The Quality & Compliance Manager is responsible to the Head of Quality, Risk and Regulatory Compliance, assuming responsibility for quality improvement and regulatory compliance across St John of God Hospital and St Joseph’s Shankill.

S/he will provide strategic and quality management leadership that will lead to the delivery of compliant, effective, efficient, and quality-assured services.

S/he will lead and coordinate both services during all regulatory inspections and be responsible for preparedness before and following  inspections.

The Quality & Compliance Manager will ensure compliance with regulations and standards by implementing a robust quality management system, using regular audits and surveys and centralise tracking. The primary goal is to assure the hospital and nursing home are in full compliance with all regulatory requirements, at all times.

The Quality & Compliance Manager will collaborate with the Risk Manager and Quality Improvement Manager . They will also work collaboratively with the relevant hospital committees, as assigned by Head of Quality, Risk and Regualtory Compliance. 

The Quality & Compliance Manager will provide staff awareness training in the areas of quality and regulatory compliance across the services.

In so doing, the post holder will ensure the provision of such leadership in accordance with the ethos and values of the service and that the organisation’s quality and regulatory requirements are improved, adhered to, implemented and maintained.

Qualifications/Experience/Knowledge, Skills & Abilities

• Educated to bachelor’s degree/Higher Diploma level (NFQ Level 8 on the Irish National Framework of Qualifications maintained by Qualifications and Quality Ireland QQI) in the area of management and/or healthcare and/quality management/or subject related to the functions of this role and evidence of on-going continuing professional development;
• Where quality management is not the primary degree, have additional qualification in quality management to Diploma level (NFQ Level 6).
• Significant Experience in Quality and Regulatory Compliance management and administration.
• Demonstrated success leading Quality teams & managing quality programs;
• Experience of working in a healthcare setting;
• Excellent organisational and time management skills and ability to plan and prioritise work while responding flexibly to rapidly changing priorities.
• Excellent communication skills – written, verbal and able to influence and negotiate at all levels;
• Team player with proven ability and willingness to lead and motivate colleagues and to work collaboratively to ensure quality and compliance objectives are met, developing constructive working relationships in pursuit of delivering high quality services and regulatory compliance;
• Ability to work autonomously and excellent time management skills to meet deadlines and manage workload;
• Good working knowledge of GDPR regulations, the Data Protection Acts and Information Governance requirements;
• Demonstrate strong teamwork, interpersonal skills, energy, enthusiasm and commitment;
• Proven ability to assume responsibility and make decisions;
• Ability to lead the change process, from problem recognition to change implementation and evaluation.

Main Duties and Responsibilities

The following is not an exhaustive listing of the duties associated with the post, but is intended as guidance for the person assigned to the position:

KEY RESPONSIBILITIES

The post holder is responsible for operation of the quality and regulatory compliance function and will:

• Prepare policies, protocols, SOP’s, and guidelines on various aspects to ensure best practice of quality management and regulatory compliance for dissemination throughout the services.
• Develop and maintain a quality management information system.
• Liaise with management to develop and oversee quality objectives and strategies for achieving them.
• Foster a culture of quality and continuous improvement.

Implementing a robust framework for quality and process improvement

• Develop and maintain a regulatory compliance information system.
• Direct the collection, measurement and presentation of data required for monitoring quality indicators and regulatory compliance.
• Review all regulatory update reports submitted by departmental heads for completeness of documentation and accuracy.
• Develop reports that analyses, aggregates and trends all quality improvement and regulatory compliance performance indicators.
• Prepares reports and analysis on quality improvement, and regulatory compliance for the Senior Management Team, Deputy/Chief Executive, Clinical Governance Committees, Sub Committees of the Board and for the Board.
• Engage with key stakeholders to ensure preparedness for all regulatory inspections e.g., MHC, HIQA, EHO
• Leads the support provided for all regulatory inspections.
• Review all regulatory inspection findings and develops and manages action plans to address non-compliance within agreed time limits.
• Develop and manage the education and technical expertise in quality improvement and regulatory compliance of the hospital and nursing home staff, medical staff. 
• Performs ongoing reviews of regulations, Irish healthcare law and appraises management of changes.
• Provides support in any system analysis reviews and reports findings to the appropriate people.
• Provides ongoing monitoring and evaluation of the effectiveness of the hospital performance in quality and regulatory compliance improvement programs. This includes an evaluation of the previous year’s plan and assures the plan for the next year is approved by the appropriate committees.
• Develop and maintain a repository of quality and compliance articles and other resource material pertaining to quality improvement and regulatory compliance for dissemination throughout the services.
• Participate in orientation and the ongoing education and training of hospital staff.
• Works collaboratively with the Infection Control Program as well as the Health and Safety Committee to identify and correct unsafe conditions and work practices.