Hospital Quality Manager

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