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ann susan james valiyakalayil

@annsusanjamesvaliyak

Hospital quality professional at Medicover Hospital who achieved NABH accreditation and raised audit compliance from 70% to 95%.

India

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At Medicover Hospital, I led the rollout of a hospital-wide Quality Management System, raising internal audit compliance from 70% to 95%. I also managed cross-functional documentation and process standardization for successful NABH accreditation.

I conducted internal audits and safety rounds, revised more than 100 SOPs and policies, and used Root Cause Analysis and Corrective and Preventive Action protocols to reduce NCR frequency by 45%.

Earlier, as a Quality Management Trainee at Fortis Escorts Hospital, I worked on quality audits and dashboards for clinical quality indicators. At Christian Medical College, Vellore, I delivered dialysis care and maintained services during COVID-19 conditions while following infection-control and PPE protocols.

Experience

Work history, roles, and key accomplishments

Associate – Quality Management

Medicover Hospital

Sep 2024 - Jul 2025 (10 months)

Led the design and rollout of a hospital-wide Quality Management System (QMS), driving internal audit compliance from 70% to 95% within one year. Orchestrated successful NABH accreditation in just 6 months by managing cross-functional documentation and process standardization across 10+ departments.

Quality Management Systems NABH Standards Internal Audit Root Cause Analysis CAPA SOP Development Risk Management Incident Management Excel Microsoft Office

Quality Management Trainee

Fortis Escorts Hospital

Jan 2024 - May 2024 (4 months)

Led 15+ comprehensive quality audits across clinical and operational departments, using NABH checklists to assess compliance, identify documentation gaps, and implement corrective actions—resulting in a 60% improvement in documentation accuracy and audit readiness. Designed and deployed internal quality dashboards to monitor clinical quality indicators (CQIs), infection control KPIs, and incident

Quality Audits NABH Standards Documentation Dashboarding Nursing Quality Indicators Infection Control Training CAPA Excel

Dialysis Technologist

Christian Medical College

Jan 2020 - Jan 2022 (2 years)

Delivered specialized dialysis care to 100+ critically ill patients per month across general wards and intensive care units (ICUs), ensuring continuity of life-sustaining treatment with strict adherence to infection control protocols. Maintained uninterrupted dialysis services during high-pressure COVID-19 conditions, strictly enforcing PPE protocols and safety measures, resulting in zero safety o

Dialysis Care Infection Control Patient Safety ICU COVID 19 Protocols PPEs