Executive

• To look after Quality Indicators of departments and monitoring of the indicators on a monthly basis.
• To check compliance of medical records by regular audits
• To train the staffs for quality related teachings, compliances, hospital policies, protocols and usages as required by quality improvement guidelines.
• To check, maintain and record the compliance of clinical Pathways and clinical Measures as selected from NABH guidelines.

Quality Monitoring & Reporting:

• Assist in the implementation and monitoring of quality assurance processes and performance indicators to ensure high standards of patient care.
• Collect, analyze, and interpret data related to patient outcomes, clinical processes, and hospital performance metrics.
• Regularly review and report on quality performance, including patient satisfaction surveys, clinical audit results, and compliance with internal policies and regulatory requirements.
• Prepare and maintain detailed reports on quality metrics for presentation to senior management and relevant stakeholders.

Audit & Compliance:

• Assist in conducting internal audits to evaluate compliance with clinical guidelines, hospital policies, and regulatory standards (e.g., NABH, JCI, ISO, etc.).
• Support the development and execution of action plans to address areas identified as non-compliant during audits or assessments.
• Participate in the preparation and coordination of external audits, inspections, and accreditation assessments.