Quality Executive

RESPONSIBILITIES:

1. Documentations:

• Developing SOPs, Manuals, policies & procedure for the departments across the units.
• Keeping the track of all SOP’s and Record of all updating.
• Ensuring the document control of all SOP, Manual, forms & Formats of the unit in co- ordination with central Quality Team.
• To ensure yearly review & updating of All SOP, Manuals, Policies & procedure.
• Keep record of the forms & formats and ensure correct numbering of the same.
• Ensure that no obsolete document is available in the department.
• Identification of new documentation requirement and completion of the same in coordination with the department within 15 days from the time of request raised

1. Implementation of Quality standards across the health center:

• Identification of the gaps and implementation within one month of post identification in co-ordination of the departmental Heads.
• Ensure Implementation of Quality standards across the unit in coordination with the On-site health center Leadership Team.
• Monitor ongoing medical education programs (together with the GP) on a monthly basis;

1. Audits:

• Monthly Quality Audits
• Ensure at least 6 monthly Internal Audit by the unit Team.
• Ensure successful completion of Cross audits & corporate audits.
• Ensure Successful completion of External audits by accreditation bodies.
• To be the point of contact and primary coordinator for Audits by accreditation bodies.
• To ensure closure of all deficiencies pointed out by external audits within the defined timeframe.
• To ensure the uploading of correct, appropriate and verified document in the portal of accreditation bodies for desktop/virtual/hybrid audits and non-compliance closure.

1. Quality Indicators:

• Developing quality indicators in line with the quality policy and as per requirements of accreditation standards.
• Ensure timely collection and submission of quality improvement data to the central Quality Team.
• Ensure the correctness of the data and proper verification of data before submission.
• Ensure timely resolution of any queries pertaining to the submitted data.
• Ensure capturing of indicator data from HIS / software tool.

1. Quality Improvement Projects:

• To ensure the conduct of quality improvement projects using appropriate tools. The minimum number of such projects shall be as defined by the central quality team.

1. Committee Meetings:

• Ensure the committee meetings as per TOR and Committee audit once annually

1. Mock Drills:

• Ensure that Mock drills are being done as per schedule and timely action has been taken.

1. Training:

• To train the Health center in NABH policies & procedures.

1. Statutory Compliance:

• To maintain all statutory compliances & remind all process owners 3 months prior to the expiry of license

1. Other Responsibilities:

• Other responsibilities assigned by IMD