Quality Head - Fortis Hospital , BG Road

Candidate with Minimum 10 +years of experience in Quality at JCI & NABH Accredited Hospital can share the profile to shwetha.s@fortishealthcare.com /9900855999

Role & responsibilities

Obtaining JCI (Sustaining JCI standards and regular updating the same) and NABH

• Interpretation and implementation of quality assurance initiatives as per JCI/NABH standards in hospital and to ensure delivery of quality care to patients
• Development and implementation of departmental policies and Procedures, as per JCI/NABH norms
• To ensure compliance and continual improvement of Quality indicators by undertaking surprise audits and mock surveys
• Work as a team to co-ordinate and provide consistency to the quality initiatives
• Continuously assessing and improving the Quality of care and services provided.
• Participating in cross-organizational activities to improve organizational Quality as appropriate
• Adopting an approach to Quality improvement that includes planning the process for improvement, setting priorities for improvement, assessing Quality systematically, implementing improvement activities based on assessment, and maintaining achieved improvements
• Supervision of medication management process in Pharmacy and patient care areas
• The candidate will be expected to be an important part of the JCIA/NABH accreditation process of the hospital
• To Co-ordinate for QIPS identified throught hospital
• Ensure ongoing documentation of mandatory requirements by JCI and NABH
• To collect data for JCI library of measures
• To co-ordinate with head of quality to generate minutes of meeting and ensure closure
• To co-ordinate for internal audits for various departments with head of quality
• Compile and analyse data for quality indicators for NABH
• To co-ordinate for mortality review meeting on regular basis
• Ensure compliance to medical records ongoing basis
• To co-ordinate with head of quality for root cause analysis FMEA
• To update and analyze CQI forms on monthly
• To have thorough understanding of standard operating procedures
• To update the standard operating procedure with the recent standards on timely and regular basis
• To keep track of control copies of SOP’s across units
• To keep track of all mandatory training related to quality and safety
• To facilitate annual mock drills (Fire disaster, Bomb treat, Emergency)
• To co-ordinate and facilitate in data collection for MOS/CESC
• To Coordinate for all the Committees and collate the Meeting of Minutes.
• Rational use of drugs
• Consultation regarding selection of drug, dose, route, dosage form, schedule and duration
• To provide Information regarding
• Drug action, drug kinetics
• Drug interactions (drug-drug, food-drug)
• Management of patients on polytherapy (multiple medications)
• Contraindications and special precautions
• To ensure and monitor drug safety
• Adverse drug reaction (ADR) monitoring
• Hospital Drug Formulary
• To initiate, co-ordinate and accomplish the task of forming our own drug formulary
• Hospital Surveys
• Suggestions to improve the quality of patient management (drug prescription, dispensing, administration, outcome) in various units/departments (according to JCI standards)
• Drug utilization studies, drug audits (mainly antimicrobials) in ICUs to know the pattern of antimicrobial prescription vs microbial growth and sensitivity.
• Assesses risk to patient and general safety and facilitates corrective steps
• Essential members of Infection control Committee
• Reviewing the infection prevention program throughout the facility; evaluating policies and procedures related to patient care infection prevention measures throughout the facility.
• Reviewing annual risk assessment from the prior year’s activities, and recommend any changes required.
• Making recommendations regarding construction and renovation projects, and participation in all Infection Control Risk Assessment (ICRA) activities and environmental rounds
• Reviewing employee health in monitoring work-related exposures
• Reviewing the components of the facility’s infection prevention and control program to include:
• Policies and procedures
• Program oversight
• Surveillance activities