Quality Executive

Certifications / Accreditations
a. To function as Accreditation Coordinator for Quality Accreditations like NABH, NABL, NABH NEC etc. and coordinate with accreditation bodies.

b. To coordinate for implementation of requirements of various Quality Certifications and Accreditations like NABH, NABL, NABH NEC.

c. To conduct Gap Identification study in line with Quality Certifications and Accreditations and produce the report to concerned Unit Head and others.

d. To Interpret and implement accreditation standards in hospital to ensure Quality care to patients.

e. To coordinate for closing observations received during external audits and forward the action report to accreditation bodies.

Document Management
a. To identify the documentation requirements and coordinate with concerned for development of the documents (POPs, SOPs, Manuals, etc) in line with Quality Certification & Accreditation Bodies.

b. To review the documents developed and revised for issuing to all concerned.

c. To control documents and records.

d. To review the existing forms and verify and make necessary changes in coordination with the concerned department in-charges/HODs.

e. To obtain the approvals and issue the documents to concern departments

Training
a. To identify the training requirements of the hospital staff in line with Quality Certification & Accreditation Bodies and coordinate with concerned HOD / in-charge for addressing the training needs.

b. To train QA staff on accreditation standards and quality concepts.

Committee & Other Meetings
a. To develop annual Committee Meetings schedule and guide QA staff in conducting the committee meetings.

b. To escalate to Unit Head for any issues and feedback on committee functioning.

c. To attend monthly HOD & in-charges meeting and discuss on the points from Quality Department which need to be addressed.

d. Committee Minutes to be circulated within one week of committee conducted

Quality Indicators
a. To share the NABH Quality Indicators data to Group and Unit Head

b. To review the NABH quality indicators trends and guide QA team and concern departments for review of the data received where required.

c. To give feedback to Unit Head for improvement required in quality indicators.

d. To coordinate for implementing the corrective actions recommended by Management.

Internal Audits & Grand Rounds
a. To develop annual internal quality audit schedule and coordinate for implementing the same.

b. To escalate the critical or repeated observations to Unit Head for taking necessary actions.

c. Conduct the grand rounds which includes IPSG, Facility, HIC etc as per the annual schedule

d. Audit and Grand round reports with closure to be shared Group monthly

Quality Improvement
a. To identify areas for improvement and discuss with Unit Head / DMS for preparation of improvement plan.

b. To coordinate for conduct of study required for quality improvement projects.

c. To analyze data collected, prepare meaningful reports and discuss with Unit Head and Group for necessary actions.

d. To guide concerned departments for conducting quality improvement projects.

Statutory Compliance Monitoring
a. Monitor validity of statutory & regulator documents, coordinate with concerned stakeholders for its implementation and maintain a copy of up to date documents.

b. Share the details to Group monthly

Incidents / Adverse Events Management

a. Persuade continuously with all stakeholders for effective implementation and improvement in reporting of Incidents

b. Verify the RCA & CAPA of the incidents and participate / guide concerned in conducting of detailed RCA and taking appropriate CAPA

c. Prepare an analysis report for every month and present it into Quality Improvement Committee

Records Management

Ensure control of records and validate the requests received for revision / addition of new forms / registers.