Assistant manager

• Coordinate implementation and ongoing compliance with applicable JCI accreditation standards.
• Maintain continuous accreditation readiness across clinical, administrative and support departments.
• Interpret accreditation requirements and translate them into hospital policies, SOPs, protocols and monitoring mechanisms.
• Coordinate internal assessments, mock surveys and preparation for external JCI surveys.
• Maintain evidence and documentation required for accreditation compliance.
• Monitor compliance gaps and coordinate timely corrective actions.

2. International Patient Safety Goals (IPSG)

Monitor and strengthen compliance with key patient safety requirements, including:

• Correct patient identification
• Effective communication among healthcare professionals
• Medication safety
• Correct-site, correct-procedure and correct-patient surgery
• Reduction of healthcare-associated infections
• Prevention of patient harm, including falls and other identified risks

3. Clinical & Quality Audits

• Develop annual and monthly quality audit plans.
• Conduct clinical, nursing, medication, infection prevention, documentation and operational audits.
• Conduct tracer methodology-based assessments to evaluate actual implementation of standards.
• Identify non-conformities, process gaps and risks.
• Prepare audit reports and monitor corrective and preventive action plans.
• Validate effectiveness of actions taken by departments.

4. Patient Safety & Risk Management

• Establish and monitor systems for reporting patient safety incidents, near misses and adverse events.
• Facilitate Root Cause Analysis (RCA) for significant incidents.
• Support Failure Mode and Effects Analysis (FMEA) or other proactive risk assessment methodologies where applicable.
• Maintain incident and risk registers.
• Identify recurring risks and coordinate preventive interventions.
• Monitor closure and effectiveness of patient safety action plans.

5. Quality Indicators & Data Analytics

• Define and monitor clinical and operational quality indicators.
• Ensure accurate and timely collection of quality data from departments.
• Analyze trends, variations and performance gaps.
• Prepare monthly/quarterly quality dashboards and management reports.
• Present significant quality and patient safety trends to relevant committees and leadership.
• Recommend data-driven improvement initiatives.

6. Continuous Quality Improvement

• Facilitate hospital-wide Quality Improvement (QI) projects.
• Identify opportunities to improve clinical outcomes, patient safety, operational efficiency and patient experience.
• Monitor improvement projects against defined objectives and timelines.
• Ensure successful improvements are standardized and sustained.