Policies and Guidelines Administrator

Policy Development & Coordination

• Coordinate the development, review, and approval of new and existing hospital-wide policies, procedures, and clinical guidelines in collaboration with subject matter experts.
  
• Manage the policy lifecycle, ensuring documents are reviewed and updated according to scheduled timelines and in response to emerging evidence or regulatory changes.
  
• Facilitate policy working groups and committee meetings, preparing agendas, documenting minutes, and tracking action items to ensure timely progress.
  
• Support the Director of Patient Safety in translating strategic safety initiatives into operational policies and procedures.
  
• Ensure all policies align with the hospital’s mission, vision, and values while meeting international accreditation standards.
  

Document Management & Control

• Maintain a centralized, version-controlled repository for all hospital policies, procedures, and clinical guidelines.
  
• Implement and manage a document control system that ensures only current, approved versions are accessible to staff.
  
• Establish and enforce standardized templates and formatting guidelines for all policy documents to ensure consistency and professionalism.
  
• Track policy expiration dates and proactively initiate review cycles with relevant stakeholders.
  
• Ensure proper archival of obsolete or superseded documents in accordance with records management policies.
  

Quality Assurance & Compliance

• Review all policy drafts for clarity, consistency, alignment with regulatory requirements, and adherence to approved templates.
  
• Verify that all policies cite appropriate evidence-based sources and reference applicable laws, regulations, and accreditation standards.
  
• Collaborate with the Quality and Patient Safety directorate to ensure policies reflect current best practices and safety requirements.
  
• Support internal and external audit preparations by ensuring policy documentation is complete, current, and readily accessible.
  
• Assist in identifying gaps in existing policies and recommend areas requiring new or revised guidance.
  

Stakeholder Engagement & Communication

• Liaise with clinical and administrative department heads to facilitate policy development and gather input from frontline staff.
  
• Coordinate the dissemination of new and revised policies to all relevant stakeholders through established communication channels.
  
• Develop and deliver training or orientation sessions on the policy development process and document control procedures.
  
• Serve as the primary point of contact for staff inquiries regarding policy availability, version status, and interpretation.
  
• Support the Director of Patient Safety in communicating policy changes and their implications to hospital leadership and committees.
  

Continuous Improvement

• Monitor external regulatory and accreditation requirements (e.g., JCI, Ministry of Health) to ensure policies remain current and compliant.
  
• Solicit feedback from policy users to identify opportunities for improving policy clarity, usability, and accessibility.
  
• Recommend enhancements to the policy management system and processes to increase efficiency and effectiveness.
  
• Stay informed about best practices in healthcare policy development and document control from peer institutions and professional bodies.
  
• Contribute to the development of key performance indicators for policy management and track compliance with policy review timelines.