ITHYAP PRIYA

• Promoted to lead both Quality Assurance and Medical Affairs, with expanded responsibilities that now influence hospital operations across the Aurelius Group. Recognized as the go-to reference for quality and medical governance, despite the absence of a formal Group QA/MA lead.
• Strategic Leadership & Cross-Hospital Support
  Reports directly to the Medical Director and CEO, actively participating in senior leadership discussions, hospital-wide planning, and high-level implementation strategies.
  Provided support to other group hospitals, including:
  
  *Aurelius Hospital Alor Setar– assisted in initial licensing preparation.
  *Aurelius Hospital Pahang – conducted cross-hospital quality audits, followed up on closure of findings.
• Leading hospital preparation for MSQH 2nd Cycle Accreditation:
  
  *Conducted self-assessment training for HODs.
  *Summarized gap analyses for MSQH surveyor engagement.
  *Coordinated 24-month report submission, including closure of prior cycle finding JCI & Regulatory Compliance.
• Key member of JCI reaccreditation task force, ensuring compliance across internal and outsourced services:

*Performed site audits and compliance reviews for outsourced services (lab, kitchen, housekeeping, laundry) to meet JCI requirements.

• Oversaw internal compliance through regular audits:
  
  *IPSG audits, active & closed medical records audit, ISO SIRIM internal audits, and other ad hoc audits requested by senior management.
• Patient Safety, RCA & Complaint Management
  Personally managed patient complaints:

*Conducted internal investigations, chaired RCA meetings, and advised senior management on resolution and preventive measures.

• Prepared management reports to guide how complaints should be closed in alignment with safety and patient experience expectations.
• Successfully led hospital-wide fall prevention and IPSG compliance projects, contributing to reduced patient incidents.
  
  Data, Performance Monitoring & Cost Reduction Initiatives
• Oversight of the entire Performance Indicator (PI) framework:
  
  *Continuous monitoring, updating, and benchmarking of hospital-wide indicators.
  Revised or added new PIs when targets were consistently met.
• Led monthly Balanced Scorecard (BSC) reporting and issued management alerts for underperformance.
• Delivered a cost-reduction project in clinical waste, successfully lowering operational costs through process optimization.
• Introduced new QIPs (Quality Improvement Projects) driven by data insights from QPS meetings and trend analysis.
• Medical Affairs & Clinical Governance
• Full responsibility over Medical Affairs operations:

*Oversaw doctor credentialing & privileging, yearly evaluations, CME planning, and service agreement preparation.

*Assisted doctors with e-invoicing processes and documentation compliance.

• Organized and led:
  
  *2 QPS meetings – highly praised for converting complex data into actionable improvements.

*1 MAC meeting and multiple M&M meetings– led RCA development and presentations, many of which were recognized by the Medical Director for referencing international best practices.

• Continues to serve as secretary to QPS, M&M, MAC, and C&P subcommittees, supporting governance and compliance efforts.

Key Achievements:

• Closed all JCI Initial Survey findings within 4 months and led the hospital through successful Focused Survey.
• Recognized by senior leadership for strong multitasking, cross-functional leadership, and problem-solving under pressure.
• Played a major role in group-level strategic projects, accreditation readiness, and cost-effective clinical operations.
• Led a team of healthcare professionals in delivering high-quality patient care, ensuring compliance with hospital protocols and regulatory standards.

• Promoted to Acting Manager, entrusted with leadership of both Quality Assurance and Medical Affairs during the hospital’s most critical phase: the JCI Focused Survey.
• Successfully closed all non-conformities identified in the Initial Survey within the 4-month deadline, meeting all JCI standards ahead of the Focused Survey.
• Demonstrated high-level multitasking and decision-making while managing two core departments under tight timelines.
• Led weekly high-level briefings with senior management to report survey readiness, action plans, and indicator outcomes.
• Oversaw a full revision of hospital-wide Performance Indicators (PIs) based on JCI and AHRQ guidelines, including:
  
• Data validation processes
  * Setting realistic benchmarks
  * Department-specific monitoring tools
  
• Extended responsibility to Medical Affairs, including:
  
  * Doctors’ credentialing and privileging (C&P)
  * Annual doctor evaluation tracking
  * Organizing CME programs
  * Supporting medical recruitment and compliance
  * Serving as secretary to QPS, M&M, C&P, and MAC committees
  * Recognized for a solution-focused, positive approach, driving dual departmental excellence under pressure.

• Provided comprehensive training to clinical staff on patient safety related topics such as IPSG, cardiac arrest management , stroke management and CPG compliances . .
• Enhanced patient safety by implementing stringent inspection processes and identifying areas for improvement.
• Monitored performance metrics closely and provided timely feedback to staff on areas requiring attention or improvement, promoting a culture of continuous learning and development.
• Ensured compliance with healthcare regulations such as MSQH and JCI by staying abreast of updates and making necessary adjustments within the organization''s systems accordingly.
• Managed documentation related to quality control procedures, maintaining an organized repository for easy access during internal audits or inspections by regulatory authorities.
• Identified root causes of recurring issues through detailed analysis, working closely with relevant teams to implement corrective actions swiftly.
• Conducted risk assessments to identify and mitigate potential quality issues
• Led and managed the implementation of JCI accreditation projects, ensuring adherence to international healthcare quality standards.
• Coordinated with cross-functional teams including healthcare professionals, administrators, and external consultants to achieve project milestones.
• Developed and maintained project plans, timelines, and budgets, ensuring efficient resource allocation and timely project delivery.
• Conducted gap analyses and risk assessments to identify areas of improvement in healthcare delivery and patient safety.
• Designed and implemented training programs for staff to promote compliance with JCI standards.
• Prepared detailed reports and presentations for senior management and regulatory bodies, documenting progress, challenges, and outcomes.
• Facilitated continuous quality improvement initiatives, fostering a culture of excellence and patient-centered care.
• Work closely with senior team when opening a new hospital under same management in monitoring and evaluate the hospital’s compliance with CKAP standards, implementing corrective actions as needed especially in creating policies and train staff according to the new policies .
• Compile detailed reports and presentations for senior management, outlining progress, compliance status, and areas for improvement
• Successfully work with the senior team and guided the hospital through the initial CKAP accreditation, .
• Implemented robust quality assurance and patient safety protocols, resulting in
• Recognized by senior management for exemplary leadership and in-depth knowledge of CKAP standards
• Conducted comprehensive gap analyses and regular audits at sister hospitals under the same management to ensure compliance with healthcare standards and regulations.
• Identified areas of non-compliance and potential risks, documenting findings in detailed audit reports.
• Collaborated with hospital staff and management to develop and implement corrective action plans to address identified gaps.
• Monitored the progress of corrective actions and provided ongoing support to ensure sustained compliance.
• Designed and conducted training sessions for hospital staff to educate them on compliance requirements and best practices.
• Prepared and presented audit findings and improvement recommendations to senior management and other stakeholders.
• Developed and maintained audit schedules and documentation to track compliance activities and outcomes.
• Ensured continuous improvement by staying updated with the latest regulations and industry standards, incorporating them into audit practice
• Regularly involved in Code Blue Drill and Stroke drill , using my knowledge on ACLS to guide team on how to manager cardiac arrest and stroke patient .

• Conducted both medical and non medical based training from a certified association
• Managed trainers’ schedules.
• Involved in store upkeep.
• Handled medical device and training equipment purchases
• Handled customised client requests for specific training.
• Created a new lesson plan and a new course according to specific guidelines
• Handled multiple new projects, including overseas training.
• Answered client requests and planned training according to their needs.
• Managed overall staff attendance and ethics.
• Directly reported to the training director regarding issues in training.
• Worked independently without the director's supervision.
• Prepared exam papers, notes, and other training materials needed for training in a short period of time.
• Created realistic models for real patient simulations and hands-on practical sessions.
• Arranged monthly meeting with other trainers and prepared the meeting agenda.
• Hired, trained, evaluated and retained high-performing, effective and diverse team embodying organizational culture.
• Developed highly effective working relationships with other departments by being positive and constructive leader.
• Increased customer satisfaction and streamlined business processes and procedures.
• Led organizational development changes, enabling organization to better respond and adapt to industry and market changes.
• Accomplished leader, skilled at maximizing employees skills and knowledge, to achieve highest performance goals.
• Served as strategic advisor and functional expert on critical strategic and operational matters.
• Led employees to develop high-performing diverse teams and deliver on ambitious goals and objectives.
• Monitored outcome measures, program outcomes and performance improvement.
• Handled overall room upkeep and incident reporting.
• Trained and delegated jobs to junior trainers.
• Experienced in giving public talks to multiple giant companies.
• Create and design power point presentation according to the topic given

• Completed patient referrals to other medical specialists.
• Improved patient outcomes and delivery of care through improved clinical quality processes.
• Confirmed consistent and accurate medical record keeping practices.
• Liaised with other healthcare professionals to develop comprehensive patient care plans and provide highest quality of care.
  
• Performed intramuscular, intravenous and intraosseous injection techniques.
• Oversaw day-to-day practice functions, patient care, medical and administrative staff and business activities.
• Communicated with patients with compassion while keeping medical information private.

• Gave one-on-one attention to children while maintaining overall focus on entire group.
• Addressed behavioral and learning issues with parents and daycare management.

• Increased brand awareness through event marketing, demonstrations, sales, and brand promotion.