Unit Head - Quality

Duties:

• Maintain and review departmental policies, objective and procedures in associate with the departmental HODs.
• Co-ordinates the planning, design and implementation of Continuous Quality Improvement projects, so as to systematically evaluate and meet patient care needs.
• Review and monitor data analysis of all quality indicators for each department and provide appropriate feedback to the concerned departments and to the top management through the Vice President-Quality & Operations of CARE Hospitals Group.
• Prepare and present regular reports on all departmental activities to the Hospital Chief Operating Officer & the Vice President-Quality & Operations.
• Conduct and oversee internal audits and provide appropriate feedback to the departments.
• Co-ordinates with NABH secretariat Office and NABH Assessors (in Accreditation process) for all communications.
• Organize, facilitate and participate on NABH accreditation team evaluation visits to different departments of organization during pre-assessment or reaccreditation.
• Conducts surprise audits along with the quality team and submits the reports to the management through the Vice President-Quality & Operations.
• Assists the Vice President-Quality & Operations in planning and conducting audits by external agencies for the purpose of accreditation.
• Strive to maintain NABH and other NABH certification requirements.
• Prepare the departments annual reports for submission to the Hospital’s Facility Chief Operating Officer through the Vice President-Quality & Operations of the Group.
• Represent the department in committees of the hospital.
• To ensure NABH application is filled online (accreditation/re-accreditation) and all the data required for the application shall be coordinated.
• Ensure all the relevant documents are uploaded on the NABH website as and when required.
• Coordinates with NABH secretariat office for any queries / issues to be addressed.
• Ensure internal communication with the staff about the accreditation process through HCOO's office.
• To maintain contact with the assessment team and to coordinate for their travel and stay.
• Ensure that closure is submitted to NABH after the completion of the assessment process well within the stipulated time frame.
• To ensure that the quality indicators report is submitted to NABH.
• Assume any other responsibilities as delegated by the Vice President-Quality & Operations or Hospital Chief Operating Officer.
• Follow up issues raised by external and internal audit report.