DHULIPUDI PAVAN KUMAR
AGM - QUALITY (REGIONAL INCHARGE)
Hyderabad
Summary
Dynamic Healthcare Quality Leader with over 12 years of experience in spearheading national accreditations, including NABH, NABL, NQAS, Nursing Excellence, and NABH Digital Standards. Proven track record in assessing more than 50 government healthcare facilities, demonstrating a commitment to enhancing quality governance and patient safety. Expertise in regulatory compliance and digital standards strengthens accreditation outcomes and elevates clinical performance. Dedicated to driving measurable quality improvements across healthcare organizations for optimal patient care and operational excellence.
Overview
12
12
years of professional experience
13
13
Certifications
1
1
Language
Work History
Assistant General Manager - Quality
KIMS Hospitals Kondapur
08.2021 - Current
- Achievements: Secured 2nd prize at the national level and 1st prize at the state level in the National Quality Olympiad conducted by CAHO (Consortium of Accredited Healthcare Organisations).
- Responsibilities: Responsible for leading and strengthening the organization’s quality, patient safety, and accreditation systems by ensuring compliance with national and international standards. Overseeing NABH, NABL, NABH Digital standards, and other accreditation programs, monitoring quality indicators, driving continuous quality improvement initiatives, ensuring effective implementation of policies and SOPs, leading internal and external audits, managing risk and patient safety programs, supporting digital quality initiatives, mentoring quality teams, and coordinating with clinical, nursing, and administrative leaders to improve care outcomes and regulatory readiness across the organization.
Quality Head (Manager)
HCG Hospitals – Vijayawada a Unit of Health Care Global Enterprise Limited
08.2020 - 08.2021
Responsibilities: Responsible for implementing and monitoring the organization’s quality and patient safety systems to ensure compliance with accreditation and regulatory standards. Including coordinating NABH accreditation and NABH entry-level certification activities, conducting internal audits, tracking quality indicators, supporting risk management and patient safety initiatives, ensuring proper documentation and SOP compliance, facilitating training and awareness programs, managing non-conformities and CAPA, and working closely with clinical, nursing, and support departments to drive continuous quality improvement and maintain audit readiness.
Quality Officer (Executive – In charge)
Apollo Hospitals Visakhapatnam – Health city & Ramnagar
01.2017 - 08.2020
Responsibilities: Being the Quality Department In-Charge (Two Units) responsible for overseeing end-to-end quality management, patient safety, and accreditation readiness across both hospitals. Led the implementation, monitoring, and tracking of Apollo Clinical Excellence Programs and Apollo 360-Degree Audits, ensuring compliance with defined clinical, operational, and patient safety benchmarks. Coordinated internal audits, quality indicators, risk management activities, and cross-functional quality improvement initiatives. Served as the key liaison for NABH assessments, including documentation, staff training, mock audits, non-conformity closure, and sustained compliance, while supporting leadership in driving a culture of continuous quality improvement and regulatory excellence.
Sr. Executive Operations & Quality
SBIMS (Shri Balaji Institute of Medical Sciences)
04.2016 - 01.2017
Responsibilities: Responsible for coordinating and implementing the NABH Entry Level Accreditation Program, including documentation, staff awareness, internal audits, and compliance tracking. Managed Biomedical Engineering functions, covering equipment maintenance, calibration, safety checks, and vendor coordination, while ensuring compliance with hospital statutory and regulatory requirements. Actively supported operational quality improvement, patient safety practices, and regulatory readiness through effective cross-departmental coordination and monitoring.
Executive Operations & Quality
Apollo Specialty Hospitals Nellore
04.2014 - 03.2016
Responsibilities: Responsible for obtaining, renewing, and maintaining all hospital licenses and statutory approvals, preparing and implementing policies and SOPs, and supporting compliance with regulatory requirements. Assisted the Unit Head in maintaining medical staff records, credentialing, and recruitment documentation, while coordinating with departments to ensure operational efficiency, documentation accuracy, and continuous regulatory readiness.
Education
PGDHRM - Human Resource Management
University College of Arts, Commerce And Law (Distance Learning)
Guntur, India01-2014
MBA - Hospital Administration
University College of Arts, Commerce And Law & NRI Medical College
Guntur, India01-2014
B.SC - Medical laboratory Technology
NRI Medical College, Guntur
Mangalagiri, India01-2012
D.M.L.T - DIPLOMA IN MEDICAL LABORATORY TECHNOLOGY
Sri Chaitanya Academy of Para Medical Technology
Narasaraopet, India01-2007
X – Class SSC -
Kakatiya Vidya Peetam
Narasaraopet, India01-2005
Skills
Healthcare Quality Management & Patient Safety
Accreditation management
Regulatory compliance expertise
Quality standards assessment proficiency
Audit readiness management
Quality Improvement Methodologies (PDCA, RCA, FMEA)
Clinical Risk Management & Governance
Performance Measurement & Quality Indicators
Documentation control and compliance
Digital Health Standards & Compliance Implementation
Training, Capacity Building & Assessor Mentoring
Comprehensive evaluations of healthcare facilities in the public sector
CAPA implementation oversight
Stakeholder Engagement & Cross-Functional Leadership
Certification
Participated in Poster presentation. Organized by the SAFETYCON_2014
Timeline
Certified patient safety officer by CAHO
02-2026
Certified Professional in Patient Safety (CPPS) (IHI)
12-2025
Programme on Implementation of NABH 6th Edition Standards for Hospitals
05-2025
ISQua Fellowship
05-2025
Programme on Implementation of NABH standards for Hospitals by Quality Council of India
06-2024
Certified Internal Surveyor for AACI International Accreditation ( American Accreditation Commission International)
08-2023
Certified Internal Auditor for ISO 45001 : 2018 Occupation Health and Safety Management Systems
03-2022
Assistant General Manager - Quality
KIMS Hospitals Kondapur
08.2021 - Current
Certified Internal Auditor for Hospitals from AHPI institute of Health Care Quality – (NABH 5th Edition)
05-2021
Quality Head (Manager)
HCG Hospitals – Vijayawada a Unit of Health Care Global Enterprise Limited
08.2020 - 08.2021
Certified Lean Six Sigma Green Belt from MSME – Technology Development Center
05-2020
IX Apollo Innovation and Quality Award 2018 for excellence in operational project
03-2018
Quality Officer (Executive – In charge)
Apollo Hospitals Visakhapatnam – Health city & Ramnagar
01.2017 - 08.2020
Certified Internal Auditor for Hospitals from AHPI institute of Health Care Quality – May 2016
05-2016
Sr. Executive Operations & Quality
SBIMS (Shri Balaji Institute of Medical Sciences)
04.2016 - 01.2017
Trained in Implementation of Blood Bank NABH Accreditation Standards – November 2015
11-2015
Executive Operations & Quality
Apollo Specialty Hospitals Nellore
04.2014 - 03.2016
Participated in Poster presentation. Organized by the SAFETYCON_2014
01-2014
PGDHRM - Human Resource Management
University College of Arts, Commerce And Law (Distance Learning)
MBA - Hospital Administration
University College of Arts, Commerce And Law & NRI Medical College
B.SC - Medical laboratory Technology
NRI Medical College, Guntur
D.M.L.T - DIPLOMA IN MEDICAL LABORATORY TECHNOLOGY
Sri Chaitanya Academy of Para Medical Technology
X – Class SSC -
Kakatiya Vidya Peetam
STRENGTHS:
- Strategic leadership in healthcare quality, patient safety, and accreditation
- Deep expertise in NABH, NABL, NQAS, Nursing Excellence, and digital standards
- Strong regulatory interpretation and compliance management skills
- Proven ability to drive organization-wide quality improvement initiatives
- Excellent audit management, risk mitigation, and non-conformity closure skills
- Data-driven decision-making using quality indicators and performance metrics
- Effective stakeholder engagement with clinicians, nursing, and leadership teams
- Strong mentoring, training, and team-building capabilities
- High accountability with a results-oriented and process-focused approach
- Adaptability to complex, multi-unit healthcare environments
HANDS ON EXPERIENCE:
- Apollo Hospitals Kakinada (NABH) Surveillance audit 11th & 12th Feb 2017
- Apollo Hospital Health city Visakhapatnam (NABH) Pre- Assessment 13th & 14th Jan 2018
- Apollo Hospitals Kakinada (NABH) Re – Accreditation 16th & 17th June 2018
- Apollo Hospitals Health city Visakhapatnam (NABH) Final assessment 30th, 31st August & 1st July 2018
- Apollo Hospitals Kakinada (NABH) Surveillance audit 14th & 15th of Feb 2020
- Apollo Hospitals Visakhapatnam (NABH) Surveillance Audit 11th & 12th July 2020
- HCG City Cancer Center – Vijayawada (NABH) Re accreditation 8th Apr 2021
- HCG Cancer Center – Ongole (NABH) entry level Audit 28th June 2021
- KIMS Hospitals Kondapur (NABH) Re - Accreditation 23rd – 25th July 2021
- Sun Shine Hospitals Gachibowli (NABH) Final Accreditation 30th June & 1st,2nd July 2022
- KIMS Hospital Kondapur (NABL) – Pre assessment 24th April 2022 and final assessment 30th, 31st July 2022
- KIMS Hospital Kondapur (NABH) – Surveillance Audit 04th & 5th March 2023
- KIMS Hospital Kondapur (NABL) -Surveillance 10th & 11 September 2023
- KIMS Hospital Kondapur (NABH- Nursing Excellence) – 16th & 17th December 2023
- KIMS Hospital Kondapur (NABH – Digital Standards) – 17th & 18th February 2024
- KIMS Hospital Kondapur (NABH – Re Accreditation) – 7th,8th & 9th March 2024
- KIMS Hospital Kondapur (NABL) Surveillance 17,18th October 2024
- KIMS Hospital Kurnool (NABH – Accreditation) – 8th,9th & 10th Nov 2024
- KIMS Hospital Gachibowli (NABH Surveillance Audit) - 04,05th April 2025
- KIMS Hospital Kondapur ( NABH Surveillance Audit ) 06,07th December 2025
ROLES & RESPONSIBILITIES:
- On-going implementation and monitoring of accreditation like (NABH/NABL, NABH – Nursing Audit, NABH Digital Standards)
- Preparing and conducting Internal Audit, Safety Audit, Infection Control Audit, Prescription Audit, Quality Monitor Audit, Tracer Audit etc on scheduled basis
- Report preparation and conducting internal monthly process plan, survey, quality checks, and training program.
- Root cause analyzing of the incident forms, feedback forms, medication error reporting forms, adverse drug reaction forms, needle stick injury forms and infection control surveillance forms etc.
- Collecting the data and tabulated in dash board and preparing graphs related to quality indicators. (departmental Quality monitors/ NABH/ Clinical Excellence monitor etc)
- Conducting meeting. (Committees, Departmental Meeting, Monthly Meeting etc.)
- Preparation of formats, consent forms, checklists and preparation of proof for printing.
- Checking compliance of case sheet through medical records audit.
- Updating of policies and procedures on documentation structure.
- Organizing Conferences, workshop, events, CME
- Inventory management like ABC analysis, FSN analysis and FIFO etc mainly in pharmacy, general store and nursing departments as per the applicability.
- Ensuring optimum utilization of Electronic Medical Records in hospital
- Reducing TAT & Waiting time in OPD/emergency/discharge process.
- Monitoring and implementation of Quality Assurance in Radiology/Lab/ ICU’s /Emergency /OT Department
- Conducting Mock drills and Providing training to staff on Mock drills
- Conducting and documenting analyzing the findings of facility inspection rounds.
- Conducting continuous training for the NABH process owners and general staff.
- Monitoring of quality indicators for various department for effective quality improvement.
- Facilitation of various inspections of the hospital.
- Coordinating in Implementation of various APOLLO TOOL KITS (Medication safety, Hand hygiene, ALOS, TKR, Angioplasty, transplantation, Stroke, ACS – Acute coronary syndrome etc)
- Collecting and analyzing data for Apollo Clinical Excellence programs like ACE-I, ACE-2, ACPP, AQP, Surgical Safety audit, ICU Audit, Consultant Tracker etc.
- 360 Degree audit: conducting regular Apollo 360 audits (Internal & External)
Declaration:
I hereby declare the above mentioned information is correct up to my knowledge and I bear the responsibility for the correctness of the above mentioned particulars. Date: 2026-02-24 Place: Hyderabad (D.Pavan Kumar)