Quality and Performance Improvement Manager


Job Description:

Maintain an extensive and broad understanding of all facets of JCI accreditation services in FVH.

Responsible for the guidance and completion of all JCI Quality Improvement projects and  documents in the respective area(s) in the hospital

  • Interacts with quality personnel at FVH facilities to ensure care is delivered and documented in accordance with prescribed practice, JCI standards and core measure requirements.
  • Monitoring quality indicator  assessments and the performance improvement projects  in the respective area(s) in the hospital.
  • Advises and trains clinical staff at FVH facilities on identifying and managing clinical risks, to ensure the safety, health and well being of all patients.
  • Compose technical review team(s) for review of methodology  and protocols  of the quality surveillance and reassessment reports including statistical analysis and validation of data.
  • Review all final reports in concurrence with technical review teams to determine final recommendation on JCI and DOH/MOH accreditation.
  • Conduct Internal audits of the hospital as assigned by the Director of quality, as needed
  • Coordinates clinical quality issues on behalf of FVH’s management team and makes recommendations for corrective action in collaboration with quality personnel in the facility.
  • Assists medical directorate’s in interpreting clinical issues and risks, and in collaboration with the operations division, advises on the modification and measuring of clinical quality indicators.
  • Researches trends and new approaches for clinical quality excellence, monitors group’s performance against international benchmarks, and advises operations and Clinical Excellence Committee on the implementation of new clinical quality methods.
  • Works closely with FVH’s medical division to develop and/or improve quality indicators and reliable processes for achieving compliance.
  • Other duties and responsibilities assigned from time to time



  • First Medical Degree (MBBS)
  • JCI  Accreditation Experience
  • Knowledge in  Statistical Analysis or Clinical Epidemiology


  • Minimum of 2 years recent experience in quality department of JCI accredited hospital
  • Recent experience in a medical quality
  • Knowledge or experience of JCI standards in an hospital setting
  • Training and presentation experience

Skills and knowledge:

  • Sound knowledge of JCI standards
  • Understanding of quality principles, continuous learning, patient focus, plus teamwork and partnering skills
  • Planning and organizational abilities, e.g.:
    • Highly motivated self-starter;
    • Ability to priorities workload and work flexibly;
    • Ability to meet deadlines with tight timescales.
    • Interpersonal /Communication Skills:
    • Ability to relate well both verbally and in writing with staff all levels in the organization
    • Ability to work effectively within different teams;
    • Ability to give clear oral presentations and training in both groups and individually;
    • Ability to write clear reports appropriate to requirements.
  • Demonstrated capacity for embracing change and learning new technologies.
  • Excellent organizational abilities, prioritize projects, handle a multitude of activities simultaneously, and pay thorough attention to detail.
  • Able to work on own initiative.
  • Team player and able to take leadership role if requested.
  • Ability to work independently and resolve practical problems

Foreign language(s):

  • English