Director of Quality & Patient Safety

Job Purpose

In keeping with the mission of the QI & PS Department and the King Abdullah
bin Abdulaziz University Hospital, the Director of Quality Improvement and
Patient Safety Department is responsible for a hospital -wide Quality
Improvement, Patient Safety and Risk Management Program and works with
hospital administration (clinical and non-clinical), departments, and the
medical staff to monitor and evaluate the quality of delivery of patient care
services provided by the hospital. The Director also ensures proper compliance
with regulatory agencies, accrediting bodies, and hospital policies and
procedures and works to develop, implement, and maintain quality assessment
and improvement programs within the facility. This position ensures that the
quality of healthcare services rendered meets or exceeds recognized national
and international standards such as JCI, CBAHI, MOH and others.

Key Accountabilities & Responsibilities

• Initiates and oversees the development of a comprehensive quality improvement, patient safety and risk management programs, plans and provides oversight for patient safety and quality committees with accountability for ensuring organization-wide awareness.


• Instills and nurtures a culture of quality, measurement, transparency, and accountability, and will be the recognized leader at the organization in establishing standards related to Quality Improvement, Patient Safety and Risk Management.


• Provides overall direction necessary to ensure that patient care services are provided in accordance with law, regulations, accreditation standards, and any other standards deemed necessary.


• Establishes the structure for the Organization's oversight of the Quality and Patient Safety Strategy including the Quality Council and other departmental and multidisciplinary team needed to accomplish the goals and objectives of the strategy.


• Develops and implements plans, programs to support of the organization's strategic plan and to maintain an atmosphere of regulatory, and accreditation readiness.


• In collaboration with the medical, clinical, and administrative staff, participates in the monitoring, reporting, patient safety, risk management and improvement activities associated with clinical guidelines, quality/safety initiatives, and accreditation and regulatory requirements.


• Provides oversight of proactive and reactive patient safety activities including root cause analyses, failure mode effects analyses, and implementation of Sentinel Event Alerts in regards to the facilitation of process, planning, implementation, and evaluation of effectiveness of process changes.


• Proactively educates leadership and staff on quality/safety, health performance improvement activities, regulatory issues, and new guidelines.


• Provides ongoing consultation to all departments (e.g., on the development and use of indicators to evaluate and improve performance).


• Provides quality management resources to assist the departments in interpreting and complying with all phases of quality improvement and accreditation.


• Develops, updates, and maintains department policies and procedures in accordance with hospital policies, laws and regulations, and accreditation standards.


• Develops and updates job descriptions of the department as needed to reflect ongoing needs.


• Protects and models the organization's values.


• Participates in the development of planning, identification, and selection of, technology to support quality improvement, patient safety and risk management initiatives.


• Generates and prepares monthly, quarterly, and annual reports and other reports as required and directed.


• Prepares bi-annual reports to KAAUH Board regarding risk management, patient safety, performance improvement program, and other reports as requested.


• Assesses, recommends, and monitors the allocated departmental budget and assists in forecasting financial requirements and workforce plan.


• Participates in the talent acquisition process for the Quality Management and Performance Improvement Department.


• In collaboration with the Director for Training and Development, identifies development needs and creates a development plan for each staff member in QIPS department.


• Serves as a liaison with regulatory and accreditation agencies to ensure organization compliance.


• Maintains a safe, secure, and healthy work environment, which supports team performance.


• Respects patients and their families to promote a patient-centered care culture.


• Participates in, and supports, quality improving and patient safety activates as an individual or as part of multidisciplinary teams.


• Performs other job related duties as required.

Job Qualifications and Experience:
Minimum or Required: Bachelor's degree in Administration or Healthcare
profession (i.e. Medicine, Nursing, Pharmacy, Hospital Administration) in
which ‎2 years minimum experience should be in a ‎300+ bed capacity hospital in
Quality Improvement. Certified Professional in Healthcare Quality (CPHQ) or
equivalent. with ‎10 years of of Experience.
Preferred: Master's degree in Administration or Healthcare Quality and Patient
Safety or relevant science. with ‎8 years of Experience OR PhD in
Administration or Healthcare Quality and Patient Safety or relevant science.
with ‎3 years of Experience.