Senior Executive/Asst Manager - Quality

Role & responsibilities

1) To study, understand & analyze the hospital policies & procedures, & identify the gaps” between them and the pursued accreditation standards.

2) To prepare a “Plan of Action” to bridge the identified deficiencies/ gaps.

3) To identify stakeholders who can support/ manage the deficiency correction.

4) Train the identified stakeholders in deficiency identification, correction methodology & recording of activity data.

Internal Quality Audit

a) Identifying potential candidates eligible for training of Internal Auditors.

b) Prepare training material for Internal Quality Auditors.

c) Organize, Coordinate & conduct the Internal Quality Auditor workshop.

d) Assess the trained auditors & evaluate their performance.

e) Plan a schedule and plan for Internal Quality Audit.

f) Prepare relevant checklists for each department based on accreditation guidelines & statutory/ industry standard / good practice guidelines.

g) Brief & Assign the auditors on their respective scope & roles in Internal QA.

h) Collect, collate & analyze the Internal Quality Audit findings and communicate to appropriate & concerned authorities in a sensitive approach.

i) To act as counsellor/ guide to all concerned, on identified deficiency corrections by adopting appropriate approach, principle & method.

j) Assist departments in finalizing responsibility owner & reasonable deadlines.

k) Re-audit the deficiency closures and follow-up.

Training Responsibilities

training needs

b) To prepare a training plan for meeting the Training needs on the same.

c) To prepare or support in preparation of, an appropriate Training material for the identified staff members in coordination with the concerned department and end user. e.g.- MSW, Medical Transcriptionist, Nursing, Duty doctors/ residents, Front Line Staff, Housekeeping, Security Services.

d) Conduct, Supervise & Support training for all employees in the following scope:

• Awareness in Quality principles; Accreditation process, standards & expectations; Organization policies.
• Safety issues for patients, staff safety at work place.
• Plan of action in case of Fire and any other Non-medical Emergencies.

e) Assist HR Team in conducting Induction (fortnightly) for all new employees with respect to sessions on Safety & its management protocols.

f) Conduct similar day-long workshop once, every quarter of a year for all new employees.

Monitoring Quality System

a) To identify basic minimal Quality Indicators for each department.

b) To identify & train the user end on the data source of collecting indicator information, data collection methodology, data compilation, analysis, interpretation & presentation.

c) To identify critical QI information and report/ escalate to the concerned organization authorities on a regular basis.

d) To maintain the results of all QI data and present it to management at appropriate intervals.

Quality Committees

committees

b) To define & describe the scope of committee activities & meeting frequency.

c) To outline the structure & composition, reporting mechanism of each committee.

d) To identify suitable committee members and their roles & responsibilities for proper functioning of the committees.

e) To initiate the committee meetings and ensure the Proforma, format & topics/ agenda covered are adequately addressing the quality accreditation requirements.

f) To ensure the minutes of the meetings are documented & copies of the same are retained with the convener and quality department.

g) Ensure & promote the follow-up of the agenda/ issues and seek active implementation of the recommendations made by the committee.

h) Convey the brief outline of the committee progress to the Apex Committee at least once a year for review.

Quality Improvement activities

a) Encourage all departments to initiate quality improvement programs in their respective areas.

b) Help / support the departments in identifying such programs and methodology to implement the same.

c) Support the HODs to encourage active participation of all department members to participate in the same.

d) Monitor & review the progress of such programs on a quarterly basis.

e) Identify programs for further improvement.

Administrative responsibilities

a) Maintain all documents/records pertaining to expenses, Quality Team staff management, requisition, grants, allocations/permission, etc.

all bills

budget and man power requirements

Documentation Responsibilities

a) To review and revise all patient care forms & formats in liaison with departments.

b) To prepare Apex Manual, other relevant manuals as prescribed by accreditation body.

c) To maintain all documents / copies of originals as required by accreditation authorities.

d) To maintain & store all documents of:

• Minutes of committees meetings.
• Incident reports, sentinel events and other critical episodes affecting quality of services as required by accreditation body.
• Quality Indicator results.
• Facility tour reports.
• Internal Audit findings.
• Self assessment tool kit.
• Communications with the accreditation body.

Workplace Ethics:

• Ensure that all department staff respects all co-workers and ensure no workplace bullying.
• Ensure that all critical findings related to patient / staff safety is reported to the concerned authority in the hospital.

Ensure there is no disclosure of patient /staff information to anyone who is not authorized by Management protocol or statutory body.