Director Audit and Compliance – Clinical & Patient Safety

The role incumbent is responsible for auditing clinical and administrative processes to ensure adherence to healthcare quality standards, patient safety protocols, and regulatory compliance in a hospital setting. The role supports continuous quality improvement initiatives, risk management, and ensures that hospital practices align with national and international accreditation standards.

Key Responsibilities:

1. Quality Assurance & Clinical Audits

• Conduct regular audits of clinical departments to assess compliance with evidence-based practices, clinical guidelines, and hospital policies.
• Analyze patient records, documentation, and outcomes to identify gaps in care or areas.
• Identify risks and opportunities for improvement in patient care processes.
• Evaluate adherence to hospital-wide quality metrics and KPIs.
• Monitor and report on key performance indicators (KPIs) related to quality and safety.

2. Patient Safety

• Audit incident reports and investigate adverse events, near-misses, and sentinel events.
• Audit implementation of patient safety programs and protocols (e.g. hand hygiene, medication safety, surgical safety).
• Review and assess hospital compliance with national patient safety goals (e.g. WHO, JCI, or local health authority standards).

3. Compliance & Accreditation

• Ensure hospital practices align with national and international standards (e.g., MoPH, JCI, ISO)
• Perform compliance audits on medical records, infection control, consent processes, and other regulated areas.
• Review environmental safety measures.
• Audit documentation, incident reports and corrective actions for regulatory compliance.

4. Reporting & Documentation:

• Prepare detailed audit reports with findings, risk assessments and recommendations.
• Track corrective actions and verify their implementation and effectiveness.
• Present findings to hospital leadership and line manager.

Qualifications:

• Education: Bachelor’s degree in Nursing or Medical degree, Health Sciences, Healthcare Administration, or related field (Master’s preferred).
• Certifications:
• Patient Safety Certification (e.g. CPPS) is a plus
• Internal Auditor Certification (ISO or equivalent) preferred
• Experience:
• Minimum 3–5 years of experience in quality management, clinical auditing, or healthcare compliance.
• Experience in a JCI-accredited hospital or healthcare setting is an advantage.

Skills & Competencies:

• Strong knowledge of healthcare quality standards and patient safety principles
• Strong understanding of healthcare risk management
• Familiarity with accreditation frameworks (e.g. JCI, ISO, local health authority)
• Analytical and detail-oriented with excellent report writing skills
• Strong communication and interpersonal skills
• Ability to manage multiple audits and prioritize tasks
• Proficient in Microsoft Office, audit tools, and healthcare data systems