Compliance Officer

The Compliance Officer coordinates accreditation readiness, monitors compliance indicators, supports risk management initiatives, conducts audits, facilitates staff education, and promotes continuous quality improvement across the organization.

1. JCI Accreditation Management

• Monitor compliance with Joint Commission International (JCI) standards including IPSG, QPS, PCI, HRP, and FMS.
• Conduct regular reviews of departmental compliance status.
• Perform gap analyses against JCI standards and organizational requirements.
• Develop, implement, and monitor corrective action plans.
• Coordinate pre-survey preparations, mock surveys, document reviews, and accreditation simulations.
• Support departments in maintaining continuous accreditation readiness.

1. Quality Improvement (QI)

• Monitor and validate Key Performance Indicators (KPIs).
• Coordinate quality improvement meetings and follow-ups with departments.
• Facilitate Root Cause Analysis (RCA) for incidents and quality concerns.
• Conduct Failure Mode and Effects Analysis (FMEA) activities as needed.
• Consolidate, analyze, and present KPI and quality performance reports.
• Support implementation of quality improvement initiatives and performance monitoring.

1. Regulatory Compliance

• Monitor regulatory submission deadlines and compliance requirements.
• Liaise with regulatory agencies such as DOH, FDA, and PhilHealth.
• Conduct compliance status reviews and ensure timely corrective actions.
• Prepare and submit regulatory documentation and reports.
• Coordinate renewal of organizational licenses and permits.
• Ensure adherence to national healthcare regulations and standards.

1. Audit and Monitoring

• Conduct routine compliance spot checks and monitoring activities.
• Plan and facilitate internal audits across departments.
• Organize mock surveys and accreditation simulations.
• Manage full audit cycles including documentation, findings, and follow-through.
• Monitor implementation of Corrective and Preventive Action (CAPA) plans.
• Maintain audit records and compliance documentation.

1. Training and Education

• Conduct compliance, accreditation, and quality-related training programs.
• Facilitate orientation programs for newly hired staff related to compliance and patient safety.
• Coordinate competency validation activities.
• Assist in annual mandatory training planning and monitoring.
• Promote awareness of organizational policies, procedures, and regulatory standards.

1. Risk Management and Patient Safety

• Monitor incident reports and patient safety events.
• Participate in incident reviews, investigations, and escalation processes.
• Conduct sentinel event investigations and support corrective actions.
• Analyze incident trends and recommend preventive strategies.
• Monitor compliance with International Patient Safety Goals (IPSG).
• Collaborate with departments to strengthen patient safety culture.

1. Documentation and Reporting

• Maintain and update compliance-related policies and documents.
• Coordinate document control activities with departments.
• Prepare committee reports, compliance dashboards, and management presentations.
• Facilitate document review and revision cycles.
• Prepare accreditation-related documentation and evidence files.
• Ensure proper maintenance and confidentiality of records.

• Bachelor’s degree in Nursing, Healthcare Administration, Public Health, Pharmacy, Medical Technology, or related healthcare field.
• At least 3–5 years of experience in healthcare compliance, quality management, accreditation, or regulatory affairs.