Quality, Risk & Continuous Improvement Manager - UPMC Kildare
Location: UPMC Kildare Hospital
Job type: Permanent
Overview of role:
The Quality, Risk & Continuous Improvement Manager is responsible for leading the hospital's quality, patient safety, risk management, and continuous improvement agenda. The role ensures compliance with national standards, drives quality improvement initiatives, supports accreditation processes, and strengthens risk mitigation strategies across the organisation.
Primary Duties and Responsibilities:
General
Quality Management
* Works in collaboration with the General manager, Director of Nursing, Chief Quality and Compliance Officer, Medical Director and hospital leadership in the development of the hospital quality improvement programme and strategy.
* Develop, implement, and monitor the hospital's Quality Management System (QMS).
* Ensure compliance with national healthcare standards (e.g. HIQA, JCI, ISO, CHKS,JAG,HSA)
* Lead quality audits, coordinate action plans, and monitor improvement outcomes.
* Analyse quality data, produce dashboards, and present reports to senior leadership.
* Support clinical and non‑clinical teams in developing and reviewing policies and procedures.
Risk Management
* Oversee the hospital's Risk Management Framework, including risk identification, assessment, mitigation, and monitoring.
* Maintain the organisational risk register and ensure regular review with senior management.
* Lead incident management processes, including investigation, root cause analysis (RCA), and implementation of learning.
* Promote a culture of open disclosure and support staff involved in incidents.
* Ensure statutory reporting of incidents and risks where required.
Patient Safety
* Implement and enhance patient safety initiatives (falls reduction, medication safety, infection prevention, etc.).
* Monitor safety indicators and clinical outcomes; identify trends and support improvement strategies.
* Facilitate multidisciplinary patient safety committees.
* Support compliance with safeguarding, patient rights, and safe‑care standards.
Continuous Improvement / Lean Management
* Lead continuous improvement activities using methodologies such as Lean, Six Sigma, PDSA cycles, and process mapping.
* Train and coach staff on quality improvement tools and techniques.
* Facilitate cross‑departmental improvement projects and evaluate their effectiveness.
* Develop and track KPIs to measure progress and ensure sustained improvement.
Accreditation & Compliance
* Lead on the preparation for internal and external inspections or accreditation surveys.
* Ensure documentation, policies, and processes meet required standards.
* Liaise with regulators and accreditation bodies.
* Support service development and change management programmes.
Data, Reporting & Governance
* Provide regular quality, risk, and patient safety reports to General Manager and Director of Nursing.
* Maintain accurate records and ensure timely submission of compliance reports.
* Support clinical audit programmes and oversee audit action plans.
* Contribute to governance meetings and promote evidence‑based decision‑making.
Education & Staff Engagement
* Deliver training on risk management, incident reporting, quality tools, and improvement methodologies.
* Promote a culture of safety, accountability, and continuous learning.
* Engage teams through communication, feedback, and recognition of improvement efforts.
Health and Safety
* Work collaboratively with other members of the team to ensure that patient care is central to all activities in the hospital.
* Participate in service delivery as part of a professional, punctual and dedicated team.
* Create, promote and maintain open communications and healthy working relationships.
* Ensure best pharmaceutical practice, having regard to legal and ethical requirements for the provision of the pharmacy service.
* Maintain the principles of equity, accountability, quality and safety in daily work.
* Work collaboratively with other staff to deliver and develop clinical pharmacy services to achieve stated goals and objectives, respecting the role of other pharmacists in ensuring safe and effective care.
* Manage and develop self and others in a busy working environment.
* Have the skills necessary to evaluate information, make effective decisions and problem-solve.
* Have the ability to manage time, deadlines and prioritise the workload.
* Assist in managing the efficient running of the dispensary. Participate in/ supervise the operation of the dispensary, and the procurement, storage and supply of pharmaceuticals and other related items.
Professional / Education
* Contribute to service development through appropriate continuous education, research initiatives, keeping up to date with literature, recent research and new developments in management, education and practice and attend staff study days as considered appropriate.
* Provide support/advice to those engaging in continuous professional development in his/her area of responsibility.
* Participate in the identification, development and delivery of induction, education, training and development programmes for nursing and non-nursing staff.
* Participate in in-service training, orientation programmes and appraisals of all nursing staff.Also, participate in nurse training programmes and any other programmes pertaining to future development in the hospital.
* Provide support supervision and professional development of appropriate staff.
* Engage in performance review processes including personal development planning e.g., by setting own and staff objectives and providing and receiving feedback.
Qualifications & Experience:
Eligible Criteria:
Qualifications
* Bachelor's degree in Nursing, Healthcare Management, Quality, or related field (Master's desirable).
* Training in Lean, Six Sigma, or quality improvement (Green/Black Belt advantageous).
Experience
* Experience in healthcare quality, patient safety, or risk management.
* Have at least 5 years' experience in healthcare administration.
* Experience with hospital accreditation essential – CHKS or JCI.
* Knowledge of healthcare standards and regulatory requirements.
* Demonstrate a high level of knowledge of developments within the healthcare quality.
* Demonstrate a knowledge of applying standards to practice, quality improvement process and quality and safety frameworks.
* Experience in the application of knowledge on standardisation to practice / process.
* Excellent IT skills: MS Office skills to include, MS Teams, Word, Excel and PowerPoint, knowledge and experience of using an email system effectively e.g., Outlook.
Core Competencies
* Leadership skills
* Quality‑focused decision‑making
* Strong organisational and project management skills
* Ability to influence and engage multiple stakeholders
* Problem‑solving and root cause analysis skills
* Data analysis and report development
* Strategic thinking and continuous improvement mindset
This job description is intended to be an outline of the areas of responsibility. As the UPMC Kildare Hospital and the post holder develop, this job description may be subject to review in light of the changing needs of the Centre.
Equal Opportunity Statement and Benefits
UPMC is an equal opportunity employer. We celebrate diversity and are committed to creating an inclusive environment for all employees.
At UPMC we provide a total rewards program that is not only market competitive, but fair and provides growth opportunities for all our colleagues.
Compensation – Competitive pay for the work employees do – base pay, performance related pay and premium pay where applicable.
Benefits – Fully paid maternity and paternity leave for new parents. Competitive Pension Plan, company funded Death in Service Benefit x 3 times. Critical Illness cover for all employees up to the age of 66.
Performance and Recognition – Rewards for performance that supports the goals and mission of UPMC through our annual ACES programme.
Work-Life Balance – Enhanced annual leave up to a maximum of 27 days. Flexible working opportunities to support you to work around external family commitments.
Development and Career Opportunities – Opportunities for each employee to reach their career goals through continued learning and/or advancement.
About UPMC
UPMC is a renowned multinational academic medical centre committed to delivering people-focused care that's close to home. Headquartered in Pittsburgh and affiliated with the University of Pittsburgh Schools of the Health Sciences, UPMC shapes the future of health through clinical and technological innovation, research and education. UPMC expands its expertise globally, bringing world-class care across continents through its UPMC International division — an owned and operated network of hospitals and ambulatory care centres in Italy, Ireland and Croatia. UPMC International brings new access to the signature specialty services of UPMC Hillman Cancer Centre, UPMC Sports Medicine and others to more people in more places around the world.
In Ireland UPMC has provided high-quality healthcare in the South East since 2006. UPMC's operations in Ireland now include UPMC Whitfield Hospital in Waterford, UPMC Sports Surgery Clinic in Dublin, UPMC Kildare Hospital in Clane, and UPMC Aut Even Hospital in Kilkenny. Outpatient care is available at the UPMC Carlow Outreach Centre, UPMC Hillman Cancer Centre radiotherapy locations in Waterford and Cork, UPMC The 4th Practice in Mallow, and across UPMC Sports Medicine Clinics in Dublin, Waterford, Limerick, Tipperary, Cork, and Mayo. UPMC has also established a nationwide Concussion Network. UPMC's Global Technology Operation Centre is based in Kilkenny.