Job Description

A. Document Preparation:

Identifying the areas where documents need to be prepared - SOPs, Policies, Manual, Work Instructions, etc.

Collecting information from departments to prepare documents

Typing the information in the appropriate format to make it a protocol/ SOP

Reviewing the documents as per the set schedule

B. Quality Indicators:

Identifying & understanding the quality indicators required by the standards (NABH & JCI)

Collecting, compiling and analyzing the Quality Indicators

Discussing, recording and implementing CA/PA for deviations from the Benchmark

Suggesting/ upgrading the quality indicators

C. Internal Quality Audits:

Scheduling the Audits

Preparing/ updating the checklist

Conducting the audits - through trained internal auditors

Assisting/ preparing audit reports

Following up with the departments to close the Non Conformances

D. Coordinating Quality Systems training programmes:

Training needs analysis through Internal audits findings/ incident analysis

Preparing training module/ material and presentations

Organising and Conducting training programmes

Evaluating/ Assessing the trainees

E. Continuous Improvement Projects:

Collecting the information/ report from all the departments on CIPs executed

Preparing a report of all the CIPs

Identifying the areas where CIPs are required and suggesting a plan of action for the same

Assisting in/using statistical tool for quality improvement

F. Coordinating Committee Meetings:

Communicating with the committee convener to conduct the meeting whenever it is due.

Making note of all the discussions and actions planned in the meetings

Preparing/ assisting in preparing the minutes of the meeting

Circulating minutes to all the concerned

Following up with the implementation of the action plans

G. Analysis of Incident Reports:

Checking and receiving Incident Reports

Carrying out Root Cause Analysis

Analyze the incident pattern

Following up for implementation of Corrective/ Preventive action

H. Conducting Facility Tour:

Reminding the Team 15 days in advance and organizing the tour (Date, Time & Location)

Preparing/ updating checklist for facility tour

Participating in the facility tour

Preparing report

Following up for implementation of Corrective/ Preventive action

I. Mock Drills:

Reminding the responsible personnel/ team 7-14 days in advance

Assisting in/ organizing mock drills

Preparing/ updating checklists for mock drills

Observing the response & making note of the same

Preparing report

Following up for implementation of Corrective/ Preventive action

J. Evaluation of outsourced services:

Preparing/ updating/ changing the evaluation format in consultation with the concerned personnel for the service.

Issuing evaluation form to the evaluators and collecting them back

Analysis of the evaluation and reporting

Following up for implementation of the Corrective/ Preventive action

K. Gap analysis for NABH (5th Edition) standards:

Reading through the standards and comparing with the existing protocols and practices

Suggesting/ implementing actions to bridge gaps

L. Participating in Quality Improvement Initiatives:

Taking part in any other initiative/ activity taken up by the Quality Team

Suggesting/ planning/ organizing new initiatives/ activities for continuous quality improvement

Ethical Responsibilities:

To keep the confidentiality of any incident that you have come across to others (other than Quality Team)

Not to disclose any patient information to outsiders or to an unauthorized personnel

To report any critical finding to the seniors immediately

Not to pass on any document or record to an outsider without taking prior permission from authorized personnel

Job Types: Full-time, Permanent

Pay: ₹720,000.00 - ₹840,000.00 per year

Benefits:

Cell phone reimbursement Health insurance Paid sick time Provident Fund
Experience:

total work: 7 years (Preferred)
Work Location: In person