- To ensure that the concerned departments are maintaining statutory compliance and related documents like Licenses etc. & regularly updating the same.
- Ensure compliance of all clinical and nonclinical processes in the hospital NABH and JCI compliant and monitor the progress of implementation.
- Create the policies and procedures of all departments in compliance with Quality certification and Accreditation Standards.
- Responsible to research, establish and monitor the implementation of best practices and compliance of all clinical and non clinical service areas.
- Responsible for maintaining standards of care by initiating quality assurance programs across the hospital covering all departments. Generate reports and record the results.
- Create SOPs for all departments in coordination with HODs.
- Design and standardize various forms and formats and get the approval for the same.
- Ensure document distribution (policies, SOPs) to all departments and documentation control.
- Responsible for identifying bottlenecks and hindrances in implementation process and fix the same and ensure the implementation as per the timelines.
- Responsible for the root cause analysis for all issues in patient care and suggest, arrive at a plan for corrective action.
- Responsible to formulate the policies in coordination with all the HOD’s and ensure implementation of the same.
Collaborative efforts through committee approach for CQI:
- Work in collaboration with the hospital GMs/HODs and Incharges responsible for quality system and accreditation at individual hospitals on Quality and Accreditation activities, focus efforts and provide consistency.
- Responsible for setting up quality indicators for all the departments in the hospital and monitor implementation and progress.
- Responsible for analyzing the results and trends of these indicators for all the departments and arrive at solutions for making further inroads.
- Responsible for maintain the MIS related to all the quality aspects of each department in the hospital and ensure that all the employees work as per the standards.
- To communicate to all the departments to implement the standards and SOPs in compliance with Quality certification and Accreditation.
- To establish the committees and ensure that collaborative efforts are been made to improve the defined areas / processes.
- Ensure that committee meetings are been held regularly.
Educational Material & Trainings:
- To create appropriate educational material for Quality improvement and distribute the same to the concerned department.
- Provides facilitation on process improvement, quality improvement and other statistical techniques and focused training to the management and employees of the hospital.
- In association with HR department, to identify the training requirement regarding Quality certification and Accreditation and to coordinate with the Trainer for conducting training programs for the employees
- In association with HR department, coordinate with all departments and ensure that trainings are been conducted at regular interval.
Key Performance Indicators: Analyzing, Monitoring & Reporting
- To direct the departments to collect data, analyze & report the outcomes in order to use in quality improvement initiatives.
- To analyze the data collected, to prepare reports indicating trends, performance measures and quality indicators.
- Assess the performance of the departments in terms of following the policies, SOPs in compliance with Quality standards.
- To monitor Clinical and Non-clinical Quality Indicators and report to Top management wherever appropriate.
- To develop and modify the Organization Dashboard appropriate to Continuous Quality Improvement Programme.
- To analyze the results of surveys and quality indicators and follow up for the implementation of recommendations on deficiencies.
- To carry out regular Internal Audit, Quality Checks, Analysis of data in order to find opportunities for the development & implement the quality systems for the same.
- To assess all departments in terms of the degree of compliance to the various quality standards and report the same to the HODs and the Management.
- To implement and coordinate quality projects like FOCUS and PDCA.
Liaison with Certifying bodies:
- To act as a liaison between organization and Quality certification and Accreditation bodies.
- To prepare annual budget for CQI in coordination with all the HODs and Incharges.
Implementation of CQI project:
- Coordinates through organizational leaders, educational activities regarding standards, systems and other quality improvement methodologies.
- To guide department implement Quality Management System.
- To ensure that the processes needed for Quality Management System and Technical Management system are established, implemented and maintained
- To assess state of readiness of hospital for Quality certification / Accreditation surveys.
- Possess information related to Hospital procedures/protocol
- Provide training to the staff
- Responsible for researching and suggesting the best practices in care management for all the departments in the hospital.
- Ensure training to all the staff in all aspects of care delivery, Patient safety regulations etc.
- Ensure education to all patients on the patient rights and responsibilities. Ensure education to all the employees on their rights and responsibilities and helping in integrating the culture of mutual trust, empathy and respect.
- Ensure assigning of responsibilities to the employees working in quality department
Ensure the training needs of the employees of all departments are identified and addressed with definite time lines.
Role:Employee Health and Safety Management
Salary: 90,000 - 1,25,000 P.A.
Industry:Medical Services / Hospital
Functional Area:Administration & Facilities
Employment Type:Full Time, Permanent
UG:MBBS in Any Specialization
PG:MBA/PGDM in Any Specialization
Cancer Treatment Services Hyderabad Pvt. Ltd.
Contact Company:Cancer Treatment Services Hyderabad Pvt. Ltd.
Address:DOOR NO.1-100/1-CCH,,AMERICAN ONCOLOGY INSTITUTE,N, Hyderabad, Telangana, India