Healthcare Quality and CBAHI Accreditation Specialist

Role Overview

This position is focused on supporting and enhancing the standards of healthcare quality and patient safety in compliance with the Saudi Central Board for Accreditation of Healthcare Institutions (CBAHI). The main objective is to ensure the organization continuously meets accreditation requirements through systematic monitoring, implementation of improvement actions, staff training, and consistent readiness for both initial and repeat surveys.

Key Responsibilities

• Create and regularly update the organization’s quality improvement plan to align with CBAHI benchmarks and internal objectives.
• Oversee the application, review, and regular monitoring of CBAHI standards within various departments including clinical, administrative, and support services.
• Draft, revise, and implement policies, procedures, operational guidelines, and required forms.
• Carry out periodic audits and compliance checks, analyzing findings and facilitating corrective actions for non-conformities.
• Guide departments to prepare for CBAHI accreditation, reaccreditation, and internal as well as mock surveys.
• Track performance across clinical and operational indicators related to patient safety and report analysis to senior leadership.
• Coordinate and facilitate committee meetings on quality and patient safety, prepare official documentation, and monitor effective follow-up on recommendations.
• Develop and deliver educational sessions for staff regarding quality standards, patient safety, and CBAHI requirements.
• Partner with HR to ensure staff records, including licenses and training, are accurate and current.
• Contribute to risk management, infection control, and quality improvement initiatives.
• Lead or join projects aimed at continuous improvement and document their outcomes.
• Ensure strict confidentiality of sensitive information related to patients and the organization.
• Undertake any additional tasks related to quality as assigned by management.

Required Education and Credentials

• Bachelor’s degree in a healthcare-focused field, such as Healthcare Administration, Hospital Administration, or Quality Management.
• Professional development or credentials in healthcare quality, risk management, accreditation, or patient safety are highly valued (e.g., Certified Professional in Healthcare Quality, Patient Safety Certification, Internal Quality Auditor Certification).

Experience

• At least 2 years of prior work in healthcare quality, accreditation, or patient safety functions.
• Experience with implementation of CBAHI standards.
• Previous involvement with facility accreditation or reaccreditation.
• Solid understanding of Saudi Ministry of Health and other regulatory frameworks.

Skills and Competencies

• Comprehensive knowledge of CBAHI accreditation standards.
• Expertise in quality improvement methods and patient safety practices.
• Proficiency in drafting structured documentation and analytical reports.
• Efficiency in identifying areas needing corrective measures and ensuring effective resolution.
• Advanced communication and presentation capabilities.
• Strong skills with Microsoft Word, Excel, and PowerPoint.
• Exceptional organizational, time management, and documentation abilities.

Behavioral Traits

• Demonstrates strong professionalism and commitment to confidentiality.
• Detail-oriented with a proactive approach to problem-solving and continuous improvement.
• Collaborative mindset, accountability, and adaptability to shifting priorities.

Key Performance Measures

• Rate of organizational compliance with CBAHI standards.
• Timeliness in closing corrective actions.
• Regular updates and completeness of policy documentation.
• Staff completion rates for mandatory training.
• Reduction in repeating errors and identified risks.
• Enhanced patient safety and quality indicators.
• Readiness for accreditation evaluations.
• Successful achievement or renewal of CBAHI accreditation status.