Role & responsibilities

Implement quality management system across the hospital. Monitor and analyze the same for improvement as per Quality head guidelines
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.
Review 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.
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.
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 along with manager regularly as per the schedule and taking actions as per the deviations noted. Reporting the same to center head and concerned department heads.

Quality Executive