The Quality Improvement Manager leads organizational quality, accreditation readiness, complaints management, incident management, policy governance, and compliance systems across Siksika Health Services. The role holds primary accountability for the development, coordination, and maintenance of organizational policies, procedures, complaints processes, incident management systems, and quality frameworks, ensuring alignment with accreditation standards, legislation, and organizational priorities.

This position operates with delegated authority to manage the full policy lifecycle, oversee the organizational complaints and incident management systems, coordinate compliance activities, and lead quality improvement initiatives across departments. The role exists to operationalize governance decisions, ensure risks and complaints are addressed systematically, and reduce executive level involvement in routine compliance, policy drafting, and quality oversight.

Decision Authority and Scope:

- Owns the organizational quality, policy governance, complaints, and incident management frameworks and manages the full lifecycle from development through implementation and review.
- Has delegated authority to coordinate cross departmental input, set timelines, and require participation in policy, complaints, incident, and accreditation activities.
- Has authority to oversee organizational complaints intake, tracking, investigation coordination, and resolution processes.
- Has authority to own and maintain the incident reporting and investigation system.
- Has authority to require program compliance with organizational policies, complaints procedures, incident reporting requirements, and accreditation standards.
- Can require program areas to participate in corrective action planning resulting from complaints, incidents, audits, or accreditation findings.
- Escalates strategic, systemic, or high risk issues to the COO but maintains operational control over quality systems, complaints processes, incident management, and compliance activities.
- Serves as the central organizational lead for accreditation coordination, audit readiness, and quality system integrity.

Quality Improvement and Accreditation:

- Lead the design and implementation of a continuous quality improvement framework across all programs and service areas.
- Coordinate accreditation readiness including gap assessments, evidence tracking, audit preparation, and follow up actions.
- Ensure accreditation standards are translated into operational processes rather than remaining at an executive planning level.
- Lead quality improvement initiatives arising from complaints, incidents, audits, and accreditation findings.
- Facilitate structured quality improvement methodologies to improve safety, compliance, and operational effectiveness.
- Monitor organizational quality indicators and implement improvement strategies where gaps are identified.

Incident and Patient Safety Management:

- Own and maintain the organizational incident reporting and management system.
- Ensure incidents, near misses,



and adverse events are documented, tracked, investigated, and resolved appropriately.
- Coordinate root cause analyses for serious incidents and ensure corrective actions are implemented and verified.
- Monitor incident trends and identify systemic safety risks.
- Ensure incident management processes align with accreditation standards, patient safety requirements, and regulatory expectations.

Complaints Management and Resolution:

- Establish and maintain a centralized organizational complaints management system.
- Receive, log, track, and monitor complaints from patients, families, community members, and staff.
- Coordinate complaint investigations with appropriate program leads, HR, Privacy, or leadership depending on the nature of the complaint.
- Ensure complaints are investigated in a timely, fair, and consistent manner aligned with organizational policies and procedural fairness principles.
- Maintain confidential complaint records and ensure appropriate documentation of findings, actions, and resolutions.
- Identify systemic issues arising from complaints and ensure corrective actions, policy changes, or training are implemented.
- Provide regular reporting to executive leadership on complaint trends, resolution timelines, and risk implications.
- Ensure complaints processes align with accreditation standards, patient safety requirements, and regulatory expectations.

Policy Governance and Document Control

- Maintain full ownership of the organizational policy governance and document control framework.
- Draft, revise, and maintain organizational policies and procedures in collaboration with program leaders.
- Establish standardized templates, document control processes, approval tracking, and review cycles.
- Maintain formal version control and archival processes for organizational policies and quality related documents.
- Ensure staff access current and approved versions of controlled documents.
- Maintain a centralized policy repository and monitor compliance with review timelines.
- Ensure policies are enforceable, clearly written, and aligned with cultural safety principles and regulatory expectations.

Risk Management and Compliance

- Conduct internal audits related to clinical operations, privacy, safety, facilities, complaints, incident management, and regulatory compliance.
- Identify organizational risk gaps and lead development of corrective action plans.
- Ensure corrective actions are implemented, monitored, and verified for effectiveness.
- Work with Privacy, HR, and Operations to maintain compliance with applicable legislation and standards.
- Monitor organizational risk trends and escalate systemic risks to executive leadership.

Regulatory and Standards Monitoring:





- Monitor changes in accreditation standards, legislation, and regulatory requirements.
- Translate regulatory changes into operational policies, procedures, and compliance actions.
- Advise leadership on compliance risks and required organizational adjustments.

Clinical Governance Support

- Support development and implementation of clinical protocols, standards, and practice guidelines.
- Work with clinical leadership to ensure consistent, safe, and compliant care delivery practices.
- Support clinical quality monitoring and continuous improvement activities.

Quality Metrics and Performance Monitoring:

- Define, implement, and monitor organizational quality and safety indicators.
- Develop dashboards and reporting tools to support leadership oversight.
- Track quality performance trends and identify improvement priorities.

Education and Implementation Support:

- Provide structured guidance to team leads on policy implementation, complaints handling expectations, and quality standards.
- Develop practical tools and checklists that enable programs to maintain compliance independently.
- Support change management related to accreditation, policy implementation, incident management, and complaints processes.

Reporting and Governance:

- Prepare regular quality, compliance, incident, complaints, and accreditation status reports for executive leadership and the Board as required.
- Track complaint trends, incident trends, audit findings, and policy completion metrics.
- Translate governance direction into operational procedures and workflows.

QUALIFICATIONS

Education and Experience:

- Post secondary education in health administration, quality improvement, public health, nursing, or a related field.
- Experience supporting accreditation processes within healthcare or community based services is strongly preferred.
- Experience managing complaints systems, incident investigations, or compliance programs is strongly preferred.
- Demonstrated experience leading policy governance and quality improvement initiatives.
- Strong understanding of quality improvement methodologies, patient safety principles, and risk management.
- Ability to influence across departments without direct supervisory authority

REQUIRED KNOWLEDGE, SKILLS, AND ABILITIES

Knowledge, Skills, and Abilities:

- Robust systems thinking and organizational governance awareness.
- Advanced policy writing and regulatory interpretation skills.
- Ability to manage confidential and sensitive complaints and investigations appropriately.
- Ability to enforce structure and accountability across departments.
- High level organizational and project management capability.
- Strong analytical and problem solving skills.

OTHER REQUIREMENTS

- An acceptable criminal record check with a recent vulnerable sector search (less than 90 days old); this will be obtained as part of the selection process after extending offer.
- Valid driver’s license and reliable transportation.
- Awareness of Indigenous languages and cultures (an asset).

📌 Quality Improvement Manager (Alberta)
🏢 Siksika Health Services
📍 Alberta