TQM SUPERVISOR

I.      Job SummaryThe Total Quality Management (TQM) Supervisor is responsible for planning, implementing, maintaining, and continually improving the hospital's Quality Management System (QMS). The position ensures compliance with ISO 9001:2015, Department of Health (DOH) regulations, hospital accreditation standards, and other applicable statutory and regulatory requirements. The TQM Supervisor oversees document control, internal quality audits, performance monitoring, corrective actions, quality improvement initiatives, and quality-related training to promote a culture of continuous improvement and patient safety.

II.     Duties and Responsibilities

1.        Quality Management System

·      Implement, maintain, and continually improve the hospital's Quality Management System (QMS).

·      Monitor compliance with ISO 9001:2015 requirements and organizational policies.

·      Assist departments in developing and monitoring quality objectives and key performance indicators (KPIs).

·      Promote a culture of quality and continuous improvement throughout the organization.

2.        Document Control

·      Administer the hospital’s Document Control System

·      Review and coordinate the approval, revision, issuance, distribution, and withdrawal of controlled documents.

·      Maintain the Master List of Controlled Documents and ensure only current versions are available for use.

·      Ensure proper retention and disposal of obsolete documents in accordance with document control procedures.

3.        Internal Quality Audit

·   Develop the Annual Internal Quality Audit Program.

·   Plan, coordinate, and facilitate internal quality audits.

·   Prepare audit schedules, audit checklists, and audit reports.

·   Monitor the implementation and effectiveness of corrective actions resulting from audit findings.

·   Maintain records related to internal quality audits.

4.        Continuous Quality Improvement (CQI)

·      Coordinate Continuous Quality Improvement (CQI) activities across departments.

·      Assist departments in identifying opportunities for improvement.

·      Facilitate the use of quality improvement tools such as Root Cause Analysis (RCA), Failure Mode and Effects Analysis (FMEA), process mapping, and other quality methodologies.

·      Monitor the implementation and effectiveness of quality improvement projects.

5.        Performance Monitoring

·      Monitor departmental KPIs and Quality Objectives.

·      Monitor Turnaround Time (TAT) indicators and other organizational performance measures.

6.      Corrective and Preventive Action (CAPA)

·   Monitor Corrective Action Requests (CARs) and improvement plans.

·   Verify completion and effectiveness of corrective actions.

·   Assist departments in conducting root cause analysis and implementing preventive actions.

7.        Risk Management

·   Support departments in conducting quality risk assessments.

·   Maintain quality-related risk records and documentation.

8.        Management Review

·   Consolidate organizational quality performance data.

·   Monitor completion of action items identified during management reviews.

9.       Training and Quality Awareness

·   Conduct orientation and training on Quality Management System requirements.

·   Coordinate ISO awareness programs.

·   Assist in the competency development of Internal Quality Auditors and process owners.

·   Promote quality awareness throughout the hospital.

10.    Regulatory and Accreditation Compliance

·      Coordinate quality-related compliance with DOH regulations and other applicable statutory requirements.

·      Support hospital accreditation, certification, and regulatory inspections.

·      Assist departments in preparing documents and evidence required during external audits.

11.    Reporting and Documentation

Prepare and submit:

·         KPI Monitoring Reports

·         Turnaround Time (TAT) Reports

·         Internal Audit Reports

·         Corrective Action Monitoring Reports

·         Corrective Action Request Reports

12.    Other Responsibilities

·         Participate in hospital committees related to quality, patient safety, and risk management.

·         Represent the TQM Department during meetings, audits, and accreditation activities.

·         Perform other quality-related duties assigned by management.

III.           Job Specifications:

a.     Education/Experience:

Academic:

Bachelor’s Degree in any of the following or related field: Nursing, MedTech, Industrial Eng’g, Healthcare Admin, Public Health, Pharmacy, Physical Therapy, Business Admin (with experience in healthcare quality management) and other allied health or management related courses

Experience:

At least two (2) to three (3) years of experience in quality management, healthcare accreditation, regulatory compliance, document control, internal quality auditing, or related functions in a healthcare setting.

Licensure: not necessary

Certification/Training:

·         ISO 9001:2015 Quality Management System Awareness

·         ISO 9001:2015 Internal Quality Auditor Training

·         Continuous Quality Improvement (CQI) Training

·         Lead Auditor Training is an advantage

·         Training in Risk Management, Patient Safety, or Healthcare Accreditation is an advantage

b.    Skills and Abilities:

a.  Knowledge of ISO 9001:2015 Quality Management System

b.  Knowledge of DOH regulations and healthcare accreditation requirements

c.  Document Control and Records Management

d.  Internal Quality Auditing

e.  Continuous Quality Improvement (CQI)

f.   Problem solving and analytical skills

g.  Data analysis and report preparation

h.  Good organizational and coordination skills

i.   Effective written and verbal communication

j.   Ability to work collaboratively with different departments

k.  Proficiency in Microsoft Office applications (Word, Excel, PowerPoint, Canva)

IV.           Working Schedule:

Monday – Saturday; 8:00AM to 5:00 PM