Assess, initiate and implement Quality improvement in line with organization policies and processes.

Identify the issues/ risk areas which depletes the Quality and bring the same to the notice of
department heads, unit head, discuss, plan and initiate the activities to plug the same with action plan

Form a NABH Team/ Committee to ensure day today clinical, operational quality aspects are met as per
the NABH Standard.

Coordinate with customer care team both at Unit and at HO to understand Patients complaints, short
comings in facilities i. e overall Patient satisfaction survey, work on meeting the gaps.

Facilitate NABH Team meeting and ensure to meet the reviewed non-conformances, observations,
cleanliness, quality procedures followed.

Conduct Periodical Internal Quality Audit and ensure all the legal & statutory requirements met, last
audits gaps closed.

Train, coach department heads/ In charges in use of quality tools, Process and techniques used to
measure effectiveness, quality and accuracy of operations, variations and solving the same.

MIS Reports, KPI, KPA s, corrective actions, target plans, time period to meet the non-complained areas.

Key observation towards industry trends, recommendation for changes and/ or Processes.

Perform other related duties/ responsibilities as assigned or requested by Management

To present the analysis of the data compiled.

To regularly receive feedbacks from departments regarding status of their work related to accreditation
preparation

Daily monitor the patient care areas regarding standards of works and patient safety audit
Orient department heads/ In charges/ Staff in use of quality tools(NABH KPIs), Process and techniques
used to measure effectiveness, quality and accuracy of operations, variations and solving the same

Make sure that all the departments to maintain necessary records/ registers for NABH Accreditation
through timely review of records

Conduct ‘Periodical Internal Quality Audit’ and ensure all the legal & statutory requirements met, last
audits gaps closed

Make sure implementation of SOPs framed by Corporate team and to frame SOPs in the necessary gap
areas

Make sure that the day-to-day clinical, operational quality aspects are met as per the NABH Standard.

To regularly receive feedbacks from departments regarding status of their work related to accreditation
preparation

Identify the issues/ risk areas which depletes the Quality and bring the same to the notice of
department heads, Management Heads, discuss, plan and initiate the activities to plug the same with
action plan

Facilitate NABH Team meeting and ensure to meet the reviewed non-conformances, observations,
cleanliness, quality procedures followed.

Perform other related duties/ responsibilities as assigned or requested by Management