Shruti Vaghela
Dubai,Dubai
Summary
Dynamic and results-oriented Hospital Quality Manager with extensive experience in healthcare quality management, accreditation, and continuous quality improvement. Seeking to contribute my expertise in enhancing patient safety, operational efficiency, and regulatory compliance to achieve organizational excellence and growth.
Overview
11
11
years of professional experience
Work History
Hospital Quality Manager & Accreditation Coordinator
Maganbhai Adenwala Mahagujarat University
04.2017 - Current
- Acting as the primary liaison between the hospital and accreditation bodies, ensuring adherence to both national and international healthcare standards
- Conducting comprehensive audits, including medical record reviews, to evaluate compliance with accreditation standards, hospital policies, and regulatory requirements
- Leading patient care system tracers to identify improvement opportunities in clinical practices, ensuring alignment with accreditation goals and patient safety standards
- Collecting, analyzing, and reporting data to support continuous readiness and ensure ongoing compliance with regulatory mandates and quality initiatives
- Developing and maintaining a conceptual framework for quality measurement and improvement activities, ensuring high-quality patient care, optimal patient flow, and provider productivity
- Collaborating with stakeholders to design and implement policies aligned with NABH standards, aimed at minimizing organizational risks and improving care quality
- Managing the investigation, auditing, and reporting of patient and customer complaints and compliments, driving improvements in care and service delivery
- Designing and delivering training on NABH standards, quality management systems, continuous quality improvement (CQI), and risk management tools for healthcare teams
- Leading quality improvement initiatives, collaborating with staff to foster a culture of continuous improvement and enhance operational efficiency
- Coordinating with NABH assessors during accreditation and re-accreditation processes, facilitating site visits and assessments to ensure compliance
- Maintaining up-to-date records and documentation related to NABH compliance and accreditation status, ensuring all information is readily accessible for audits and assessments
- Providing recommendations and solutions for quality and process improvements, ensuring continuous enhancement in patient care and operational processes
- Liaising with administrators, department heads, managers, and committees to identify and advance quality improvement projects aligned with NABH standards
- Developing and implementing patient safety procedures, standards, and specifications to maintain safe, high-quality care
- Assisting in the development of policies and procedures that align with NABH standards, ensuring continuous improvement in patient care quality and safety
- Setting up and maintaining control procedures and documentation for quality initiatives, ensuring accurate reporting and audit tracking
Quality Coordinator
METAS of Seventh Day Adventist Hospital
06.2015 - 03.2017
- Responsible for the efficient coordination and implementation of Quality Management Systems (QMS) and Quality Improvement (QI) initiatives across all hospital operations
- Supporting continuous quality improvement by assisting all departments in developing and maintaining plans focused on enhancing care quality, maximizing patient and customer outcomes
- Delivering training sessions on Quality Management and continuous quality improvement practices to empower staff with the knowledge to enhance service delivery
- Conducting audits based on national and international healthcare quality standards to ensure compliance and identify areas for improvement
- Analyzing audit results, preparing detailed reports, and providing recommendations to address deficiencies and drive process improvements
- Collaborating with staff to gather, analyze, and review data to support ongoing quality improvement initiatives
- Developing and supporting QI activities at the organizational, divisional, and departmental levels, ensuring active participation from all employees and fostering a culture of continuous improvement
- Promoting a collaborative, multidisciplinary approach to quality improvement, facilitating effective communication and teamwork across departments
- Maintaining a close working relationship with the Associate Clinical Services Coordinator to ensure alignment with quality improvement goals and initiatives
- Fostering cooperative, productive working relationships within the healthcare team, ensuring consistent engagement in QI projects
- Leading the Quality Steering Committee by providing relevant, up-to-date information on quality management and improvement activities, and driving progress toward organizational goals
Resident Medical Officer
METAS of Seventh Day Adventist Hospital
01.2014 - 06.2015
- Conducting brief admission examinations for patients when appropriate and documenting clinical findings accurately
- Providing 24-hour medical service within the critical care area on a rotational basis, ensuring timely and effective patient care
- Informing admitting consultants of any changes in patient conditions and the actions taken, ensuring clear and continuous communication regarding patient care
- Performing clinical procedures as requested by consultant medical staff and nursing staff, including phlebotomy and monitoring intravenous drug administration
- Initiating and adjusting in-patient prescriptions based on consultant requests, ensuring appropriate treatment protocols
- Conducting regular patient visits, especially for critical care patients, documenting clinical observations and updates in patient records
- Familiarizing with and adhering to relevant hospital procedures and policies, ensuring compliance and safety in patient care
- Participating in the clinical risk program by reporting clinical incidents, drug errors, and near misses to improve patient safety and quality of care
- Actively participating in clinical audits and supporting the implementation of clinical governance processes to ensure best practices
- Carrying out cardiac arrest and other emergency procedures as per hospital policy, ensuring timely and efficient response in critical situations
- Initiating emergency treatments for patients, staff, and visitors, ensuring thorough documentation of all actions taken
- Promoting seamless patient care through effective collaboration with all hospital departments to address patient needs
- Actively participating in in-service education programs, including CPR, health and safety training, fire safety, and other NABH-related training
- Promoting the hospital by maintaining a customer-focused approach, providing excellent care to patients, consultants, and staff at all times
Education
Masters of Hospital Administration -
Indian Institute of Public Health
Gandhinagar, Gujarat09.2023
Post Graduate Diploma in Hospital and Healthcare Management - undefined
Symbiosis Centre of Healthcare
Pune, Maharashtra05.2015
Bachelor of Medicine and Surgery in Ayurveda - undefined
J.S. Ayurveda College
Nadiad, Gujarat10.2012
Lean Six Sigma Green Belt -
Versigma – Exemplar Global
New Delhi10.2017
Skills
- Healthcare Administration
- Continuous Quality Assessment
- Policy Development
- Process Optimization
- Staff Training
Trainings and Workshops
- 3 Days training on Ayush Entry Level Assessor Training Program by Quality Council of India, New Delhi
- 3 days training program on Implementation of NABH Standards by Quality Council of India, New Delhi
- 2 days training program on Implementation of Standards for Nursing Excellence Certificates by Quality Council of India, Mumbai
- 1 day training program on implementation of Panchkarma Standards Organisation, by Quality Council of India, Mumbai
- 1 day training program on Continuous Quality Improvement : Tools and Techniques by Quality Council of India, Mumbai
- 2 days training program on Infection Prevention and Control Conclave by Wockhardt Hospitals Ltd, Mumbai
- 2 days training program on Quality and Accreditation in Healthcare by Symbiosis Centre of Healthcare, Pune
Languages
English
Hindi
Gujarati
Personal Information
- Age: 34
- Gender: Female
Timeline
Hospital Quality Manager & Accreditation Coordinator
Maganbhai Adenwala Mahagujarat University
04.2017 - Current
Quality Coordinator
METAS of Seventh Day Adventist Hospital
06.2015 - 03.2017
Resident Medical Officer
METAS of Seventh Day Adventist Hospital
01.2014 - 06.2015
Post Graduate Diploma in Hospital and Healthcare Management - undefined
Symbiosis Centre of Healthcare
Bachelor of Medicine and Surgery in Ayurveda - undefined
J.S. Ayurveda College
Masters of Hospital Administration -
Indian Institute of Public Health
Lean Six Sigma Green Belt -
Versigma – Exemplar Global
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