Nabh Co-ordinator

Implement NABH standards and achieve the Accreditation.
- Assist in developing Hospital policy and departmental manual as per NABH standards.
- To study, understand and analyse the hospital policies and procedures,” Identify the gaps” between them and the pursued accreditation standards.
- Working with operational staff to establish procedures, standards, and systems.
- To identify stakeholders who can support/manage the deficiency corrections.
- Train the identified stakeholders in deficiency identification, correction methodology and recording of activity data.
- Ensuring good quality of clinical and non-clinical services.
- Prepare relevant checklist and forms for each department based on accreditation guidelines & statutory/good practice guidelines.
- Collect, collate and analyse the internal quality audit findings and communicate to appropriate & concerned authorities in a sensitive approach.
- Monitor and access compliance with quality standards and identify the gaps, take actions if necessary.
- To identify critical information and report/escalate to the concerned organization authority on a regular basis.
- Design and implement quality improvement programme.
- Conducting safety preparedness mock drill and produce report.
- Facilitate conduct of committee meetings like mortality meeting, Infection control meeting, Clinical Audit meeting, Quality Assurance Meeting etc.
- To identify suitable committee members and their roles and responsibility for proper functioning of committee.
- Ensuring that the hospital meets all regulatory compliances.
- Assisting in medical administration processes.
- Acting as catalyst for change and improvement in performance and quality.
- Determining training needs of staff with respect to awareness in quality and departmental processes.
- To prepare a training plans, modules and conduct the training as per needs.
- To review and revise all patient care forms and formats in liaison with departments.
- To maintain all documents /copies of originals as required by accreditation authorities.
- To maintain & store all documents of:
a. Departmental manuals

b. Minutes of committee meetings

c. Incident reports,sentinel reports

d. Quality indicator results

e. Internal audit report findings & Self assessment toolkit

Schedule:

- Day shift

Ability to commute/relocate:

- Gandhinagar - 382421, Gujarat: Reliably commute or planning to relocate before starting work (required)

**Experience**:

- total work: 2 years (preferred)

**Speak with the employer**
+91 7575007718