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Urgent Hiring - Quality Manager (NABH & Accreditation)

Location: Tezpur, Assam

Hospital Type: Multi-Speciality Hospital

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Position

Quality Manager - NABH & Accreditation

Qualification

Masters Degree in Hospital Administration (MHA), Hospital Management (MHM), Healthcare Quality, Nursing, or a related Healthcare Discipline

Certification/Formal Training in NABH Quality Management - Preferred

Six Sigma, Lean Healthcare, or Patient Safety Certification - Added Advantage

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Experience

Minimum 5-8 Years of experience in Hospital Quality Management

At least 3 Years of Hands-on Experience managing NABH Accreditation activities

Experience in policy formulation, quality audits, documentation, and regulatory compliance is mandatory

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Key Responsibilities

NABH Accreditation & Compliance

Lead and coordinate NABH Entry Level, Progressive Level, Full Accreditation, and renewal activities

Ensure continuous compliance with NABH standards and statutory regulations

Coordinate internal and external NABH assessments and CAPA implementation

Quality Management System (QMS)

Develop, implement, monitor, and continuously improve the Hospital Quality Management System

Monitor quality indicators, dashboards, and Continuous Quality Improvement (CQI) initiatives

Policies, SOPs & Documentation

Develop, review, standardize, and maintain hospital policies, SOPs, manuals, protocols, and quality documentation

Ensure proper document control and periodic revisions

Internal Audits & Compliance

Conduct quality audits across all departments

Identify non-conformities and ensure timely corrective and preventive actions (CAPA)

Patient Safety & Risk Management

Implement patient safety goals, incident reporting, Root Cause Analysis (RCA), and risk mitigation strategies

Promote a culture of patient safety throughout the organization

Clinical Quality Monitoring

Monitor clinical, nursing, laboratory, pharmacy, and support service quality indicators

Prepare monthly quality reports and recommend improvement initiatives





Infection Prevention & Control

Coordinate with the Infection Control Team to ensure compliance with infection prevention protocols and quality standards

Training & Staff Development

Conduct induction programs and regular NABH, Quality, and Patient Safety training sessions for hospital staff

Regulatory Compliance

Ensure compliance with healthcare laws, Biomedical Waste Management Rules, Fire Safety regulations, and other statutory requirements

Patient Experience

Monitor patient feedback, complaints, and satisfaction scores, and implement quality improvement initiatives

Committee Coordination & Reporting

Coordinate Quality Committee meetings, prepare reports, monitor action plans, and present quality performance to hospital leadership

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Required Skills

Thorough knowledge of NABH standards and accreditation processes

Strong understanding of Hospital Quality Management Systems

Expertise in documentation, SOP drafting, audits, RCA, and CAPA

Excellent analytical, leadership, communication, and training skills

Strong organizational and problem-solving abilities

Proficiency in Microsoft Office and Hospital Information Systems (HIS)

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Key Performance Indicators (KPIs)

Continuous NABH compliance across all departments

Successful NABH Accreditation and Surveillance Audits

Timely completion of internal audits and CAPA closures

Improvement in quality indicators and patient safety outcomes

High staff training compliance

Improved patient satisfaction scores

Zero major regulatory non-conformities

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Job Type

Full-Time

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Salary

Best in Industry (Negotiable based on qualification and experience)

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Benefits

Opportunity to lead Quality & NABH Accreditation for a growing multi-speciality hospital

Professional growth in hospital quality leadership

Supportive management and multidisciplinary clinical workplace

Long-term career development opportunities

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Interested candidates may share their updated CV along with current salary, expected salary, notice period, and details of NABH accreditation projects handled. Immediate joiners will be preferred.

📌 Quality Manager (NABH & Accreditation) (Assam)
🏢 Medico Hub
📍 Assam