QUALITY MANAGER JOB DISCRIPTIONNABH Accreditation Compliance:Ensure hospital meets NABH standards, criteria, and guidelines.Lead the preparation and submission of documentation for NABH accreditation.Oversee the hospitals readiness for NABH assessments and audits.Maintain and update the quality management system to stay compliant with NABH guidelines.Manage regular internal audits and assessments to monitor compliance with NABH standards.Maintain committee meeting and minutesMaintain incident report ,RCA and CAPA Quality Management System (QMS):Develop and implement quality management policies, procedures, and guidelines.Monitor hospital-wide quality indicators and ensure effective corrective actions for any non-compliance or adverse trends.Drive continuous improvement through process optimization and innovation.Regularly review clinical and operational data to identify quality improvement opportunities. Training and Development:Conduct regular training for staff on quality protocols, safety practices, and NABH guidelines.Encourage a culture of quality awareness, patient safety, and best practices throughout the hospital.Organize workshops and seminars related to quality, patient safety, and NABH standards.¢ Patient Safety and Satisfaction:Oversee patient safety protocols, incident reporting systems, and root cause analysis of incidents.Collaborate with clinical teams to analyze patient satisfaction data and recommend improvement strategies.Ensure that complaints and grievances are handled efficiently and improvements are made based on feedback.¢ Data Collection and Reporting:Ensure the collection, analysis, and reporting of key quality metrics (such as patient outcomes, infection rates, and patient satisfaction).Prepare and present reports on quality metrics to hospital management and external accrediting bodies as needed.Monitor risk management and develop reports on adverse events, with appropriate corrective actions. ¢ Collaboration with Stakeholders:Work closely with clinical, administrative, and support staff to drive quality initiatives across departments.Coordinate with external bodies and consultants for accreditation, audits, and training programs.Liaise with hospital leadership to ensure quality goals align with the overall hospital strategy.¢ Policy Development & Implementation:Ensure effective implementation of hospital policies regarding infection control, medication management, patient care, and health & safety.Develop and review emergency preparedness plans and ensure staff readiness in line with NABH standards.IN CLINICAL SIDE:(LIFELINE)1. Monitoring Patient Safety and Clinical StandardsMorning Rounds: Participate in daily rounds with nursing staff and other healthcare teams to monitor patient conditions, care plans, and progress. Ensure compliance with safety protocols, infection control, and patient care standards.Adverse Event Reporting: Oversee the identification and documentation of any patient safety incidents (e.g., falls, medication errors, pressure ulcers). Ensure all adverse events are properly reported, analyzed, and addressed.Infection Control Monitoring: Review infection control practices (e.g., hand hygiene, isolation precautions) to ensure compliance. Conduct random spot checks or audits of nursing units to ensure adherence to protocols.2. Review of Daily Nursing Logs and DocumentationPatient Care Documentation: Regularly check patient care records and nursing documentation for accuracy and completeness. Ensure nursing staff follow the proper documentation protocols.Compliance with Care Protocols: Monitor that nursing staff are following clinical protocols (e.g., medication administration, patient assessment, wound care). Randomly review care documentation to ensure it meets the required standards.3. Staff Training and Adherence to GuidelinesDaily Huddles/Briefings: Attend or facilitate daily huddles with nursing staff to address immediate quality issues, safety concerns, and operational updates. Provide quick refreshers on quality protocols.Ongoing Training: Identify training gaps or knowledge areas requiring reinforcement (e.g., patient handling, infection control practices) and schedule training sessions as needed.4. Patient Satisfaction and Feedback MonitoringDaily Feedback Collection: Review daily patient feedback (verbal or written) and survey results related to nursing care. Analyze patient satisfaction reports specific to nursing services and escalate recurring concerns.Complaint Resolution: Oversee the process for handling complaints and grievances related to nursing services. Ensure that issues are addressed and resolved promptly, following quality protocols.5. Quality Audits and Spot ChecksRandom Audits: Conduct spot audits of nursing practices such as hand hygiene, correct patient identification, patient transfers, and infection control measures. Record findings and provide feedback to staff.Checklist Reviews: Ensure that nursing units are using checklists and protocols for common procedures (e.g., medication administration, surgical safety, catheter care). Verify that these tools are being correctly utilized and followed.6. Monitoring Key Quality Indicators (KQIs)Clinical Indicators Tracking: Monitor key nursing-related quality indicators such as patient falls, pressure ulcers, medication errors, infection rates, and patient satisfaction. Ensure data is accurately recorded and reported.Benchmarking: Compare the unit's performance against predefined benchmarks to ensure continuous improvement. Discuss underperforming areas with nursing teams and provide support for improvement.7. Collaborating with Nursing LeadershipCoordination with Nurse Managers: Meet daily with nursing leadership (e.g., Nurse Managers, Charge Nurses) to review performance metrics, challenges, and quality improvement initiatives.Resource Allocation: Work with nursing leadership to ensure adequate staffing levels and resources are available to support quality care, especially during peak times.8. Continuous Quality Improvement (CQI)Data Analysis: Continuously analyze data on nursing care quality. Identify patterns, trends, and areas for improvement (e.g., recurrent issues with specific procedures or areas of care).Root Cause Analysis (RCA): In case of any recurring quality issue (e.g., high fall rates or infections), lead root cause analysis to identify underlying factors and implement corrective actions.9. Ensuring Compliance with Standards and ProtocolsNABH Accreditation Standards Compliance: Regularly verify that nursing units are following NABH standards related to patient care, infection control, patient rights, and documentation.Policy Updates and Adherence: Monitor compliance with any updates or changes to nursing policies and procedures, ensuring that all staff are aware and properly following new guidelines.10. Communication and ReportingDaily Reporting: Prepare and submit daily/weekly quality and safety reports for nursing units to hospital leadership. These should include patient safety data, incident reports, audit results, and any corrective actions taken.Interdepartmental Communication: Communicate daily with other departments (e.g., clinical teams, risk management, and infection control) to ensure smooth and coordinated quality efforts