Overview and Purpose of the Role

Reporting to Director, Quality, Safety & Enterprise Risk, the incumbent will play a key role in leading, developing, implementing quality, safety, and integrated risk management programs and policies, that foster a proactive and integrated culture of continuous quality improvement, safety, and accountability.

Key Duties and Responsibilities:

Quality Improvement and Assurance and Patient Safety

• Champion a culture of quality improvement and safety by proactive reporting of quality improvement opportunities and risks and promoting use of quality improvement methods

• Develop and maintain the Centre's Quality Assurance Program and Quality Improvement Plan (QIP)

• Analyze current practices and workflows, collect and use data to identify and implement opportunities for improvement (e.g., root cause analyses following adverse events or near-misses)

• Collaborate with clinical programs to lead quality improvement and patient safety initiatives, utilizing varying methods (i.e., Lean, PDSA, FMEA)

• Continuously monitor trends and issues in quality and patient safety

• Synthesize data and additional evidence to inform quality improvement and safety initiatives, including conducting literature reviews, analyzing hospital data and report trends to leadership

• Conduct regular audits, performance metrics review, chart reviews, and outcome analyses to monitor quality indicators and identify opportunities for improvement

• Support policy and procedure development

• Assist with facilitating safety huddles and quality, safety, and policy-related committees

• Using incident reporting system and additional tools as required, track, investigate, and report incidents, adverse events, and near misses using structured frameworks (e.g., RCA), and communicate findings to relevant stakeholders

• Support preparation and review of mandatory reporting requirements that meet governmental and organizational performance objectives

Risk Management

• Proactively collaborates with all the teams to identify risks and risk mitigation strategies

• Maintain and manage the Centre's Risk Management Program, including risk register, incident tracking, and legal or regulatory incident reporting

• Collaborate with team members to ensure compliance with privacy regulations (PHIPA) and infection prevention and control (IPAC) protocols

• Monitor trends and potential risks, escalating concerns to leadership when necessary

Emergency Preparedness

• Support the development and review of emergency codes and policies

• Develop, update, and test the Emergency Preparedness and Response Plan, ensuring alignment with provincial guidelines (e.g., Emergency Management Ontario)

• In collaboration with other teams, coordinate emergency drills (fire, pandemic, lockdown, etc.) and debriefs with interdisciplinary teams

• Liaise with community emergency services and public health authorities as needed

Policy System Administration

• Serve as the e-Policy System Administrator, managing the digital policy and procedure platform

• Oversee version control, document workflows, policy updates, and access permissions

• Ensure that all staff have access to current policies and are notified of changes in a timely manner

• Coordinate policy reviews and approvals with department leads and leadership

Education & Training

• Develop and deliver staff training on quality, risk, safety, and compliance topics

• Facilitate onboarding of new staff in areas related to patient safety and quality

Regulatory & Accreditation Readiness

• Enable compliance with all applicable regulatory requirements, inspections, surveys, and accreditation and professional oversight bodies (e.g., CPSO, Accreditation Canada, ORNAC, Ontario Health, Ministry of Health)

• Maintain required documentation and ensure ongoing readiness for accreditation

• Stay current with changes to healthcare regulations and standards in Ontario and advise leadership accordingly

Corporate Responsibilities:

• Participate in all mandatory training requirements and work in compliance with the Occupational Health and Safety Act and Regulations, company Policies and Procedures, as well as established industry guidelines

Skills & Qualifications:

• Undergraduate degree in Nursing, Health Sciences, or a related healthcare field is required
• Master's degree in a related field preferred
• Certification in Quality, Risk Management, Lean, and/or Emergency Preparedness
• Minimum 3 years of recent experience in a healthcare setting, with at least 2 years in quality improvement, patient safety, or risk management, preferably in an ambulatory or surgical environment
• Strong understanding of Ontario healthcare regulations, CPSO standards, IPAC protocols, and accreditation processes
• Experience in change management is an asset
• Ability to exercise significant discretion and sensitivity involving responsibility for protecting sensitive information and ensuring compliance with data security policies and oversee the development and implementation of confidentiality procedures
• Experience with Meditech Expanse is an asset
• Superior interpersonal skills including the ability to work effectively in a team environment
• Strong organizational, critical thinking, analytical, and problem-solving skills
• Detail-oriented with a focus on accuracy and compliance
• Excellent verbal, written and communication skills
• Proven ability to work in a fast-paced environment and manage multiple projects simultaneously
• Proactive approach to improving processes and systems for better operational efficiency
• Ability to adapt to new technologies and systems quickly
• Computer proficiency in MS Office (Word, Excel, Outlook)
• Satisfactory passing of a criminal record check/vulnerable sector check
• Provide proof of Immunization and TB records

Company DescriptionA large-scale, not-for-profit ambulatory health services centre is being established in Richmond Hill, Ontario, with expected opening in the summer of 2025. The centre's mission is to alleviate pain and improve quality of life for Ontarians, while establishing a new standard of efficient ambulatory care which will enhance the efficiency of the public health system. The centre will offer a wide range of same-day surgeries, procedures, diagnostics, and clinical services.
We are dedicated to providing an inclusive and accessible work environment. If you require accommodations at any phase during the recruitment process please let us know. We will collaborate with you to ensure that your needs are met in a timely and effective manner. All information disclosed will be kept confidential and used solely for the purpose of providing appropriate accommodations.Company DescriptionA large-scale, not-for-profit ambulatory health services centre is being established in Richmond Hill, Ontario, with expected opening in the summer of 2025. The centre's mission is to alleviate pain and improve quality of life for Ontarians, while establishing a new standard of efficient ambulatory care which will enhance the efficiency of the public health system. The centre will offer a wide range of same-day surgeries, procedures, diagnostics, and clinical services.We are dedicated to providing an inclusive and accessible work environment. If you require accommodations at any phase during the recruitment process please let us know. We will collaborate with you to ensure that your needs are met in a timely and effective manner. All information disclosed will be kept confidential and used solely for the purpose of providing appropriate accommodations.