Director - Clinical Governance

Role Overview

Governance and Strategic Planning

• Define the vision and goals for clinical governance, medical quality, patient safety, clinical risk, and accreditation.
• Develop strategic and operational plans, budget planning, implementation timelines, progress reporting, and effectiveness monitoring.
• Establish governance policies, procedures, and standards aligned with regulatory and accreditation requirements.
• Maintain the clinical risk register and ensure mitigation actions and leadership escalation are in place.

Accreditation and Compliance

• Develop and implement service-line accreditation plans in compliance with accreditation bodies such as CBAHI and JCI.
• Lead audits against MOH and regulatory clinical standards and guidelines.
• Develop corrective action plans from audit findings and monitor implementation.
• Collaborate with patient relations, operations, and experience leaders to maintain quality standards.

Clinical Guidelines and Risk

• Oversee the evidence-based Clinical Guidelines Program, including development, review, implementation, dissemination, compliance monitoring, and improvement.
• Conduct clinical risk assessments and analyses of clinical practices and operational procedures.
• Maintain incident reporting systems, coordinate multidisciplinary incident responses, and monitor learning outcomes.
• Ensure governance requests, complaints, incidents, feedback, coroner requests, and medico-legal issues receive timely responses.

Quality Improvement

• Analyze clinical and governance data to identify performance trends, risks, and improvement opportunities.
• Design and lead initiatives that improve patient safety, clinical outcomes, and continuous improvement.
• Develop and monitor metrics to measure the effectiveness of quality improvement initiatives.
• Share findings and lessons learned with stakeholders to support organization-wide learning.

Stakeholder Engagement

• Build relationships with internal and external stakeholders, including regulatory authorities and accreditation bodies.
• Communicate governance updates, results, and initiatives across the organization.
• Facilitate cross-departmental collaboration and represent Clinical Governance in leadership meetings and external forums.

People Leadership

• Set and approve team performance goals, conduct evaluations, allocate work, and monitor adherence to policies and procedures.
• Determine department manpower requirements and identify annual training needs.
• Manage team administrative requests, including vacation, departures, and related HR matters.

Required Skills and Qualifications

• MBBS with an active medical license in Saudi Arabia and board certification in a primary care specialty from SCFHS or an equivalent body.
• At least 10 years of experience practicing as a consultant in a hospital setting.
• Arabic and English communication skills, clinical risk and incident investigation expertise, and clinical data analysis proficiency.
• Knowledge of healthcare regulations and accreditation standards, including MOH, CBAHI, and JCI.
• Proficiency in Microsoft Office Suite and healthcare quality management systems; CPHQ or CPPS certification is preferred.