Healthcare Quality and CBAHI Accreditation Specialist

Location

Riyadh on-site

Employment Type

Full-time.

Job Purpose

To support the implementation, monitoring, and continuous improvement of healthcare quality and patient safety standards in accordance with the requirements of the Saudi Central Board for Accreditation of Healthcare Institutions (CBAHI). The role is responsible for ensuring organizational compliance, identifying gaps, preparing corrective action plans, and maintaining continuous readiness for accreditation surveys.

Key Duties and Responsibilities

•⁠ ⁠Develop and update the annual quality improvement plan in line with the organization’s objectives and CBAHI requirements.

•⁠ ⁠Review, implement, and monitor CBAHI accreditation standards across clinical, administrative, and support departments.

•⁠ ⁠Prepare, review, and update policies, procedures, forms, and operational guidelines.

•⁠ ⁠Conduct regular internal audits and compliance assessments.

•⁠ ⁠Identify non-conformities and performance gaps and prepare corrective and preventive action plans.

•⁠ ⁠Follow up on corrective actions and ensure timely closure of identified gaps.

•⁠ ⁠Prepare the healthcare facility for CBAHI accreditation, reaccreditation, and mock survey visits.

•⁠ ⁠Monitor clinical, operational, and patient safety key performance indicators.

•⁠ ⁠Analyze quality data and prepare periodic reports for senior management.

•⁠ ⁠Monitor incident reports, medical errors, and near-miss events.

•⁠ ⁠Participate in root cause analysis and recommend appropriate improvement actions.

•⁠ ⁠Support risk management, infection prevention, patient safety, and quality improvement programs.

•⁠ ⁠Coordinate quality and patient safety committee meetings, prepare meeting minutes, and follow up on recommendations.

•⁠ ⁠Deliver training and awareness sessions related to CBAHI standards, quality, and patient safety.

•⁠ ⁠Coordinate with Human Resources to ensure staff files, licenses, competency assessments, and mandatory training records are complete and updated.

•⁠ ⁠Ensure departments maintain required records, forms, safety documents, and emergency preparedness evidence.

•⁠ ⁠Work closely with medical, nursing, administrative, and support teams to ensure proper implementation of quality standards.

•⁠ ⁠Prepare regular reports on compliance levels, risks, deficiencies, and improvement plans.

•⁠ ⁠Lead or participate in continuous quality improvement projects and measure their effectiveness.

•⁠ ⁠Maintain the confidentiality of patient and organizational information.

•⁠ ⁠Perform any other quality-related duties assigned by management.

Educational Qualifications

•⁠ ⁠Bachelor’s degree in a healthcare-related field, Healthcare Administration, Hospital Administration, Quality Management, or a related discipline.

•⁠ ⁠Additional qualifications or professional training in healthcare quality, patient safety, risk management, or accreditation are preferred.

•⁠ ⁠Professional certifications are an advantage, such as:

 * Certified Professional in Healthcare Quality (CPHQ).

 * Healthcare Quality Management Certification.

 * Patient Safety Certification.

 * Risk Management Certification.

 * Internal Quality Auditor Certification.

Experience Requirements

•⁠ ⁠Minimum of two years of experience in healthcare quality, patient safety, or accreditation.

•⁠ ⁠Practical experience in implementing CBAHI standards.

•⁠ ⁠Previous participation in preparing a healthcare facility for accreditation or reaccreditation is preferred.

•⁠ ⁠Good knowledge of Saudi Ministry of Health regulations and other relevant healthcare regulatory requirements.

Required Skills

•⁠ ⁠Strong knowledge of CBAHI standards and healthcare accreditation requirements.

•⁠ ⁠Good understanding of quality improvement and patient safety principles.

•⁠ ⁠Ability to prepare professional policies, procedures, reports, and action plans.

•⁠ ⁠Strong analytical and data interpretation skills.

•⁠ ⁠Ability to identify gaps and develop effective improvement plans.

•⁠ ⁠Excellent communication and coordination skills.

•⁠ ⁠Strong presentation and training skills.

•⁠ ⁠Proficiency in Microsoft Word, Excel, and PowerPoint.

•⁠ ⁠Excellent documentation and organizational skills.

•⁠ ⁠Ability to work under pressure and meet accreditation deadlines.

Behavioral Competencies

•⁠ ⁠High level of professionalism and confidentiality.

•⁠ ⁠Attention to detail.

•⁠ ⁠Accountability and ownership.

•⁠ ⁠Analytical thinking and problem-solving.

•⁠ ⁠Teamwork and collaboration.

•⁠ ⁠Initiative and continuous improvement mindset.

•⁠ ⁠Flexibility and adaptability.

•⁠ ⁠Effective time management.

Key Performance Indicators

•⁠ ⁠Percentage of compliance with CBAHI standards.

•⁠ ⁠Percentage of corrective actions closed within the agreed timeframe.

•⁠ ⁠Completion and regular updating of policies and procedures.

•⁠ ⁠Staff compliance with mandatory training requirements.

•⁠ ⁠Reduction in recurring incidents and identified risks.

•⁠ ⁠Improvement in quality and patient safety indicators.

•⁠ ⁠Departmental readiness for accreditation surveys.

•⁠ ⁠Successful achievement or renewal of CBAHI accreditation.