Quality Assurance Six Sigma

DR. LUBNA S. MANSURI

HEALTHCARE PROFESSIONAL

Exp: 7 Years and 7 Months

Designation: Manager – Current Company

Corporate Quality Assurance Sterling Hospitals

Current Location: Ahmedabad - 380009, Gujarat, India

OBJECTIVE

“A challenging position in one of the reputed institute at a growth oriented firm, which will allow me to both further utilize

my skills and acquire new abilities”

CAREER SUMMARY: (VISA Received, IM-1 Canada immigration: APPLICATION: B057730632)

ACADEMIC QUALIFICATION

Qualification M-Y of Institute

passing

Certified “Internal Counselor” on NABH Standards (3rd edition of Nov 2012 Quality Council of India

NABH Standards)

Certified Green belt in “Lean Six Sigma” June 2010 Quality Council of India

Post Graduate Certification In Quality Management And Accreditation Of June 2008 Academy of Hospital

Hospital Organization (PG Certification In QM & AHO) Administration

Post-Graduation Diploma in Hospital And Health Care Management May 2007 Symbiosis Center of

(PGDHHM) Healthcare

Bachelor in Homoeopathic system of Medicine and Surgery April-2006 Ahmedabad

Central Council Of Homoeopathy Homoeopathic Medical

Registration Number: G-8572 College

KNOWLEDGE, SKILLS, TRAINING

Knowledge on: Skills:

• •

Fundamentals of “Quality” Good Communication and Interpersonal Skills

• •

Applying the “Quality Tools” on various processes Good Analytical skills and able to do the

and to solve the problem Brainstorming for better outcome

• •

Comprehensive Interpretation of NABH and JCI Manage & train the team and employ the team

Standards Work

• •

Conducting Clinical Audit Able to make quick decision and manage in

• stressful conditions

Good knowledge on ICH & GCP Guidelines.

• Read, Listen, understand the information & ideas

• Good understanding on Guidelines for the

presented in writing and through spoken words &

functioning of the Ethics Committee for Clinical

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Research sentences

COMPUTER SKILLS

• Certified in “Basic computer skills on Windows / Microsoft word / Excel / Power point / Internet & Email” from

Ahmedabad Management Association dated June 18 to June 28 2007

TRAINING

• Participated in 3 days Implementation Programme on NABH Standards (3 rd edition – Latest) dated 23-24-25

Nov 2012

• Participated in One Day Interactive Workshop on “Clinical Audit” conducted by National Accreditation Board for

Hospitals and Healthcare Providers dated November 20, 2011 through Patient Safety and Quality of Healthcare department of

Quality Council of India.

• Successful completion of the training program from Long life Multi-specialty Hospital dated September 9 to October

25, 2006

• Participated in Workshop and training for “Good Clinical Practices for Ethics Committee”

• Participated in 3 day Training programme on “Infusion Therapy” and developed the team of 36 nurses trained in

infusion therapy

PROJECT STUDY

• Project study on “management of dental emergency services in government dental hospital” from government dental

hospital, Asarva, Ahmedabad

• Two National Demonstration Projects on “Lean Six Sigma” at Sterling Hospitals

o “Reducing TAT for Discharge Process”

o “Reducing TAT for Laboratory Services”

• Various projects have been guided like OPD utilization, OPD Patient Satisfaction Survey, FMEA on Discharge Process,

Lean six sigma on OPD waiting time, Quality Assurance – A key of competitive advantage for hospitals, Performance Indicators

– a mirror for services provided, Transformation of SOPs From Standard Based to Process Oriented, Central Procurement System

etc

WORK EXPERIENCE

CURRENT EMPLOYER: STERLING HOSPITALS (6 years and 6 months till Feb 13, 2014)

MANAGER – CORPORATE QUALITY ASSURANCE Aug 2011 till date

ASSISTANT MANAGER – CORPORATE QUALITY ASSURANCE Aug 2010 to Aug 2011

CLINICAL ADMINISTRATOR Aug 2007 to Aug 2010

Duties & Responsibilities of current employment:

• Interpretation and Implementation of National and International Standards (NABH and JCI) to ensure the delivery of quality

care

• Working at both – Operational and strategic level for the smooth functioning of the Healthcare Operations

• To define the training requirement as per Accreditation System (NABH//JCI) from time to time and Oversee the Training

program

• To follow documentation control system

• Regulate Committee functioning and ensure that actionable are complied with in predefined timelines

• Generating reports on Quality Indicators, Safety Indicators, and Utilization Indicators etc on monthly basis. e.g. Patient

Satisfaction, Nursing Quality Indicators, OPD & OT Utilization etc

• Monitoring of legal compliances

• Work in association with a consistent team to co-ordinate quality initiatives and provide consistency in such initiatives (like

Pioneers and champions)

• Consult with boards of directors, senior managers, operational In charges and key implementation personnel regarding

requirements of Quality Management System and Accreditation standards to maintain and establish standards for the health

care services

• Broaden the Quality Assurance & Improvement program to establish safety standards including sentinel event

• Plan, organize, direct, control and evaluate the delivery of health care services within all groups of the Hospitals

• Develop evaluation systems to monitor varied activities, its implementation and sustenance pertaining to quality of health

care given to patients e.g. Internal Assessment, Self Assessment, Tracer Methodology (Live Patient Monitoring System)

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• Undertake focused audits, mocks surveys, surprise audits to assess state of readiness for accreditation and focusing upon

continual improvement.

• Exhibits high degree of responsibility for confidential matters.

• Function as the Member secretary of Sterling Hospital Ethics Committee for Clinical Research.

• Training of Staff at all the units of Sterling Group on “Informed Consent”, ICH – GCP guidelines, Ethics Committee on a

periodic basis

• Responsible for the activities of the Group Quality Head – Quality in his absence

PREVIOUS EMPLOYERS

LONG LIFE MULTISPECIALITY AND MULTIUTILITY HOSPITAL (1 year and 1 month)

HOSPITAL ADMINISTRATOR 2006 TO 2007

Duties & Responsibilities:

• To provide the report of actions and recommendations to Head of the hospital on regular basis

• Responsible for prioritization, management, organization, planning and oversee implementation of the services in addition to

basic responsibility as a Medical officer

• To ensure implementation level accordingly in co-ordination with the Hospital staff

• Monitoring of clinical and non-clinical areas and processes to improve quality of services

• To coordinate for TPA and Mediclaim procedures and documentation

PATHIK NURSING HOME AND RESEARCH CENTER (11 months)

COORDINATOR / SUB INVESTIGATOR – CLINICAL RESEARCH 2006 to 2007

Duties and Responsibility:

• To perform and coordinate all the Clinical Research Site activities

• Development of Manpower Planning and execution for the clinical research department as per the needs for smooth

functioning of the department

• To screen the proposals for their completeness and submission as per the SOP depending on the risk involved

• To ensure the quality of health care given to patients and as per the ICH – GCP guidelines

• Represent the department or establishment at meeting with officials, the public, and other organizations

• To review and provide favorable opinion on the clinical trial protocol

• The preparation, approval and periodic review of the Standard Operating Procedure (SOP) which cover all functions of IRB

and to ensure the implementation of the same accordingly

• To inform the IRB of amendment changes to the protocol

PROFESSIONAL ACHIEVEMENTS

• Successfully completed NABH (Pre-assessment, Final Assessment, Surveillance (2) and Reaccreditation (Ahmedabad

and Vadodara (as per the NABH 3 rd edition)) at Sterling Hospitals and ensuring the sustainability (Implementation) of all

NABH standards across the Hospital. Successfully completed NABH Preassessment of Sterling Hospitals, Rajkot.

(Worked for total 13 NABH Assessments)

• Participated as Leader for the Sterling Hospitals Lean Six Sigma Projects which were awarded by the QCI and NBQP as

the BEST National Demonstration Projects in the year 2010

• Worked closely for getting the approval like Kidney Transplantation (got 5 years of permission for vadodara unit), Liver

Transplantation (got 5 years permission for ahmedabad unit)

• Active Participation for various healthcare awards like FICCI awards, Hospital Management Asia awards, ICICI

Lombard, CNBC healthcare etc

• Worked as Editorial assistant for Journal of Sterling Hospital (JOSH) for consultants on scientific article and case studies

• Received Six Sigma Healthcare Excellence Awards 2013 of appreciation for “Best Patient Safety” constituted by Six Sigma

Star Healthcare Pvt.Ltd. Received “CNBC Healthcare Awards” for best multispecialty Hospital in 2013

ACADEMIC ACHIEVEMENTS

• Awarded for the excellent performance in BHMS

• Awarded as “CCIM Top Ten-Award” outstanding High School Student by The Consultative Committee of Indian in

UNITED STATES and CANADA

• Awarded(Letter) for honour in SSC and Awarded for performance in HSC

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PROGRAMS ATTENDED

• “Second Management Consultation On Health Care In India” from Indian institute of Management, Ahmedabad

(IIMA) dated June 25-29, 2007

• 9th National Seminar on “Hospital and Health Care Management” and “Hospital And Medico-Legal

Management” from Symbiosis center of healthcare, Pune dated 9th May To 13th May 2007

REFERENCE: It shall be provided as per the request

MOBILITY AND FLEXIBILITY: Willing to relocate anywhere in CANADA

DECLRATION:

I hereby declare that the above-mentioned information is correct and true as per my knowledge

Dr. Lubna Mansuri,

Place: CANADA

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