- Develop, implement, and maintain the hospital's Quality Management System (QMS).
- Lead organization-wide quality improvement and patient safety initiatives.
- Establish quality policies, procedures, and clinical governance frameworks.
- Monitor compliance with regulatory authorities, accreditation standards, and hospital policies.
- Conduct quality assessments, gap analyses, and process improvement initiatives.
- Coordinate internal and external quality audits.
- Lead hospital readiness for JCI, DOH, CAP, and other accreditation programs.
- Ensure continuous compliance with accreditation standards.
- Coordinate corrective and preventive action (CAPA) plans following audits.
- Monitor implementation of quality improvement recommendations.
- Develop, monitor, and analyze hospital Key Performance Indicators (KPIs).
- Lead JAWDA KPI data collection, validation, certification, and reporting.
- Prepare monthly quality dashboards and trend analysis reports.
- Present quality performance reports to leadership committees and department heads.
- Recommend action plans based on quality performance outcomes.
- Lead patient safety initiatives across all departments.
- Monitor incident reporting systems and root cause analyses.
- Facilitate implementation of corrective and preventive actions.
- Promote a culture of safety and continuous improvement.
- Plan and conduct internal quality audits.
- Coordinate external regulatory inspections and accreditation surveys.
- Monitor audit findings and ensure timely closure of corrective actions.
- Develop and review hospital-wide policies and procedures.
- Ensure document control and compliance with QMS requirements.
- Maintain quality documentation and records.
- Conduct quality awareness and patient safety training programs.
- Educate staff on quality standards, JCI requirements, and QMS processes.
- Support competency development related to quality management.
- Promote the hospital's vision, mission, and quality objectives.
- Collaborate with department heads to improve operational performance.
- Participate in strategic planning for quality and patient safety.
- Foster multidisciplinary collaboration and effective communication.
- Support staff recruitment, retention, and professional development initiatives.
- Bachelor's Degree in Healthcare Administration, Hospital Administration, Nursing, Business Administration, or a related healthcare field.
- Master's Degree is preferred.
- Certified Professional in Healthcare Quality (CPHQ) preferred.
- Certified Internal Auditor or Lead Auditor qualification is an advantage.
- JCI Accreditation training is preferred.
- Minimum 5–8 years of experience in healthcare quality management.
- At least 3–5 years in a leadership role within an accredited healthcare facility.
- Experience with DOH Abu Dhabi regulations, JCI Accreditation, and JAWDA KPIs is mandatory.
- Quality Management Systems (QMS)
- JCI Accreditation Standards
- DOH Regulations
- JAWDA KPI Management
- Clinical Governance
- Patient Safety Programs
- Risk Management
- Root Cause Analysis (RCA)
- Performance Improvement (PI)
- Internal & External Auditing
- Policy Development
- Data Analysis & Reporting
- Microsoft Office Suite (Advanced Excel & PowerPoint)
- Strong communication and presentation skills
- Leadership and team management
- Primarily office-based within the hospital environment.
- May require movement between departments and hospital facilities.
- Prolonged computer use and participation in audits, meetings, and inspections.
- JCI Accreditation Compliance
- DOH Regulatory Compliance
- JAWDA KPI Performance
- Audit Completion Rate
- Corrective Action Closure Rate
- Incident Reporting & RCA Completion
- Policy Review Compliance
- Staff Quality Training Completion
- Patient Safety Indicator Performance
- Departmental Quality Improvement Project Completion
Skills Required
- Bachelor’s degree in Healthcare Administration, Hospital Administration, Nursing, Business Administration, or a related healthcare field
- Master’s degree
- 5–8 years of experience in healthcare quality management
- 3–5 years of leadership experience within an accredited healthcare facility
- Experience with DOH Abu Dhabi regulations
- Experience with JCI Accreditation
- Experience with JAWDA KPIs
- Certified Professional in Healthcare Quality (CPHQ)
- Certified Internal Auditor or Lead Auditor qualification
- JCI Accreditation training
- Knowledge of Quality Management Systems, clinical governance, patient safety, risk management, root cause analysis, performance improvement, auditing, policy development, and data analysis
- Advanced proficiency in Microsoft Excel and PowerPoint
- Strong communication, presentation, leadership, and team management skills
What We Do
Royal is a leading provider of services and customized software to the Health Care industry. Headquartered in New York, NY we serve a broad client base across North America. Royal's leadership team combined, offer over 70 years of collective experience in technology, financial services, management consulting, and healthcare fields. Together these complimentary disciplines ensure best practices and tailored innovation in the application of technology to solve our client's unique challenges and achieve measurable business results. We understand information is more than just getting data from point A to point B. There are many operational and technology factors involved to support the needs of health care firms. Information in the right hands, at the right time, and for the right cost remains a key factor that differentiates successful companies from the rest of the pack. Managed solutions and information management offer new options that leverage the strength of information, workflow automation, and cloud services. Our product offerings focus on patient and provider workflows, delivered through a suite of integrated products: - RoyalPay® for insurance verification, estimation and streamlined payment processing - Royal Kiosks™ for patient pre-registration, paperless on-site registration, access and engagement - RoyalMD® for complete practice and referral management - Royal Forms™ for secure electronic forms - Royal Alerts™ for robust messaging and notifications - Report Guard® for encryption, connectivity, and interoperability services Royal Solutions Group owns and operates RoyalPay, Inc., its revenue cycle management division, and its own Health Information Exchange (HIE), offering centralized data management and robust interoperability capabilities with any third party system. Contact us today for a customized analysis of how Royal Solutions can create value for your business. Email: [email protected] | Phone: 646.405.4878
