Summary
Overview
Work History
Education
Skills
Certification
LNGG
Hobbies and Interests
Accomplishments
Publications
Training
SUMMARY OF RESPONSIBILITIES
Timeline
Generic
Shubhangi Chandrakar

Shubhangi Chandrakar

Naya Raipur

Summary

Quality Management professional with successful career delivering efficiency and standardization, and maintaining all JCI, NABH, ISO and QS 9001 and Six Sigma Quality Systems. Drives smooth operation of hospital and service lines, coordinate efforts of employees and facilitate communication between management and end-user departments. Apply creativity in improving clinical processes to achieve higher safety and quality of services offered to patients. Experience in reviewing and interpreting regulatory requirements, implementation of corporate compliance, risk management and incident reporting followed by corrective action programs.

Experienced with heath care quality management practices and standards. Utilizes quality tools to conduct clinical audit and process improvement projects. Strong understanding of regulatory compliance and process improvement strategies.

Focused Quality Controller with 16 years of experience in JCI and NABH accreditation and certifications. Possesses superior knowledge to train and educate staff while maintaining optimal service quality and efficiency. Builds and maintains effective working relationships with all stakeholders. Quality assurance professional with solid foundation in managing quality systems and driving continuous improvement. Proven ability to enhance productivity and ensure compliance with industry standards. Known for fostering team collaboration and adapting to changing requirements. Skilled in quality auditing and process optimization. Diligent Quality Manager with 16 years of experience making clinical and nonclinical services meet internal and external standards. Skilled in market research, project management, and statistical analysis. Organized and analytical with excellent written and verbal communication skills.

Overview

17
17
years of professional experience
1
1
Certification

Work History

AGM – Quality & Administration

Balco Medical Centre, Raipur, a unit of VMRF
11.2019 - Current
  • Conduct morning huddle meeting with operations team and ensure key concerns are addressed by chairing the morning meeting and guiding stakeholders on their daily operational activities
  • Responsible for leading the NABH Assessment of175 bedded Oncology Super specialty Hospital in the Nava Raipur region of Chhattisgarh, it is a unit of Vedanta Medical Research Foundation
  • End to end responsibility of Quality Department in the organization including coordination, documentation, training and implementation of standards of NABH
  • Responsible for day-to-day operational assistance in hospital by Feedback and complaints management
  • Plan, initiate and implement quality improvement projects based on priority matrix and cost and efficiency requirements of the institution
  • Plan, strategies and initiate opportunities for recognition of excellence in the key care functions and services of hospital by implementation of recognized accreditation cum certification program like NABL, Nursing Excellence, CSSD Excellence and LEED certificate by Indian Green Building Council (IGBC)
  • Additional responsibility includes admin duties assigned by the MD’s office from time to time in the field of operations and strategy

Head – Quality Management

Medeor Hospital, Dubai, a unit of VPS Healthcare
04.2018 - 11.2019
  • Responsible for leading JCI triennial survey of75 bedded multi-specialty hospital in the Bur Dubai region, a unit of VPS Healthcare
  • Report to the Head of Institution and VPS Corporate Quality Officer on the status of Quality Parameters, quality calendar activities and QI data accuracy after the audit and analysis
  • Coordinate the Hospital Committee meetings; a department review meet of members of core quality team as a part of Continuous Quality Compliance Agenda programme
  • Follow-up with the departments on monthly activities scheduled as per the Quality Calendar
  • Maintenance of Quality Dashboard centrally and updating of noncompliance to respective associates
  • Report to the Dubai Health Authority on the mandatory health indicators, coordinate for the audit and inspections
  • Coordinate the quality initiatives of VPS Corporate Office in Abu Dhabi so as to bring about a harmonized sync on quality and service excellence

Manager – Quality Management

Continental Hospitals, Gachibowli, Hyderabad
04.2014 - 09.2017
  • Responsible for heading Quality in JCI & NABH accredited post assessment phase of a700 bedded Super specialty multidisciplinary hospital in financial district of Hyderabad
  • Report to Head of Institution on status of Quality Parameters, quality calendar activities and QI data accuracy after audit and analysis
  • Coordinate Hospital Committee meetings; department review meet of members of core quality team as part of Continuous Quality Compliance Agenda programme
  • Follow-up with departments on monthly activities scheduled as per Quality Calendar
  • Maintenance of Quality Dashboard centrally and updating of noncompliance to respective associates
  • Coordinate Institutional Ethics Committee Activities with respect to enrolment of hospital ethics committee with CDSCO, training of members on Good Clinical Practices and Schedule Y and projects for clinical trials
  • Coordinate quality initiatives of Parkway’s Corporate Office in Singapore so as to bring about harmonized sync between two groups on quality and service excellence

Assistant Quality Manager

Wockhardt Hospitals, Corporate Office, BKC, Mumbai
06.2013 - 01.2014
  • Working as Assistant to Head of Quality at Corporate Office of Wockhardt Hospitals Limited
  • Responsible for conducting monthly review meeting on Quality Indicators data and Quality Improvement Projects
  • Report to Head, Quality on status of Shared Quality Agenda projects, quality calendar activities and QI data accuracy after visit to locations
  • Coordinate biannual Quality Conclave; project review meet of members of core quality team as part of Shared Quality Agenda programme
  • Follow-up with locations on monthly activities scheduled as per Quality Calendar
  • Maintenance of Quality Dashboard centrally and updating of noncompliance to respective associates
  • Assist all project leaders of all ongoing SQA projects as Corporate Resource in conducting projects, data analysis and interpretation
  • Actively involved in launch of new SQA projects i.e. Antibiotic Stewardship Program, Improvement of Dietary services and Medical Records Review

Assistant Operations Manager

Columbia Asia Hospitals, Pune
09.2012 - 05.2013
  • Participated as core team during commissioning of hospital
  • Actively involved in HIS and process flow training of staff during the pre opening phase and continued training on regular basis
  • Responsible for overall setup, operations and performance of the Surgical Units of hospital
  • Coordinate with the biomedical department for installation of equipments in OT, Cathlab & Endoscopy; training and orientation of staff on the latest technology and handling of machines
  • Clinical: (To work with medical administration)
  • Ensure implementation of and compliance with clinical pathways/protocols
  • Operational: (To work with operations head)
  • Financial Review: (To work with the Finance Manager)
  • Ensure optimal utilization of OT, Cathlab & Endoscopy
  • Inventory control and management of consignment items in the department
  • Management of clients i.e
  • Doctors & patients, staff and vendors for day to day operations of100 bedded multispeciality hospital in Pune
  • Risk assessment, training, risk mitigation and plan for risk reduction, maintenance of Risk Registers in the organization
  • OT Scheduling, cancellation and rescheduling of procedures
  • Update OT, Cathlab & Endoscopy MIS on a daily/weekly/monthly basis
  • Meet all doctors for case to case review and unique requirements
  • Meet all patients admitted in the hospital on a daily basis
  • Billing of all procedures
  • Ensure procedure prospectus is updated as per the upcoming requirements
  • Conduct training on Brand Service Standards, operations manual and process flow in the department
  • Conduct inter and intra department audit and review compliance as per the departmental manual; ensure timely closure of the non compliances
  • Undertake training on operations procedures in the department
  • Active participation in induction and orientation of new joiners, training of staff on incident reporting, quality assurance and emergency codes
  • Collection, analysis and reporting of Quality indicators on monthly basis

Assistant Manager, Quality Assurance

Columbia Asia Hospitals, IMO, Bangalore
02.2011 - 09.2012
  • Policy Review: Formatting of all policies, Reviewing of all Policies with the help of VP – QA, Version Number & Record Keeping of Policies, Keep records of the suggestions from Corporate Office
  • Department Manual Review: Obtain inputs from all units, Review the manuals with GM-QA & VP-QA, Formatting of Manuals
  • Forms and Formats Review: Obtain inputs from all units, discuss with domain heads and finalise the change requirements, make changes in the forms and keep versions
  • Operations Audits: Prepare audit schedule, yearly audit calendar, materials for conduct of audit, Coordinate with various auditors, Participate in conduct of Audit, Collate the Audit report and format
  • Quality Indicators: Obtain Indicators from all units, collate the data received from all units
  • Quarterly Data Review (IR): Obtain Incident Reports from all units, collate the data received from all units, analyse the Incidents and present it to the Executive committee in India Management Office, follow-up on closure report
  • Corporate Audit: follow-up with units for closure of all points, coordinate with all units and the Corporate team in Malaysia
  • Licenses: Follow-up on Laws and Regulations in each hospital, create and maintain the compliance sheet, sound alarm if necessary

Assistant Manager, Quality Management

BGS Global Hospitals, Bangalore
11.2009 - 02.2011
  • In charge for Quality initiatives and preparing the organization for NABH Accreditation
  • Part of the team for NABH pre assessment at BGS Global Hospital, Bangalore and NABH final assessment at Global Hospital and Health City, Chennai
  • Documentation of policies, Standard Operating Procedures, Manuals and forms
  • Actively involved in all policy related decisions for the hospital
  • Conducting operational audits and Facility Maintenance Audits
  • Coordinating training of staff & doctors on NABH standards, Procedures, Policies and Emergency codes in the hospital
  • Assimilating, presenting and addressing patient feedback in the hospital

Quality Coordinator

Academy of Hospital Administration, Noida
06.2008 - 10.2009
  • In charge of Quality initiatives and preparing the organization for NABH Accreditation during deputation in Baroda
  • Liaising with the hospital, Consultancy & the Health Ministry while preparing the hospital for accreditation by submitting monthly/ weekly/ daily reports, presentation of status reports
  • Documentation of Policies, manuals and forms for the hospital
  • Conducting clinical, operational and facility audits in the hospital
  • Conducting process training, Mock drills and emergency codes awareness

Education

Ph.D. - Quality

Jharkhand Rai University
Ranchi, Jharkhand
06-2026

Post Graduate Certificate - Quality Management & Accreditation of Healthcare Organization

Academy of Hospital Administration, Noida
Noida, U.P.
01.2009

MBA - Hospital Administration

Institute of Management Studies, Devi Ahilyabai University
Indore, M.P.
01.2008

BBA - Hospital Administration

Institute of Management Studies, Devi Ahilyabai University
Indore, M.P.
01.2006

Senior Secondary School - undefined

Sector10, Bhilai, Chhattisgarh
Bhilai, Chhattisgarh
01.2002

Senior Secondary School - undefined

Sector10, Bhilai, Chhattisgarh
Bhilai, Chhattisgarh
01.2000

Skills

  • JCI & NABH Accreditation Specialist
  • Quality management system
  • Quality training
  • Customer satisfaction
  • Quality planning
  • Operational excellence
  • Internal auditing
  • Document control

Certification

  • Certified Internal Auditor (ISO9001:2015 QMS & ISO14001:2015 EMS), Trained at Ministry of Micro, Small and Medium Enterprise, a GOI Organization
  • NABH Assessor Course – Organized by Quality Council of India, held in Hyderabad on26th July to31st July2017.
  • Simpler Green Belt certification in Lean Healthcare, Conducted by Quality Council of India and Simpler Healthcare –10th December2010, Bangalore

LNGG

English & Hindi

Hobbies and Interests

Home Décor, Gazals & Current Affairs.

Accomplishments

  • NABL & Nursing Excellence Program Re-Accreditation of BALCO Medical Centre in Sep'2024 and First Time Accreditation in Dec'2022.
  • NABH Re-Accreditation of BALCO Medical Centre in Oct2023 and First Time Accreditation in Jan2021.
  • Published a chapter titled: “A Comparative Study of Annual Survey on Patient Safety Culture at Balco Medical Centre in the year2021-2022” in the book “Research Trends in Commerce & Management”, ISBN:978-81-19477-20-3 in Aug'2023; along with co-author and Research guide Dr. Anusha Priya, Associate Professor, Commerce & Management, Jharkhand Rai University, Ranchi
  • Published paper at International Journal of Creative Research Thoughts on Topic: "Impact of Accreditation on Quality of Private hospitals" in02-June-2023; UGC Approved Journal No:49023 (18)
  • Attended certificate program on Recent Advances in Quality Management: a three-day online session on implementation of NABH5th Ed. by Academy of Hospital Administration, Noida – conducted in May'2022
  • Completed Program on Implementation of NABH5th Ed. in June'2021 – conducted by Quality Council of India
  • Shortlisted Poster Presentation in award category on topic: A Comparative Study of Annual Survey on Patient Safety Culture – conducted in January2021 &2022 - About staff perception of safety initiatives and feedback mechanism in Global Conference6th Edition CAHOCON2022 on “Building Culture of Safety” in March2022
  • Shortlisted Video Presentation in award category on topic: - Celebrating World Patient Safety Day on17th Sep'2021 in Global Conference6th Edition CAHOCON2022 on “Building Culture of Safety” in March2022

Publications

  • Digitization Initiatives Of Hospital Operations In BMC – International Conference SASH2021 on “Technology to Heal: Building Synergies and Affordable Healthcare” in December2021
  • Paper Presentation on topic: Digitization Initiatives Of Hospital Operations In BMC – International Conference SASH2021 on “Technology to Heal: Building Synergies and Affordable Healthcare” in December2021
  • Paper Presentation on topic: BMC – A LEED Certified Green Hospital Building – International E-Conference on “Multidisciplinary Approach for Sustainable Development in September2020
  • NABH Final Assessment of BALCO Medical Centre in Jan2021
  • JCI Survey – Reaccreditation of Medeor Hospitals Dubai in Jan2019 & Initial Survey of Medeor Hospitals Al Ain in Feb2019
  • Speaker in National Nursing Conclave – Quality in Nursing can Redefine Healthcare –11th to12th April2015, Continental Hospitals, Hyderabad
  • Quality Conclave, Conducted by the Core Quality Team of Wockhardt Hospitals Pvt. Ltd –3rd July2013, Mumbai
  • BMC-CANCER CONCLAVE2024 – Annual Cancer Conclave of Chhattisgarh on Choosing Wisely – common sense Oncology, organized on20th to22nd Sep'2024 in Hotel Mayfair Lake Resort, Naya Raipur – Was part of Organizing committee and faculty for the session, “Effective Communications”.
  • BMC-CANCER CONCLAVE2023 – First International Cancer Conclave of Chhattisgarh on Cancer Care Closer to Home – shifting Paradigms, organized on17th &18th June'2023 in Hotel Mayfair Lake Resort, Naya Raipur – Was part of Organizing committee and coordinator of the session, “Patient Navigation Program”.
  • CAHOCON20226th Edition – An Annual Global Conference on Building Culture of Safety in Healthcare on2nd &3rd March2022 in Grand Hyatt, Kochi
  • SASH2020 – An Annual National Conference on Safe & Sustainable Hospitals on21st to23rd Feb2020, organized by AIIMS New Delhi
  • International Patient Experience Summit & Eminence Awards by Fleming. On11th &12th September2019 in Shangri-La Hotel, Dubai
  • AIDET Patient Communication Workshop, Conducted by Studer Group on13th &14th September2018 in Abu Dhabi, UAE
  • Seminar on Infection Control – Challenges Ahead , conducted by CII Institute of Quality – Columbia Asia Hospital Bangalore,29th May2010
  • Awareness program on Accreditation of Medical Imaging Services, organized by Quality Council of India on18th September,2010 at BGS Global Hospitals, Bangalore.
  • Seminar on Hospital Administration on8th April2006 at IMS, DAVV, Indore, M. P
  • MEDRECON-2006, VI Annual National Medical Records Conference at Choithram Hospital & Research Centre, Indore, M. P.
  • CONPAC-2005, National Conference on Hospital Management at Nutan Girls College, Bhopal, M. P.
  • NWBMW-2004, National Workshop on Biomedical Waste Management at Choithram Hospital & Research Centre, Indore, M. P.
  • PRABANDHNAM-2004, National Conference on Hospital Administration at IMS, DAVV, Indore, M. P.

Training

  • BMC-CANCER CONCLAVE2024 – Annual Cancer Conclave of Chhattisgarh on Choosing Wisely – common sense Oncology, organized on20th to22nd Sep'2024 in Hotel Mayfair Lake Resort, Naya Raipur – Was part of Organizing committee and faculty for the session, “Effective Communications”.
  • BMC-CANCER CONCLAVE2023 – First International Cancer Conclave of Chhattisgarh on Cancer Care Closer to Home – shifting Paradigms, organized on17th &18th June'2023 in Hotel Mayfair Lake Resort, Naya Raipur – Was part of Organizing committee and coordinator of the session, “Patient Navigation Program”.
  • CAHOCON20226th Edition – An Annual Global Conference on Building Culture of Safety in Healthcare on2nd &3rd March2022 in Grand Hyatt, Kochi
  • SASH2020 – An Annual National Conference on Safe & Sustainable Hospitals on21st to23rd Feb2020, organized by AIIMS New Delhi
  • International Patient Experience Summit & Eminence Awards by Fleming. On11th &12th September2019 in Shangri-La Hotel, Dubai
  • AIDET Patient Communication Workshop, Conducted by Studer Group on13th &14th September2018 in Abu Dhabi, UAE
  • Quality Conclave, Conducted by the Core Quality Team of Wockhardt Hospitals Pvt. Ltd –3rd July2013, Mumbai
  • Simpler Green Belt certification in Lean Healthcare, Conducted by Quality Council of India and Simpler Healthcare –10th December2010, Bangalore
  • Seminar on Infection Control – Challenges Ahead , conducted by CII Institute of Quality – Columbia Asia Hospital Bangalore,29th May2010
  • Awareness program on Accreditation of Medical Imaging Services, organized by Quality Council of India on18th September,2010 at BGS Global Hospitals, Bangalore.
  • Seminar on Hospital Administration on8th April2006 at IMS, DAVV, Indore, M. P
  • MEDRECON-2006, VI Annual National Medical Records Conference at Choithram Hospital & Research Centre, Indore, M. P.
  • CONPAC-2005, National Conference on Hospital Management at Nutan Girls College, Bhopal, M. P.
  • NWBMW-2004, National Workshop on Biomedical Waste Management at Choithram Hospital & Research Centre, Indore, M. P.
  • PRABANDHNAM-2004, National Conference on Hospital Administration at IMS, DAVV, Indore, M. P.

SUMMARY OF RESPONSIBILITIES

  • Plan, strategize, initiate and implement quality improvement projects in the organization for maintaining accreditation standards.
  • Accreditations: Prepare for and Coordinate International as well as National accreditation activities to accomplish the project with minimal non-conformities.
  • Hospital Visit: To all locations for ensuring compliance to quality parameters.
  • Quality Indicators: Maintenance of Quality Indicators Dashboard, Clinical Parameters and Performance indicators for strategic and managerial purposes.
  • In-depth knowledge of hospital operations and having experience in facility planning and other support areas like Housekeeping, Food Services, Maintenance, Stores, Pharmacy etc.
  • Training & Orientation of staff on hospital processes and work flow.
  • Address patient care issues and challenges of staff are resolved in time by trouble shooting and escalation if required.
  • Act as an identifier of risk involved in the work place, train staff on risk identification, mitigation and precautions for future.
  • Conduct feedback analysis and present the same to all associates for improvement and reward to best performer.
  • Cost analysis and utilization of resources, conduct break even V/s actual study on monthly basis for review meetings

Timeline

AGM – Quality & Administration

Balco Medical Centre, Raipur, a unit of VMRF
11.2019 - Current

Head – Quality Management

Medeor Hospital, Dubai, a unit of VPS Healthcare
04.2018 - 11.2019

Manager – Quality Management

Continental Hospitals, Gachibowli, Hyderabad
04.2014 - 09.2017

Assistant Quality Manager

Wockhardt Hospitals, Corporate Office, BKC, Mumbai
06.2013 - 01.2014

Assistant Operations Manager

Columbia Asia Hospitals, Pune
09.2012 - 05.2013

Assistant Manager, Quality Assurance

Columbia Asia Hospitals, IMO, Bangalore
02.2011 - 09.2012

Assistant Manager, Quality Management

BGS Global Hospitals, Bangalore
11.2009 - 02.2011

Quality Coordinator

Academy of Hospital Administration, Noida
06.2008 - 10.2009

Senior Secondary School - undefined

Sector10, Bhilai, Chhattisgarh

Senior Secondary School - undefined

Sector10, Bhilai, Chhattisgarh
  • Certified Internal Auditor (ISO9001:2015 QMS & ISO14001:2015 EMS), Trained at Ministry of Micro, Small and Medium Enterprise, a GOI Organization
  • NABH Assessor Course – Organized by Quality Council of India, held in Hyderabad on26th July to31st July2017.
  • Simpler Green Belt certification in Lean Healthcare, Conducted by Quality Council of India and Simpler Healthcare –10th December2010, Bangalore

Ph.D. - Quality

Jharkhand Rai University

Post Graduate Certificate - Quality Management & Accreditation of Healthcare Organization

Academy of Hospital Administration, Noida

MBA - Hospital Administration

Institute of Management Studies, Devi Ahilyabai University

BBA - Hospital Administration

Institute of Management Studies, Devi Ahilyabai University
Shubhangi Chandrakar