Manager, Quality, Safety & Accreditation

Baycrest Hospital

has an exciting opportunity for a

Manager, Quality, Safety & Accreditation

Quality and Heritage Department

Posting Number: 9920

Position Type: Full Time

Bi-Weekly Hours: 70 Hours

Union: Non-Union

About Us

Baycrest Hospital and the Apotex Jewish Home for the Aged provide specialized geriatric care for older adults with complex medical, cognitive and dementia-related needs. As Canada’s only health system fully dedicated to aging and brain health, we bring together compassionate care, clinical excellence and leading expertise in dementia care, cognitive health and seniors’ wellness.

Our integrated continuum — spanning hospital care, long-term care and community-based seniors’ services — ensures every older adult benefits from evidence-based practice, geriatric medicine and a team deeply experienced in aging and brain-health care.

Job Summary

Reporting to the Chief Heritage and Quality Officer, the Manager, Quality, Safety & Accreditation leads the planning, implementation, and evaluation of quality improvement, patient/resident safety, and accreditation activities. The Manager also ensures compliance with regulatory standards while driving a culture of continuous improvement, safety, and person-centred care. Concurrent with this role, the Manager serves as the Lead for the Seniors Quality Leap Initiative (SQLI) Secretariat, a North American consortium that supports service providers in aging care improve care quality housed at Baycrest.

The incumbent will provide direct leadership to the quality portfolios in the hospital and long-term care home and function as a liaison with key internal and external stakeholders.

The Manager is responsible for supporting the direction for the hospital and long-term care home’s quality improvement programs. They monitor and evaluate performance and actively guide the identification of priorities, set improvement direction and support the implementation of initiatives that drive measurable impact. The Manager also provides leadership and expertise in patient safety and will contribute to the development of systems to reduce the potential for error that may contribute to unintended adverse client outcomes.

Grounded in the principles of the Quintuple Aim, the Manager ensures that quality and safety initiatives advance improvements in the patient and resident (client) experience, population health outcomes, provider and staff experience, value and stewardship of resources, and health equity.

Key Responsibilities

Quality

· Leads the development, implementation, monitoring, and evaluation of organization-wide quality improvement programs and initiatives in collaboration with leadership and quality committees.

· Provides direction, coaching, and expertise to leaders and teams in establishing and achieving quality improvement goals, including oversight of annual Quality Improvement Plans and rapid cycle improvement initiatives.

· Oversees quality improvement processes across the hospital, including the analysis and interpretation of quality indicators, scorecards, and performance metrics to support data-driven decision-making and actionable outcomes.

· Ensures organizational compliance with applicable quality, healthcare, and long-term care legislation, and escalates significant quality or risk-related matters to Senior Leadership and external stakeholders as required.

· Provides operational and strategic leadership for SQLI initiatives, including governance support, stakeholder and partner relations, budget oversight, contract management, and coordination of consortium activities and meetings.

Safety

· Serves as an organizational expert and resource on client safety best practices, promoting a strong culture of safety across the hospital.

· Oversees the Safety Event Reporting System (SERS), including the tracking, analysis, evaluation, and reporting of safety events and trends.

· Leads and supports the investigation and management of high-risk safety events, including root cause analysis and the development and monitoring of corrective action plans.

· Develops, implements, and sustains patient/client safety improvement initiatives and strategies to enhance organizational learning and continuous improvement.

· Facilitates effective communication and collaboration with leaders and staff to identify risks, share safety-related information, and implement solutions that improve safety outcomes.

Accreditation

· Leads organizational preparation and readiness activities for Accreditation, ensuring compliance with Accreditation Canada standards and requirements.

· Coordinates the collection, review, and organization of accreditation documentation for submission to Accreditation Canada.

· Develops and facilitates education, training, and capacity-building initiatives to support accreditation readiness and continuous quality improvement across the organization.

Administration

· Provides leadership and day-to-day management of the Quality and Safety team.

· Co-chairs key quality committees and prepares briefing materials, status updates, and reports for committees, senior leadership, and the Board.

· Leads and supports quality and safety initiatives using established improvement methodologies to drive measurable outcomes.

· Oversees the coordination, analysis, and reporting of quality of life and resident experience surveys, presenting findings and recommendations to relevant committees and stakeholders.

· Develops and produces reports and dashboards to support senior leadership and the Board in monitoring performance, planning, and decision-making.

Who You Are

· You bring superior communication skills and can tailor messaging effectively to diverse audiences across all levels of the organization.

· You are a skilled influencer and relationship builder, able to engage stakeholders, establish credibility, and drive alignment while constructively challenging the status quo to enable positive change.

· You excel at simplifying complexity, translating data and information into clear, concise, and actionable insights that support decision-making.

· You are an effective and credible leader, with strong facilitation and presentation skills, capable of motivating teams and fostering collaboration in a fast-paced, client-focused environment.

· You are highly organized and adaptable, with strong time management skills and the ability to manage multiple competing priorities with confidence and composure.

· You bring proven project management, change management, quality improvement and safety expertise, along with strong skills in data collection, analysis, and report writing to support evidence-informed decision-making.

What You Bring

· Masters’ degree in healthcare, business, engineering or related field;

· Completion of courses or certifications in quality improvement, LEAN, agile/experimental design;

· Regulated Health Professional with current certificate to practice is an asset;

· Educational preparation in quality improvement, certificate in quality improvement or equivalent training in the use of quality improvement methods and tools;

· Minimum five (5) years progressive leadership and management in a health care setting preferred;

· Minimum three (3) years’ experience in identifying, implementing and monitoring safety initiatives within a health-care environment;

· Minimum three (3) years’ experience in facilitating quality improvement, applying quality improvement methods and tools and an ability to coach and mentor staff;

· Demonstrated use of various data sources (i.e. Canadian Institute of Health Information data base, interRAI, client experience surveys, demonstrated expertise in the integration and application of patient safety related investigation/reporting approaches including root cause analysis, LEAN, PDSA;

· Proficiency in use of office support software (Word, Excel, PowerPoint and Access) and quality tools software packages (i.e. Visio);

· Demonstrated ability to evaluate outcomes using a balanced scorecard perspective.

Compensation

At Baycrest, we take pride in ensuring our compensation structure is internally equitable and compliant with pay equity legislation. We believe compensation should be transparent, equitable, and reflective of your experience and growth. Our salary ranges are structured to support progression, from learning the role to demonstrating full proficiency.

For this position, the salary range is $102,072 to $127,590.

Your placement within the target hiring range will depend on your job-related knowledge, skills, abilities, and relevant education and experience, as well as considerations such as market conditions and internal equity. The starting salary will be determined using these factors to ensure fairness and consistency across the organization.

Required Skills


Required Experience