Director - Clinical Governance

The Director – Clinical Governance leads the Clinical Governance function and agenda for Bupa, ensuring the organization's commitment to clinical excellence, patient safety, excellence in medical information and clinical guidelines and regulatory compliance for healthcare authorities and accreditation bodies. The role leads the development and implementation of a comprehensive clinical governance framework, fostering a culture of continuous improvement and risk management. In addition, the Director oversees clinical risk assessments, mitigation strategies, and conducts thorough investigations into patient incidents, while supporting cross-functional efforts to comply with regulations and provide excellence in patient care

Medical Quality, Patient Safety, Clinical Risk & Institutional Accreditation Framework Development

·        Define the vision and goals for Clinical Governance, Medical Quality and Patient Safety, Clinical Risk, and Accreditation.

·        Develop and set the strategic and operational plan for the Clinical Governance function, incorporating budget planning.

·        Prepare the execution plan and timeline for implementing the Medical Quality and Patient Safety strategic plan and follow up on implementation phases.

·        Establish governance policies, procedures, and standards in line with regulatory and accreditation requirements.

·        Collaborate with senior management to ensure alignment on strategic objectives.

·        Submit periodic progress reports on strategic plans and operations.

·        Ensure the strategy is continuously updated to include relevant local and national requirements, and develop processes to monitor its effectiveness.

·        Develop and maintain the Clinical Risk Register and ensure mitigation actions are in place, with appropriate escalation to Bupa leadership for patient safety risks.

Develop and implement plans for accreditation of service lines in compliance with accreditation bodies (e.g., CBAHI, JCI, etc.).

Clinical Guidelines & Compliance Oversight

·        Contribute to the development of clinical policy, ensuring the suite of clinical policies, procedures, and guidelines is complete, current, evidence-based, and appropriately catalogued.

·        Ensure robust and integrated governance arrangements are in place across all medical services, in line with best practice.

·        Lead audits of compliance with MOH and regulatory clinical standards and guidelines.

·        Provide strategic oversight and governance of the organization's Clinical Guidelines Program, ensuring the development, review, implementation, dissemination, compliance monitoring, and continuous improvement of evidence-based clinical guidelines through an effective governance framework, multidisciplinary engagement, and organizational adoption to enhance quality, patient safety, and clinical outcomes.

·        Analyze qualitative and quantitative data resulting from governance and clinical audit projects.

·        Conduct workshops and training sessions for staff on compliance requirements.

·        Develop corrective action plans based on audit findings and monitor their implementation.

Collaborate with patient relations, operations, and experience leaders to ensure quality standards are met

Clinical Risk Management and Incident Reporting

·        Maintain quality patient care, identify patient safety issues, and implement learning outcomes and areas for improvement across all services.

·        Lead the governance team to ensure all clinical governance requests, complaints, incidents, patient feedback, coroner requests, and medico-legal issues are responded to in a timely manner.

·        Conduct regular risk assessments and analyses of clinical practices and operational procedures.

·        Develop and maintain systems for incident reporting and the capture of learning outcomes.

·        Monitor compliance with risk management protocols across clinical services.

·        Coordinate multidisciplinary teams to effectively respond to clinical incidents.

·        Promote incident reporting across clinical services and ensure incidents are reported, acted upon, and outcomes monitored within all clinical departments.

Utilize data and analytics to identify trends and patterns indicative of potential risks in healthcare delivery

Clinical Quality Improvement Initiatives

·        Analyze clinical data to identify performance trends and areas for improvement.

·        Design and lead initiatives aimed at enhancing patient safety and clinical outcomes.

·        Collaborate with clinical staff to implement quality improvement strategies and embed a culture of continuous improvement.

·        Develop and monitor metrics to measure the effectiveness of quality improvement initiatives.

Share findings and lessons learned with relevant stakeholders to support organization-wide learning

Stakeholder Engagement and Communication

·        Foster effective relationships with internal and external stakeholders, including regulatory authorities and accreditation bodies.

·        Regularly communicate governance updates, results, and initiatives across the organization.

·        Facilitate cross-departmental collaboration to enhance clinical governance and ensure alignment.

·        Represent the Clinical Governance department in leadership meetings and external forums.

Any other duties as assigned by the line manager

Administrative & People Leadership

·        Set and approve performance goals for team members and manage their annual performance evaluations.

·        Monitor and ensure team members' adherence to approved policies and procedures.

·        Monitor subordinates' performance and assign daily tasks in line with departmental priorities.

·        Determine the manpower requirements of the Clinical Governance department in accordance with organizational policies.

·        Identify annual training needs for the team and evaluate the effectiveness of training provided.

·        Manage administrative requests from team members, including vacation, departures, and related HR matters.

Any other duties as assigned by the line manager

•         Proven leadership, team management, and organizational development capabilities.
•         Expertise in clinical risk management, incident investigation, and root cause analysis (RCA) methodologies.
•         Proficiency in clinical data analysis and use of analytics to identify trends and drive quality improvement.
•        Experience working across diverse healthcare environments is an advantage.
•         Excellent written and verbal communication skills in both Arabic and English.
• Proficient in Microsoft Office Suite and healthcare quality management systems
•         Medical degree (MBBS) with an active medical license in the Kingdom of Saudi Arabia.
•         Board certification in a primary care specialty by the Saudi Commission for Health Specialties (SCFHS) or equivalent.
•         Minimum 10 years of experience practicing as a Consultant in a hospital setting.
•         Professional certification in healthcare quality preferred (e.g., CPHQ, CPPS).
•         Deep clinical knowledge and ability to evaluate healthcare practices, standards, and guidelines.
• Strong knowledge of healthcare regulations, accreditation standards, and compliance requirements (MOH, CBAHI, JCI).

Medical and Surgery