Position Summary

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

Responsibilities include, but will not be limited to:

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 require program compliance with organizational policies, complaints

procedures, incident reporting requirements, and accreditation standards.

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

• 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.

• 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.
• 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.

Policy Governance and Document Control:

• Maintain full ownership of the organizational policy governance and document control

framework.

• 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.

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.

Education & 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.

Other Requirements

• Valid driver’s license and reliable transportation for community outreach and mobile testing.
• Criminal record clearance.
• Awareness of Indigenous languages and cultures (an asset).

Contact Info:

Email: Recruitment@siksikahealth.com

Phone: 403-361-1358