- Work with Management, Clinicians & Non-Clinicians to monitor and ensure preparation for accreditation of all services.
- Support a culture that enables staff to understand and comply with quality, risk and patient safety guidelines to meet relevant accreditation standards and legislative obligations.
- Lead and conduct annual quality audits via the current quality management provider, review and maintain audit tools.
- Analyse audit results creating improvement plans and act on audit findings and recommendations to ensure compliance.
- Manage and review the organisation’s document control system; assuring compliance and ensuring that there is a QMS in place for the identification, storage, protection, retrieval, retention and disposition of these records.
- Ensure an internal audit schedule is in place which delivers risk minimisation, compliance to accreditation and quality standards.
- Manage and coordinate the clinical & managerial indicator collection system and maintain any incident and risk registries.
- Evaluate and submit analysis/benchmarking reports to Management, stakeholders and relevant committees in a timely manner on :
- Clinical & managerial indicators
- Clinical & managerial incidents
- Clinical & managerial risk and patient safety
- Patient feedback/satisfaction and patient experience
- Quality Improvement audits and evaluations
- Management of the corrective action system ensuring all non-conformities are recorded and
investigated to determine root cause and ensuring corrective or improvement activities are
closed out in a timely manner.
- Maintain incident reporting system ensuring appropriate completion and follow up of incidents by management in a timely manner.
- Work with staff to promote and encourage a reporting culture of clinical incidents, near misses and hazards across the organisation.
- • Review and further develop Complaints Management Framework.
- Review of customer feedback, patient complaints and maintain the tracker to do the follow up with management.
- Review and upkeep of policies and procedures (including patient privacy and confidentiality), liaising with relevant staff to ensure compliance and best practice guidelines are implemented.
- Review, analyse and enact updates to legislation, regulations, standards and guidelines on QMS and facilitate changes to processes and procedures to ensure adherence with updated
requirements.
- Co-ordinate the Quality Committee and implement changes required.
- Educate, coach and mentor staff and clinicians on the tools and processes required for the
ongoing accreditation process and QMS.
- Co-Ordinates in the planning of mandatory training as per the standards and educational programs as appropriate to quality and safety needs of the organization.
- Lead, facilitate and support the development and implementation of quality improvement
projects to deliver improved safety and quality outcomes for patients.
- Adhere to the requirements of Occupational Safety and Health legislation.
- Identify and report safety hazards
- Conduct & Participate in all committee meetings
- Initiate emergency, safety practices and measures as appropriate.
- Assures application of a tracking method to monitor progress towards goals by collecting
accurate, timely data to display the quality, cost, and service outcomes.
- Ensuring that the hospital meets all regulatory compliances such as BMW, Blood Bank/Storage license, AREB regulations, etc.;
- Ensure to keep a record of non-functional equipments and time line for its repair along with
AMC of all equipments.
- Planning and work-out modalities towards upliftment, preventive maintenance of equipments & vehicles and modernization of hospital
- Other tasks as and when required by the management.
- To ensure the development and implementation of goals, objectives, policies, procedures and systems pertaining to the quality assurance and NABH regulatory functions.
- Manage, maintain and follow-up the hospital quality mock inspections reports.
Job Types: Full-time, Permanent
Pay: ₹25,000.00 - ₹35,000.00 per month
Benefits:
- Cell phone reimbursement
- Commuter assistance
- Flexible schedule
- Health insurance
- Internet reimbursement
- Life insurance
- Paid sick time
- Paid time off
- Provident Fund
Experience:
- total work: 1 year (Preferred)
Work Location: In person
