The Role
Lead and manage the facility's quality and performance management programs, ensuring regulatory and accreditation compliance (DOH, JCI, Tasneef). Oversee KPI measurement, data collection/validation, audits, training, improvement projects, and cross-department collaboration to improve patient safety and outcomes. Supervise quality staff, report events, and guide strategic quality priorities and budgets.
Summary Generated by Built In
Job Purpose:
Responsible for planning and monitoring the consistent readiness of all quality management and quality
improvement processes under the guidance of the facility's leadership. Also responsible for ensure
effective and efficient quality data and performance management program that aims to improve patient
outcome and safety .The role oversees and coordinates facility efforts to monitor and maintain
regulatory and accreditation standards while creating a culture of quality in the facility.
Responsibilities:
- Initiates and oversees the development of a comprehensive quality improvement program
- Manages all regulatory aspects , DOH Audit/Inspection and all activities in relation to the
accreditation and certification activities at SSMC
- Ensures SSMC meets all regulatory and accreditation requirements including DOH , audits,
Tasneef and licensing requirements
- Reviews regularly the Quality program in light of changes in the needs of the organization an
in the law and policies and procedures of managerial and governmental bodies
- Ensures DoH standards for hospitals are implemented and followed in the facility
- Manages to work collaboratively with various stakeholders to ensure compliance with the
standards and recommendations
- Collaborates and partners with all the departments and practices to ensure quality and safety
priorities are implemented
- Coordinates development, implementation, and evaluation of the facility's overall quality
improvement program with the other departments
- Develops and implements systems, policies, and procedures for the identification, collection,
and analysis of performance measurement data
- Monitors the related staff performance and the quality of the studies, to ensure quality, cycle
time and budgetary control of the entire patients satisfaction research process
- Identifies the quality improvement methodology and concepts to be followed, in coordination
with management directions
- Provides strategic oversight of proactive and reactive quality improvement activities Provides
input for the department budget related to quality
- Oversees the reporting of events as required by regulatory agencies
- Acts as a resource to the staff; providing relevant training, mentoring, assessment and
development plans
- Ensures that the work of the department/section is effectively coordinated with other
departments/sections in a timely manner and is aligned to the overall facility goals
- Leads, facilitate and advise on internal quality improvement teams
- Plans and supervises the day to day activities of the section; streamlining processes wherever
possible
- Evaluates workload, conduct performance evaluation and initiate necessary disciplinary
actions
- Acts as an expert of quality and safety issues in all task forces/committees to establish
performance innovation priorities
- Provides leadership updates in the development and management of the quality priorities and
improvement initiatives: identifying trends, prioritizing and recommending improvements, and
ensuring JCIA compliance
Role-Specific Job Responsibilities
- Implementing an effective performance management system through establishment and
monitoring of quality measures and key performance indicators.
- Lead departments to identify performance measures and use data to initiate performance
improvement projects, whilst using hospital approved quality frameworks.
- Lead the reporting and management of Hospital Quality Index measures, Jawda KPIs, Clinical
Practice guidelines measures including primary data collection and/or validation, data Analysis & action plan for improvement Establishing Hospital quality index as a benchmark tool with SSMC to identify opportunities for
improvement and implement best practices.
- Maintaining accurate and reliable data collection and validation methodology and ensure
adequate collection systems and tools are in place.
- Assigning and endorsing roles for team members responsible for KPI abstraction, validation,
submission and improvements
- Implement a continuous survey readiness program to ensure continuous compliance with
accreditation requirements.
- Lead internal audits, DOH Jawda Data Certification Audit by Tasneef and liaise with relevant
department/s for action plan development and follow up to close findings within the set
period.
- Lead the implementation of a clinical audit program to ensure full compliance with clinical
practice guidelines.
- Conducting multidisciplinary hospital wide quality training (examples: JCI, Clinical audit
training, DOH KPIs data collection and validation etc.
- Overseeing the progress of KPI improvement plans and discuss/ escalate challenges identified
through JAWDA Sub-Committee, QPS Committee, CPC, SEOT and Clinical Board
Requirements
Educational Qualification:
Required:
• Bachelor's degree or equivalent in a relevant field such as quality, performance
management and clinical practice
• Master's degree in a relevant field
Specialist Certifications:
Required:
• Certified professional in health care quality CPHQ
• Certifed lean six sigma
Desired:
• Certified Quality Management (CQM) , IHI fellowship etc.
Experience:
Required:
• More than 10 years of relevant progressive experience in a similar role with 4 years
of supervisory experience
Desired:
• Experience in a large Healthcare facility
Additional Requirements:
Required:
• Proficiency in English language
• MS Office and computer proficiency
• Strong analytical and problem-solving skills
• Ability to deal with multiple issues simultaneously (multitask) and move them all towards
resolution
• Good communication skills
• Member of quality associations as IHI , ASQ and ISQUA
Desired:
• Proficiency in Arabic language
• Strong negotiation skills
• Proven organizational skills
Skills Required
- Bachelor's degree or equivalent in quality, performance management, or clinical practice
- Master's degree in a relevant field
- Certified Professional in Healthcare Quality (CPHQ)
- Certified Lean Six Sigma
- Certified Quality Management (CQM) or IHI fellowship
- More than 10 years of relevant progressive experience with at least 4 years supervisory experience
- Experience in a large healthcare facility
- Proficiency in English
- MS Office and general computer proficiency
- Strong analytical and problem-solving skills
- Ability to multitask and manage multiple issues toward resolution
- Good communication skills
- Membership in quality associations (IHI, ASQ, ISQUA)
- Proficiency in Arabic
- Strong negotiation skills
- Proven organizational skills
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The Company
What We Do
TalentOne is a UAE-based recruitment and staffing partner and a PureHealth asset. It connects skilled professionals with businesses and provides customized workforce solutions, including recruiting, payroll and administrative support, medical licensing, PRO services, and call-center/customer-service staffing. The company uses technology, AI, data analysis, and industry knowledge to make hiring efficient while helping employers build teams and candidates advance their careers.
