Quality Executive

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.