Manager, Quality Resources

Sunway Medical Centre Penang; Permatang Pauh; On-site; MYR 200,000 - 260,000; Full time

Job summary

Sunway Medical Centre Penang seeks a seasoned leader to champion quality and patient safety across the hospital. The role provides strategic oversight of regulatory reporting, accreditation readiness and performance monitoring, partnering with clinical and operational teams to strengthen governance and drive sustained improvements.

Responsibilities include leading licensing, MOH reporting, MSQH accreditation readiness, and quality analytics, with a focus on risk management and incident

Qualifications

• Bachelor in Nursing or BSc required.
• Valid Nursing License required.
• 8+ years of relevant experience with 3–5 years in a managerial/leadership role.

Responsibilities

• Lead licensing and regulatory compliance for the hospital.
• Oversee MOH mandatory reporting requirements.
• Drive MSQH accreditation activities and survey readiness.
• Lead quality governance, risk management and committee activities.
• Manage audits across departments and close corrective actions.
• Lead incident governance, RCA, and incident documentation.

Skills

Regulatory compliance

Quality improvement

Audit management

MSQH accreditation

Data analysis

Incident management

Education

Bachelor in Nursing

Bachelor of Science

Job description

To lead and drive the hospital’s quality and patient safety agenda by ensuring regulatory compliance, accreditation readiness, effective risk management, incident governance and continuous quality improvement. The role provides strategic oversight of quality systems, regulatory reporting, audit management and performance monitoring, while partnering with clinical and operational teams to strengthen governance, promote a culture of safety and achieve sustained improvements in healthcare quality and patient outcomes.

Job Responsibilities

1. Hospital Licensing & Regulatory Compliance

Lead hospital operating licence renewals, applications for new or additional services, and submissions to CKAPS for renovation or structural changes.

Oversee liaison with CKAPS and relevant regulatory authorities to ensure compliance with PHFSA and applicable healthcare regulations.

2. MOH Mandatory Reporting

Oversee the timely, accurate and complete submission of mandatory MOH reports, including AD1, IR1, IR2A, IR2B and MPSG.

Establish and monitor tracking mechanisms to ensure regulatory reporting compliance.

3. Accreditation & Standards Management

Lead hospital-wide MSQH accreditation activities, ensuring compliance with applicable standards and measurable elements.

Drive accreditation readiness, internal and external survey preparations, and the monitoring and closure of corrective action plans.

4. Quality Governance & Committee Leadership

Lead QR representation and contributions to CPCC, Risk Management & QIP, and Forms Committee activities.

Drive clinical incident trend analysis, MPSG oversight, clinical performance indicator monitoring, risk register management, QIP implementation and monitoring, and hospital form review and endorsement.

5. Audit & Compliance Management

Lead hospital-wide cross-departmental and compliance audits, including Fall, Patient Identification (ID), Dispensing and other applicable audits.

Oversee QR rounds to assess adherence to policies and standards, and drive timely closure of audit findings through systematic follow-up.

Oversee daily screening and governance of electronic incident reports (e-IR).

Lead root cause analysis (RCA) for significant incidents and drive the implementation, monitoring and closure of corrective and preventive actions.

Ensure robust incident documentation, evidence management and timely incident closure.

7. Quality Analytics & Performance Reporting

Lead analysis of incident trends, quality performance indicators and MPSG compliance to identify risks, improvement opportunities and areas requiring management attention.

Oversee monthly quality reports, quarterly audit reports and ad hoc analytical reports for management review, ensuring timely submission and actionable insights.

8. Training & Quality Awareness

Lead hospital-wide training and awareness initiatives covering incident reporting, IPSG/MPSG, risk management, policies and procedures, and MSQH standards.

Promote a strong culture of quality, accountability and patient safety through targeted engagement and awareness campaigns.

9. Document Control & Quality Systems

Oversee governance of hospital Policies & Procedures, ensuring effective document control, version management and adherence to established practices.

10. Continuous Quality Improvement

Lead the planning and execution of hospital-wide quality and patient safety initiatives, campaigns and events.

Drive departmental engagement in quality improvement initiatives to strengthen compliance, operational effectiveness and patient outcomes.

Job Requirement

Education Level: Bachelor in Nursing or relevant Bachelor of Science

Licenses & Certification: Valid Nursing License (Applicable to Nursing Background)

Working Experience: At least 8 years of relevant experience, with 3–5 years in a managerial or leadership capacity

Technical Expertise: Hospital licensing, CKAPS/MOH compliance, MSQH accreditation, clinical incident management, audits and risk management, data analysis and reporting

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.

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.