Quality Head

Principal Accountabilities

Key Results Areas

· To ensure NABH & NABL standards are reviewed periodically and implemented as per the latest edition.

· To report to the management on periodic basis about the functioning of quality team and status of quality department functions.

· Periodic supervision and monitor the functioning of central and unit specific quality teams.

· Periodically verify and ensure the implementation of Quality Indicator reports and recommendations on deficiencies.

· Periodic verification of the case sheet auditing report, for retrospective and live cases.

· To conduct internal audits in accordance with CQI programme as per defined schedule.

· To conduct mock drills as per schedule and to verify the drills report.

· To plan and conduct various surveys, audits, and studies as per defined schedule and requirement.

· To conduct training classes for hospital staff on quality parameters and relevant hospital policies and procedures.

· To verify and supervise the process of Incident Reporting involving; reporting of incident, analysis of incident and action taken with respect to the incident.

· To plan document preparation and implementation of Quality Management Systems.

· To supervise the process of updation of department manuals as and when policies and procedures are amended / revised.

.To verify the maintenance of all the documents, files and reports related to Quality Assurance department.

· To plan various committee meetings as per Continuous Quality Improvement programme schedule.

· To Interpret and implement quality assurance standards in the hospital.

· To liaise and train all the departments on quality management system.

· To innovate, initiate and implement required QMS standards and related processes.

· Adherence to all mandatory compliances as per the QMS standards.

Team Development:

· Periodic review meetings with quality team across the organization.

· To update the team with new systems and standards of various QMS applicable to the organization.

· Impart / Update QMS knowledge, case studies to the team for better efficiency in process operations and meeting of individual, team and organizational quality goals.

Key Performance Indicators

· Regular internal audit as per the SOP.

· Periodic review of quality indicators data.

· Periodic committee meetings.

· Organisation policies and procedures, SOPs as per the accreditation guidelines.

Implementation of Quality Management Systems.