What is the role of Quality Manager / Quality Coordinator in a Hospital?

Introduction:

Quality management principles and practices are becoming widely integrated into organizational activities, the role and responsibility of the quality assurance officer is changing and evolving. One perspective on the future of quality assurance professionals suggests that their actions in the pursuit of quality improvement will increasingly become more indistinct from the usual activities performed by departmental managers.

It is expected that regular line managers will subsume more and more of the roles once performed by quality professionals. As quality improvement becomes institutionalized as a preferred ‘way-of-life’ in many organizations, the actions and functions traditionally performed by the quality manager may be seen as redundant.

A typical quality manager in healthcare has a complex function with diverse responsibilities that encompass the clinical as well as the administrative. The exact role of these individuals is rapidly changing and evolving as technology and new forms of work organization emerge and diffuse into healthcare institutions.

Importance of Quality Management Professionals:

As per National Accreditation Standard (CQI 1 C) every healthcare organization need a designated individual for coordinating and implementing the quality improvement programme. This should preferably be a person having a good knowledge of accreditation standards, statutory requirements, hospital quality improvement principles and evaluation methodologies, hospital functioning and operations. For example, accreditation co-ordinator, quality management representative, quality manager.

Role of Quality Manager:

The focus of the role of Quality Coordinator is to support the hospital’s mission “to deliver exceptional patient care in an environment where quality, respect, caring and compassion is the core of our practice”.

This position is responsible for contributing to hospital-wide and departmental quality initiatives. This involves performing the assessment and analysis of operations and processes.

Additionally, the Quality Coordinator works collaboratively with staff and managers to promote, design and implement improvements and innovations at Hospital.

The purpose of the Quality Coordinator is patient-centeredness, staff vitality, process efficiency and waste reduction, and safe and reliable patient care.

Responsibilities of Quality Manager:

1. Undertakes quality initiatives, audits, risk management as due in conjunction with the Quality Manager.

2. Consults with administrative and medical staff Managers, department heads, and committees as appropriate to finalise and advance the organization goals.

3. Assesses institutional/departmental readiness and identifies strategies to achieve goals as directed by Top Management.

4. Leads the teams by Training and advising team members to fulfil their role in a quality team.

5. Works to ensure that quality improvement and innovation work remains focused on one or more of the following goals: patient-centeredness, staff vitality, process efficiency and waste reduction, and safe and reliable patient care.

6. Maintains accountability for ongoing self-development activities, especially related to presentation facilitation, change management and application of quality improvement activities.

7. Organising all Official Meetings / training sessions related to Quality Policies and standards.

All mandatory Quality indicators for NABH need to be collected, analyse, report generation, correction and improvement action

8. All quality manuals and Policies need to be collected and stored along with Document control record.

9. OPD and IPD Patient Feedback Report need to be analyze on monthly basis.

10. Mock drills need to be conducted on Quarterly basis and observation report to be collected and documented within defined time frame (24 Hours) strictly.

11. Active File ,MRD, IPD Prescription, Discharge Summary, Incident Reporting, Nurse Hand over, Blood & Component usage and wastage, TAT of Lab., Radiology, Blood Bank, Time taken for Initial Assessment of IPD, Time taken for Initial Assessment of Emergency, Time taken for Discharge Audit, Time taken for Initial Assessment of OPD, Housekeeping, Laundry and Nursing Audit of patient care services need to be Conducted and Documented ensuring in the process :-

• Ensure Participation of Medical and nursing staff in this system
• Parameters of audit need to be verified by Quality Coordinator 
• All audits need to be documented by Quality Coordinator
• Ensure implementation of all Final Suggested points by the committees

12. Hospital Committees Meeting Minutes need to be documented as per suggested periodicity and as per NABH standard list of committees are given below: -

• Apex Committee
• CPR Committee
• Drug Control Committee
• Safety Committee
• Hospital Infection Control (HIC)Committee
• Quality Assurance Committee
• Medical Audit & review Committee
• Disaster and emergency preparedness committee
• Employee and Patient grievance handling Committee
• Sexual Harassment Committee
• Credential and Privileging Committee 
• Blood Transfusion Committee

13. Review all NABH Register of all departments on monthly Basis: OPD, Emergency, Wards, ICU, Labor Room, O.T, NICU, PICU, CSSD, Laundry, Blood Bank, Radiology, Pathology, Dialysis and MRD.

14. Ensure Implementation of All NABH Form and Formats in their respective areas whenever required.

15. Monthly CQI Data Collection excel sheet and its PPT need to be prepared within defined time frame.

16. Ensure Audit Report of Patient safety devices in all Clinical and Non-Clinical areas.

17. Ensure Quarterly Round & Report of Facility Inspection Round.

Written by:

Dr. Praveen Bajpai

Director of Ingenious Healthcare Consultants Pvt. Ltd.
Founder of Skill Sathi

MBA in Hospital administration, PG Diploma in Quality Accreditation, PG Diploma in Medico Legal System, M. Phil in Hospital Mgmt. from BITS Pilani, P.hD in Management, Certified NABH Auditor, Certified NABL Auditor, Certified Auditor for Clinical Audits, Green Belt in Six Sigma, Certified in Hospital Infection Control Practices, Certified trainer for International Patient Safety Goals, Certified Auditor for JCI 7th Edition Standards 

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