Sumithra Gopalakrishna Pillai

Quality Management Manager at Specialized Medical Center

• India
• My current job since March 2018

Quality Management Specialist at Specialized Medical Center

• September 2015 to February 2018

Nurse

• September 2007 to September 2010

Quality Improvement

Nursing supervisor

• India
• January 2006 to August 2007

staff Nurse

• January 2004 to January 2006

14. Laboratory Team
15. Diagnostic & Imaging Team
 Managing /supervising risk management program - Incident reporting.
 Coordinating/collaborating Patients Complaints handling, Patient Satisfaction Survey, and Employee
Satisfaction Survey

Arabia

• to

Assist in the National (Central Board Accreditation for Heath Care Institution) Accreditation process and
achieved the accreditation with remarkable compliance.
2. Achieved excellent remarks (Diamond) during Third Cycle Accreditation Canada International
Accreditation Survey April 2015
3. Assisted the Department Director in last two cycles of Accreditation Canada Surveys
CURRICULUM VITAE

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4. Participated in Aramco Mock Survey-2013
5. Conducted Clinical and Non Clinical Audit as Hospsitalwide
6. Active Involvement and Patient Safety Programs, Required Organizational Practices and Essential
Safety Requirements
7. Membership in all the Medical and Non Clinical Committees
8. Organized Workshops, courses and symposium for quality improvement, Patient Safety and Risk
Management and provided training to the department quality management coordinators.
9. Developed data entry application software for all the patient safety programs and Organizational
practices
10. Developed Hospital wide Leadership Performance Dashboard and Balance Score Card
11. Assisted other department to develop Departmental Dashboard and Balance Score Cards.
Current Responsibilities
1. Manages the annual development, review, revision, implementation, and evaluation of the
Integrated Quality Management (IQM)Plan and Program to maintain adequacy, effectiveness
and continuous stability.
2. Provides support to the Quality Management Committee (QMC) and Leadership in developing
the IQM Program, goals, objectives, and targets in line with the organization Strategic Pillars
and in keeping with the Mission, Vision and Core Values.
3. Manages all documents pertinent to the IQM Plan and Program (i.e. identifying the needs for,
planning, developing, reviewing, revising and updating of hospital-wide and departmental
policies, procedures, guidelines, protocols, plans, etc. as per the Saudi Central Board for
Accreditation of Healthcare Institutions (CBAHI) and international standards and ensures all
policies, procedures, protocols, plans, forms and manuals are standardized, authorized,
approved and maintained across the organization.
4. Plans and organizes internal clinical audit activities (i.e. policies, patient safety program
initiatives such as the Essential Safety Requirements, and other national and international
patient safety initiatives, quality reviews (i.e. medical records review, surgical review, morbidity
and mortality, laboratory safety, etc.), clinical practice guidelines, other high volume, problem-
prone, high risk, and high cost processes, as well as for the relevant medical necessity within
CURRICULUM VITAE

at fiscal

• India
• to

the organization to ensure continuous compliance with local, national and international
standards and other regulatory requirements.
5. Proactively identifies and implements key performance indicators (KPIs) and measures to drive
performance improvement; collaborates with the Leadership to identify, establish and implement
a process for selecting criteria and monitoring data for quality indicators according to Saudi
CBAHI standards to monitor and evaluate clinical care, quality, safety and services.
6. Coordinates the organizational data collection, analysis, interpretation, reporting and
management requirements (i.e. KPIs and measures, performance dashboard, etc.) for quality
IQM Program with the department quality management coordinators, data analyst/statistician,
and department/service heads
7. Oversees statistical information relevant to IQM is collected consistently and that the information
is accurately reported within the specified time frames.
8. Ensures compliance with the stakeholders’ requirements, IQM policies, local, national and
international IQM standards as well as relevant laws, rules and regulations of the Kingdom of
Saudi Arabia.
9. Ensures communication of IQM program initiatives, activities, and results to the
departments/services, committees, staff and other relevant groups to be used as the basis for
improving the organization processes and systems.
10. Identifies and designs appropriate organization-wide and department education and training
programs for IQM; develops and implements a recognition program related to IQM for individual
staff, quality improvement and patient safety teams, and departments/services.
11. Conducts new employee and medical interns orientation, in-service and annual staff education
and training related to IQM theories, concepts, principles, standards, policies, procedures,
processes systems, and staff roles and responsibilities related to the IQM activities.
12. Performs managerial and supervisory responsibilities in accordance with the organization’s
policies and applicable laws such as developing department structure, mission, vision, core
values, goals and objectives; managing the department policies, procedures, functions and
activities; reviewing job descriptions of each staff in conjunction with the QMD Director;
developing and managing the budget for staffing and capital expenses, controlling costs;
planning, scheduling and changing procedures for the department through sound

Director

• to

coaching, mentoring staff and on-the-job trainees; planning, assigning, managing, and
scheduling work assignments; scheduling of staff, appraising performance, developing
individual career path and goals; rewarding, counseling and disciplining staff; addressing
complaints and resolving conflicts and problems; making recommendations to the QM Director
on employment, promotions, corrective disciplinary actions, and other staff activities in order to
maintain an efficient and effective department.
13. Attends and actively participates in intra/interdepartmental and organization committee
meetings as assigned.
14. Attends trainings, workshop, seminars, and conferences/symposium that are IQM specific both
internal and external for the purpose of conveying and gathering information required to perform
functions and disseminate information from trainings to appropriate staff.
15. Performs additional responsibilities or any projects as assigned by the Quality Management