Job Summary

Key Responsibilities

Quality Management

• 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.

Accreditation & Regulatory Compliance

• 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.

Performance Management

• 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.

Patient Safety

• 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.

Quality Audits

• Plan and conduct internal quality audits.
• Coordinate external regulatory inspections and accreditation surveys.
• Monitor audit findings and ensure timely closure of corrective actions.

Documentation & Policy Management

• Develop and review hospital-wide policies and procedures.
• Ensure document control and compliance with QMS requirements.
• Maintain quality documentation and records.

Training & Staff Development

• 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.

Leadership Responsibilities

• 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.

Education

• Bachelor's Degree in Healthcare Administration, Hospital Administration, Nursing, Business Administration, or a related healthcare field.
• Master's Degree is preferred.

Certifications

• Certified Professional in Healthcare Quality (CPHQ) preferred.
• Certified Internal Auditor or Lead Auditor qualification is an advantage.
• JCI Accreditation training is preferred.

Experience

• 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.

Knowledge & Skills

• 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

Physical Requirements

• 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.

Key Performance Indicators (KPIs)

• 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