Quality & Accreditation

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Job Summary

Focus

Indicators

Financial/ Business

• Undertakes quality initiatives, audits, risk management as due in conjunction with the Quality and Unit Head.
• To conduct surprise audits/ investigations in various clinical and non-clinical areas in the hospital and submit findings report to HODs & Top Management.
• To recommend management on continual quality improvement activities.
• To keep a track of the worldwide developments in the area of healthcare quality and adopt best practices to refine the existing processes.
• To conduct and coordinate hospital committees meetings.

People

• To guide cross functional teams on various activities on quality aspects and to identify the training needs.
• To coordinate and conduct training programs and to implement quality management systems and technical management system in compliance with quality certification and accreditation.
• Responsible for training/educating staff and new joiners on different emergency codes and hospital policies.

Customer

• To do periodical rounds on the aspects of patient safety.
• To do internal auditing of various functions /areas of hospital as per the accreditation body guidelines.

Operations

• Works to ensure that quality improvement and innovation work remains focused on one or more of the following goals: patient-centeredness, staff vitality, process efficiency, waste reduction, and safe & reliable patient care.
• Ensuring clean surroundings, OPD Areas, Wards, Labour Room, OT and Patient
• amenities and outsourced services
• Periodical assessment of hospitals on quality check list and arrive at a score for the facility
• Identification of gaps, develop action plan under the guidance of department head and monitor compliance
• To participate in various clinical audits being conducted in the hospital and take necessary actions against the same.
• To coordinate activities related to quality certifications and accreditations like NABH.
• To Interpret and implement Quality assurance standards in hospital to ensure patient safety & quality care to patients.
• To analyse the data collected and to prepare reports indicating trends, performance measures of quality and key performance indicators.
• To collect, collate, analyse and report Quality Indicators of various functions of the hospital.
• Conducts awareness sessions through mock drills to prepare team to handle crisis situations.
• To facilitate the external audits conducted by the Accreditation Body.

• Any other portfolio that may be entrusted by the management from time to time.

Educational Qualifications:

• Any graduate with Master’s Degree in Hospital Management

Work Experience

• Having 3-5 years of experience as a quality Manager
• Sound knowledge on the Concepts of Quality to the hospitals (NABH)
• Knowledge of regulatory requirements
• Knowledge of qualifications and validations
• Knowledge of Quality Management System
• Knowledge and experience of handling regulatory audits (NABH etc.)

Expected Deliverables

• Continuous Improvement Projects
• Compliance and Documentation
• No NC’s in Audit
• Training and Education