Medical Services Quality Management

Dr. Mohita Chandra

DIRECTOR MEDICAL SERVICES

M.B.B.S, PGDHHM, MBA ( Hospital & Health Administration), CERTIFIED IN SIX SIGMA & LEAN MANAGEMENT

+91-995******* +91-981******* *****************@*****.*** Delhi, India linkedin profile AREA OF EXCELLENCE CLINICAL ADMINISTRATION OPERATIONS STRATEGY Receiver of TIMES HEALTHCARE leadership and various other awards in the field of healthcare. Goal-driven, compassionate, and accountable professional with more than 27 years of experience in multi-specialty, tertiary care, and quaternary care hospital settings. Adaptable administrator, accustomed to the integration of new healthcare delivery systems, and restructuring of processes to meet increasingly complex regulatory environments. Ability to maintain a healthy and productive relationship with all stakeholders. Well-versed with quality management systems. 1. Overall clinical governance to ensure clinical teams follow standardised clinical protocols and pathways for health care delivery.

2. Clinical capability building by not only onboarding appropriate talent but also by nurturing the in-house talents and providing platforms for career progression.

3. Monitoring clinical outcomes against pre-defined tangible parameters. 4. Quality management by ensuring best practices as per national (NABH) and international (JCI) norms which are dynamically evolving to patient safety and safe outcomes. 5. Service excellence by providing end-to-end multidisciplinary care to patients under one roof. 6. Growth to ensure design plan and develop expansion of departments and initiate new services and programs. 7. Finance contribution by defining and developing annual operational plans and ensuring optimum utilisation of assets and clinical services.

8. Digitization to reduce manual interference in clinical processes. 9. Innovation and research by encouraging clinicians for research and publications. WORK EXPERIENCE 27 YEARS

DIRECTOR MEDICAL SERVICES 2020-PRESENT

SIR HN RELIANCE FOUNDATION HOSPITAL, MUMBAI 350 Beds

● Overall leadership for the medicine and surgical departments of the Hospital through a team of Clinical Directors, ensuring the best clinical outcomes through global standards of care and clinical services.

● Developing and reviewing clinical policies, procedures, and clinical pathways and driving compliances across the Hospital

● Architecting Annual Operating Plans for the clinical specialties and the support departments for holistic growth across Clinical Services, Brand Value, Innovation and digitization, Quality, Academics, and People pillars.

● Statergizing in collaboration with finance and marketing for growth by taking new initiatives in terms of services

/ value-added departments.

● To Monitor the KRAs and KPIs on an annual, quarterly, and monthly basis.

● Planning annual budgets for the clinical specialties including both Opex and Capex for world-class infrastructure and state of the art equipment.

● As a key member of the Senior Leadership Team of the Hospital responsible for day-to-day clinical operations and excellence across the clinical journey of the patient from admission to discharge and maximising Net Promoter Score.

● Part of the Quality Committee and responsible for overseeing the Quality indicators, conducting CAPA, and taking remedial actions to mitigate any risks to patient safety.

● Responsible for leading and mentoring the Quality team for JCI and NABH conducting audits to ensure compliance with the defined accreditation standards.

● Responsible for the governance structure of the Hospital. Member of various Hospital Committees.

● Defining governance framework and clinical privileges across the various levels of clinical hierarchy.

● Overall responsible for ensuring optimum utilisation of assets and services to bring in efficiency.

● Overall responsibility for selection and empanelment of the most suitable clinicians and high level of engagement during their association with the Hospital.

● Overseeing the clinical trials

● Developing robust academic programs through DNB, MUHS, and Institutional Fellowships including oversight of the Nursing College

● Presenting management reports and dashboards for governance and board meetings. KEY ACCOMPLISHMENTS

● Successfully completed the JCI ACCREDITATION with no non-conformities against 1300 standards.

● Implemented Robust Mortality review process to bring down SMR to 0.4 (way less than Benchmark of 1)

● Introduced short day care surgeries and defined clinical pathways for various surgeries ( Joint replacement, CABG, head & neck oncology surgeries) to bring down ALOS by 2.4 days.

● Changed case Mix of surgical Vs medical cases.

● Re-engineered process flows to reduce waste time and Increased OT efficiency to increase utilisation by 18 percent.

● Digitally Established the golden hour care pathway for PAMI, STROKE, SEPSIS, and SHOCK for better patient outcomes.

NEW INITIATIVES / PROGRAMS UNDERTAKEN

● Launch of TAVR ( trans aortic valve replacement) program. This has not only increased the average revenue per bed but has also decreased ALOS to 48 hours compared to the conventional valve replacement surgeries.

● Built up the transplant program by augmenting the clinical capabilities and putting together a robust team. Re-visited the process and aligned the teams together. Successfully running liver, Heart, kidney, and Lung transplants with world-class outcomes.

● Initiated and operationalised High dose therapy inpatient facility as per AERB guidelines.

● Augmented the ONCO radiation program by the successful launch of Ethos from Varian.

● Defined parameters to implement monitoring of clinical outcomes for 14 specialties.

● Successfully implemented physician scorecard evaluation.

● launch of a one-stop breast clinic.

● Establish centre for Robotic Surgery for Bariatric, uro-oncology, and Joint replacement.

● Launched a Bi-plane cath lab to cater to neuro and vascular cases. MEDICAL SUPERINTENDENT 2015 – 2020

MAX SUPER SPECIALITY HOSPITAL PATPARGANJ, NEW DELHI 375 Beds

● Re-engineer and implementation of Policies and Procedures.

● Lead quality improvement program and ensure NABH accreditation.

● To work in close collaboration with the clinical director and HOD to deliver world-class health care delivery.

● Enabled and coordinated for Cost optimization.

● Identified and audited critical processes for risk mitigation as per IPSG for patient safety.

.

MAX SUPER SPECIALITY HOSPITAL VAISHALI, UTTAR PRADESH

● Led the delivery of top-quality Diagnostic, Surgical, and Medical Services to inpatients and outpatients.

● To effectively plan and manage day to day functioning of the hospital and its various departments both clinical and non-clinical.

● To define and implement an effective hospital infection control program.

● Compliance to Statutory requirements.

AWARDS RECEIVED

2nd MHC Annual Patient Safety Conference

● 1st Prize: "HEALTHiCU: ARE THE ICU’S HEALTHY?

AN ASSESSMENT MODEL"

● 2nd Prize: "Nursing Transformation"

● 3rd Prize: "Clinical Excellence Meet: Driving Quality Improvement through Monitor, Measure and Improve

Approach"

● 3rd Prize: Transfusion Services

16th Energy Efficient Summit 2017

● "Most Innovative Project in Energy"

● "Most Efficient Unit"

CAHOCON 2017

● Recognitions under AHPI Awards 2017-18

● 2nd Prize for Oral Paper Presentation

● 3rd Prize: "COMPLIANCE TO FIVE

MOMENTS OF HAND HYGIENE AMONG

HEALTHCARE WORKERS IN A TERTIARY

CARE HOSPITAL: AN OBSERVATIONAL

STUDY"

Max Annual Day Awards

● Healing Hands Award 2017

● Khushi Award and Sevabhav Award

● Lean and Six Sigma approach in Dietetics and Food & Beverage

● Dhruv Award

GROUP MEDICAL SUPERINTENDENT 2010 – 2015

CENTRE FOR SIGHT HOSPITAL, NEW DELHI, A LEADING CHAIN OF EYE CARE HOSPITALS.

● Provided overall leadership to multiple centres across Delhi NCR and northern India, ensuring quality assurance through meticulous monitoring of established policies and procedures. Liaised effectively with Department Heads to foster cohesive coordination.

● Spearheaded the development of robust Grievance Redressal systems catering to the needs of both employees and patients while overseeing the operational aspects of multiple centres in the region.

● Managed Medico-legal issues by coordinating with legal aids and maintaining thorough records.

● Oversaw accreditation processes conducted regular Departmental Audits and Identified and fulfilled training needs across various employee levels to streamline workflow.

● Coordinated with external agencies and ministries for private and PSU empanelment as well as, Formulated and executed departmental policies and procedures effectively.

● Strategically planned staff recruitment, working hours, and institutional policies compliant with industry standards (NABH).

● Determined pricing strategies for diverse healthcare procedures. PROBLEM-SOLVING AND PLANNING SKILLS

● Directed health and medical services while effectively engaging with personnel at different skill levels.

● Addressed day-to-day patient-generated issues and interacted proactively with skilled, semiskilled, and unskilled personnel.

● Implemented benchmarking and established performance parameters in each field to ensure operational efficiency.

MEDICAL SUPERINTENDENT 2004 – 2009

METRO GROUP OF HOSPITAL 300+ Beds

● Managed overall hospital administration and operations.

● Oversaw clinical governance and ensured high-quality patient care.

● Facilitated inter and intra-hospital coordination for seamless patient care.

● Led recruitment and selection processes for qualified personnel.

● Formulated, reformed, and applied hospital policies effectively.

● Coordinated and planned marketing strategies in collaboration with the marketing team. COORDINATOR HEALTHCARE SERVICES

● Coordinating marketing services for health check ups

● Inter-hospital coordination

● Driving profit centre

● Promoted to medical superintendent

DEPUTY MEDICAL SUPERINTENDENT 1998 - 2004

KAILASH GROUP OF HOSPITALS 300+ Beds

● Overall general administration of the hospital

● Overlooking entire patient care & scheduling, including patient counselling

● Coordinating various services within and across hospitals

● Responsible for formulating policies & procedures as per guidelines

● Human resource management and control

MEDICAL ADMINISTRATOR

● (Trauma Center) & Critical Care Services Coordinator (ICUs & ICCUs)

● Coordinated diverse critical care services, with a focus on cardiac care.

● Managed human resources effectively within the critical care departments.

● Ensured seamless coordination within the trauma centre for optimal operations.

● Provided high-level critical care to patients in specialised units. ASSISTANT HOSPITAL ADMINISTRATOR 1995-1998

SRI RAM SINGH HOSPITAL AND HEART INSTITUTE 200+ Beds

● Started as Assistant Hospital Administrator, subsequently promoted to Medical Administrator, overseeing overall General Administration.

● Responsible for day-to-day operations.

● General administration and vendor development.

● Human resource management

● Documentation of Administrative Policies & Procedures. ADMINISTRATOR, CLINICAL & BUSINESS DEVELOPMENT 1994 - 1995 DENTAL & POLYCLINIC A medical organisation, dealing with dental and medical clinical procedures.

● Setting and heading profit centre

● Responsible for day-to-day operations

● General administration and business development

● Drive sales and marketing

● Human resource management

RESIDENT DOCTOR (ICCU) 1993-1994

INLAKS AND BUDHRANI HOSPITAL, PUNE

● Managed patient care within the Intensive Coronary Care Unit (ICCU), overseeing critical medical treatments and procedures.

● Provided attentive and comprehensive care to patients with acute cardiac conditions.

● Collaborated with multidisciplinary teams to ensure coordinated and efficient patient management.

● Administered emergency interventions and monitored critical care protocols to stabilise patients.

● Executed timely assessments, diagnostics, and treatments in accordance with established medical standards.

● Communicated effectively with patients and their families, offering support and explaining treatment plans.

● Contributed to the continuous improvement of patient care by actively participating in medical rounds and discussions.

Languages Known - English, Hindi, Marathi, Persian DOB- 06.03.1969

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