Quality & patient Safety Manager
Key Responsibilities
The duties of a Quality & Patient Safety Manager are highly focused on systematic improvement and risk mitigation:
- 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).
- 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.
- 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.
- 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.
- 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.
- 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.
