Manager, Quality & Patient Safety – Off Campus Hospitals

Manager, Quality & Patient Safety – Off Campus Hospitals

Entity: Aga Khan University Hospital

Location: Karachi, Pakistan

Introduction:

The Aga Khan University Hospital (AKUH) is a not-for-profit healthcare institute that offers all medical services to their patients under one roof. In addition to the tertiary care hospital in Karachi, AKUH has a network of 4 Off-Campus Hospitals, 30+ Medical Centres, and over 290+ Clinical Laboratories, 30+ Pharmacies in over 120+ cities across Pakistan. It also offers Home Healthcare Services and home deliveries of medicines. The hospital provides zakat for those patients who are eligible, and the health systems offers generous patient welfare to support those in financial need. In recognition of its high quality and patient safety, the AKUH is accredited by the Joint Commission International (JCI) as an Academic Medical Centre and its Clinical Laboratories are accredited by the College of American Pathologists (CAP) for fast and accurate testing.

As an equal opportunity employer, AKU believes in promoting a diverse and inclusive culture and is committed to adopt appropriate standards for safeguarding and promoting a respectful relationship with and between diverse workforce of its faculty, staff, trainees, volunteers, beneficiaries, wider communities, and other stakeholders with whom it works, including children and vulnerable adults and expects all employees/trainees and partners to share this commitment.

Responsibilities:

The Manager, Quality & Patient Safety will play a leadership role across the four Off-Campus Hospitals, focusing on strengthening quality management systems, enhancing patient safety, and ensuring regulatory and accreditation compliance. Reporting to the Chief Operating Officer (COO), Off-Campus Hospitals, you will be responsible for leading hospital-wide quality improvement, risk management, incident reporting, complaints management, performance measurement, safety culture initiatives, and staff education, while working closely with clinical and administrative leadership to promote patient-centered care and organizational reliability.

• Leading the development, implementation, and monitoring of the Quality & Patient Safety (QPS) Program across Off-Campus Hospitals.
• Developing and executing the annual QPS operational plan aligned with institutional and regulatory standards.
• Overseeing risk management processes including maintenance of risk registers, incident reporting systems, patient complaints management, and timely closure of corrective and preventive actions (CAPAs).
• Conducting and facilitating Root Cause Analyses (RCA), Failure Mode and Effects Analysis (FMEA), and other quality improvement methodologies.
• Monitoring and analyzing quality indicators, KPIs, patient safety metrics, and preparing monthly/quarterly dashboards for senior leadership.
• Ensuring compliance and readiness for accreditation and regulatory standards including SafeCare, SHCC, ISO, and other applicable frameworks.
• Leading and facilitating quality improvement projects using CQI, PDSA, Lean, and other structured methodologies.
• Supporting infection prevention and control initiatives in collaboration with IPC teams, including audits and compliance monitoring.
• Managing and improving patient experience and feedback systems to enhance patient-centered care outcomes.
• Providing training and capacity building to clinical and non-clinical staff on quality improvement tools, patient safety, data interpretation, and policy compliance.
• Supporting clinical governance activities including morbidity and mortality reviews, peer review processes, and quality committees.
• Supervising QPS coordinators and ensuring effective team performance and delivery of objectives.

Requirements:

The incumbent must have:

• Master’s degree in Healthcare Quality, Hospital/Health Administration, Public Health, or a related field.
• Bachelor’s degree in Medicine, Nursing, or equivalent clinical background preferred.
• Formal training in Quality Improvement, Patient Safety, or Healthcare Management is desirable.
• Preferred certifications: CPHQ, CPPS, SafeCare Licensed Assessor, ISO 9001 Lead/Internal Auditor.
• Valid professional license/registration (e.g., PMDC, PNC), where applicable.
• 5–7 years of relevant experience in healthcare quality management, patient safety, risk management, or accreditation.
• Experience working with SafeCare, JCIA, ISO, SHCC, or similar accreditation standards.
• Demonstrated experience leading quality improvement initiatives (PDSA, RCA, FMEA, audits).
• Experience working with multidisciplinary clinical and administrative teams.
• Strong understanding of healthcare quality management and patient safety frameworks.
• Knowledge of accreditation standards (ISO 9001:2015, SafeCare, JCIA, SHCC).
• Expertise in risk management principles and event reporting systems.
• Proficiency in data analysis, dashboard development, and performance reporting.
• Strong analytical, problem-solving, and systems-thinking skills.
• Leadership and team facilitation skills.
• Excellent communication and stakeholder engagement skills.
• Ability to manage multiple priorities, projects, and deadlines effectively.

Comprehensive employment reference checks will be conducted