Leadership & Quality Management Surveyor| Essential Safety Requirements Surveyor
Saudi Central Board of Accreditation for Healthcare Institution (CBAHI)
Total years of experience :13 years, 7 Months
KEY ACHIEVEMENTS
• Survey healthcare facilities seeking accreditation from CBAHI, including 10+ hospitals as Leadership & Quality
Management Surveyor and 30+ as ESR Surveyor
RESPONSIBILITIES
• Survey, review, and assess the performance of organisations without bias, using expert knowledge of the accreditation
standards, expertise from the workplace, and experience of surveying.
• Adhere to CBAHI Code of Ethics and Code of Conduct and Conflict of Interest policies.
• Maintain current knowledge of CBAHI accreditation programs, services and policies by participating in ongoing
education and CBAHI development programs.
• Participate in related CBAHI surveyors’ activities.
• Maintain and improve skills and knowledge in quality improvement within the surveyor’s area of expertise.
KEY ACHIEVEMENTS
• Develop, maintain and evaluate quality improvement, patient safety and risk management programs with objective
of working toward the implementation of national and international quality standards (e.g. CBAHI and JCIA).
• CBAHI reaccreditation 2016 and 2019.
• JCIA reaccreditation 2017.
RESPONSIBILITIES
• Lead all operational activities for quality, accreditation and performance improvements.
• Advise administration, hospital heads and other clients responsible for developing or implementing quality initiatives.
• Contribute to hospital-wide strategic plans including the education, management of information, prevention and
control of infection, patient safety, general safety, and quality improvement plan.
• Coordinate performance improvement, utilization management, risk management, reengineering/reorganization and
the CBAHI, JCIA survey preparation process.
• Present education programs on variety of topics including performance improvement, risk management, CBAHI and
JCIA topics.
• Develop a customized Performance Measurement System for individual hospitals.
KEY ACHIEVEMENTS
• Develop, maintain and evaluate the quality improvement, patient safety and risk management programs with the
objective of working toward the implementation of national and international quality standards (e.g. CBAHI).
RESPONSIBILITIES
• Lead all operational activities for quality, accreditation and performance improvements.
• Advise administration, hospital heads and other clients responsible for developing or implementing quality initiatives.
• Assist clients with the analysis, interpretation, and visualization of their quality improvement data to identify and
target areas of patient care needing improvement.
• Apply performance and process improvement methodologies.
• Coordinate performance improvement, utilization management, risk management, reengineering/reorganization and
the CBAHI survey preparation process.
• Present education programs on variety of topics including performance improvement, risk management, CBAHI topics.
• Develop a customized Performance Measurement System for individual hospitals
KEY ACHIEVEMENTS
• Develop, maintain and evaluate the quality improvement, patient safety and risk management programs with the objective of working toward the implementation of national and international quality standards (e.g. JCIA).
RESPONSIBILITIES
• Lead all operational activities for quality, accreditation and performance improvements.
• Advise administration, hospital heads and other clients responsible for developing or implementing quality initiatives.
• Contribute to hospital-wide strategic plans including the education, management of information, prevention and control of infection, patient safety, general safety, and quality improvement plan.
• Assist clients with the analysis, interpretation, and visualization of their quality improvement data to identify and target areas of patient care needing improvement.
• Apply performance and process improvement methodologies.
KEY ACHIEVEMENTS
• Planned for implementation of the JCI, CBAHI, SAMSO accreditation standards.
• CBAHI accreditation 2012.
RESPONSIBILITIES
• Reviewed and presented results of quality interventions for clinical and operational performance improvements.
• Identified and championed the selection of process improvement activities across the enterprise.
• Developed and managed quality improvement strategies for the business unit.
• Assisted in the development and application of the strategic mission and vision for the business unit.
• Managed the evaluation, development and coordination of quality management initiatives for the service line to achieve clinical goals and strategic objectives.
• Promoted effective patient safety and performance improvement initiatives to improve patient care.
• Participated in the planning, development, and implementation of service line performance improvement programs.
• Assessed performance and provided training on standards and regulations impacting patient care.
• Identified organisational risks to management.
KEY ACHIEVEMENTS
• Coordinated compliance with national accreditation standards, providing associated training to staff.
RESPONSIBILITIES
• Implemented continuous improvement initiatives, reviewing their effectiveness and recommending improvements.
• Trained staff on continuous quality management and other related topics.
• Maintained Incident Reporting System database, analysed data, prepared reports, and identified Sentinel Events.
• Maintained Medication Safety Program database, analysed data, and prepared reports.
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