The Quality Manager is responsible for overseeing and ensuring the highest standards of quality within the hospital. This role involves developing and revising hospital-wide policies, conducting audits, and managing quality improvement initiatives.

The Quality Manager will work closely with various departments to maintain compliance with NABH requirements and enhance patient care and staff performance.

Policy Development and Legal Compliance:

- Develop and maintain hospital-wide policies.
- Regularly revise quality manuals and policies, ensuring they are collected, stored, and documented appropriately.
- Review and inform relevant authorities regarding changes or renewals of legal licenses or MOUs.

Auditing, Monitoring, and Quality Indicators:

- Conduct frequent audits and checks for ward rounds and file management systems as per NABH requirements.
- Collect, compile, verify, correct, and present quality indicators.
- Regularly analyze OPD and IPD patient feedback reports and report findings to the AGM.
- Conduct prescription audits and prepare reports.
- Conduct mock NABH audits and submit reports on findings and recommendations. Meetings, Training, and Awareness:
- Schedule and conduct meetings, preparing minutes of meetings (MOM).
- Conduct training classes or awareness programs for all employees with the support of HR and nursing teams.
- Organize official meetings and training sessions related to quality policies and standards.




- Coordinate and direct all types of color code mock drills as per schedule and requirement norms.

Patient and Employee Satisfaction:

- Conduct patient satisfaction surveys and review reports to take corrective actions.
- Participate in performance evaluations and employee satisfaction surveys.
- Observe and manage the skill matrix and skillset evaluation process.

Quality Improvement Initiatives:

- Undertake quality initiatives and risk management activities.
- Consult with administrative and medical staff, department heads, and committees to advance organizational goals.
- Lead and advise team members to fulfill their roles in the quality team.
- Ensure quality improvement and innovation work focuses on patient-centeredness, staff vitality, process efficiency, waste reduction, and secure patient care.

Documentation and Compliance:

- Maintain the confidentiality and privacy of departmental information.
- Document, verify, conduct root cause analysis (RCA), and prepare corrective and preventive actions (CAPA) for incident reporting, blood and component usage, wastage, and TAT of labs, radiology, blood bank, etc.
- Regularly review all NABH registers across departments.
- Ensure the implementation of all NABH forms and formats in respective areas as required.
- Conduct monthly facility inspection rounds and ensure the implementation of findings.
- Complete tasks assigned by the AGM/Quality Head within the defined timeframe and report appropriately.

📌 Quality Manager (Bhopal)
🏢 Peoples Hospital
📍 Bhopal