JOB TITLE: Head of Quality Management Carmel International Hospital
Location: Ho Chi Minh City, Vietnam
Reports to: Chief Executive Officer (CEO) Carmel International Hospital
JOB SUMMARY:
The Head of Quality Management is responsible for leading the hospital-wide quality assurance and patient safety programs, with a strategic focus on achieving Joint Commission International (JCI) accreditation. This role oversees the planning, implementation, monitoring, and evaluation of quality initiatives, ensuring that clinical and operational practices align with international best practices, regulatory standards, and Carmel International Hospitals mission of delivering world-class healthcare.
The Head of Quality Management collaborates with clinical, administrative, and support service leaders to foster a culture of continuous improvement, patient-centered care, risk management, and regulatory compliance.
KEY RESPONSIBILITIES:
Quality Leadership & Governance
- Lead the hospitals quality and patient safety strategy, including the development and implementation of a hospital-wide Quality Management System (QMS).
- Establish and chair the hospitals Quality Council and relevant sub-committees (e.g., Patient Safety, Infection Control, Risk Management).
- Serve as the primary advisor to executive leadership on all quality-related matters, including accreditation readiness, regulatory compliance, and quality performance.
- Foster a culture of continuous quality improvement, safety, and accountability across all departments.
- Ensure compliance with local, national, and international regulations, including those from the Ministry of Health, Department of Health, and other accreditation bodies.
- Lead the hospitals preparation for JCI accreditation including gap analyses, policy development, and staff readiness.
Performance Improvement & Data Management
- Design and oversee the hospitals Performance Improvement Program, including identification of key KPIs, benchmarking, and dashboard reporting.
- Utilize data analytics and root cause analysis tools (e.g., RCA, FMEA) to drive evidence-based improvements in clinical and operational outcomes.
- Coordinate hospital-wide quality improvement projects in collaboration with departmental leaders.
- Monitor quality metrics and publish regular performance reports for leadership review and decision-making.
Risk Management & Patient Safety
- Develop and implement an effective Risk Management Program to identify, assess, and mitigate clinical and operational risks.
- Lead incident reporting systems, adverse event reviews, and investigations of sentinel events or near-misses.
- Promote a Just Culture that encourages transparent reporting and learning from errors without blame.
- Ensure effective operation of patient safety programs, including hand hygiene, medication safety, fall prevention, and infection control.
Policy Development & Document Control
- Oversee the development, approval, implementation, and review of hospital-wide policies, procedures, and SOPs in line with JCI standards.
- Establish and maintain a centralized Document Control System to ensure policy accessibility, version control, and compliance.
- Collaborate with department heads to ensure departmental policies align with overall hospital quality standards.
Training & Staff Engagement
- Organize hospital-wide training programs on quality management, patient safety, accreditation, and performance improvement.
- Conduct orientation sessions for new staff on hospital quality goals, expectations, and standards.
- Provide coaching, mentorship, and professional development opportunities for the Quality Management team.
- Encourage cross-departmental collaboration and staff engagement in quality initiatives.
Internal Audits & Continuous Monitoring
- Plan and lead regular internal audits, clinical practice evaluations, and compliance reviews across all departments.
- Track audit findings and support departments in implementing corrective and preventive actions (CAPA).
- Report audit results to hospital leadership and accreditation bodies as required.
- Maintain a readiness state for unannounced surveys or inspections.
QUALIFICATIONS & EXPERIENCE:
Education & Certifications
- Bachelors degree in Healthcare Administration, Public Health, Quality Management, or a related clinical field.
- Professional certification in healthcare quality or patient safety (e.g., CPHQ, CPPS, JCI Internal Surveyor, Six Sigma) is highly desirable.
Experience
- Minimum 810 years of experience in healthcare quality management, patient safety, or hospital accreditation.
- At least 5 years in a senior leadership or department head role, preferably in a JCI-accredited hospital.
- Demonstrated success in leading hospital-wide quality initiatives and accreditation processes.
- In-depth knowledge of JCI standards, MoH regulations, ISO 15189, and international healthcare quality frameworks.
- Strong understanding of clinical workflows, risk management principles, infection control, and performance improvement tools.
