
• Communicate study results and data to relevant committees, departments, and stakeholders.
• Share best practice models and care processes across the system to enhance patient outcomes, satisfaction, and cost-effectiveness.
• Maintain all records pertinent to the JCI process and facilitate Quality Improvement plan meetings.
• Submit quarterly quality activity reports to the QPS committee.
• Approve data for submission to DOH on JAWDA KPIs as required.
• Maintain records of policies, procedures, guidelines, and other documents, ensuring circulation of current and de-circulation of expired documents.
• Provide educational and technical assistance to committees and departments to meet Quality Assurance objectives.
• Maintain active involvement in clinical space design, construction, and hygiene.
• Perform administrative responsibilities and justify the need for training in Quality Assurance processes.
• Coordinate and monitor compliance with Joint Commission on Accreditation of Hospitals activities.
• Conduct mock surveys and perform an annual evaluation of the Quality Improvement Program.
• Develop training/orientation programs for key members to facilitate system expansion and standardization.
• Perform miscellaneous duties as requested by the hospital general manager.
• Comply with all OSH and infection control policies, standards, and procedures and cooperate with hospital management to meet those requirements.
• Work according to documented OSH procedures and instructions.
• Be familiar with emergency and evacuation procedures.
• Report OSH hazards, incidents, near misses, and assist in the preparation of risk assessments and incident reports.
• Comply with waste management procedures and policies.
• Attend applicable OSH/Infection control training programs, mock drills, and awareness programs.
• Use appropriate personal protective equipment and safety systems.
• Ensure workplaces are safe and without health, safety, or environmental risks.
• Ensure implementation of DOH, NMCRH OSHMS, and infection control policies and standards.
• Ensure adequate budget and resources for FMS/OSH/PCI management.
• Designate a Safety Facilitator responsible for coordinating OSH activities within the department.
• Regularly discuss OSH issues in departmental/management meetings.
• Ensure provision of OSH information, training, and supervision.
• Implement and monitor the effectiveness of the risk management program.
• Develop, monitor, and support the implementation of the hospital OSHMS in line with DOH, Health Sector OSHMS policies and standards.
• Report to the entity OSH Committee and other relevant committees on developing programs and policies for OSHMS, Infection Control, and Patient Safety standards.
• Conduct or participate in incident and outbreak investigations as applicable.


• Master's degree in Hospital/Healthcare Administration/Management with a bachelor's degree in a healthcare field.
• At least 5+ years of experience in healthcare quality management in a hospital setting.
• Excellent command of spoken and written English.
• Strong knowledge of healthcare clinical fundamentals, patient safety standards, and performance improvement standards.
• Proficiency in CQI tools and techniques, data analytics, and leading performance improvement teams.
• Commitment to ongoing professional development beyond minimum requirements and an understanding of management objectives with the ability to implement a systems approach.
• Proficiency in Microsoft Word and Excel.