Job Description

Implement NABH standards and achieve the Accreditation.

Assist in developing Hospital policy and departmental manual as per NABH standards.

To study, understand and analyse the hospital policies and procedures," Identify the gaps" between them and the pursued accreditation standards.

Working with operational staff to establish procedures, standards, and systems.

To identify stakeholders who can support/manage the deficiency corrections.

Train the identified stakeholders in deficiency identification, correction methodology and recording of activity data.

Ensuring good quality of clinical and non-clinical services.

Prepare relevant checklist and forms for each department based on accreditation guidelines & statutory/good practice guidelines.

Collect, collate and analyse the internal quality audit findings and communicate to appropriate & concerned authorities in a sensitive approach.

Monitor and access compliance with quality standards and identify the gaps, take actions if necessary.

To identify critical information and report/escalate to the concerned organization authority on a regular basis.

Design and implement quality improvement programme.

Conducting safety preparedness mock drill and produce report.

Facilitate conduct of committee meetings like mortality meeting, Infection control meeting, Clinical Audit meeting, Quality Assurance Meeting etc.

To identify suitable committee members and their roles and responsibility for proper functioning of committee.

Ensuring that the hospital meets all regulatory compliances.

Assisting in medical administration processes.

Acting as catalyst for change and improvement in performance and quality.

Determining training needs of staff with respect to awareness in quality and departmental processes.

To prepare a training plans, modules and conduct the training as per needs.

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

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

To maintain & store all documents of:

a. Departmental manuals

b. Minutes of committee meetings

c. Incident reports,sentinel reports

d. Quality indicator results

e. Internal audit report findings & Self assessment toolkit

Job Type: Full-time

Pay: ?25,000.00 - ?45,000.00 per month

Benefits:

Provident Fund
Ability to commute/relocate:

Gandhinagar, Gujarat: Reliably commute or planning to relocate before starting work (Required)
Experience:

total work: 2 years (Preferred)
Work Location: In person