Policies & Guidelines Administrator at The African Medical Centre of Excellence (AMCE)

Job Purpose

• The Policies and Guidelines Administrator will support the development, implementation, and maintenance of a comprehensive policy and clinical guidelines framework at AMCE. This role is essential to ensuring that all hospital policies, procedures, and clinical guidelines are systematically developed, regularly reviewed, and effectively disseminated to support evidence-based practice and regulatory compliance. The role holder will work collaboratively with clinical and administrative departments to ensure standardization and accessibility of all guidance documents.

Key Accountabilities/Responsibilities

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• Ensure proper archival of obsolete or superseded documents in accordance with records management policies.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.

Qualifications & Experience

• Bachelor’s degree in Health Administration, Nursing, Public Health, Law, or a related field. A Master’s degree is an advantage.
• Minimum of 3-5 years of experience in a healthcare setting.
• Mandatory: At least 2 years of direct experience in policy development, document control, quality improvement, or clinical governance within a hospital or healthcare organization.
• Demonstrated knowledge of accreditation standards (e.g., JCI, ISO) and regulatory requirements in healthcare.
• Experience with document management systems and version control processes is highly desirable.

Skills & Competencies

• Document Management Expertise: Strong understanding of policy lifecycle management, version control principles, and document control best practices.
• Attention to Detail: Meticulous approach to reviewing documents for accuracy, consistency, and adherence to templates and formatting standards.
• Organizational Skills: Excellent ability to manage multiple concurrent policy reviews, track deadlines, and maintain an organized document repository.
• Technical Proficiency: Proficiency in Microsoft Office Suite (particularly Word for template management) and experience with document management software or databases.
• Writing & Editing: Exceptional written communication skills with the ability to edit complex clinical and administrative content for clarity and consistency.
• Collaboration & Influence: Ability to work effectively with diverse stakeholders, including clinical leaders, department heads, and committee members.
• Process Orientation: Systematic approach to establishing and following procedures to ensure consistent outcomes.
• High Integrity: Demonstrated professionalism and discretion in handling confidential and sensitive organizational documents.