Job Description

Responsible for interpreting, defining, implementing, coordinating, monitoring, evaluating and reporting the quality improvement and patient safety program for the organization and the organization's adherence to DOH and JCI standards.



• Standards and Objectives Expertise: Possesses in-depth knowledge of the standards, measurable elements, and objectives of the Department of Health (DOH) and Joint Commission International (JCI).
• Quality Improvement Plan Development: Develops and maintains the hospital's quality improvement (QI) plan.
• Implementation and Follow-Up: Effectively participates in the implementation and follow-up of QI plan activities.
• Quality Improvement Initiatives: Undertakes various quality improvement initiatives and activities.
• Resource for Departments: Serves as a resource to all departments, divisions, units, and ambulatory services, and establishes committees related to Quality Assurance.
• Cost-Effective Resource Utilization: Promotes and facilitates cost-effective resource utilization related to infection control policies and procedures.
• Problem Area Prioritization: Establishes priorities for investigating problem areas based on their potential adverse impact on patient care.
• Patient Care Evaluation: Develops and monitors effective patient care review and evaluation mechanisms to ensure desired results are achieved.
• Technical Guidelines: Directs the implementation and maintenance of technical guidelines and frameworks within which the quality of care is evaluated.
• Liaison with Quality Facilitators: Coordinates with quality facilitators to manage staff education, variance collection, and analysis.
• System-Wide Variance Database: Establishes and manages a system-wide variance database for benchmarking, system improvement opportunities, length of stay, and resource management.
• Continuous Quality Improvement: Provides ongoing assessment and support for continuous quality improvement, quality assurance, and risk management priority programs.
• Medical Record Evaluation: Evaluates patients' medical records to identify areas of concern and plans for improvement.
• Information Communication: Communicates appropriate information from studies and data sources to relevant committees, departments, and individuals.
• Best Practice Models: Identifies and shares best practice models and care processes that achieve optimal patient outcomes, enhance patient/family and staff satisfaction, are cost-effective, and resource-appropriate.
• Record Maintenance: Maintains all necessary records pertinent to DOH, JCI, and Environmental Health and Safety Management System (EHSMS) processes.
• Meeting Facilitation: Facilitates Quality Improvement plan meetings.
• Monthly Reporting: Submits monthly reports of quality activities to the Quality and Patient Safety (QPS) Committee.
• Document Management: Maintains records of policies, procedures, guidelines, forms, and other documents, ensuring circulation of current documents and de-circulation of expired ones.
• Quality Assurance Activities: Maintains records of all quality assurance activities.
• Educational and Technical Assistance: Provides educational and technical assistance to committees and departments in meeting their quality assurance objectives.
• Clinical Space Management: Actively involved in all aspects of clinical space design, construction, and hygiene.
• Administrative Responsibilities: Performs administrative duties and justifies the need for training in the quality assurance process, working with appropriate groups to initiate training.
• Accreditation Compliance: Coordinates and monitors all Joint Commission on Accreditation compliance activities and participates in the survey process, including mock surveys.
• Annual Evaluation: Conducts an annual evaluation of the Quality Improvement program and submits reports to the QPS committee.
• Training Program Development: Develops training/orientation programs for key members to facilitate system expansion and standardization.


• Educational Background: Graduate, preferably in a science stream.
• Experience: At least one year of experience in healthcare quality.
• Professional Growth: Takes responsibility for own continued professional growth beyond minimum preparation. Understands management objectives and is capable of implementing a system approach.
• Certifications: Certified Professional in Healthcare Quality (CPHQ) or other quality certificates are desirable but not mandatory.
• Language Skills: Excellent command of oral and written English; knowledge of Arabic is advantageous but not essential.
• Service Delivery: Ability to review procedures and implement new models of service delivery to meet client and organizational requirements.
• Commitment to Quality: Demonstrated commitment to quality outcomes and the ability to consult with staff regarding continuous improvement.
• Approach: Possesses a "can do" and flexible approach.
• Communication and Organizational Skills: Highly developed communication and organizational skills at all levels.
• Compassionate Care: Ability to provide compassionate care that respects patients' cultural preferences.
• Computer Skills: Proficient in Microsoft Word and Excel.
• Autonomy and Teamwork: Ability to work autonomously with minimal supervision and as part of a team within a complex clinical setting.