Accreditation Specialist

Job Title : Executive / Sr. Executive / Team Lead - Quality Job Grade :

Department : Quality

Reporting to : Medical Director / Dr. Farhan

Location : Unit

Job Summary : Responsible for devising and establishing quality procedures, standards and specifications in the hospital and promote Quality Improvement in all the process & procedures of the hospital.

Focus

Indicators

Financial / Business

Undertakes quality initiatives, audits, risk management as due in conjunction with the Quality and Unit Head.

To conduct surprise audits / investigations in various clinical and non-clinical areas in the hospital and submit findings report to HODs & Top Management.

To recommend management on continual quality improvement activities.

To keep a track of the worldwide developments in the area of healthcare quality and adopt best practices to refine the existing processes.

To conduct and coordinate hospital committees meetings.

People

To guide cross functional teams on various activities on quality aspects and to identify the training needs.

To coordinate and conduct training programs and to implement quality management systems and technical management system in compliance with quality certification and accreditation.

Responsible for training / educating staff and new joiners on different emergency codes and hospital policies.

Customer

To do periodical rounds on the aspects of patient safety.

To do internal auditing of various functions / areas of hospital as per the accreditation body guidelines.

Operations

Works to ensure that quality improvement and innovation work remains focused on one or more of the following goals : patient-centeredness, staff vitality, process efficiency, waste reduction, and safe & reliable patient care.

Ensuring clean surroundings, OPD Areas, Wards, Labour Room, OT and Patient

amenities and outsourced services

Periodical assessment of hospitals on quality check list and arrive at a score for the facility

Identification of gaps, develop action plan under the guidance of department head and monitor compliance

To participate in various clinical audits being conducted in the hospital and take necessary actions against the same.

To coordinate activities related to quality certifications and accreditations like NABH.

To Interpret and implement Quality assurance standards in hospital to ensure patient safety & quality care to patients.

To analyse the data collected and to prepare reports indicating trends, performance measures of quality and key performance indicators.

To collect, collate, analyse and report Quality Indicators of various functions of the hospital.

Conducts awareness sessions through mock drills to prepare team to handle crisis situations.

To facilitate the external audits conducted by the Accreditation Body.

Any other portfolio that may be entrusted by the management from time to time.

Educational Qualifications :

Any graduate with Master’s Degree in Hospital Management

Work Experience

Having 3-5 years of experience as a quality Manager

Sound knowledge on the Concepts of Quality to the hospitals (NABH)

Knowledge of regulatory requirements

Knowledge of qualifications and validations

Knowledge of Quality Management System

Knowledge and experience of handling regulatory audits (NABH etc.)

Expected Deliverables

Continuous Improvement Projects

Compliance and Documentation

No NC’s in Audit

Training and Education