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QZAT Consultants

Implementing
Quality Management System in
Hospitals & Healthcare Concerns
Adhering
NABH Standards
By,
Saneeb K.R.
Sree Soumiya K.M

About

QZAT Consultants
QZAT is a professionally managed consultancy specializing in
hospitals & healthcare concerns. It is an empanelment which has
empanelled with talent resources of Healthcare Concerns such
as Quality Assurance Managers, Infection Control Nurses,
Pharmacists and Doctors. The combined strength of these
professionals, Team QZAT, forms the core strengths of
consultancy. Individually, the team members have excelled in
their field of expertise and specialties.

Why Quality Management System??


Quality Management System ensures,
Patient Safety & Care.
Improvement in the image of the hospital Enhances
confidence of patients, public , insurance agency and
regulatory authorities in Quality of service.
Improvement in the Quality of Documentation and records
Employees understanding of individual & departmental
objectives with the goals.
Wasteful expenses & activities are minimized and the
efficiency is enhanced.

To Nurture & Build


Quality Culture in
Healthcare Facilities

We would join you to build


a
Quality
Healthcare
system ensuring patient
care & safety and growth
of
the
healthcare
organization.

QZAT Modules
Training For Clinical &
Non Clinical Staff
Internal Audits
Facility Audits
Clinical Audits
Medical Records Audit
Setting Quality Indicators
& Performance indicators

Quality Initiatives
Mock Drills
Documentation &
Document Control
GAP Closure
/Corrective &
Prevention Action
(CAPA) & RCA- Root
Cause Analysis

TRAINING FOR CLINICAL & NON CLINICAL


STAFF
Training program will be offered for Admin & Clinical Staff
to ensure Patient safety & Care. A few training topics
include:
Medication Management
Infection Control
Hospital Emergency & Disaster Management program
Facility Management & Safety
Human Resource Management
Medical Records Management

INTERNAL AUDITS
Internal Audits are conducted by the Healthcare
organization to ensure that there is an effective adherence of
standards and staff awareness about the same. Audits are
conducted once in four months to ensure the adherence.
FACILITY AUDITS
Facility Audits are conducted to ensure that there is
adequate safety and preventive measures related to facility
which include Fire safety, Environment safety, Electrical
Safety, Infrastructure Safety and Medical Equipment safety.
Facility Audit is conducted twice in a year.

CLINICAL AUDITS
A quality improvement process that is seeks to improve
patient care and outcomes. The parameters will be defined
by the organization and the audits are done by various
Medical and nursing staff.
MEDICAL RECORDS AUDIT
Medical records audit are conducted to ensure that there is
completeness and accuracy in Medical records of every
patients. Eg. Unique Identifiers for each record, Entry made
in records are dated, timed and signed appropriately etc.
QUALITY INITIATIVES
Quality Initiatives are set to help to spread health awareness
& safety precautions to the patients.

SETTING
QUALITY
INDICATORS
&
PERFORMANCE INDICATORS
Quality Indicators- Quality Indicators are statistical
measure of the performance of functions, systems or
processes overtime. Clinical & Non Clinical Indicators are
set to monitor and track the Quality of services in each area.
The indicators are collected from different departments and
are analyzed by the Quality Team and the same is presented
to the Top Management for their review.
Performance Indicators- The organization develops key
Indicators suitable for it and reviews them on a certain
period. This helps the top management to assess their
growth.

MOCK DRILLS
Mock Drills are conducted to ensure the readiness of staff to
handle emergency situations such as a Medical
Emergencies, Internal/ external disaster, Fire accident etc.,
The mock drill are conducted on frequent period to ensure
staff awareness about the same and their roles and
responsibilities during the emergency situations.
DOCUMENTATION & DOCUMENT CONTROL
Organization should have their Policies and Procedures to
adhere. The Manuals should be laid and practiced by the
staff. There should be a proper method to control the
Documents and it must be reviewed every year.

GAP CLOSURE /CORRECTIVE & PREVENTION


ACTION (CAPA) & RCA- ROOT CAUSE ANALYSIS
Corrective Action and Preventive Actions, Root Cause
Analysis is done by the Quality team to ensure the non
compliances or incidence never reoccurs. The RCA done
must be reviewed again to ensure the loop is complete.

PROFILE OF THE
QUALITY CONSULTANTS
SREE SOUMIYA K.M

SREE SOUMIYA K.M- Masters in Business Administration- HR &

Marketing

Experience Details
From

To

Years of Experience Employer

Designation

07.10.11

22.09.12 1 Year

AVN Arogya Healthcare Ltd

Guest Relations
Officer

26.12.12

19.11.13 1 Year

Livewell Institute of Rehabilitation

ManagerRelationship

20.11.13

17.04.15 1 Year and 6 Months

Vadamalayan Hospital, Madurai,


Tamil Nadu, India

Quality Manager

02.05.15

Till Date Still Working

QZAT Consultants

Quality
Consultants

Quality Training Conducted by the Consultants

SUPPORT REQUIRED FROM THE


HOSPITAL

Commitment of top management


Designation of a nodal person to interact with the QZAT Team
A Quality Team- Senior Person should head the Team.
Providing proactive support in
Formulation of teams and committees, Conduction of meetings in a
scheduled manner, Compilation of Documents with suitable secretarial
assistance,
Organization of trainings, audits, performance measurements and
assessments.
Timely fulfillment of gaps and accreditation compliances
Arranging for delivery of lectures- Training Venue & Trainees
Access to records and documents for undertaking historical and concurrent
data analysis.
Deputing Executives and other staff to assist in undertaking surveys and
collecting data primary and secondary, based on templates developed by
the Team QZAT.

Contact Us

Sree Soumiya K.M


Mobile : 09944321855
Email-sreesoumiya@gmail.com
QZAT Consultants
Email: qzatindia@gmail.com
Website: www.qzat.org