Executive - Quality

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 -