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Manager, Accreditation

2 months ago

Riyadh, Saudi Arabia King Faisal Specialist Hospital and Research Centre Full time

Manages and oversees the Accreditation plan in line with the hospital mission, vision, provision of service and strategic objectives. Assume responsibility of leading, organizing and executing all accreditation related activities.

**Essential Responsibilities and Duties**:
1. Manage the development and revision of Accreditation Section policies & procedures to ensure standardization among KFSH&RC sites, serve as a healthcare quality expert, and change agent in accreditation, safety and risk and PI. Promote a culture of continues improvement that leads to sustained results and optimal performance

2. Develops a monitoring process to measure compliance with the accreditation standards including IPSG and lead its execution. Prepare and present related periodic reports/

3. Collaborates internally with QM department and sections in identifying areas for improvement and leads the efforts to implement the improvement and support HRO related activities.

4. Collaborates externally with hospital’s entities and services to identify areas for improvement within accreditation and compliance to effectively develop, lead and execute efforts to implement the improvement.

5. Generates reports on compliance findings related to regular tracers, audits and quality rounds to identify areas for improvement and provide specific finding reports with detailed analysis as needed.

6. Identify sources of valid and reliable information and metrics to monitor performance trends. Analyze and integrates information from different sources and provide recommendations to enhance actions and decision-making.

7. Demonstrates expertise in the use of analytical and statistical tools and techniques to provide in depth view and recommendations

8. Promotes hospital wide awareness of accreditations standards and encourages participation and leader involvement.

9. Develops an annual educational plan regarding accreditation standards and methodology.

10. Utilizes Quality improvement methodologies to evaluate, measure capabilities and redesign operations to achieve the desired outcomes and Track, monitor and communicate progress to all stakeholders. Additionally, Implement accountability structures and controls required to deploy, monitor and ensure compliance with the work changes

**Education**:
Master’s or Bachelor's Degree in Nursing, Quality, Healthcare, or other related discipline is required.

**Experience Required**:
**Grade 11**:
Six (6) years of related experience with Master’s, or eight (8) years with Bachelor’s Degree, including three (3) years’ experience in quality and two (2) years in a senior/ supervisory capacity position is required.

**Grade 12**:
Eight (8) years of related experience with Master’s, or ten (10) years with Bachelor’s Degree, including four (4) years’ (Grade 11) related experience is required.

**Other Requirements(Certificates)**:

- Certified Professional Healthcare Quality is preferred.
- Certification in Lean, Six Sigma and/or other PI methodologies are preferred.
- Certification in Healthcare Accreditation is preferred.
- Audit and compliance certification is preferred.
- PMP is preferred.

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