MEDICAL AFFAIRS & QUALITY MANAGER

Pantai Hospital Penang; Bayan Lepas; On-site; MYR 120,000 - 180,000; Full time

Benefits offered by this job

Competitive salaries & benefits

Job summary

Pantai Hospital Penang seeks a qualified MAQ Manager to drive quality governance, patient safety, and accreditation readiness. You will coordinate audits, manage corrective actions, and lead cross-functional teams to sustain regulatory compliance and hospital-wide quality initiatives.

Responsibilities include monitoring clinical indicators, reporting to management, and overseeing risk management processes. The role emphasizes collaboration with medical and operational leaders to improve outcomes

Qualifications

• Experience in quality management and accreditation programs.
• Strong audit and risk management capabilities.
• Familiarity with regulatory requirements and patient safety standards.
• Ability to coordinate cross-functional teams.
• Data collection and performance indicators analysis.

Responsibilities

• Identify, coordinate and monitor quality improvement initiatives with stakeholders to enhance patient safety and compliance.
• Lead and coordinate the Internal Quality Audit Program, ensuring audits are conducted within required timelines.
• Coordinate corrective and preventive actions arising from audits, inspections, and incidents.
• Collaborate with stakeholders to establish and implement quality standards and accreditation programs.
• Lead accreditation activities to ensure all applicable requirements are met and maintained.
• Coordinate collection, validation, monitoring and analysis of hospital clinical and quality indicators.
• Review and report Hospital Balance Score Card indicators and Audit Risk Management Committee indicators.
• Lead data collection and review for Value Driven Outcomes and other clinical outcome initiatives.
• Prepare and present quality, patient safety, risk management and accreditation reports to Hospital Management and relevant committees.
• Oversee implementation and effectiveness of quality improvement projects.

Skills

Quality Improvement

Auditing

Regulatory Compliance

Risk Management

Data Analysis

Stakeholder Collaboration

Tools

eHIR system

Job description

1. Identify, coordinate, and monitor the implementation of quality and process improvement initiatives in collaboration with key stakeholders to improve processes, enhance patient safety, and ensure compliance with applicable regulatory and accreditation requirements.

2. Lead and coordinate the Internal Quality Audit Program and ensure that internal and external audits are conducted within the required timelines.

3. Coordinate corrective and preventive actions arising from audits, inspections, accreditation assessments, incidents, clinical complaints and other quality-related findings.

4. Collaborate with relevant stakeholders to establish and implement quality standards, accreditation programs, and organizational requirements within the respective operational units.

5. Lead, coordinate and monitor accreditation activities to ensure that all applicable accreditation requirements are met and maintained.

6. Coordinate the collection, validation, monitoring and analysis of hospital clinical and quality indicators.

7. Review and report the Hospital’s Balance Score Card (BSC) indicators and Audit Risk Management Committee indicators in a timely and accurate manner.

8. Lead and coordinate data collection, validation, monitoring and review for Value Driven Outcomes (VDO) and other clinical outcome improvement initiatives.

9. Prepare and present quality, patient safety, risk management and accreditation reports to Hospital Management and relevant committees.

10. Oversee the implementation and effectiveness of quality improvement projects.

11. Monitor compliance with applicable laws and regulatory requirements relevant to private hospitals, including:

• oPrivate Healthcare Facilities and Services Act 1998 and its applicable regulations;
• oMedical Act 1971 and its amendments;
• oPersonal Data Protection Act 2010;
• oCompetition Act 2010;
• oMedical Device Act 2012 and its applicable regulations; and
• o other applicable legislation, regulatory requirements, standards and guidelines.

Clinical Safety and Risk Management

1. Review and evaluate clinical and operational risks and the corresponding mitigation measures in collaboration with relevant stakeholders to eliminate or minimize identified risks.

2. Ensure that incident reporting, investigation, escalation and risk management system is maintained.

3. Coordinate or conduct investigations and root cause analyses for reported incidents, serious reportable events and sentinel events to identify root causes, contributing factors, mitigation measures and recurring trends.

4. Develop, coordinate and monitor corrective and preventive actions arising from incident investigations and risk assessments.

5. Follow up on process improvements and mitigation measures intended to reduce adverse events and prevent recurrence.

6. Ensure that mandatory reports are submitted to the relevant authorities within the stipulated timelines, in collaboration with the Person in Charge and other designated responsible officers.

7. Identify and document learning points from incidents, serious reportable events and sentinel events for organizational learning, case studies, staff updates and awareness training.

8. Coordinate the implementation, maintenance and user training of the electronic Hospital Incident Reporting (eHIR) system to ensure compliance with Hospital and Ministry of Health reporting requirements.

9. Manage and coordinate the review of patient care-related complaints in collaboration with the relevant Heads of Department.

10. Conduct or coordinate clinical and medico-legal case reviews and work with internal and external legal advisers in managing potential and litigated medico-legal cases.

11. Maintain appropriate confidentiality and ensure that sensitive incident, complaint and medico-legal information is handled in accordance with applicable laws and Hospital policies.

Medical Affairs

1. Coordinate and support the Medical and Dental Advisory Committee (MDAC) and its subcommittees in carrying out their advisory, governance, and oversight responsibilities in accordance with the Hospital’s bylaws and applicable regulatory requirements.

2. Ensure that meetings of the Medical and Dental Advisory Committee (MDAC), Clinical Heads of Department, and relevant Hospital committees are scheduled and held in accordance with the approved meeting calendar and applicable requirements.

3. Liaise with the Person in Charge (PIC), Medical and Dental Advisory Committee Chairperson, Clinical Heads of Department and other relevant stakeholders to ensure that clinical governance policies and practices are aligned with recognised professional standards, evidence-based practices and recommended guidelines.

4. Manage and coordinate the credentialing, privileging, re-credentialing, and re-privileging of medical practitioners in accordance with Hospital policies and applicable regulatory requirements.

5. Maintain accurate and secure records relating to the appointment and contractual agreements of medical practitioners.

6. Support and monitor medical practitioner on-call rosters to ensure adequate specialist coverage and continuity of patient care.

7. Monitor the validity of medical practitioners’ registrations, Annual Practicing Certificates, National Specialist Register registrations, professional indemnity coverage, and other relevant licenses, certifications, or qualifications.

8. Coordinate the annual performance review and professional practice evaluation of medical practitioners in accordance with Hospital policies.

9. Support the application and renewal process of the Hospital’s operating licenses in collaboration with the Person in Charge, Hospital Management and relevant departments.

10. Maintain oversight of relevant regulatory certifications and monitor their timely renewal by the respective departments or designated owners.

11. Maintain accurate, confidential, and up-to-date records relating to medical practitioners, including credentialing, privileging, contracts, licenses, certificates, performance evaluations and committee decisions.

12. Facilitate the orientation and onboarding of newly appointed medical practitioners on relevant Hospital policies, clinical governance requirements and administrative processes.

Document Control

1. Manage and coordinate the review, revision, approval, issuance and implementation of Hospital Operating Policies and Procedures in accordance with the approved review schedule.

2. Ensure that Hospital Operating Policies and Procedures are current and compliant with applicable statutory, regulatory, accreditation, and organizational requirements.

3. Maintain the document control system to ensure that approved documents are properly identified, version-controlled, secured, archived and accessible to authorized staff.

4. Liaise with document owners and relevant stakeholders to ensure that Hospital Operating Policies and Procedures are reviewed and updated within the required timelines.

5. Coordinate the development or revision of Hospital Operating Policies and Procedures to address changes in legislation, regulatory requirements, accreditation standards, clinical practices, and organizational processes.

6. Ensure that obsolete documents are appropriately withdrawn, archived, and protected against unintended use.

Infection Prevention and Control

1. Provide management oversight and support for the implementation of the hospital-wide Infection Prevention and Control Program.

2. Ensure that appropriate infection prevention and control policies, procedures and standards are established and maintained with the Infection Control Committee, Clinical Heads of Department and other relevant stakeholders to provide best practice and safe environment to staff and patients.

3. Ensure that applicable infection prevention and control requirements issued by the Ministry of Health and other relevant authorities are implemented and monitored for compliance.

4. Ensure that an appropriate surveillance programmed is maintained to monitor healthcare-associated infections, communicable diseases, antimicrobial resistance trends and compliance with isolation and infection prevention precautions.

5. Review infection prevention and control indicators, surveillance findings, audit results, outbreaks and identified risks with the relevant committees and Hospital Management.

6. Monitor corrective and preventive actions arising from infection control surveillance, audits, incidents, outbreaks and regulatory inspections.

7. Support staff awareness activities relating to infection prevention and control.

Information Management, Communication and Training

1. Support the effective and timely management of quality, clinical governance, patient safety, risk and medical affairs information and communication at the Hospital and Malaysia Corporate Office levels.

2. Attend Hospital committees, clinical committees and subcommittees as required.

3. Ensure that data and reports presented to Hospital committees and clinical subcommittees are accurate, complete, validated and submitted in a timely manner.

4. Provide regular communication and updates to staff regarding quality management, patient safety, clinical governance and risk management program.

5. Identify and recommend training needs to support continuing education and compliance with accreditation standards, regulatory requirements, incident reporting requirements, patient feedback and organizational policies.

6. Coordinate relevant training, awareness program, briefings and competency assessments in collaboration with the Human Resources Department, Training Department and relevant subject matter experts.

7. Understand and comply with Pantai Hospital Penang’s policies, procedures, codes of conduct and confidentiality requirements.

8. To assist as and when the need arises in the arrangement of community service projects and other projects conducted by the Hospital.

General and Other Responsibilities

1. Participate in quality improvement projects and activities, regularly review work practices to support continuous improvement and meet stakeholder expectations and organizational requirements.

2. Attend relevant formal and informal education, training, and professional development programmed.

3. To undertake any other duties as assigned by the immediate superior.

The following duties will be included if the MAQ Manager is registered with the Malaysian Medical Council (MMC) with a valid Annual Practicing Certificate(APC) and professional indemnity coverage:

1. Perform medical examinations for Hospital staff and corporate clients when the designated Medical Officer is unavailable.

2. Provide appropriate medical advice in response to public enquiries or during Hospital marketing and community activities.

3. Conduct blood donor screening in accordance with approved blood bank policies, donor eligibility criteria, screening standards and applicable regulatory requirements.

4. Provide clinical coverage at the Executive Health Screening Department when the designated Medical Officer is unavailable.

5. Perform such clinical duties within authorized scope of practice, competency, credentialing and privileging.

Competitive salaries & benefits will be offered to the successful candidates.