The document provides a summary of Dr. Ahmed Kassem Ghoneem's qualifications and experience in healthcare quality management. It lists his education and certifications in fields including management, healthcare utilization, data analysis, and quality management. It then describes his work experience in quality management roles for various hospitals in Saudi Arabia and Egypt from 2008 to present. Finally, it outlines his core skills and achievements in areas such as quality improvement, accreditation, clinical guidelines, data analysis, and leading quality projects.

1. 2013 Certified in Management applications, healthcare utilization
and strategic planning
ICDM, Saudi Arabia
2012 Certified in Business Process Management
ICDM, Saudi Arabia
2011 Certified in Advanced Data Analysis
ICDM, Saudi Arabia
2008 Certified in Advanced Healthcare Communication
Johns Hopkins University Bloomberg School of Public Health in
Cooperation with the American University of Cairo,
2007 Certified in training of trainers
Ain Shams University, Cairo – Egypt
2007 Six sigma Green built,
American university of Cairo, Cairo – Egypt
2007 Lean Green built
American university of Cairo, Cairo – Egypt
2006 Diploma in Total Quality Management,
American University of Cairo, Cairo – Egypt
2002 Baccalaureate of Medicine and Surgery, Faculty of Medicine,
Al-Azhar University, Cairo – Egypt
Q Dr. Ahmed Kassem Ghoneem
HEALTHCARE QUALITY AND UTILIZATION MANAGEMENT CONSULTANT
EDUCATION AND CERTIFICATIONS

2. April 2016-present
Quality manager – Saudi German Hospital Cairo
2015-2016 Freelance consultant for in gulf area
2011-2015 Head of performance excellence – King Fahd Specialist
Hospital –Dammam KSA (350 bed Tertiary hospital with core
Competency in oncology, transplant, neuroscience and
Genetics accredited for
- JCI
- ISO 9001
- IAEA
- HACCP
- CAP
- ASHI
- AAHRPP for clinical research
2008-2011 Quality Manager -Mouwasat hospital – KSA
(Group of sex hospitals all accredited For JCI, CBAHI AND
CAP)
2007-2008 Director of Quality at El Haram Health Administration, MOH
GIZA
2007-2008 Head of Health Education Department at El Haram Health
Administration, MOH – GIZA
WORK EXPERIENCE

3. 2006-2007 Chairman of Quality Council at Kafr El-Gabal Health Center,
MOH - GIZA
2005-2006 Family Medicine Physician at Kafr El-Gabal Health Center,
MOH -GIZA
STRATEGIC PLANNING
- Expert in facilitating the process of organization wide strategic planning using
SWOT analysis ,
- Expert in facilitating the process of translation of hospital strategic goals into
operational plans using Balanced scorecard and mapping there implementation
using (PERT) methodology as well as monitoring of the achievements using KPIs
(Key performance indicators
UTILIZATION MANAGEMENT
- Expert in the process of planning for future organization resource expansion and
subsequent appropriate budget allocation using forecasting and queuing
- Expert in leading the process of planning for new beds as well as analysis of
current beds utilization using new advanced methodologies including electronic
bed board , DRG , Clinical practice guidelines forecasting models, queuing theory
and simulation models
- Expert in conducting and training for initiating feasibility studies for any newly
proposed healthcare related projects
- Expert in building an organization wide utilization analysis system using a
network of KPIs monitored overtime using SPC (Statistical process control)
analysis tools
CORE SKILLS & AREAS OF STRENGTH

4. QUALITY IMPROVEMENT, SAFETY AND PERFORMANCE EXCELLENCE
- Expert in leading the Development, implementation, coordination and monitoring
of hospital wide performance improvement and safety programs
- Expert in the process of monitoring performance using Key performance
indicators with long experience in all KPI process roadmap including selection ,
collection , validation , analysis , and reporting
-
- Expert in initiating a standardized framework for the quality improvement
projects road map as part of the quality program scope , this road map includes
 Identify sources for proposing improvement project areas
 Selection and prioritization criteria of the project area
 Selection of appropriate methodology (FOCUS-PDCA/LEAN/SIX-
SIGMA)
 Project planning and charter
 Project monitoring completion and evaluation.
-
CLINICAL PRACTICE GUIDELINES AND PATHWAYS
- Expert in leading and coordinating the process of evidence base standardization of
clinical care through initiation, monitoring of compliance as well as effectiveness
evaluation of clinical practice guidelines and clinical pathways.
- Expert in improving hospital utilization of clinical practice guidelines and
pathways implementation through
 Improving average length of stay (Non profit making hospital)
 Reduce the cost of non indicated procedures and investigations (Non
profit making hospitals)
 Reduce insurance rejection rate (profit making organization)
 Improve revenue through increase the number of evidence based
requested investigations and consultations (not to miss evidence based
requested investigations)

5. BUSSINESS PROCESS REENGINEERING
- Expert in conducting and training for BPR methodology that include the
following
 Select the end to end process to be redesigned
 Prepare ,Involve and ensure buy-in by the concerned frontlines and
managers across the whole BPR lifecycle
 Identify process architecture (e.g. related laws and regulations , fixed and
flexible roles to be considered in the redesign phase)
 Mapping the current AS IS process flow and identifying all related
barriers and bottle necks
 Data collection for each process step that include but not limited to ,step
turnaround time and its distribution , number of transactions , Number of
resources and their availability time distribution , added value and non
added value steps , and areas of interactions with other processes in the
same or in deferent areas/departments (sound of integration)
 Redesign the process to achieve the maximum efficiency and quality
within the predefined process architecture
 FMEA for new process
 Expert in simulating the old and the new processes using simulation
software e.g. ARENA
 Pilot implementation
 Full implementation , feedback and monitoring of the redesigned process
PROJECT MANAGEMENT
- Expert in project planning and management
- expert in project output data collection planing analysis interpretation and
reporting
- Expert in using project planning tools that includes and not limited to
 Gaunt chart

6.  PERT (Project evaluation and review technique) methodology
 Identifying the critical path and subsequent critique for crushing the
project timeline
 Human recourse distribution
ORGANIZATION DEVELOPMENT
- Expert in assisting the process of formulation/revision of philosophy, objectives
and contents of organization policies
- Expert in formulating reviewing and improving Organization structures and
organization charts aiming to serve organization vision , mission and strategic
goals
QUALITY ACCREDITATIONS
- Expert in JCI standards , their interpretation and monitoring with full knowledge
about history of standards changes over the last three editions (3rd
, 4th
,and 5th
editions)
- Expert in CBAHI standards , their interpretation and monitoring
- Expert in preparing hospitals and other healthcare organizations for both above
mentioned accreditation systems
- Expert in Egyptian national accreditation standards
RISK MANAGEMENT
- Expert in helping hospitals and other healthcare facilities to initiate an
organization wide (clinical and non clinical) risk management program that
incorporates risk identification and assessment , reporting , prioritization
,prevention and control
- Expert in utilizing and educating risk management tools both proactive and

7. reactive risk management tools that include but not limited to root cause analysis
(RCA) , failure mode and effect analysis (FMEA) ,and risk grading matrix.
- Expert in assessing and measuring hospital/healthcare organization safety culture
(Safety culture AHRQ)
TRAINING, EDUCATION, AND CONSULTATIONS
- Expert in assessing healthcare quality training needs , Planning and co-
ordination of these training activities
- Expert in designing and conducting different healthcare quality , management and
utilization training courses and consultations ,this includes and not limited to the
following training and consultation activities
 Bed planning and utilization using Forecasting , queuing model and
diagnosis related groups (DRG)
 JCI Accreditation in 12 months
 CBAHI accreditation
 Staffing plan
 Hospitals utilization analysis
 Management tools (Strategic-Tactical-Operational-Supply chain)
 Advanced statistical analysis
 Six sigma breakthrough improvement
 PDCA and FOCUS-PDCA improvement methodology
 Clinical practice guidelines and clinical pathways roadmap
 Statistical process control (SPC)
 Strategic planning using Key performance indicators (KPI) roadmap
and Balanced Score Card
 Data Management
 Data analysis using SPSS
 Business Process management in healthcare

8. DATA MANAGEMENT
- Expert in all data management roadmap steps including collection ,sampling ,
validation , analysis , Reporting , and Benchmarking
- Expert in using all advanced data analysis tools (either Quantitative or
Qualitative) to support data based decision making
- Expert in using and training for most of the quantitative and qualitative data
analysis software (e.g. SPSS , Minitap , Pathmaker , N-Vivo )
- Expert in using SPC (statistical process control ) concept and methodology
CHARTS REVIEW AND TRACER METHODOLOGY
- Expert in leading and teaching and training of organization staff to conduct
organization wide tracer methodology for the following areas aiming to improve
continuity of care ,patient centered care , system integration as well as a
preparedness tool for JCI accreditation.
 Clinical tracer
 Maintenance and equipment tracer
 Infection control tracer
 Facility management and safety tracer
- Expert in the process of Closed and Open patient chart review based on both JCI
and CBAHI accreditation standards , this process include the following
 How often
 Sampling
 JCI/CBAHI required documentation formats (Validating current hospital
formats)
 Audit method (How and when to audit)
 Data aggregation formats and database

9.  Data Validation
 Data analysis
 Reporting formats
PATIENT EXPERIENCE CENTERED AND INTEGRATED CARE:
- Expert in designing tools to collect patient needs
- Expert in analyzing and interpreting patient needs data in terms of new strategic
objectives as well as new process of care redesign requirements
- Expert in designing and redesigning integrated care programs that tackle the
patient needs and ensure removing inter-disciplines silos
ANALYSIS SOFTWARE
- Expert in utilizing and training for the following analysis software
 SPSS (Quantitative data analysis software)
 Pathmaker (Quantitative data analysis software)
 Minitab (Quantitative data analysis software)
 N-vivo (Qualitative data analysis software)
 Arena (Process simulation software)
- Prepared and Assist 3 hospitals (Mouwasat Jubail , Mouwasat Qatif , King Fahd
specialist hospital) to get 3 JCI accreditation and 3 reaccreditation (3rd
and 4th
edition JCI standards)
- Conducted and assist in 4 JCI mock surveys which was held by AGI group (Prof.
Assaf El-Assaf – Prof. of Quality and Safety in Oklahoma University / Prof. Seval
Aqugnum).and JCI consultants (Dr.Derick Pasternak”)
ACHIEVEMENTS

10. - Prepared and assist Mouwasat hospital Madinah for Central Board of
Accreditation for Healthcare Institutes (CBAHI) accreditation.
- Shared in 3 facility safety mock surveys which was held by Prof. Azimi Mehedy,
Oklahoma – USA)
- Led and supervised the preparation of different hospitals and healthcare centers
for National Egyptian accreditation
- Supervised the process of implementation of Business process Management to
improve clinical and administrative processes in King Fahd specialist hospital as
the project manager with PWC company (Pricewaterhouse cooper)
- lproject manager for implementation of ERP system in king fahd specialist
hospital ,Saudi arabia
- Led and Supervised the process of initiation and implementation of Ongoing
professional practice evaluation program (OPPE) in king Fahd specialist hospital-
Dammam
- Supervised the process of KPIs (Key performance indicators) initiation roadmap
in King Fahd Specialist hospital , Mowasata hospital Jubail , Mouwasat hospital
Qatif and Mouwasat hospital Madinah
- Supervised the process of clinical practice guidelines and pathway initiation,
monitoring of implementation and effectiveness evaluation together with linking
the implementation to improve hospital utilization e.g. A.L.O (average length of
stay ) , radiology and lab utilization. In the above mentioned 4 hospitals

11. - Coordinated and supervised many improvement projects that include but not
limited to :
Six Sigma Projects:
 Reduce the Surgical Site Infection Rate In Clean Operative Procedures
 Reducing Ventilator Associated Pneumonia (VAP) In ICU
 Reducing The Rate of Catheter Associated Urinary Tract Infection (CAUTI)
 Reducing Central Line Catheter Blood Stream Infection (CLABCI) In ICU
 Reducing Unit Acquired / Hospital Acquired Pressure Ulcer Rates
 Reduce Admission Process Turnaround Time (TAT)
 Reducing Percent of Pending Referral Cases
 Reducing the Percentage of False Positive Blood Culture Results Due To
Contamination
 Reducing Lab Specimens Rejection Due To Clotting
 Reducing Lab Specimens Rejection Due To Hemolysis
 Reducing Response Time For Isolation Room Terminal Cleaning
 Reducing Actual Time of Isolation Room Terminal Cleaning
Lean Projects:
 Communicating Laboratory Critical Results
 Live Kidney Donor Evaluation
 Use of Emergency Drugs In ICU
 Improving The Process For Dispensing Discharge Medication
 Improve the In Patient Admission Process
 Improve The In-patient Discharge Process

12.  Organizing the Operating Room Booking In Neurosurgery Department
 Reducing the Turnaround Time (TAT) Between Cases in The Operating Room
(OR)
 Improving Patient Flow In Emergency Department (ED)
 Improving Admission Criteria to Pediatric Department To Meet The Scope of
Service of A Tertiary Care
 Improving The Admission Process To The Day Procedure Unit (DPU)
 Reducing Waiting Time from Arrival To Administration of Chemotherapy
 Improve The Out Patient Department (OPD) Booking in Rheumatology Clinic
 Reducing MRI Access Time
 Improve TAT In ER Samples
 Elimination of Redundancies In Interventional Radiology (IR) Pre-Procedure
Workup
 Improving the Recruitment Process Cycle Time
 Improving The Nursing Overtime Process
 Improve the Call Center Process
 Streamlining the Direct Purchasing Process
 Management process of lab reagents
FOCUS-PDCA
 Reducing Medication Error
 Improving Hand Hygiene
 Improving Waste Segregation
 Improving Patient involvement in Care Process
 Reducing Hospital acquired pressure ulcers
 Reducing Chemo contamination
 Improving Response to call bell

13.  Improving the process of High alert medications management
 CUTI infection
 Improve volume of blood extraction in Pediatric ICU
- Coordinated and supervised initiation of hospital departmental manuals in
Mouwasat hospital group
- Put a standardized strategy for hospital utilization analysis to improve income and
reduce costs using up-to-date quality tools (software proposal for utilization
analysis approved as feasible project by many of international healthcare software
companies) –Mouwasat hospital group
- Initiated a forecasting model for all utilization KPI in King Fahd Specialist
Hospital Dammam
- Supervised the preparation of implementation of schedule B Quality standards of
ARAMCO contract in Mouwasat hospital group
- Led the initiation , execution , and monitoring of strategic plans in Mouwasat
hospital Jubail , Qatif , Madinah ,King Fahd specialist hospital
- Led and supervised the initiation , implementation of corporate risk management
program for Mouwasat hospital group after they decided to share in the stock
market
- Supported Mouwasat hospital Jubail operation through the following :
 Initiated a statistical based software program for stock control (analytical
rather than operational i.e. tool for auditing stock control processes by top
management) in cooperation with IT department

14.  Business planning for a lot of IT projects including SABIC center
communication project and online approval center
 Initiated a statistical based program for evaluation of effectiveness of
marketing department tools and their impact on hospital services growth
etc using curve estimation tools
 Initiated data analysis support for the following feasibility studies in
Mouwasat group ;
 Outpatient clinics expansion
 Physiotherapy department expansion
 Inpatient capacity expansion
 Best way to utilize the Space near Mowasat Jubail
hospital
- Worked with top management in Mouwasat Jubail to initiate a statistical based
artificial intelligence software program to support decision making
- Initiated bed utilization analysis model in King Fahd Specialist Hospital
Dammam using the following tools
 Electronic bed board
 Forecasting Model
 Queuing model
 DRG (Diagnosis related groups)
 CPG (Clinical practice guidelines and pathways)
- Speaker in many events including but not limited to
 Babtain hospital symposium for healthcare quality and patient safety
 Dammam university HIM (Health Information Management) annual
symposium
 Quality and safety event King Faisal Specialist hospital Riyadh
 Quality and safety events KFSH-D

15.  Quality and safety events Mouwasat Group
 Oncology nursing Club