Summary

Healthcare accreditation specialist with 8+ years of experience in the field of healthcare Quality Assurance and Accreditation(Qatari accreditation,JCIA,NABH,NABL) . Double Post Graduate in Hospital administration and Quality management from the prestigious  BITS-PILANI , I have supervised and coordinated implementation of  Qatar national ACCREDITATION  standards, JCIA, NABH and NABL Standards across large number of corporate and government institutions  .I was associated with more than 15 NABH assessments across 12 corporate hospitals including pre assessments, Final assessments , Surveillance assessments and Re-accreditation assessments with minimal non compliance.A  Certified TRAINER by Manipal Executive education academy. I aspire to become a subject matter expert in the field of Healthcare Quality and Accreditation

WORK EXPERIENCE

Work History

MANAGER-QUALITY ASSURANCE

May 2014 - Present
ASTER DM HEALTHCARE WLL-QATAR
  • Heading Quality assurance and accreditation initiatives across 6 medical centres of Aster DM  Healthcare in Qatar.
  • Working closely with supreme council of health(supervisory government authority on health policy and quality in Qatar) for various projects in line with the N.H.S (national health strategy).
  • Development, implementation and verification of compliance to treatment pathways and standardized     clinical practice guidelines across medical centers.
  • Testing, training and implementation of electronic prescription module in medical centres. Working with clinicians on troubleshooting of the same and ensuring proper use.
  • Active participation in the implementation Health system performance agreement project(HSPA)     piloted by supreme council of health wherein periodic performance reporting done , by a set of 15 key  performance indicators. Undertook training and roll-out initiative of HSPA log sheets and indicator procedure manual.
  • Working closely with top management and unit admin on implementation of MANDATORY NATIONAL ACCREDITATION STANDARDS BY QATAR GOVERNMENT across all units of Aster in Qatar
  • Development of policies, procedures and forms with the help of medical team . Training and             implementation of these in day to day work for ensuring max compliance to accreditation standards of quality and patient safety.
  • Liaisoning with patients and unit administration on handling and resolving complaints of service quality and clinical quality.
  • Performance reporting of medical centres (quality performance dashboard) in the dimensions of     quality and patient safety to corporate headquarters(CHQ,) located in Dubai. Working with chief quality officer in implementation of quality initiatives.
  • Working with dept. Hods and staff for implementation of quality improvement activities (reduction in turn around time, bounces, errors etc) .
  •  Certified trainer by LEAD TEAM of CHQ. Participation in regular training of staff in occupational safety, patient safety and quality .

MANAGER-MEDICAL SERVICES(QUALITY)

Dec 2010 - Apr 2014
QUALITY CARE INDIA LTD/CARE HOSPITAL GROUP

  • NABH and NABL Implementation and supervision of quality improvement activities across all units of  CARE hospital group including clinical audits.8 accredited hospitals. I have  coordinated(In-person) More than 15 assessments including pre assessments, final assessments and surveillance assessments.
  • Leading internal audit groups for assessing organizations readiness for undergoing NABH                  Accreditation 
  • Planning, organizing and conducting Quality improvement projects and initiatives across various  departments 
  • Direct Reporting to senior management (Vice president- Quality Assurance) about any non-               compliances/ issues and responsible for preparing appropriate closure plan 
  • Developing and implementing Quality System training plans and imparting trainings for maintaining safety and quality standards across hospital
  • Maintaining Master data base of clinical and non- clinical Quality indicators of each units. Setting       accepted benchmarks, analysis and initiating corrective and preventive action for the same.
  • Preparation of Complete documentation of Standard operating procedures, Policies and Work instructions against NABH standard requirements
  • Training , overseeing and implementation of various periodic emergency mock drills
  • Designing clinical audits and outcome measures in consultation with clinicians team .Implementation of    audit checklist , tracking and reporting of improvement to the master committee 


NABH accredited hospitals

Care hospital banjara hills
Care hospital nampally
Care hospital musheerabad
Care hospital vishakapatnam
Care hospital nagpur
Care hospital surat
Care hospital bhuvaneswar
Care hospital raipur

NABL accredited labs

Care hospital banjara hills
Care hospital nampally
Care hospital musheerabad

ASSISTANT MANAGER-QUALITY

Apr 2010 - Jan 2011
GLOBAL HOSPITALS AND HEALTH CITY
  • Coordinating Implementation of NABH standards
  • Implementation of policies, procedures and coordinating audit
  • Conducting audits and assisting Manager Quality assurance 
  • Monitoring and tracking of Quality indicators 

SENIOR CONSULTANT-QUALITY(NABH AND ISO)

Jul 2008 - Mar 2010
ACME INDIA PVT LTD

  • Chief Coordinator for Cuddalore ditrict PHC's ISO (ISO accreditation of 48 PHC's)
  • Worked as  the chief Coordinator for NABH Accreditation of 500 bedded Cuddalore District               Government  Headquarters hospital(1 of the 12 selected for NABH)
  • Took part in various stages of NABH accreditation process of Vijaya Hospitals(Chennai )(Maturity       audits), Sankara Nethralaya ( chennai )(System study, Awarenesss and documentation)
  • Conducting periodic quality and safety trainings 


Education

Education

M.S QUALITY MANAGEMENT 

2011 - 2013
BIRLA INSTITUTE OF SCIENCE -BITS PILANI

MASTER OF SCIENCE  IN HOSPITAL ADMINISTRATION

2006 - 2008
BHARATHIYAR UNIVERSITY

BACHELOR OF SCIENCE IN BIOCHEMISTRY 

2002 - 2005
BHARATHIYAR UNIVERSITY 

Skills

Skills

Quality Management system Documentation

Root cause analysis and Proactive risk assessment

Training and capacity building

Internal Auditing 

Healthcare Quality Assurance 

Hospital Accreditation

Certifications

Certifications

Certified "TRAINER"

MANIPAL EXECUTIVE EDUCATION / ASTER DM LEARNING AND DEVELOPMENT TEAM

REFERENCES 

DR SAMEER MOOPEN

CEO

ASTER DM HEALTHCARE-QATAR

DRSAMEER@DMHEALTHCARE.COM, +974-74799499


DR S.K IYENGAR

VICE PRESIDENT -QUALITY 

QUALITY CARE INDIA LTD

DRIYENGAR@CAREHOSPITALS.COM, 9849019448


DR.RAJEEV CHOUREY

CHIEF HOSPITAL ADMINISTRATOR

QUALITY CARE INDIA LTD

RAJMEETU@CAREHOSPITALS.COM