Quality & Patient Safety Manager

Job Title: Quality & Patient Safety Manager

Location: Kashi

Reports To: CMO/ CEO

Role Purpose

A Quality & Patient Safety Manager will maintain and continuously enhance the standards of quality and patient safety. He will lead and guide the team of Patient Care, takes the initiatives of training for the continuous improvement of the quality standards and patient care and minimize risks within a hospital. He will be ensuring the organization meets and exceeds regulatory standards and fosters a culture of safety.

Key Responsibilities

The duties of a Quality & Patient Safety Manager are highly focused on systematic improvement and risk mitigation:

1. Quality Improvement Initiatives:

• Develop, implement, and maintain the hospitals Quality Management System (QMS) in alignment with NABH or JCI standards.
• Conduct regular internal quality audits and assessments to identify the areas of risk and take necessary actions for the risk prevention.
• Monitor clinical and operational data of surgical success rates, infection rates, and patient recovery times and follow the risk prevention plan.
• Coordinate clinical quality improvement programs in collaboration with ophthalmologists, nurses, and technicians of the team.
• Lead quality improvement initiatives and projects using recognized methodologies such as Root Cause Analysis (RCA), Failure Mode and Effects Analysis (FMEA), and Plan-Do-Study-Act (PDSA).

2. Patient Safety and Risk Management:

• Conduct patient satisfaction surveys, analyze data, and implement corrective actions.
• Train staff on communication, empathy, and patient engagement skills.
• Investigate and analyze patient safety incidents, near misses, and adverse events to determine root causes.
• Develop and implement action plans to prevent recurrence of patient safety events and mitigate future risks.
• Manage the hospital's risk management program, including incident reporting systems and risk registers.
• Improve patient journey workflows from registration to discharge.
• Promote a "culture of safety" where staff feel empowered to report errors and collaborate on solutions without fear of punitive action.
• Conduct root cause analyses (RCAs), failure mode and effects analyses (FMEAs), and recommend corrective/preventive actions.
• Address and resolve patient grievances and feedback in a timely and professional manner.

3. Regulatory Compliance and Accreditation:

• Ensure the hospital's compliance with all local, state, and federal healthcare regulations and standards
• Prepare for and participate in regulatory surveys and inspections.
• Develop and maintain policies and procedures related to quality, patient safety, and risk management.

4. Infection Control and Safety:

• Work closely with the Infection Control Committee to ensure sterilization, disinfection, and hygiene protocols are followed.
• Monitor post-operative infection rates and implement preventive measures.

5. Data Analysis and Reporting:

• Collect, analyze, and interpret data on patient outcomes, quality metrics, and safety events.
• Create and present clear, data-driven reports to hospital leadership, committees, and staff to inform decision-making and drive change.
• Monitor key performance indicators (KPIs) and report on progress towards quality and safety goals.

6. Deliverables & Accountability

We expect that under your leadership

• Quality management System is well implemented with continuous improvement plan.
• Proper documentation for hospital (NABH) accreditation, regular mock audits for the gap analysis.
• Professionally handling of the patients grievance and close the loop by feedback mechanism.
• Training plans for infection prevention and control, patient care mechanism and maintaining high quality standards.
• Analytics of the data to identify the areas of improvement to deliver the high standard of eye care.

Warm Regards

Jolly Nayak

3POINTHRM