Accreditation Coordinator

Job Title CBAHI Consultant (Part-Time) Reporting ToChief Executive Officer / Quality & Patient Safety Director Employment Type Part-Time / Project-Based
Job Purpose To lead, guide, and support the healthcare facility in achieving and maintaining CBAHI accreditation through gap analysis, policy development, staff training, internal audits, and full readiness for official survey visits.
Key Duties & Responsibilities1. Accreditation & Compliance Conduct a comprehensive gap analysis against current CBAHI standards. Develop and monitor CBAHI implementation roadmap and timeline. Ensure compliance with CBAHI chapters including:Governance & Leadership Patient Safety Infection Prevention & Control Quality Improvement Facility Management & Safety Human Resources Medical & Clinical Services2. Policies, Procedures & Documentation Review, update, and standardize policies, procedures, and forms in line with CBAHI requirements. Ensure proper document control system (versioning, approvals, dissemination). Align internal policies with MOH, SCFHS, and Saudi laws where applicable.3. Training & Awareness Conduct CBAHI awareness sessions for leadership and staff. Train department heads on standards interpretation and evidence preparation. Coach teams on tracer methodology and survey readiness.4. Internal Audits & Mock Survey Plan and conduct internal audits across all departments. Lead mock surveys simulating official CBAHI assessment. Identify non-conformities and ensure corrective action plans (CAPs) are implemented.5. Survey Preparation & Support Support the organization during CBAHI survey visits (on-site or virtual). Coordinate with CBAHI surveyors and facility leadership. Ensure availability of required evidence, staff readiness, and compliance.6. Continuous Improvement Establish KPIs related to quality and patient safety. Support post-accreditation sustainability and re-accreditation readiness.
Qualifications & Experience Mandatory Healthcare background (Medicine, Nursing, Quality, or Healthcare Administration). Minimum 5–10 years experience in healthcare quality and accreditation. Proven hands-on experience with CBAHI accreditation (at least one successful survey). Strong knowledge of Saudi healthcare regulatory environment. Preferred Certified CBAHI Surveyor (current or former). Experience with multi-site healthcare organizations. Additional exposure to JCI / NABH / ISO is an advantage.
Key Competencies Expert knowledge of CBAHI standards Strong auditing and analytical skills Excellent communication and training skills Ability to work independently and deliver results under timelines