Quality Manager

Business head can assign anyone in unit to ensure below responsibilities are take care:

Quality & Accreditation:

• Need to ensure that HODs/Incharges and staff throughout the organization to ensure that the quality management system is functioning properly.
• Need to focus on changes and how to implement them and provide training, tools, and techniques to enable others to achieve quality standards.
• Ensure Accreditation & Certifications- NABH, NNF, RGUHS. Ensure initiation, implementation, training and sustenance of Accreditation Standards.
• Ensure Internal and External Audits and Assessments (Corporate Audits, NABH, NNF, RGUHS etc.), prepare Action Taken Report (ATR), ensure closures of same, collect evidences and submit the closure report to respective internal/external assessors/auditing authority.
• Ensure coordination within the departmental heads and facilitate for effective implementation of quality and accreditation standards in all the departments
• Assure quality through review mechanism and continued quality improvement
• Accelerate departments for Healthcare Quality Awards. Identification of projects, topics which can be sent to such Awards as nominations for poster and paper presentation
• Ensure that team facilitate and conduct trainings
• Ensure that Annual Events Calendar prepared.
• Ensure that Code Commanders, Committee Coordinators for Committee Meetings, Mock Drills and ensuring completion of events as per Annual Events Calendar.
• Ensure Committee Files, Mock Drill Reports are updated- MOM, Action Taken Report, Presentation etc.
• To conduct Committee Performance Audit at Center Head level and share the report with Corporate Quality for further action.
• Make sure that collection, compilation, analysis and monitoring of hospital wide quality Indicators- NABH and organization defined indicators. Report the same to Corporate Quality within defined timelines in the format approved by HOD and Corporate Quality.
• To educate the concerned department staff about Quality Indicators to be monitored and to facilitate the monitoring.
• Ensure accuracy of quality indicators data through periodic Data Validation and share the report with Corporate Quality. Ensure corrective and preventive actions are initiated and implemented.
• Make sure of Incident Report Monitoring and assist and/or initiate appropriate measures/actions as required as per Quality Tools- RCA CAPA FMEA Fishbone Analysis 5 why etc. Ensure closure of incidents within the defined timelines.
• Facilitate, coordinate and participate in (to name a few but not limited to) Internal Quality Audits, Facility Rounds, Active Medical File Audit, Hazmat Audit, Committee Performance Audit and Quality Rounds etc. and ensure closure of non-conformities within stipulated time frame and documentation of same.
• Make sure that training programme for the particular department staff runs as per requirement.
• Ensure that performance measure and identify any areas of improvement/weakness, recommending and implementing improvements
• Ensure tracking and analyzing of information in order to formulate process improvement strategies, ensure regulatory readiness and grade quality outcomes.
• Make sure that Quality Improvement Projects are conducted along with stakeholders, facilitate Clinical Audits
• Make sure vendor visit (BMW, Blood bank, laundry) to be done as per recommended timeline.
• Make sure that Quality Assurance audit for outsource services conducted as per timeline.

Data Management & Documentation:

• Ensure develop, implement, monitor, review and revise/update- Accreditation wise, as per Organization requirement Policies, SOPs, Work Instructions, Manuals any other documents on timely basis as per defined policy
• Ensure proofreading of forms and formats (new and existing), registers, patient education material, signages and propose and implement changes, modifications if required.
• To keep a track and control of documentation- Policies, manuals, SOPs, Work Instructions and schedule the review and revision
• Keep a track of Legal Tracker and raise red flag for any deviations/delay in application, expiry of licenses
• Ensure monitoring and advising on the performance of the quality management system, producing relevant data and reporting on performance, measuring against set standards.

Training & Development

• Make sure that trainings are execute and new training modules are developed for same based upon hospital and NABH/certification/accreditation requirements
• Ensure active involvement of staff in training activities for departments as per the requirement and develop in-house training modules
• Ensure training of new hires and Interns during Induction Classes and Refresher Trainings.

  Role & responsibilities

Preferred candidate profile