Sandhya Dileep Kumar

• Overall Quality compliance management in hospital and Seven Cluster Clinics.
• Quality Lead for all regulatory, National, and International Audits in hospital and clinics
• Unit-level DOH JAWDA Quality lead for all submission, audit, and compliance
• Manage, participate, and coordinate to ensure quality initiatives across Group with focus on continuous improvement of systems and processes
• Collaborate with Medical Director, Hospital Director, Corporate Quality, and Patient Safety Manager in development and implementation of annual MCME quality and patient safety strategy
• Represent MCME-MNOO on Patient safety forums with relevant stakeholders, develop, implement, and oversee quality action plans, providing reports to Head of Department, and Quality Committee
• Apply relevant legislation guidelines and standards to improve quality within Hospital, and provide guidance, advice, or direction to employees to ensure that clinical practice is evidence-based to facilitate positive outcomes
• Participate, facilitate, and Oversee accreditation process ensuring all accreditation standards are met and maintained specific to each standard and department
• Member of various Clinical and Management Committees
• Develop, write, and communicate policies and processes related to quality improvement for Hospital in collaboration with relevant departments
• Responsible for communicating new policies and changes to policies within organization
• Periodically review Hospital policies and procedures and make recommendations for revisions to relevant Head of Department and support
• Assist in development of guidelines and monitoring of protocols to ensure employee adherence to relevant policies, processes, competency expectations, and Company procedures.
• Perform Quality and Clinical reviews and evaluations as appropriate
• Monitors documentation within databases and acts as liaison with users
• Responsible for leading quality improvement projects to enhance patient safety and satisfaction within hospital
• Sets clear standards for performance, evaluates job performance, and provides effective feedback.
• Establishes systems to measure effectiveness, efficiency, and service and creates and maintains reporting mechanisms.
• Demonstrates understanding of fire and emergency procedures, and participates in fire and disaster drills.
• Demonstrates understanding of safety and security procedures, and applies safety and security precautions.
• Demonstrates understanding of hazardous materials plan and demonstrates proper use of equipment.
• Reports KPI data and implements corrective actions to address results of audits as necessary.
• Works with clinical departments to develop and implement corrective action plans to address department deficiencies.
• Ensures patients are provided with professional, kind, and respectful care and supervises and evaluates level of patient care.
• Evaluate and recognize priorities and select effective team members.
• Ensures that patient-centered approach to care is maintained throughout hospital with guidance from Medical Director and Clinical experts.
• Lead and participate in ad-hoc quality improvement projects
• Assist in development, design of methodology and data collection process for internal databases
• Responsible for end-to-end process and timely resolution of Occurrence Variance Reporting for hospital
• Responsible for documentation and referencing of all quality policies and forms in hospital
• Fosters climate conducive to collaborations and educational experiences for all staff.
• Evaluate, monitor, coach, and mentor performance of quality staff.
• Evaluate own performance based on professional practice standards, relevant regulations, and organizational criteria and perform continuous improvement.
• Develops implements and evaluates system for performance improvement.
• Provide orientation, in-service training, and continuing education for all staff in area of responsibility.
• Participates in interdisciplinary teams.
• Involved in employee relations and disciplinary meetings to ensure adherence to policies and procedures while maintaining good working environment when required.
• Develop and maintain excellent networks and professional relationships with internal and external key stakeholders of Hospital
• Promote and perform continuous quality improvement monitoring and compile data for trend analysis and reporting; this will include drawing clinical quality data from different databases
• Develop and maintain unified organizational report of quality and safety indicators from across Hospital.
• Provides ad-hoc reports when required
• Risks are identified and Internal controls are implemented in coordination with department leads and Team, both Clinical and Non-clinical
• Audits are conducted to ensure that risk management is implemented
• Monitors and reports any issues related to safety in facility and department
• Verbalize, orient, and facilitate training and demonstration on importance on clear understanding of reporting mechanism (OVR system) for any risk identified
• Participate and provide direction in safety procedures in event of internal or external disaster

• Lead quality compliance management overall concerning DOH/JCI/CARF/JDC standards in facility except for financial management
• Advisory support and participation in implementation of policies, procedures, and established standards in hospital including monitoring and orientation of staff hospital-wide for quality management awareness assurance and compliance
• Supervise proper maintenance of records; allocation and appropriate utilization of manpower and other resources to their optimum effectiveness within Quality and Patient Safety Department
• Manage and conduct internal compliance audit of Quality/Tasneef /Infection control and OSH to assure and sustain compliance to regulatory standards
• Focused solution on correction of gaps identified supportive approach can help success of quality activities and enhance safer working environment for healthcare providers and a healthy environment for patients.
• Coordinate with all department heads and develop Business continuity management plan as responsible Business Continuity Management Coordinator
• Manage daily operations by sharing and supporting workloads within team; assuring manpower and resources are provided according to department needs to optimize team's productivity and satisfaction.
• Active Vice-chairperson for Clinical documentation committee
• Active Vice-chairperson for Operations huddle meetings with department heads
• Managed and participated in mock audit for JCIA and CARF preparedness program.
• Manage administrative supervision to all levels of staff assigned in Quality team/Medical Records department and Operations team
• Ensure and Implement quality improvement programs through hospital-wide committees
• Implementation of quality improvement educational programs for staff in collaboration with HR
• Analyze risk from hospital rounds, incident reports, regulatory audits, and internal audits, communicate, facilitate, and coordinate with respective department and safety department in ensuring compliance with clinical and OSH risk management Program in facility as per standards.
• Prepare and share monthly Operational reports with Senior leadership and the CEO.

• Overall management of Quality department and quality compliance in hospital concerning DOH/JAWDA/TASNEEF/ADHICS/ADPHC/JCIA Standards.
• Quality Management Lead for Audits/Inspections and any quality-related program.
• Manage and ensure QMS system is reviewed at regular intervals to assess its continued suitability and effectiveness.
• Manage departments to develop policies and procedures for all chapters of JCI standards, implementing and sustaining implementation. Upgrading system to meet the requirements of the 7th edition of JCI standards.
• Quality lead and survey coordinator for JCIA/DOH and other regulatory bodies
• Provide orientation for new employees on policies and quality standards.
• Manage Occurrence variance reporting and Incident management system
• Manage Complaint Management or the patient experience program
• Manage and develop a hospital-wide committee structure and make sure that the committee meets as per schedule.
• Follow up on decisions and report to the Board of Directors through the Quality Council and Senior Executive Committee.
• Facilitate/Manage/participate in improvement project models like FOCUS PDCA, FMEA, and RCA for process improvement and performance improvement.
• Manage and Conduct Quality Council and Management Review Meeting
• Manage all Quality department-related tasks but Not limited.
• Collaborated with cross-functional teams to develop and implement effective corrective action plans for identified nonconformances.
• Manage Quality assurance for the cluster clinics

• Overall management of the Quality department and quality compliance in the hospital concerning DOH/JAWDA/JCIA Standards.
• Review amend and implement the Quality management system by DOH/JAWDA/JCIA Standards
• Quality lead for JAWDA Pay for Quality program.
• Ensure that all stakeholders adhere to maintaining and developing their part of the QMS system
• Ensure the QMS system is reviewed at regular intervals to assess its continued suitability and effectiveness
• Manages and implements the quality management and quality improvement programs for the facility.
• Oversees quality assurance and compliance functions.
• Ensures programs and services are implemented at the highest standards and patients receive the highest level of care.
• Responsible for monitoring and updating policies and procedures to include regulatory changes.
• Collaboration and coordination with key organizational executive leadership and relevant stakeholders is responsible for the implementation of the Quality and Patient Safety Program.
• Lead the Quality department team, and work to ensure that all managers, process owners, and supervisors within the organization are provided with the appropriate guidance, education, tools, and support to develop and maintain their roles and responsibilities in the quality management program.
• Facilitate and support the Occupational Health and Safety Management System (OHSMS) program and the Infection Control Program to best meet the needs of the organization and the Hospital.
• Responsible for initiating and conducting risk assessments in all departments and areas of the hospital including the implementation of specific quality management and safety (risk mitigating) programs.
• Responsibility was handled to create a culture of safety and quality data quality using the full range of functions and application quality proposing workflow improvements.
• Acts at all times in a manner that provides a positive role model for less senior staff members.
• Responsible for the operational management of the Quality and Risk Management Department including recruiting, hiring, orienting, supervision, and appraisal of employees.
• Investigate, analyze, and document actual and potential quality and safety risks at the facility
• Recognizes and addresses patient safety/risk exposures by evaluating near misses, occurrence reports, clinical surveillance, and regulatory/legislative standards.
• Directs quality management, risk reduction, and patient safety program and the work of the hospital quality and patient safety committee.
• Guides support and assist on the development of policies and procedures affecting organizational safety, clinical quality, and risk reduction.
• Recommends and facilitates changes of processes, workflows, and equipment to improve quality and patient safety, based on identified quality potentials and risks.
• Takes initiative to address and eliminate barriers to the implementation of quality enhancement and risk reduction
• Coordinate patient complaint management process compliance departments as appropriate.
• Identifies organizational-wide functions and routine business practices that require policies, procedures, and processes and works with key staff to keep policies and procedures updated.
• Coordinates and implements the required annual training for all employees assesses the need for additional training and education and develops appropriate education as needed.
• Demonstrates commitment to cost-effectiveness in providing services and supports the continuous effort to conserve resources while providing individualized high-quality care.
• Validates quality processes by establishing specifications and quality attributes; measuring production; documenting evidence; determining operational and performance qualifications; and writing and updating quality assurance procedures especially, JAWDA KPIs and Internal Hospital Measures.
• Liaising with auditors and ensuring the execution of corrective action and compliance with customers’ specifications
• Supports the organizational orientation/induction programs for all newcomers and or Internal/departmental ensure that all new joiners are educated and informed about the requirements of the Quality and Patient Safety Program
• Manage Cluster clinic's quality assurance and management. Quality lead for all the DOH audits and JCIA surveillance

• Overseeing day-to-day operations and keeping the CEO apprised of significant events for two medical centers under the same group to keep the organization running smoothly while meeting business goals.
• Monitor and analyze industry trends to identify opportunities for organizational growth and competitiveness.
• Drove revenue growth with the successful launch of new products and services to meet customer needs.
• Communicate business performance, forecasts, and strategies to investors and shareholders.
• Fostering employee alignment with corporate goals; and overseeing human resource management.
• Overall management of the Quality department and quality compliance in the medical center concerning DOH/JAWDA Standards.
• Provide orientation for new employees on policies and quality standards.
• Operations management with enhance patient care flow monitoring, redirecting, and allocating optimized resources as required.
• Scrutinizing daily reports and monthly reports from departments; overlooking functions and growth of medical centers by providing operational and financial advice to Managers and management.
• Analysis of audit/inspection reports and develop/advise corrective and preventive actions as appropriate.
• Investigate and take corrective action on customer complaints as per policy and work rules.
• Intervene and solve problems related to intra-departmental issues. Facilitate interdepartmental communication, negotiation, and decision-making.
• Review the performance of contracted/outsourced services and provide an analysis report with recommendations to the CEO.
• Responsible for seeing that the organization’s strategic initiatives are carried out through its daily activities.
• Responsible for crisis management, interpreting policy, and making timely decisions that directly impact patient care, ensuring timely and effective communication, collaborating among departments, and providing operational oversight throughout the Medical Centers and Pharmacies in the group
• Management representative to Negotiate with suppliers and contractors to get the best price and service, from a facility operational perspective.
• Administrative liaison with patients, families, employees, and external customers – DOH, etc.
• Advisory member for Successful marketing management of various continuing medical education programs, Health awareness programs, and social events organized on behalf of the Medical Center.
• Monitoring standards of working practice within the departments as per the facility policy
• Identifying the training needs of staff and advising HR to arrange training sessions.
• Overseeing the activities of the patient care Departments like Operations/Administrative, HR and Nursing Staff, BME, Medical Records, Customer care, Transport staff, Pharmacy etc.
• Manage implementation of DOH/OSHMS standards in the facility providing appropriate guidance to safety officer, support and monitoring the implementation of the OSHMS programs as per OSHAD SF Version 3.1 and Health Sector EHSMS requirements
• Manage implementation of Infection Control activities in coordination with the Infection control committee and infection control Nurse to ensure the process is in place to enhance the Infection control compliance implementation, Performance, monitoring, audits and inspection results, incidents, and any Legal changes regarding
• Facilitate and perform incident investigations, and facility risk assessment to evaluate the occupational health and safety Risks and hazards.
• Vice Chairperson for Quality Council and Infection control committees'
• Acting Authority on behalf of the CEO to provide crisis management, interpret policy, and make timely decisions that directly impact patient care, ensure timely and effective communication, collaborate among departments, and provide operational oversight throughout the facility.
• Negotiate with suppliers and contractors to get the best price and service, from a healthcare operational perspective.

• Overall Management of the Quality Department for Hospital and cluster clinics
• Quality Lead for the Hospital and the cluster clinics
• Facilitate Quality compliance in the hospital as per DOH standards. Initialized implemented and sustained the changes required for complying with DOH.
• Responsible for preparation, and revision of policies and procedures in compliance with the regulatory standards. All department Policy preparation in coordination with the department in charge/representative as per the latest DOH standards
• Manage DOH Clinical review Complaints and investigations,
• Manage and lead DOH audits both clinical and technical,
• Oversee and facilitate OSHMS DOH and Third-party audits
• Review KPIs per department and perform data analysis to guide team members with appropriate corrective and preventive action plans to achieve and sustain the improvement.
• Responsible for Occurrence variance report analysis and incident management system
• Quality representative to interact with the Lab Director and team to comply with the ISO Lab accreditation.
• Facility quality lead representative for DOH JAWDA KPI submission, audits, or any DOH meetings and DOH workshops
• Coordinate with the clinical and non-clinical departments for the Data collection and validation for the JAWDA indicators, review the reports, and present to leadership before DOH submission
• Provide training and orientation/ awareness sessions for assigned Jawda champions in data preparation for JAWDA indicators
• In addition to Quality department responsibility, assigned an OSH representative to Al Raha Hospital
• Responsible for the Preparation of Policies and SOPs in compliance with the OSHAD SF Version 3.1
• Assist and support the Management in consultation and implementation of DOH/OSHMS standards and as per OSHAD SF Version 3.1 and Health Sector EHSMS requirements and standards.
• Conduct internal audits and inspections and facilitate the annual external Audits and Health Sector audits/inspections.
• Perform facility risk assessment to evaluate the occupational health and safety Risks and hazards.
• Develop objectives and monitor the performance of objectives and compliance with OSHMS requirements.
• Report to the CEO on the progress of OSHMS implementation, Performance, monitoring, audits and inspection results, incidents, and any Legal changes regarding OSHMS.
• Provided comprehensive training programs for employees on quality assurance standards, fostering a culture of excellence throughout the organization.
• Establish and monitor quality and patient safety strategic goals & objectives and report to CEO

• SOS Management Representative to ADNOC Clients and Outsourced Employees to solve challenges and leverage growth opportunities.
• Responsible for ensuring that HR Operations are successively organized.
• Lead the HR team members, and ensure all HR processes including recruitment, onboarding, learning/development, and compensation/benefits and employee relations are managed and administered appropriately. Provide advice and assistance to employees
• Coordinate with team leaders for the outsourced candidate’s Mobilization process – issuing offer letters, employment visas, air tickets, hotel accommodation, local transportation, offshore medicals, training, security passes, travel cards, and offshore travel.
• Responsible for monitoring and completing the onboarding of new employees.
• Providing advice and assistance to employees to complete the process, and communicating confidently and effectively with senior managers regarding Overseeing amendments/termination/demobilization letters to be prepared.
• Coordinate with the Branch Manager, Accounts Dept., PRO department, and other team members for all day-to-day activities for existing and new employees
• Ensure timely procedures to arrange for final settlements, visa/labor card cancellation, etc.
• Attends to escalated employee/payroll inquiries and provides guidance or recommendations in concurrence with the HR Manager on issues or concerns.
• Administration of warning letters
• Conducts exit interviews and creates staff turnover reports
• Ensures accuracy of Time and Attendance System
• Assists the Operation Manager for the compilation of statistics/reports.
• Assists the Recruitment Teams with ad hoc recruitment processes
• Coordinates and conducts new employee orientation as required
• Ensures that employee and department confidentiality is maintained
• Pending payment collection – Follow-up with clients for payment settlement. To address aging analysis and deficits and take action for the collection
• To report any business-related issues to management as well as to forward weekly business reports about the department.
• Responsible for the allocation and prioritization of the work of the HR coordinators
• To ensure that the Contracts Administrator updates & maintains records of clients and contract employees systematically to create sound & accurate historical data

• Manage Medical Directors Office
• Preparing a synopsis of reports received from officers/Managers.
• Assist Manager Quality, compliance, and accreditation in preparation of Policies and procedures, Audits, Inspections, quality rounds, etc.
• Coordinate and support the Quality department for JCIA/DOH/ISO/EHSMS and Ministry of Labor inspections under the supervision of Manager Quality accreditation and compliance.
• Actively participate during all drills concerning EHSMS
• Participate and support in conducting internal investigations on customer complaints in coordination with the Medical Committee/HOD as appropriate.
• Assist Quality team with JAWDA Data collection validation process and management.
• Communicate issues identified by front-line staff to the appropriate administrative team
• Review and Scrutinizing daily reports from departments and peripherals centers, prepare a synopsis, and forward it to the Medical Director and assistant medical director
• Supervise regional office Administration activities and report to the Medical Administration Manager
• Support Medical Superintendent in preparing doctor’s duty schedule, including operational regular duty, on-call duty, and peripheral clinic visit duty schedule.
• Prepare and furnish Pharmacy Purchase orders
• Coordinating with HR and Medical Administration for short-listed candidates Interview with Medical Director
• Verification and auditing of LPOs forwarded to the Medical Directors' office for approval
• Managing tasks about recruitment: Selection information, arranging interviews, following up with the candidates for the recruitment process, negotiation as per requirement, etc as advised by the Medical Director
• Coordinate and handle employee grievances reaching the Medical Administration and Medical Director's office
• Coordination and active team leader for walk-in Interviews arranged for the Medical Group
• Monitoring Joining Formalities, monitoring, Uniform compliance, etc during department rounds
• Coordinating timely Appraisal Management for staff confirmation, Promotion, Transfer, and Visa Renewal and relief in association with the HR Manager.
• Assist HRM during the appraisal and Evaluation of staff in coordination with department heads and finally obtain approval from the Medical Director for yearly increments accordingly
• Assisting Medical Superintendent for OPPE of Doctors
• Analyzing the Training Needs and reporting to HR and the Training coordinator to follow up Reviewing Prepared monthly, yearly & annual training schedules and forwarding them to the Medical Director Monitoring Exit Interviews and follow-up feedback to the Management
• Participation in the PMS (Performance Management System) on requirement
• Coordinating for the completion of the cancellation procedures of resigned/terminated staff
• Partially Coordinating with the Insurance audit team for Auditing of Patient financial bills forwarded to the director’s office to check the compliance of the documentation policy and to recheck whether coded and billed appropriately.
• Review of Insurance In and out approval procedure register and advise insurance approval team to follow up with insurance companies for approval escalating the request on a priority basis if required
• Review Daily reports of Insurance coordinators and follow up with them for the earliest completion of the task within the stipulated time frame.
• Coordinating with Doctors for the reply to queries from insurance companies if required.
• Monitoring renewals of Trade Name, Initial Approval, Preliminary approvals of DOH, etc
• Safe custodian of original documents like all Quality Accreditation Certifications and Outsourced Contracts concerning our facility etc. Monitoring the renewals with outsourced services
• Managing and organizing the Continuing Medical Education Programme, entrusted as CME coordinator of the hospital
• Managing and organizing various health awareness programs and events in-house and coordinating outside health awareness programs.
• Entrusted as events coordinator for in-house and outside health awareness programs
• Responsible for the Preparation of the annual CME report to the regulatory body for license renewal purposes
• Preparing monthly, half-yearly & annual training/events/CME schedules as per the requirement
• ADDITIONAL RESPONSIBILITIES
• Assisting the HR Manager with Data analysis and data preparation forthe Staff Satisfaction Survey, Staff turnover, and leave management.
• Key contact and coordinator role with all regional centers, pharmacies, and hospitals, meeting staff and solving their issues for the smooth functioning of the departments
• Support HRM to ensure that all personnel action forms that are submitted to accomplish recruiting, promotion, salary changes, terminations, leaves, absence, and all other personal actions are reviewed promptly for compliance with the company policies and procedures
• Support clinical, operational, and facility services throughout the entire Hospital and regional centers

Kerala Institute of Medical Sciences (KIMS), Trivandrum, Multi-specialty, 450 bedded hospitals, KIMS, Trivandrum, Kerala, India

• Good Clinical Practice Certified assigned Clinical Human Research Study Coordinator of the Research Team on all the Cardiology Trials headed by Dr.Vijayaraghavan, Principal Investigator
• Oversee all the administration management of the Vice Chairman’s Office and Cardiology Department. Responsible and accountable for patient care in all areas like registration, refraction, consultation, counseling, diagnostic, patient counseling, and patient feedback.
• Played an integral role as Research/Study coordinator in managing various anticoagulant medication efficacy projects such as REMEDY (1160.47), RECOVER (1160.53), Lilly Protocol H7T-MC- TABY, DU176b-C- U301 RIVAROXACS-3001