Quality Risk Manager Hospital

Quality, Risk & Continuous Improvement Manager

Overview of role: 

The Quality, Risk & Continuous Improvement Manager is responsible for leading the hospital’s quality, patient safety, risk management, and continuous improvement agenda. The role ensures compliance with national standards, drives quality improvement initiatives, supports accreditation processes, and strengthens risk mitigation strategies across the organisation.

Benefits – Fully paid maternity and paternity leave for new parents. Competitive Pension Plan, company funded Death in Service Benefit x 3 times. Critical Illness cover for all employees up to the age of 66.

Performance and Recognition – Rewards for performance that supports the goals and mission of UPMC through our annual ACES programme.

Work-Life Balance – Enhanced annual leave up to a maximum of 27 days. Flexible working opportunities to support you to work around external family commitments.

Development and Career Opportunities – Opportunities for each employee to reach their career goals through continued learning and/or advancement.

Primary Duties and Responsibilities: 

General

Quality Management

• Works in collaboration with the General manager, Director of Nursing , Chief Quality and Compliance Officer , Medical Director and hospital leadership in the development of the hospital quality improvement programme and strategy.
• Develop, implement, and monitor the hospital’s Quality Management System (QMS).
• Ensure compliance with national healthcare standards (e.g. HIQA, JCI, ISO, CHKS,JAG,HSA)
• Lead quality audits, coordinate action plans, and monitor improvement outcomes.
• Analyse quality data, produce dashboards, and present reports to senior leadership.
• Support clinical and non‑clinical teams in developing and reviewing policies and procedures.

 Risk Management

• Oversee the hospital’s Risk Management Framework, including risk identification, assessment, mitigation, and monitoring.
• Maintain the organisational risk register and ensure regular review with senior management.
• Lead incident management processes, including investigation, root cause analysis (RCA), and implementation of learning.
• Promote a culture of open disclosure and support staff involved in incidents.
• Ensure statutory reporting of incidents and risks where required.

Patient Safety

• Implement and enhance patient safety initiatives (falls reduction, medication safety, infection prevention, etc.).
• Monitor safety indicators and clinical outcomes; identify trends and support improvement strategies.
• Facilitate multidisciplinary patient safety committees.
• Support compliance with safeguarding, patient rights, and safe‑care standards.

Continuous Improvement / Lean Management

• Lead continuous improvement activities using methodologies such as Lean, Six Sigma, PDSA cycles, and process mapping.
• Train and coach staff on quality improvement tools and techniques.
• Facilitate cross‑departmental improvement projects and evaluate their effectiveness.
• Develop and track KPIs to measure progress and ensure sustained improvement.

Accreditation & Compliance

•  Lead on the preparation for internal and external inspections or accreditation surveys.
• Ensure documentation, policies, and processes meet required standards.
• Liaise with regulators and accreditation bodies.
• Support service development and change management programmes.

Data, Reporting & Governance

• Provide regular quality, risk, and patient safety reports to General Manager and Director of Nursing.
• Maintain accurate records and ensure timely submission of compliance reports.
• Support clinical audit programmes and oversee audit action plans.
• Contribute to governance meetings and promote evidence‑based decision‑making.

Education & Staff Engagement

• Deliver training on risk management, incident reporting, quality tools, and improvement methodologies.
• Promote a culture of safety, accountability, and continuous learning.
• Engage teams through communication, feedback, and recognition of improvement efforts.

Health and Safety

• Work collaboratively with other members of the team to ensure that patient care is central to all activities in the hospital.
• Participate in service delivery as part of a professional, punctual and dedicated team.
• Create, promote and maintain open communications and healthy working relationships.
• Ensure best pharmaceutical practice, having regard to legal and ethical requirements for the provision of the pharmacy service.
• Maintain the principles of equity, accountability, quality and safety in daily work.
• Work collaboratively with other staff to deliver and develop clinical pharmacy services to achieve stated goals and objectives, respecting the role of other pharmacists in ensuring safe and effective care.
• Manage and develop self and others in a busy working environment.
• Have the skills necessary to evaluate information, make effective decisions and problem-solve.
• Have the ability to manage time, deadlines and prioritise the workload.
• Assist in managing the efficient running of the dispensary. Participate in/ supervise the operation of the dispensary, and the procurement, storage and supply of pharmaceuticals and other related items.

Qualifications & Experience:

Eligible Criteria:

Qualifications

• Bachelor’s degree in Nursing, Healthcare Management, Quality, or related field (Master’s desirable).
• Training in Lean, Six Sigma, or quality improvement (Green/Black Belt advantageous).

Experience

• Experience in healthcare quality, patient safety, or risk management.
• Have at least 5 years’ experience in healthcare administration.
• Experience with hospital accreditation essential – CHKS or JCI.
• Knowledge of healthcare standards and regulatory requirements.
• Demonstrate a high level of knowledge of developments within the healthcare quality.
• Demonstrate a knowledge of applying standards to practice, quality improvement process and quality and safety frameworks.
• Experience in the application of knowledge on standardisation to practice / process.
• Excellent IT skills: MS Office skills to include, MS Teams, Word, Excel and PowerPoint, knowledge and experience of using an email system effectively e.g., Outlook.

For more information contact me at sonia.tzaferi@cplhealthcare.com