Executive, Quality Resources

Sunway Medical Centre Penang; Permatang Pauh; On-site; MYR 48,000 - 72,000; Full time

Job summary

Sunway Medical Centre Penang is seeking an experienced Quality & Incident Management Administrator to support the hospital-wide incident reporting process, review reports, and coordinate corrective actions. You will assist in RCA, consolidate reports, escalate serious incidents, and prepare MOH reporting.

You will help coordinate accreditation activities (MSQH, JCI, ACHS) and maintain documentation. A Bachelor of Science or Nursing with at least 2 years’ experience is required; clinical

Qualifications

• Education: Bachelor of Science or Bachelor of Nursing.
• Experience: Minimum 2 years in relevant field.
• Preferred: clinical background.

Responsibilities

• Administer hospital-wide incident reporting process (receiving, recording, tracking).
• Assist in reviewing incident reports for completeness and follow-up with departments for CAPA.
• Support investigations and prepare documentation for Root Cause Analysis (RCA).
• Summarise and track remedial actions for reporting to Heads of Department.
• Escalate sentinel events or serious incidents promptly for action.
• Assist in MOH incident reporting with adherence to timelines.
• Maintain records of incidents, investigations and lessons learned.
• Coordinate accreditation activities (MSQH, JCI, ACHS) and collect evidence.
• Support data collection and analysis for quality improvement and reporting.
• Coordinate risk management activities and maintain risk registers.

Skills

Quality improvement tools

English proficiency

Education

Bachelor of Science / Bachelor of Nursing

Job description

Administer the hospital-wide incident reporting process, including receiving, recording, tracking and maintaining incident reports.

Assist in reviewing incident reports for completeness and follow up with relevant departments on corrective and preventive actions.

Support incident investigations, including the preparation of documentation and compilation of information required for Root Cause Analysis (RCA).

Assist in consolidating incident reports, summarising key issues and tracking remedial actions for reporting to the relevant Heads of Department and superiors.

Escalate potential sentinel events or serious incidents to the superior promptly for further assessment and action.

Assist in preparing and submitting reports for incidents reportable to the Ministry of Health (MOH), in accordance with established requirements and timelines.

Maintain proper records of incidents, investigation findings, corrective actions and lessons learned.

Accreditation and Audits

Assist in coordinating accreditation activities and audits relating to standards such as the Malaysian Society for Quality in Health (MSQH), Joint Commission International (JCI), the Australian Council on Healthcare Standards (ACHS) and other applicable standards.

Support Heads of Department in preparing, compiling and maintaining documents and evidence required for accreditation and regulatory compliance.

Provide administrative and coordination support for accreditation surveys, internal audits and external assessments.

Continuous Quality Improvement

Assist in coordinating quality improvement, patient safety and clinical effectiveness activities to support the achievement of organisational goals.

Support the collection, compilation and analysis of operational and quality-related data to monitor progress and identify areas for improvement.

Maintain accurate and timely records, reports and documentation relating to quality improvement activities.

Clinical Data

Coordinate the collection and compilation of clinical and quality-related data from internal and external sources relating to patient safety, resource utilisation, system issues and other quality functions.

Assist in preparing data summaries, reports, charts and presentations to support the monitoring of quality performance.

Assist in identifying trends, variances and potential areas of concern from the data collected, and highlight findings to the superior for further review.

Liaise with relevant departments to obtain, verify and clarify data as required.

Assist in coordinating risk management activities to promote patient safety and compliance with accreditation standards and International Patient Safety Goals (IPSG).

Assist in maintaining risk registers, risk assessment records, action plans and related documentation.

Quality Improvement Projects

Assist in coordinating quality improvement projects with the respective Heads of Department and relevant teams.

Job Requirement

Education Level: Bachelor of Science / Bachelor of Nursing

Working Experience: Minimum 2 years of relevant working experience

Required Skills: Understand / familiar with quality improvement tools, comprehend professionally in English

Candidates with a clinical background are preferred

Sunway Healthcare is part of the Sunway Group, one of Malaysia's largest conglomerates with core interest in property, construction, education and healthcare. The group currently runs Sunway Medical Centre, which is one of the largest private tertiary hospitals in the region with 636 beds and is accredited with the Australian Council on Healthcare Standards (ACHS). The group is also building 5 more hospitals in different cities in Malaysia which will complete in stages over the next four years.