- Quality Management System Develop, implement, and maintain the hospital''s Quality Management System (QMS).
- Ensure compliance with NABH, NABL, and other applicable healthcare quality standards.
- Review and update hospital policies, SOPs, protocols, and quality manuals.
- Monitor adherence to quality indicators and patient safety goals.
- Accreditation & Compliance Lead NABH accreditation and surveillance activities.
- Coordinate departmental compliance with accreditation standards.
- Ensure compliance with statutory and regulatory requirements.
- Prepare the hospital for internal and external quality audits.
- Clinical Quality & Patient Safety Monitor clinical quality indicators and patient safety metrics.
- Conduct root cause analysis (RCA) for incidents, adverse events, and sentinel events.
- Implement corrective and preventive actions (CAPA).
- Promote infection control, medication safety, and risk management initiatives.
- Audit & Continuous Improvement Plan and conduct internal quality audits across departments.
- Analyze audit findings and ensure timely closure of non-conformities.
- Drive quality improvement projects using quality tools and methodologies.
- Monitor departmental KPIs and recommend process improvements.
- Training & Awareness Conduct quality induction and ongoing training programs for hospital staff.
- Create awareness regarding quality standards, patient safety, and accreditation requirements.
- Support departments in implementing best healthcare practices.
- Documentation & Reporting Maintain quality documentation, audit reports, and accreditation records.
- Prepare monthly quality dashboards, MIS reports, and management review presentations.
- Track quality indicators and present improvement plans to senior management.
- Team Coordination Coordinate with medical, nursing, administrative, and support departments.
- Facilitate quality committee meetings and follow up on action plans.
- Encourage a culture of continuous quality improvement throughout the organization