- 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.