Director Audit and Compliance – Clinical & Patient Safety

The role incumbent is responsible for auditing clinical and administrative processes to ensure adherence to healthcare quality standards, patient safety protocols, and regulatory compliance in a hospital setting. The role supports continuous quality improvement initiatives, risk management, and ensures that hospital practices align with national and international accreditation standards.

Key Responsibilities : 1. Quality Assurance & Clinical Audits

Conduct regular audits of clinical departments to assess compliance with evidence-based practices, clinical guidelines, and hospital policies.

Analyze patient records, documentation, and outcomes to identify gaps in care or areas.

Identify risks and opportunities for improvement in patient care processes.

Evaluate adherence to hospital-wide quality metrics and KPIs.

Monitor and report on key performance indicators (KPIs) related to quality and safety.

2. Patient Safety

Audit incident reports and investigate adverse events, near-misses, and sentinel events.

Audit implementation of patient safety programs and protocols (e.g. hand hygiene, medication safety, surgical safety).

Review and assess hospital compliance with national patient safety goals (e.g. WHO, JCI, or local health authority standards).

3. Compliance & Accreditation

Ensure hospital practices align with national and international standards (e.g., MoPH, JCI, ISO)

Perform compliance audits on medical records, infection control, consent processes, and other regulated areas.

Review environmental safety measures.

Audit documentation, incident reports and corrective actions for regulatory compliance.

4. Reporting & Documentation :

Prepare detailed audit reports with findings, risk assessments and recommendations.

Track corrective actions and verify their implementation and effectiveness.

Present findings to hospital leadership and line manager.

Qualifications : Education :

Bachelor’s degree in Nursing or Medical degree, Health Sciences, Healthcare Administration, or related field (Master’s preferred).

Certifications :

Patient Safety Certification (e.g. CPPS) is a plus

Internal Auditor Certification (ISO or equivalent) preferred

Experience :

Minimum 3–5 years of experience in quality management, clinical auditing, or healthcare compliance.

Experience in a JCI-accredited hospital or healthcare setting is an advantage.

Skills & Competencies :

Strong knowledge of healthcare quality standards and patient safety principles

Strong understanding of healthcare risk management

Familiarity with accreditation frameworks (e.g. JCI, ISO, local health authority)

Analytical and detail‑oriented with excellent report writing skills

Strong communication and interpersonal skills

Ability to manage multiple audits and prioritize tasks

Proficient in Microsoft Office, audit tools, and healthcare data systems

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