·        Ensure adherence to internationally accepted standards of care, including but not limited to those recommended by JCI, NABH, NABL and other quality systems

·        Review accreditation standards from time to time and train/facilitate implementation through best practices industry wide in clinical and operational processes.

·        Work collaboratively with all disciplines and departments to develop, implement, and manage quality programs to ensure optimum quality of care and patient safety at times

·        Assist HOD to monitor, evaluate, and respond appropriately and in a timely manner to internal or external communications/queries, any patient feedback and expectations pertaining to quality of patient care and safety through one-on-one communication, surveys, focus groups, regular memoranda, committee meetings, formal and informal communication methods

·        Standardize processes, documents & templates based on the inputs from HODs

• Support the HODs to prepare and monitor the policies and procedures of the hospital and ensure they are reviewed and revised regularly to meet the set criteria.

·        Assist HOD in reducing variation in clinical and business processes by implementing quality standards

·        Assist HOD in conduction of periodic audits to gauge quality of patient care and safety across the hospital

·        Measure & analyse service indicators, operational indicators, clinical outcomes, clinical pathways to help HODs understand the trends and improve the stricture, process & outcome related to these indicators

·        Monitor, maintain and publish hospital wide Quality MIS / Indicators and present for management reporting.

·        Analyse incidents reported and ensure root cause analysis, assist functional team to formulate Corrective and preventive measures and monitor the implementation of same.

·        Review and evaluate audit data and develop action plans in collaboration with all HODs / committees to ensure quality patient outcomes in confirmation with vision, mission, values of the hospital and as per accreditation standards.

·        Interface and coordinate with all Quality Ambassadors to implement quality assurance programs across their respective departments

·        Implement quality improvement projects to improve the day-to-day operational quality of care and patient safety including participation in risk assessment programs as and when required

·        Conduct quality awareness training programs for new joinee and across departments as per the training calendar

·        Support governance mechanisms to ensure that clinical research activities are carried out under ethical guidelines

·        Drive a culture of Patient Safety and Quality Care across the hospital wherein every team member owns up Patient Safety and Quality Care

·        Coordinate with outside agencies with respect to quality initiatives of the hospital

·        Keep abreast with trends in Hospital Quality domain which results in bettering the clinical outcomes & recommend its implementation (with required improvisation, if need be)