The Role
Manages healthcare quality and patient safety systems, including audits, incident investigations, risk assessments, CAPA, quality indicators, dashboards, accreditation readiness, regulatory compliance, continuous improvement projects, policy updates, patient complaints, quality committees, and staff training. The role supports DHA inspections and standards such as JCI, CBAHI, and ISO 9001.
Summary Generated by Built In
Job Summary
1. Quality Management System
The Quality Manager is responsible for developing, implementing, monitoring, and continuously improving the organization’s healthcare quality and patient safety systems. The role ensures compliance with applicable healthcare regulations, accreditation standards, clinical policies, quality indicators, patient safety requirements, and internal procedures. The Quality Manager works closely with clinical and non-clinical departments to identify risks, monitor performance, conduct audits, investigate incidents, implement corrective and preventive actions, and promote a culture of continuous quality improvement. Should be familiar with DHA requirements as well as relevant international accreditation standards. DHA maintains healthcare standards, inspection checklists, performance measures, and regulatory requirements for licensed facilities.
Key Responsibilities
- Develop, implement, and maintain the healthcare facility’s Quality Management System (QMS).
- Develop annual quality and patient safety plans aligned with organizational objectives.
- Establish quality objectives, indicators, targets, and improvement priorities.
- Maintain quality policies, procedures, guidelines, forms, and controlled documents.
- Ensure effective document control and version management.
- Promote a culture of continuous quality improvement across all departments.
- Lead patient safety initiatives and risk-reduction programs.
- Monitor and analyze patient safety incidents, adverse events, near misses, medication errors, falls, complaints, and clinical risks.
- Coordinate incident investigation and Root Cause Analysis (RCA).
- Develop and monitor Corrective and Preventive Actions (CAPA).
- Conduct risk assessments and maintain risk registers.
- Escalate serious incidents and high-risk findings to appropriate management.
- Develop and execute annual clinical and operational audit plans.
- Conduct medical record/documentation audits.
- Monitor compliance with clinical policies, procedures, and approved guidelines.
- Audit infection prevention and control, medication management, patient identification, consent, documentation, emergency preparedness, and other quality-sensitive processes.
- Prepare audit reports and follow up on action plans.
- Track closure and effectiveness of corrective actions.
- Develop and monitor Key Performance Indicators (KPIs) and quality indicators.
- Prepare monthly and quarterly quality dashboards.
- Analyze trends, variances, and performance gaps.
- Present quality performance to senior management and relevant committees.
- Use data to identify improvement opportunities and measure outcomes.
- Coordinate organizational readiness for DHA inspections and other regulatory assessments.
- Support preparation for accreditation surveys such as JCI, CBAHI, ISO 9001, or other applicable accreditation programs.
- Conduct internal mock surveys and gap assessments.
- Monitor compliance with regulatory and accreditation requirements.
- Maintain evidence and documentation required for inspections and accreditation.
- Follow changes in applicable healthcare regulations and standards.
DHA’s regulatory framework includes facility inspection, clinical audit, performance measures, healthcare standards, and self-inspection checklists, making regulatory readiness an important component of a UAE healthcare Quality Manager role.
6. Continuous Quality Improvement- Lead Quality Improvement (QI) projects using methodologies such as PDCA, PDSA, Lean, Six Sigma, and DMAIC, where appropriate.
- Facilitate multidisciplinary quality improvement teams.
- Identify process inefficiencies and recommend evidence-based solutions.
- Measure improvement outcomes before and after interventions.
- Ensure successful improvement projects are standardized and sustained.
- Review and update clinical and operational policies.
- Ensure policies are aligned with current regulations, accreditation requirements, and evidence-based practice.
- Coordinate policy approval through appropriate committees.
- Monitor staff compliance with approved policies and procedures.
- Monitor patient complaints, feedback, and satisfaction results.
- Analyze complaints for recurring quality and safety issues.
- Coordinate investigations and corrective actions.
- Develop initiatives to improve patient experience.
- Monitor patient satisfaction and service quality indicators.
- Coordinate meetings of relevant quality and patient safety committees.
- Prepare agendas, reports, dashboards, minutes, and action trackers.
- Follow up on committee decisions and outstanding actions.
- Provide management with regular quality performance reports.
- Develop and deliver quality and patient safety training.
- Conduct awareness sessions on incident reporting, RCA, CAPA, audits, patient safety, and regulatory compliance.
- Promote staff understanding of quality objectives and organizational standards.
QUALIFICATIONS
- Bachelor’s degree in Healthcare Management, Nursing, Medicine, Pharmacy, Allied Health, Quality Management, Public Health, or a related healthcare discipline.
- Master’s degree in Healthcare Management, Quality Management, Healthcare Administration, Public Health, or related field is preferred.
- CPHQ – Certified Professional in Healthcare Quality
- Lean Six Sigma Green Belt or Black Belt
- ISO 9001 Lead Auditor / Internal Auditor
- Certified Patient Safety Professional (CPPS)
- Risk Management certification
- JCI/accreditation-related training
- 5–8+ years of healthcare quality experience, with at least 2–3 years in a Quality Manager, Quality Lead, Quality Coordinator, or equivalent role.
- Experience in hospitals, outpatient medical centers, clinics, day surgery centers, or healthcare groups.
- Experience with healthcare accreditation and regulatory inspections is strongly preferred.
- UAE healthcare experience and knowledge of applicable regulatory requirements are advantage.
Skills Required
- Bachelor's degree in Healthcare Management, Nursing, Medicine, Pharmacy, Allied Health, Quality Management, Public Health, or a related healthcare discipline
- Master's degree in Healthcare Management, Quality Management, Healthcare Administration, Public Health, or a related field
- 5-8+ years of healthcare quality experience
- At least 2-3 years in a Quality Manager, Quality Lead, Quality Coordinator, or equivalent role
- Experience in hospitals, outpatient medical centers, clinics, day surgery centers, or healthcare groups
- Experience with healthcare accreditation and regulatory inspections
- UAE healthcare experience and knowledge of applicable regulatory requirements
- CPHQ certification
- Lean Six Sigma Green Belt or Black Belt
- ISO 9001 Lead Auditor or Internal Auditor certification
- Certified Patient Safety Professional certification
- Risk Management certification
- JCI or accreditation-related training
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The Company
What We Do
Tadawi General Hospital is a Dammam-based general hospital serving patients in the Eastern Region of Saudi Arabia, including Al Khobar, Dhahran, and Qatif. Established in 1994, it provides comprehensive, integrated healthcare for different age groups through services such as surgery, laboratory care, cardiac catheterization, physical therapy and rehabilitation, inpatient pharmacy, specialized centers, emergency care, and other medical departments and clinics.
