Quality & patient Safety Manager

Key Responsibilities

The duties of a Quality & Patient Safety Manager are highly focused on systematic improvement and risk mitigation:

1. Quality Improvement Initiatives:

Ø  Develop, implement, and maintain the hospital’s Quality Management System (QMS) in alignment with NABH or JCI standards.

Ø  Conduct regular internal quality audits and assessments to identify the areas of risk and take necessary actions for the risk prevention.

Ø  Monitor clinical and operational data of surgical success rates, infection rates, and patient recovery times and follow the risk prevention plan.

Ø  Coordinate clinical quality improvement programs in collaboration with ophthalmologists, nurses, and technicians of the team.

Ø  Lead quality improvement initiatives and projects using recognized methodologies such as Root Cause Analysis (RCA), Failure Mode and Effects Analysis (FMEA), and Plan-Do-Study-Act (PDSA).

1. Patient Safety and Risk Management:

Ø  Conduct patient satisfaction surveys, analyze data, and implement corrective actions.

Ø  Train staff on communication, empathy, and patient engagement skills.

Ø  Investigate and analyze patient safety incidents, near misses, and adverse events to determine root causes.

Ø  Develop and implement action plans to prevent recurrence of patient safety events and mitigate future risks.

Ø  Manage the hospital's risk management program, including incident reporting systems and risk registers.

Ø  Improve patient journey workflows from registration to discharge.

Ø  Promote a "culture of safety" where staff feel empowered to report errors and collaborate on solutions without fear of punitive action.

Ø  Conduct root cause analyses (RCAs), failure mode and effects analyses (FMEAs), and recommend corrective/preventive actions.

Ø  Address and resolve patient grievances and feedback in a timely and professional manner.

1. Regulatory Compliance and Accreditation:

Ø  Ensure the hospital's compliance with all local, state, and federal healthcare regulations and standards

Ø  Prepare for and participate in regulatory surveys and inspections.

Ø  Develop and maintain policies and procedures related to quality, patient safety, and risk management.

1. Infection Control and Safety:

Ø  Work closely with the Infection Control Committee to ensure sterilization, disinfection, and hygiene protocols are followed.

Ø  Monitor post-operative infection rates and implement preventive measures.

1. Data Analysis and Reporting:

Ø  Collect, analyze, and interpret data on patient outcomes, quality metrics, and safety events.

Ø  Create and present clear, data-driven reports to hospital leadership, committees, and staff to inform decision-making and drive change.

Ø  Monitor key performance indicators (KPIs) and report on progress towards quality and safety goals.

1. Deliverables & Accountability

We expect that under your leadership

Ø  Quality management System is well implemented with continuous improvement plan.

Ø  Proper documentation for hospital (NABH) accreditation, regular mock audits for the gap analysis.

Ø  Professionally handling of the patient’s grievance and close the loop by feedback mechanism.

Ø  Training plans for infection prevention and control, patient care mechanism and maintaining high quality standards.

Ø  Analytics of the data to identify the areas of improvement to deliver the high standard of eye care.