Ensured hospital-wide compliance with laws, policies, and standards for quality of patient care, andfacility licensure and/or accreditationResponsibly managed development, implementation, and ongoing monitoring of Continuous Quality Improvement (CQI) program and acted as a liaison for administration, training, operations, and CQI related matters▪Evaluated collected data every month and report descriptive statistical analysis to the respective hospital committees▪Prepared and Implemented Forms/Templates/documents/formats in various departments.▪Follow up of Incidents & Sentinel events and Performing Root Cause Analysis of the same.▪Attended the meetings with MD, CHA Committee chairman & all HOD’s▪Analysis of Operation Theatres Utilization and Performing the root Causes.▪Quality Indicators and Implementations of the Same.▪Follow up with liaison officer for Licenses approvals & follow-up.▪Evaluated & audited all departments at regular Intervals▪Coordinating & Promoting quality-related activities and advocacy across various client hospitals.▪Assist, support and conduct NABH & JCI, Nursing Excellants assessment ▪Estimating client’s requirements in terms of Structure, Process, and outputs for improving quality of healthcare services.▪Providing support to client hospitals in taking appropriate and time-bound actions on the closure of the gaps, identified during initial self-assessment.▪Ensuring conduct of client’s meetings regularly and taking follow-up actions and Presenting ActionTaken Report (ATR) during the meetings.▪To Provide Technical Assistance to achieve compliance with statutory requirements such as AERB guidelines, Biomedical (Management & Handling) rules.▪Review Patient and employee satisfaction and develop action plans toaddress concerns of patients, which led to poor satisfaction.•Coordinated with Concern Clinician on Clinical Audit and same presented during the JCI.

•Headed Quality& Operations department for NABH Re Surveillance 2020at Apollo Hospitals, Kakinada on 15th and 16th Feb 2020.•NABH Internal counselor/Auditor for NABH 4th Edition standards certified by QCI/NABH•SPOC for conducting 360 degrees Internal Audit by Top management team in Apollo Hospitals, Kakinada. •SPOC for implementation for Apollo Quality Dashboard, Apollo Light House, Incident reporting, Apollo Clinical Excellence.•To update the Internal quality indicators (TASCC) of Apollo Hospitals apart from NABH metrics, which include ACE I & II, ACPPP, ICU Checklist, Surgical Safety checklist, AQP&ATR monthly in Apollo Hospitals, Kakinada.•To coordinate &conduct the training for the staff as per NABH•To coordinate with concerns for effective implementation of tool kits (Apollo Tool kits like Medication safety, HAPU).•To collect and analyze departmental Quality indicators trends and prepared in the form of PowerPoint Presentation and presented in various flat forms & HOD’s, Quality Committee & Various committee meetings.•To conduct Quality Internal departmental audits (Announced & Unannounced) as per schedule and share the report to the concerned departmental HODs and follow-ups for the closure.•To coordinate with Finance Head and fill the MIS of Apollo Hospitals, Kakinada monthly.•SPOC for updating of daily MIS to the corporate team, SOPC for NABH & ISO implantation •SPOC for AOP (Annual operation plan) of all the departments for Apollo Hospitals, Kakinada.•SPOC for WOW (War on wastage) project, 7 Cost saving, and 7 Revenue generation projects along with Manager Finance for Apollo Hospitals, Kakinada.•To update and analyze the VOC (Voice of the customer) and NPS (Net promoting score) monthly for Apollo Hospitals, Kakinada.•To maintain the Licenses of Apollo Hospitals, Kakinada, and ensure that they are renewed as per the requirements. To ensure that they are updated regularly by the concerned officials/authorities and in GOAL software.

• To update the Internal quality indicators (TASCC) of Apollo Hospitals apart from NABH metrics, which include ACE I & II, ACPPP, ICU Checklist, Surgical Safety checklist, AQP&ATR monthly in Apollo Hospitals, • To coordinate &conduct the training for the staff as per NABH• To coordinate with concerns for effective implementation of tool kits (Apollo Tool kits like Medication safety, HAPU).•To coordinate for conducting facility & safety rounds and prepared a detailed report on same and report has submitted to the safety committee & concern HOD’s for the follow-ups.•To collect and analyze departmental Quality indicators trends and prepared in the form of PowerPoint Presentation and presented in various flat forms & HOD’s, Quality Committee & Various committee meetings.•To conduct Quality Internal departmental audits (Announced & Unannounced) as per schedule and share the report to the concerned departmental HODs and follow-ups for the closure.•To Coordinate with concerns for conducting various Mock drills as per schedule.•Conducting the committee meetings as per the schedule and preparing the Minutes of meeting & Circulate to the concerns and follow up for any open points•Prepare the departmental manual, POPs & SOP as per the NABH standard.• Find out the Route cause for the incidents reports using fishbone & 5Y analysis and same to be discussed with concerned HOD• To coordinate and SPOC for CRM (Chief Risk Management) team during their audit and ensure that all the non-conformities given are closed within the stipulated time.•To maintain the Licenses of Apollo Hospitals, ensure that they are renewed as per the requirements. To ensure that they are updated regularly by the concerned officials/authorities and in GOAL software. •To coordinate the implementation of quality systems – NABH, ISO, NABL & Nursing Excellence•To support in preparation and maintenance of documents of all policies, procedures and work instructions/ manuals, sop, Technical procedures.

As an Executive collect the departmental Quality indicators andmake a POWERPOINT presentation present to the departmentHOD’s.• Conduct Quality Internal departmental audits and submit thereport to the concerned departmental HODs and the same issubmitted to the Incharge of the Quality department.• Coordinating to conduct various Mock drills as per schedule.• Had follow-ups to Liaison officer regarding statutory-relatedissues/ requirements.• Conducting the committee meetings and preparing the Minutes ofthe meeting.• Prepare the departmental manual, POPs & SOP as per theNABH standard.• Collecting analyzing & classification of incident reporting’s sameas presented to the Concerns departmental Incharges.

• To be a NABH consultant to implement the NABH Standards in the hospital to get accreditation. • To get Accreditation Prepare SOPS, Departmental Manuals in coordination with concerns HOD’s.• To train the staff as per NABH norms. • Conduct Internal departmental Audits as per NABH norms prepare a report on observations & Submit to the management follow-up with concerns HOD’s for the closure.• Collect and analyze the Quality indicators data from different departments and the same was presented to the Department Heads and Management for improvements.• Guides provided to the staff about NABH accreditation• To maintain the Licenses and ensure that they are renewed licenses as per the requirements. To ensure that they are updated regularly to concerned Authorities. • As a consultant improve my business and find new clients for my organization

As A Quality Internee daily went for rounds to collect the feedback from patients and if any helps /action is required discuss with management to solve the issues, collect the quality indicators from different departments, documentation of all like cash sheet update ,MLC's and counselling to the patients. training to the staff, conducting departmental audits. and submit the report to the senior manger .