Job Description

Work with Management, Clinicians & Non-Clinicians to monitor and ensure preparation for accreditation of all services. Support a culture that enables staff to understand and comply with quality, risk and patient safety guidelines to meet relevant accreditation standards and legislative obligations. Lead and conduct annual quality audits via the current quality management provider, review and maintain audit tools. Analyse audit results creating improvement plans and act on audit findings and recommendations to ensure compliance. Manage and review the organisation's document control system; assuring compliance and ensuring that there is a QMS in place for the identification, storage, protection, retrieval, retention and disposition of these records. Ensure an internal audit schedule is in place which delivers risk minimisation, compliance to accreditation and quality standards. Manage and coordinate the clinical & managerial indicator collection system and maintain any incident and risk registries. Evaluate and submit analysis/benchmarking reports to Management, stakeholders and relevant committees in a timely manner on : Clinical & managerial indicators Clinical & managerial incidents Clinical & managerial risk and patient safety Patient feedback/satisfaction and patient experience Quality Improvement audits and evaluations Management of the corrective action system ensuring all non-conformities are recorded and
investigated to determine root cause and ensuring corrective or improvement activities are

closed out in a timely manner.

Maintain incident reporting system ensuring appropriate completion and follow up of incidents by management in a timely manner. Work with staff to promote and encourage a reporting culture of clinical incidents, near misses and hazards across the organisation. o Review and further develop Complaints Management Framework. Review of customer feedback, patient complaints and maintain the tracker to do the follow up with management. Review and upkeep of policies and procedures (including patient privacy and confidentiality), liaising with relevant staff to ensure compliance and best practice guidelines are implemented. Review, analyse and enact updates to legislation, regulations, standards and guidelines on QMS and facilitate changes to processes and procedures to ensure adherence with updated
requirements.

Co-ordinate the Quality Committee and implement changes required. Educate, coach and mentor staff and clinicians on the tools and processes required for the
ongoing accreditation process and QMS.

Co-Ordinates in the planning of mandatory training as per the standards and educational programs as appropriate to quality and safety needs of the organization. Lead, facilitate and support the development and implementation of quality improvement
projects to deliver improved safety and quality outcomes for patients.

Adhere to the requirements of Occupational Safety and Health legislation. Identify and report safety hazards Conduct & Participate in all committee meetings Initiate emergency, safety practices and measures as appropriate. Assures application of a tracking method to monitor progress towards goals by collecting
accurate, timely data to display the quality, cost, and service outcomes.

Ensuring that the hospital meets all regulatory compliances such as BMW, Blood Bank/Storage license, AREB regulations, etc.; Ensure to keep a record of non-functional equipments and time line for its repair along with
AMC of all equipments.

Planning and work-out modalities towards upliftment, preventive maintenance of equipments & vehicles and modernization of hospital Other tasks as and when required by the management. To ensure the development and implementation of goals, objectives, policies, procedures and systems pertaining to the quality assurance and NABH regulatory functions. Manage, maintain and follow-up the hospital quality mock inspections reports.
Job Types: Full-time, Permanent

Pay: ₹25,000.00 - ₹35,000.00 per month

Benefits:

Cell phone reimbursement Commuter assistance Flexible schedule Health insurance Internet reimbursement Life insurance Paid sick time Paid time off Provident Fund
Experience:

total work: 1 year (Preferred)
Work Location: In person