أخصائي اعتماد

Responsible for leading and coordinating all accreditation and compliance activities related to Facility Management across the healthcare organization. This role ensures that facility operations—including safety, maintenance, environment of care, infection control, and emergency preparedness—meet the standards of national and international accreditation bodies such as CBAHI, JCI, and CAP. The specialist works closely with site facility teams, quality management, and leadership to maintain continuous readiness and alignment with healthcare regulatory and accreditation requirements. Organizational Accountabilities Promote a culture of compliance, safety, and continuous improvement within the Facility Management division. Ensure Facility Management policies and procedures align with organizational standards and accreditation requirements. Collaborate with Quality, Safety, and Risk Management departments to ensure integration of accreditation standards into daily operations. Support leadership in strategic planning, audits, and facility readiness assessments for accreditation surveys. Contribute to organizational performance improvement initiatives related to environmental safety, maintenance, and sustainability. Functional Accountabilities Review, interpret, and apply accreditation standards (CBAHI, JCI, NFPA, etc.) relevant to Facility Management. Coordinate and prepare documentation, evidence, and reports for accreditation surveys. Conduct internal audits and mock surveys to ensure compliance with facility standards. Develop and deliver training programs for facility staff on accreditation-related topics. Provide coaching and guidance to ensure consistent understanding of standards across facilities. Track and report compliance metrics, deficiencies, and corrective action plans. Prepare comprehensive readiness and gap analysis reports for management review. Liaise with engineering, housekeeping, biomedical, and safety teams to align practices with accreditation standards. Participate in multidisciplinary committees such as Environment of Care (EOC) and Safety Committees. Continuous Improvement: Recommend process improvements based on survey findings, trends, and best practices. Stay up to date with evolving accreditation and regulatory requirements in the healthcare sector. Key Contacts Key Internal Stakeholders Facility Management Director Facilities Management Team (engineers, supervisors, technicians) Other Hospital Departments (HR, Procurement, Quality, Infection Control) Key External Stakeholders External contractors, service providers, and regulatory authorities (as required) Knowledge and Experience 5–8 years of experience in healthcare facility management, quality, or accreditation roles. Strong understanding of CBAHI, JCI, NFPA, and Ministry of Health regulations related to facility safety, maintenance, and environmental care. Education and Certifications Bachelor’s degree in Engineering (Mechanical, Electrical, Biomedical, or Facility Management) or related field is required. Accreditation-related certifications (e.g., Certified Healthcare Facility Manager - CHFM, Certified Healthcare Safety Professional - CHSP, or CBAHI Assessor certification) are an advantage. Ongoing professional development in healthcare quality or accreditation systems is desirable.