Director of Quality and Risk Management

Job Purpose:

Oversees the development and implementation of organization wide quality and risk management programs; ensuring full compliance of the Fakeeh Health Care facility with regulatory and accrediting bodies. Champions and acts as the ultimate quality and patient safety custodian.

Key Responsibilities and Duties

• Provides day-to-day oversight and direction of the Quality and Risk Management Department functional tasks and activities, namely QRM documents management, risk management, data management, audits, reviews and performance improvement activities.
• Manages day-to-day logistics of the QRM department including decisions on work assignments and schedules of members of the department, recruitment and annual evaluation. Responsible for developing skills and competencies of members of the department.
• Regulatory and Accreditation Compliance: Leads and coordinates all activities related to compliance with local and international healthcare regulations and standards. Manages the hospital’s accreditation processes, ensuring adherence to criteria set by accrediting bodies. Provides and enhances quality and safety excellence programs, aligning them with guidance on center of excellence accreditation that meets hospital goals to improve patient outcomes and operational efficiencies.
• Policy Development: Oversees and assists as needed in the process of development and revision of hospital policies and procedures to enhance quality, compliance, and safety. Ensure that all policies reflect current regulations and best practices.
• Data Management: Responsible for identifying suboptimal trends in data collected on regular basis and in bringing variations to the attention of leaders and end users. Ensure timely collection, analysis, and interpretation of quantitative and qualitative data for key performance indicators (KPIs). Has the ultimate responsibility to ensure that collected data are sensible, validated, properly displayed and are shared with involved staff in timely manner.
• Performance Improvement Projects: Leads and manages performance improvement initiatives that focus on enhancing patient safety and quality of care. Utilize different methodologies to drive changes and achieve better outcomes.
• Oversees the development and maintenance of QRM documents.
• Oversees the quality of clinical documentation by analyzing quantitative review data (collected by medical informatics) and qualitative review data (jointly collected with medical and nursing leadership). Addresses suboptimal performance with involved leaders and in assigned committees.
• Safety Campaigns and Awareness activities: Organizes and spearheads safety-related campaigns and observance days to promote a culture of safety within the hospital. Develops educational content and events that engage and inform staff about critical safety issues and best practice.
• Oversees risk management tasks assigned to the risk manager including OVR analysis and interpretation and collaborates in design and development of mitigating plans and programs and oversees the development of relevant policies and procedures related to risk identification, risk management and risk mitigation. Covers the role of quality and risk manager during leaves or absences of the latter.
• Safety Culture: Conducts safety culture surveys and assessments to gauge current practices and areas needing attention. Perform rounds and use tracers to ensure compliance with national and accreditation standards and International Patient Safety Goals (IPSG).
• Implements and assigns training programs, in coordination with the Academic Training Affairs Department within the organization involving all staff and focusing on quality improvement methodologies and tools, risk assessment, policy development, data management and interpretation, just culture, investigation of occurrence and accreditation.
• Attends and actively participates in hospital committees as applicable.
• Participates in Leadership Rounds and maintains a database on all feedback and action taken.
• Develops a Quality and Risk management Department orientation and ongoing in-service program in line with the Human Capital Management and the Academic and Training Affairs.
• Participates in the Fakeeh Care Budget process once per year and as per the outline within the policy.

All Fakeeh Care employees are responsible for continuous improvement, including:

• Performing all duties and tasks in a manner that supports Fakeeh’s Person-Centered care values.
• Acts as major advocate for patients’ safety
• Actively contributing to continuous improvement initiatives, within the scope of the role.
• Adherence to safety protocols and proactively seeking to address any job-related safety concerns.
• Maintaining strict confidentiality of all sensitive information accessed or encountered during work.
• Complying with cybersecurity policies and standards to protect Fakeeh’s systems and participating in awareness training and initiatives to prevent cyber threats.
• Adhering to and upholding Fakeeh Care’s code of conduct, policies and ethical standards.
• Completion of mandatory education as per the requirement, at least one month prior to expiration.

Requirements

Skills and Abilities:

• Computer Literacy.
• Communication Skills.
• Good Analytical Skills and Critical Thinking.
• Ability to interpret studies, report, literature and regulations and apply it to work processes.
• Judgement and decision making skills.
• Organizational skills and time management skills.
• Ability to maintain highest ethical standards in the work environment.
• Mastering and practicing the following skills:
  • Methods and processes of improvement
  • Data aggregation, validation, and analysis
  • Risk identification and management

Experience: 5+ years’ of experience in quality and performance improvement with 4 years in managerial level

Education: Bachelor’s degree in healthcare administration, Nursing, Medical Science, or related Medical / clinical field (master’s degree preferred). Relevant certifications in quality management, risk management, or patient safety (e.g., Certified Professional in Healthcare Quality, Certified Professional in Patient Safety) are a must.

Language: Excellent command of oral and written English and Arabic.

Licenses / Certifications: N/A