Quality Improvement & Risk Manager

CEBU VELEZ GENERAL HOSPITAL

Is currently looking for:

QUALITY IMPROVEMENT & RISK MANAGER

Division: Hospital Operations

Reports To:

• Operational Reporting: Chief Operating Officer (COO), Healthway Cebu-Velez General Hospital
• Functional Reporting: Corporate Head for Quality and Care Excellence Advancement (QCEA), Healthway Corporate Office

 I.  POSITION SUMMARY

The Quality Improvement and Risk Manager is responsible for planning, implementing, monitoring, and continuously improving the hospital’s quality management, patient safety, clinical risk management, and regulatory compliance programs. The role ensures that the hospital maintains high standards of patient care, operational excellence, accreditation readiness, and adherence to national healthcare regulations and international best practices.

This position works collaboratively with medical staff, nursing services, allied health professionals, department heads, and administrative teams to foster a culture of safety, accountability, quality improvement, and evidence-based healthcare delivery.

1. Quality Improvement Management

• Develop, implement, and maintain hospital-wide Quality Improvement (QI) programs and initiatives.
• Establish measurable quality indicators and key performance metrics across clinical and non-clinical departments.
• Monitor departmental compliance with quality standards, policies, and procedures.
• Lead continuous quality improvement projects using methodologies such as:
• PDCA/PDSA
• Root Cause Analysis (RCA)
• Lean Healthcare
• Six Sigma principles
• Clinical audit processes
• Analyze quality data, trends, incident reports, and patient outcomes to identify opportunities for improvement.
• Prepare and present quality performance reports to hospital leadership and committees.
• Coordinate quality assurance reviews and internal audits and support departments in developing corrective and preventive action plans.
• Conduct orientation and training programs related to Quality Improvement, Patient Safety, Risk Management, Incident Reporting, Regulatory Compliance, and other relevant learnings needed for hospital-wide Quality Improvement and Risk Management.
• Provide coaching and support to departments on quality improvement initiatives and facilitate workshops, meetings, and committee discussions related to healthcare quality and safety.

1. Risk Management and Patient Safety

• Develop and oversee the hospital’s Risk Management and Patient Safety Program.
• Identify, assess, mitigate, and monitor operational, clinical, legal, financial, and reputational risks.
• Facilitate investigation of adverse events, sentinel events, near misses, and patient complaints.
• Facilitate Root Cause Analysis investigations and ensure timely implementation of corrective actions.
• Maintain incident reporting systems and risk registers.
• Coordinate patient safety initiatives and campaigns throughout the hospital.
• Promote a culture of transparency, safety, and non-punitive incident reporting.
• Collaborate with department heads to reduce clinical and operational risks.

1. Regulatory Compliance and Accreditation

• Ensure the hospital’s compliance with Department of Health (DOH) regulations and all other applicable standards.
• Lead hospital preparation for accreditation and certification programs.
• Coordinate external audits, inspections, and accreditation visits.
• Ensure policies and procedures are updated and aligned with current standards.

1. Policy Development and Documentation

• Develop, review, revise, and standardize hospital policies, procedures, protocols, and guidelines.
• Ensure document control and proper dissemination of updated policies.
• Maintain quality management documentation and records.
• Assist departments in developing manuals and SOPs.

1. Data Management and Reporting

• Collect, validate, analyze, and interpret quality and risk-related data.
• Develop dashboards and reports for executive leadership and committees.
• Monitor key performance indicators and utilize healthcare information systems for reporting and analytics.

1. Stakeholder Engagement & Collaboration

• Collaborate with Nursing, Medical Staff, IPC, HR, and Operations.
• Provide advisory support to department heads on quality and patient experience matters.
• Facilitate cross-functional alignment for quality and safety priorities.

1. Strategic & Operational Support

• Advise the COO on quality risks, system gaps, and improvement opportunities.
• Provide data-driven recommendations for operational decisions.
• Support hospital strategic initiatives impacting care delivery.
• Perform additional duties and special assignments as directed by the COO.

III. QUALIFICATIONS

Education:

• Bachelor’s degree in Nursing, Allied Health, Healthcare Administration, or related field Master’s degree preferred

Experience:

• At least 5–7 years of experience in healthcare quality, nursing, or hospital operations.
• Experience in healthcare accreditation programs - preferred

Core Competencies:

• Enterprise alignment and systems thinking
• Knowledge in Quality Improvement methodologies (PDSA, RCA, Lean principles)
• Data analytics and performance management
• Leadership and stakeholder engagement
• Communication and governance reporting
• Patient-centered care and service excellence