Quality Executive

· Implement NABH standards and achieve the Accreditation.

· Assist in developing Hospital policy and departmental manual as per NABH standards.

· To study, understand and analyse the hospital policies and procedures,” Identify the gaps” between them and the pursued accreditation standards.

· Working with operational staff to establish procedures, standards, and systems.

· To identify stakeholders who can support/manage the deficiency corrections.

· Train the identified stakeholders in deficiency identification, correction methodology and recording of activity data.

· Ensuring good quality of clinical and non-clinical services.

· Prepare relevant checklist and forms for each department based on accreditation guidelines & statutory/good practice guidelines.

· Collect, collate and analyse the internal quality audit findings and communicate to appropriate & concerned authorities in a sensitive approach.

· Monitor and access compliance with quality standards and identify the gaps, take actions if necessary.

· To identify critical information and report/escalate to the concerned organization authority on a regular basis.

· Design and implement quality improvement programme.

· Conducting safety preparedness mock drill and produce report.

· Facilitate conduct of committee meetings like mortality meeting, Infection control meeting, Clinical Audit meeting, Quality Assurance Meeting etc.

· To identify suitable committee members and their roles and responsibility for proper functioning of committee.

· Ensuring that the hospital meets all regulatory compliances.

· Assisting in medical administration processes.

· Acting as catalyst for change and improvement in performance and quality.

· Determining training needs of staff with respect to awareness in quality and departmental processes.

· To prepare a training plans, modules and conduct the training as per needs.

· To review and revise all patient care forms and formats in liaison with departments.

· To maintain all documents /copies of originals as required by accreditation authorities.

· To maintain & store all documents of:

a. Departmental manuals

b. Minutes of committee meetings

c. Incident reports,sentinel reports

d. Quality indicator results

e. Internal audit report findings & Self assessment toolkit

Job Type: Full-time

Pay: ₹25,000.00 - ₹45,000.00 per month

Benefits:

• Provident Fund

Ability to commute/relocate:

• Gandhinagar, Gujarat: Reliably commute or planning to relocate before starting work (Required)

Experience:

• total work: 2 years (Preferred)

Work Location: In person