Job
Description
The Head of CC&QC will be responsible to oversee and drive excellence in clinical operations and quality care delivery. This role demands a strategic leader with a deep understanding of hospital-based clinical workflows, quality protocols, patient safety, and risk management. As the primary custodian of clinical monitoring, documentation compliance, and patient experience outcomes, you will play a critical role in ensuring that all aspects of patient care—from admission to discharge—adhere to the highest standards of clinical effectiveness, ethical practice, and regulatory compliance. Key responsibilities: Clinical Service Delivery Management: Outpatient Care Monitoring - Outpatient Care Cycle monitoring and compliance monitoring - Consultation, TAT monitoring, and compliance reporting Follow-up monitoring and compliance Randomised Cross-Referral Checking Adverse Event Monitoring and follow-up Inpatient Care Monitoring - Bedside Care Management - Admission - Review of Admission Ward Transfer Assessment and high-risk flagging Referral Monitoring, Assessment and Fulfilment Consultant Visit Monitoring and Fulfilment Counselling compliance and monitoring Admission Refusal Monitoring and Compliance Outcome Monitoring Adherence to plan of care - Addressing discrepancies when found. Documentation Compliance and Medication Administration Compliance Privileged bedside procedure monitoring and compliance (Life-saving in critical care setting + Non- Non-life-saving routine bedside procedures) Adverse event documentation and follow-up up i.e. code blue/red / violet Plan of care adherence report - Discrepancy Reporting Medication Error Reporting Summary - according to the designed reporting template Privileged Bed-Side and life-saving procedure compliance report - if any discrepancies are found to be reported and documented Adverse Event Reporting (Weekly Summary) Inpatient Documentation Compliance Report (Report of Discrepancies if found) Review of Bedside Care KPI’s Monthly Plan of Care Deviation Report Monthly Medication Error Summary Privileged Procedure adherence compliance Adverse Event Compilation, along with response summary and action taken Monthly Inpatient Documentation Compliance Variance Report Surgical & Interventional Care Monitoring - Protocol compliance and monitoring - Surgery and Procedure Workflow compliance Documentation compliance, i.e., Consents and necessary medico-legal documentation Addressing discrepancies when found and documenting the action taken. Adverse Event Documentation Clinical Support Service Delivery monitoring and compliance with quality parameters Diagnostics TAT monitoring (IP and OP) Diagnostics Orders compliance and fulfilment (IP) and action taken for discrepancies Infection control monitoring and compliance as per norms Bio-Medical Waste Management monitoring and compliance as per norms CSSD protocol compliance Clinical Human Resource Management - Clinical Care Service Delivery Manpower Planning Clinical Care Roster Management & Optimisation with concerned department heads. Lifecycle Management - Training, Privileging and Appraisal - Upgradation and Retrenchment planning. Workflow mapping for all clinical care-related employees Quality Control Protocols for important clinical care scenarios about clinical service delivery Critical Manpower Level Document Creation Key clinical care functionaries identification and roadmap planning Orientation document preparation for clinical care staff (Position-wise) Clinical Care Positions Recruitment Protocol - Requisition, Interview and Assessment, end user vetting and exit interview protocol. Privileging protocol and certification Primary Lead for Quality Areas Domain Management Quality Control (NABH, NABL) and clinical Audits Adherence to industry standard norms on clinical care quality protocols for infection control, bio-medical waste management. Periodic Meetings with Clinical Care service delivery stakeholders on important cases/issues on protocol/quality parameters shortcomings. Compliance monitoring of the clinical service delivery workflow as outlined in the above points. Abnormal Reporting monitoring, and follow-up action Random diagnostics report cross verification (for different modalities) Abnormal Reporting Documentation and follow-up action taken Sudden Adverse outcome documentation and follow up action LAMA / DOPR higher centre referral report Clinical Risk Management Timely identification, documentation, and escalation of clinical and operational risks Implementation and monitoring of risk mitigation strategies in coordination with relevant clinical and administrative stakeholders Development of a Clinical Risk Register and periodic review of high-risk cases, outcomes, and trends. Proactive participation in root cause analysis (RCA) and failure mode effects analysis (FMEA) for adverse events. Collaboration with Quality and Safety teams to ensure implementation of corrective and preventive actions. Patient Experience Management (PREMs) Introduction and implementation of Patient Reported Experience Measures (PREMs) tools across inpatient and outpatient settings. Systematic collection, analysis, and reporting of patient feedback using structured PREMs methodologies. Identification of actionable insights from patient experience data to inform service improvement. Regular coordination with clinical teams to enhance patient-centric care delivery based on PREM's outcomes. Monitoring PREMs trends and submitting periodic dashboards/reports to senior leadership. Qualifications: MBBS/BDS/BHMS/BAMS with a Master’s degree in Hospital Administration (MHA), Health Management, or Public Health (MPH) from a recognised institution Certification in NABH, NABL, or other healthcare quality standards preferred Additional training or certification in Risk Management, Patient Safety, or Clinical Governance is an advantage Experience: Minimum 5-7 years of experience in hospital operations or clinical administration, with at least 3 years in a quality or patient safety leadership role Proven experience in managing end-to-end inpatient and outpatient clinical workflows Hands-on involvement in hospital accreditation processes (e.g., NABH/NABL audits) Demonstrated experience in clinical quality monitoring, risk mitigation, and adverse event management Exposure to PREMs implementation or patient experience measurement tools is desirable Desired Skillsets: Strong understanding of clinical protocols, patient safety norms, and quality indicators Expertise in developing and implementing SOPs for clinical documentation, care pathways, and compliance standards Proficient in data analysis and report generation for clinical quality metrics, adverse events, and performance KPIs Excellent coordination skills with clinical, diagnostic, and administrative teams Ability to identify clinical risks proactively and implement effective mitigation strategies Strong interpersonal, communication, and leadership skills Competence in handling sensitive situations with ethical clarity and professional discretion Tech-savvy with working knowledge of hospital information systems (HIS), quality dashboards, and audit tools Show more Show less
