Associate Director Quality

Company Description

Shifa International Hospitals Limited, located in Islamabad, is a 550-bed quaternary care medical facility offering a wide range of diagnostic, outpatient, and inpatient services across more than 35 medical and surgical specialties. Known for its expert team of U.S. and European-trained physicians and surgeons, Shifa is committed to delivering world-class healthcare. The hospital prioritizes compassion and quality, fostering an environment that supports exceptional medical practices and patient care.

Role Description

This is a full-time, on-site role for a Senior Manager Quality based in Islamabad. The Senior Manager Quality will oversee the quality assurance and control processes across various departments within the hospital. Key responsibilities include developing, implementing and monitoring quality management systems, ensuring compliance with national and international healthcare standards, conducting regular audits, and driving continuous improvement initiatives to enhance patient care and safety.

Responsibilities

• Implement and oversee the hospital-wide Quality Improvement and Patient Safety Program in alignment with organizational objectives.
• Work closely with the Chief Quality Officer to ensure effective planning, execution and monitoring of quality and patient safety initiatives.
• Lead and direct the activities of the Quality team, ensuring achievement of departmental goals and compliance requirements.
• Establish, implement and continuously improve a corporate-wide Quality Management System (QMS) aligned with patient safety objectives, regulatory requirements, and accreditation standards (ISO/JCIA or equivalent).
• Develop and update the organization’s Quality Improvement Plan and oversee processes related to incident reporting, quality compliance, staff training, quality improvement.
• Review non-conformances, corrective actions, and incident reports to identify trends and implement preventive strategies.
• Coordinate for effective root cause analysis (RCA) for sentinel events and adverse events, ensuring timely corrective and preventive actions.
• Develop, monitor and report departmental Quality Indicators and KPIs to senior management.
• Plan, coordinate and conduct internal and external quality audits, including accreditation and certification surveys (e.g., JCIA/ISO).
• Review audit findings and formulate strategic recommendations to improve clinical and operational quality of care.
• Develop evaluation tools to generate quantitative and qualitative data validating compliance with accreditation and regulatory standards.
• Ensure clinical and operational processes comply with applicable guidelines, regulations and quality system requirements.
• Promote integration of quality initiatives across all hospital departments through collaboration, education and stakeholder engagement.
• Establish a hospital-wide training program for all staff on matters related to quality improvement and patient safety.

Qualifications

• MBBS / BDS / Pharm D / MScN/ MSc Health Care Management / MBA / BSN or any other relevant degree
• At least 10 years of relevant experience
• Strong knowledge of quality management systems, quality assurance and quality control methodologies
• Proven experience in audits, compliance and process improvement initiatives
• Proficiency in analyzing data metrics and implementing data-driven decision-making processes
• Excellent leadership, teamwork and communication skills to foster collaboration across interdisciplinary teams
• Detailed knowledge of national and international healthcare standards (JCI) and regulations