Quality Manager - Medanta Hospital - Noida
(2025-10)
- Led end-to-end Quality Department setup for a newly commissioned Medanta hospital in Noida, establishing all foundational systems, workflows, and governance structures.
- Spearheaded commissioning readiness activities including policy development, SOP drafting, risk assessments, and operational alignment.
- Designed and implemented the Quality & Patient Safety Framework tailored to a new hospital environment.
- Drove complete NABH 6th Edition accreditation implementation from ground zero, including gap assessments, documentation structuring, training, and evidence compilation.
- Established a robust audit program, including internal audits, tracer audits, safety rounds, medical record audits, and compliance monitoring.
- Ensured >95% compliance across departments through continuous follow-up and performance reviews.
- Created and standardized all mandatory manuals, hospital-wide policies, SOPs, forms, registers, and formats, ensuring alignment with Medanta corporate standards.
- Led harmonization with Pan-Medanta documentation, reducing duplication and ensuring consistency across units.
- Developed and implemented a comprehensive Patient Safety Program, including incident reporting, RCA/FMEA, CAPA, and patient safety indicators.
- Formulated and monitored KPIs, quality indicators, and department scorecards for all clinical and non-clinical departments.
- Initiated clinical audits, mortality & morbidity review processes, and infection control surveillance.
- Conducted extensive NABH, patient safety, and quality training for all staff during pre-opening and post-opening phases.
- Established a Quality Champions program across departments to strengthen frontline engagement.
- Ensured 100% compliance with all statutory norms including Biomedical Waste, AERB, Fire & Safety, PCPNDT, Pharmacy, HR, FSSAI, and other government regulations.
- Set up Hazardous Material Management, safety drills, emergency codes, and mock drill programs.
- Established Committee structures (QMC, Infection Control, Safety Committee, Transfusion Committee, etc.) and ensured timely reviews.
- Implemented Quality MIS dashboards, audit tracking systems, incident reporting software, and document management systems.
- Worked closely with IT for integrating quality workflows in HIS during initial setup.
Head of Quality - Yatharth Hospital - Omega Greater Noida
(2024-08 - 2025-05)
- Lead and oversee the hospital's Quality Management department, managing a dedicated team of three professionals focused on ensuring high standards of healthcare quality and compliance.
- Develop, implement, and monitor quality improvement strategies in alignment with NABH and other regulatory standards.
- Conduct internal audits and support the execution of surveillance audits to maintain accreditation and ensure continuous improvement.
- Collaborate with department heads, clinicians, and staff to drive process improvements, enhance patient safety, and ensure the effective implementation of operational policies.
- Provide guidance and mentorship to the quality team, fostering a culture of excellence and continuous learning.
- Develop and oversee key quality indicators, analyzing data to identify trends and proactively address areas for improvement.
- Organize and lead regular Quality Steering Meetings to discuss findings, review performance metrics, and develop action plans for enhanced quality outcomes.
- Manage the implementation of quality assurance programs, mock drills, and internal audits, ensuring compliance with hospital policies and industry best practices.
- Ensure timely reporting and documentation of quality performance, incidents, and corrective actions, ensuring all records are accurate and up to date.
- Assist in strategic decision-making processes by providing insights and recommendations to enhance service delivery, cost efficiency, and operational excellence.
- Achieved NABH surveillance audit for the hospital.
- NABH focus assessment for BMT.
Deputy Manager, Quality Department - Sarvodaya Hospital - Greater Noida
(2023-06 - 2024-08)
- Spearheaded NABH, NABL, and other accreditation processes.
- Developed policies and strategies for improved operational effectiveness.
- Coordinated with cross-functional teams to improve patient care and operational efficiency.
- Achieved NABH accreditation, ECHS, CGHS empanelment, and NABL accreditation.
- Successfully completed Kidney Transplant certification and DNB program processing.
Assistant Manager, Quality and Systems - Jaypee Multi-Specialty Hospital
(2019-06 - 2023-06)
- Led NABH 5th Edition re-accreditation and surveillance audits for hospital and blood bank.
- Engaged in strategic planning and cost control initiatives within the quality framework.
- Achieved NABH accreditation and re-accreditation, desktop surveillance for NABH, NABH-Blood Bank, QCI for Jaypee, Chitta and NABL accreditation.
Clinical Instructor and Quality Assurance Coordinator - Dubai Healthcare Provider - Dubai
(2016-09 - 2019-05)
- Led quality risk management programs and ensured compliance with DHA standards.
- Worked on implementing and improving clinical documentation practices and quality audits.
Senior Staff Nurse, ICU - Sir Ganga Ram Hospital - Delhi
(2010-03 - 2016-07)
- Provided intensive care in the ICU and supported emergency procedures.
- Demonstrated expertise in life-saving techniques like central line insertion, tracheotomy, and intubation.
