JOB DESCRIPTION
1. To implement department wise quality parameters as per the policies and procedures and guide the hospital to achieve NABH accreditation.
2. Develop monthly training programs based on the identified gaps as per the NABH standards.
3. Conducting monthly Committee Meetings along with all the HODs and ensuring minutes are circulated to the committee members as per the yearly committee schedule
4. Monitoring department wise Quality indicators data on monthly basis and present the same in the concerned committee meetings.
5. Frame work formation of Quality Improvement Processes and Methodology as per gaps observation on daily rounds.
6. Plan for departmental NABH audit prior to NABH assessment as per the schedule.
7. Provide guidance to all the HODs about areas of improvement indicated in internal audit and monthly quality indicators
8. Medical record audit data to be collected from HOD MRD on monthly basis , clinical record audit data to be collected from Clinical audit committee members and prescription audit data for OP and IP to be collected from Pharmacy Team on monthly basis and analyzed the same separately
9. Distribute the finalized manuals and SOPs as per the requirement of NABH and ensuring their implementation through monthly training sessions.
10. Conducting Internal and External audits as per the Quality Calendar
11. Send report on weekly basis to Swamiji and hospital superintendent as per the requirement
12. Ensuring the regular follow-up on infection control activities with the coordination of Infection Control nurse and infection control officer
13. Ensuring that the hospital meets all regulatory compliances and intimate the management in case there is any licenses about to get expired
14. To ensure all the reported adverse events (near miss, no harm, sentinel events) along with adverse drug reaction, medication errors to be documented, analyzed and presented in the management.
15. Coordinate NABH external assessment and bridge the gaps in coordination with all the stake holders and achieve NABH accreditation.
16. Any other responsibilities to be carried out as assigned by your reporting manager
Pay: ₹289,434.15 - ₹962,737.55 per year
Work Location: In person
