Address Designation: Executive Quality Reporting to : Clinical / Non Clinical Reporting Direct: Asst Quality Manager Indirect: Group Medical Director / Cluster Head Function: To ensure compliance across all departments of NU Hospitals, with regard to National/International Accreditation Standards Key Result Areas: Maintain the renewal process of NABH certification Identify areas requiring quality indicators monitoring To constantly implement, follow up and update CQIs in all departments Standardization of documents across all departments of the hospital Institute documentation and implementation of process and policies across all levels of the hospital Acceptable Qualifications: A Bachelor Degree in any field and preferably A Master Degree in Hospital Administration field. Minimum 1 year experience in the quality department of an NABH accredited Hospital. Knowledge & Skills: Knowledge of current NABH standards Knowledge of all statutory requirements Knowledge of computer usage, HMIS, internet - Relevant to job requirement Experience of quality initiatives in the hospital industry Knowledge about Hospital Services Ability to implement and monitor quality indicators and parameters Must drive with initiative and commitment, must possess problem solving and decision making skills Good Communication Job Responsibilities: To support and guide documentation and implementation of process and policies. Identify lacunae in quality practices, and ensure corrective action Monitoring statutory and regulatory status and escalate to Manager Administration/Cluster Head in case of any lapse.
Updating the status of functioning of all mandatory committees and escalate to Group Medical Director for any deviation from the TOR (Terms of Reference) Collecting and Analyzing Quality Indicators –clinical and nonclinical indicators Scheduling, conducting& documenting MOM of all meetings and follow up of observations with RCA, CAPA with evidences 1) Quality Committee meeting 2) CPR Committee meeting 3) Safety Committee meeting 4) Mortality & Morbidity Committee meeting 5) Clinical Audit committee meeting 6) Quality Indicator/Committee Meeting 7) Management review meeting 8) Asset Disposal Committee meeting To monitor other committee meetings –Medical record Review, Pharmacy and Therapeutic, Hospital Infection Control, Biomedical waste committee meeting. Ensure all other committee’s as per the list meets as per the frequency and also the maintenance of proper documentation. Submission of quarterly indicators to NABH & also to update the same in NABH website To ensure and follow up with all the process owners for the updation of the CQIs every month in the QIS software Update Safety, Quality, Apex manual every year after co ordinate with chairman of the committees Yearly once target and threshold should be changed as per the guidance from the quality committee chairman Conducting emergency codes and disaster drills on a monthly, quarterly & half yearly basis as per the schedule To identify & implement additional CQIs in all departments Scheduling and Conducting Internal Audit & follow up of corrective & preventive action, root cause analysis and closure of non-conformances. NABH assessment & follow up of closures on non conformances with proper evidence within the given timeframe from NABH team Auditing the each departments as per the NABH standards and escalate to management if any deviations found Ensuring the details received from pharmacy and MRD is shared to the concerned authority in the stipulated time. Co-ordination and follow up for the external audits with external bodies NABH / AHPI / CAHO / FICCI / NABH Nursing Excellence Arranging materials, payments and documents for external bodies awards / conference etc Training to the newly joined staff during induction on Quality information. Attending all webinars conducted by the external bodies and documenting the same Responsible for control of documents (preparation and Distribution of documents, forms and formats etc., to respective departments for the review) Executive - Updating the status of functioning of all mandatory committees and escalate to Group Medical Director for any deviation from the TOR (Terms of Reference) Collecting and Analyzing Quality Indicators –clinical and nonclinical indicators Scheduling, conducting& documenting MOM of all meetings and follow up of observations with RCA, CAPA with evidences 1) Quality Committee meeting 2) CPR Committee meeting 3) Safety Committee meeting 4) Mortality & Morbidity Committee meeting 5) Clinical Audit committee meeting 6) Quality Indicator/Committee Meeting 7) Management review meeting 8) Asset Disposal Committee meeting To monitor other committee meetings –Medical record Review, Pharmacy and Therapeutic, Hospital Infection Control, Biomedical waste committee meeting. Ensure all other committee’s as per the list meets as per the frequency and also the maintenance of proper documentation. Submission of quarterly indicators to NABH & also to update the same in NABH website To ensure and follow up with all the process owners for the updation of the CQIs every month in the QIS software Update Safety, Quality, Apex manual every year after co ordinate with chairman of the committees Yearly once target and threshold should be changed as per the guidance from the quality committee chairman Conducting emergency codes and disaster drills on a monthly, quarterly & half yearly basis as per the schedule To identify & implement additional CQIs in all departments Scheduling and Conducting Internal Audit & follow up of corrective & preventive action, root cause analysis and closure of non-conformances. NABH assessment & follow up of closures on non conformances with proper evidence within the given timeframe from NABH team Auditing the each departments as per the NABH standards and escalate to management if any deviations found Ensuring the details received from pharmacy and MRD is shared to the concerned authority in the stipulated time. Co-ordination and follow up for the external audits with external bodies NABH / AHPI / CAHO / FICCI / NABH Nursing Excellence Arranging materials, payments and documents for external bodies awards / conference etc Training to the newly joined staff during induction on Quality information. Attending all webinars conducted by the external bodies and documenting the same Responsible for control of documents (preparation and Distribution of documents, forms and formats etc., to respective departments for the review) Executive -
