Establish and implement quality management system across the hospital. Monitor and analyze the same for improvement
Ensure the compliance of all the accreditation and certifications standards implemented in the system through close monitoring
Liaisoning with the external bodies of accreditation and certifications for the regular audit programs.
Preparing and revising all the hospital policies, procedures, work instructions and department manuals periodically as per the hospital policy in coordination with the corporate quality team.
Conducting process audits assigned by the corporate quality team in the defined tool and reporting the same on monthly basis.
Conducting active medical records audit as per the sample require NABH sample size.
Establishing a mechanism to identify, manage and mitigate potential risks in coordination with the concerned stakeholders.
To coordinate and ensure the facility/safety rounds has been conducted at regular intervals
Implementation of quality indicators across the hospital. Monitor, analyze, validate, and utilize the data for process and system improvement. Reporting the same in a standardized format to the head-quality on monthly basis.
Guide, educate and support all departments in implementation of standard requirements and quality indicators
Coordinating with all departments for establishing department-oriented objectives and its revision whenever required.
Conducting internal audits throughout the hospital once in a quarter and coordinating with all department for taking corrective and preventive actions based on observations and findings and reporting the same to the top management.
Preparation of quality assurance programs at all required areas in coordination with the concerned department heads.
Conducting minimum 2 quality improvement projects annually in coordination with the Head-Quality by adopting various quality tool (FOCUS-PDCA, FMEA, Lean management etc.) on different aspects and indictors.
Overall management of hospital committees and its compliance as per the defined TOR. Generating a compliance report on quarterly basis and report the same to the management and Head- Quality.
Conducting quality rounds regularly as per the schedule and taking actions as per the deviations noted. Reporting the same to center head and concerned department heads.
Establishing a system to track and monitor all the statutory requirements and licenses and reviewing it every month to ensure the compliance.
Coordinating with various committees and departments for conducting mock drills periodically and keeping the records for the same.
Overall management of hospital incidents To ensure all hospital incidents are reported, analyzed and appropriate RCA and CAPA has been taken for the same. Reporting the same to management and Head-quality regularly.
Conducting training and orientation to the staff on quality and accreditation standards.
Any other works assigned by the quality head and center head.