Key Responsibilities

A. NABH Compliance

1. Monitor compliance with applicable NABH standards across clinical, nursing, diagnostic and support departments.
2. Assist in implementation and monitoring of hospital policies, procedures, SOPs and quality protocols.
3. Maintain department-wise NABH compliance records and evidence.
4. Coordinate with respective HODs for closure of identified gaps and non-conformities.
5. Support preparation for NABH surveillance, reassessment and other external assessments.
6. Ensure timely availability and proper maintenance of documents and records required for accreditation.

B. Quality Audits
1. Prepare and conduct internal quality audits as per the approved audit plan.
2. Conduct departmental rounds and identify deviations from approved SOPs and standards.
3. Verify compliance with clinical and administrative processes through document review, observation and staff interaction.
4. Prepare audit reports and communicate observations to concerned departments.
5. Follow up with departments for timely closure of audit findings.

C. Quality Indicators & Data Monitoring
1. Collect, validate, compile and analyse hospital quality indicators.
2. Monitor indicators relating to:

- Patient safety
- Medication errors
- Patient falls
- Pressure injuries
- Hospital-acquired infections
- Hand hygiene compliance
- Clinical documentation
- Patient waiting time
- Discharge turnaround time
- Patient complaints
- Mortality and morbidity
- Readmission / unplanned return, wherever applicable
- Incident reporting

1. Prepare monthly Quality Dashboard / MIS for management review.
2. Identify trends, deviations and areas requiring corrective or preventive action.

D. Incident Reporting & Patient Safety
1. Monitor reporting of clinical and non-clinical incidents.
2. Maintain the Incident / Near-Miss / Sentinel Event records.
3.



Assist in investigation of incidents and preparation of Root Cause Analysis (RCA).
4. Coordinate preparation and implementation of Corrective and Preventive Action (CAPA).
5. Monitor effectiveness of CAPA and ensure timely closure.
6. Escalate critical patient safety concerns to the Quality Head / Hospital Management immediately.

E. Infection Control & Patient Safety Coordination
1. Coordinate with the Infection Control Team for monitoring of relevant quality indicators.
2. Support audits relating to hand hygiene, biomedical waste management, sterilization, isolation practices and infection prevention measures.
3. Assist in monitoring compliance with patient identification, medication safety, surgical safety and other patient-safety practices.
4. Participate in patient safety initiatives and awareness programmes.

F. Documentation & Record Management
1. Maintain the Quality Department's master records, audit reports, CAPA records, quality indicators and committee records.
2. Ensure controlled circulation and availability of approved policies, SOPs and formats.
3. Maintain records of document revisions, review dates and approvals.
4. Ensure quality-related documents are properly indexed, traceable and readily retrievable.
5. Coordinate with departments for timely review and revision of documents.

G. Training & Quality Awareness
1. Assist in conducting quality and NABH awareness programmes for employees.
2.



Coordinate induction / orientation sessions relating to quality and patient safety.
3. Maintain training attendance and competency-related records.
4. Create awareness among staff regarding hospital policies, SOPs and patient safety practices.

H. Patient Feedback & Grievance Monitoring
1. Monitor patient feedback and satisfaction survey processes.
2. Analyse complaints, suggestions and feedback received from patients and attendants.
3. Identify recurring issues and coordinate with concerned departments for corrective action.
4. Prepare periodic feedback analysis for management review.

I. Quality Committee Coordination
1. Coordinate meetings of Quality / Patient Safety / relevant quality committees as assigned.
2. Prepare meeting agenda, minutes and action trackers.
3. Follow up with concerned departments for closure of action points.
4. Maintain committee records and supporting documentation.

J. Management Reporting
1. Prepare monthly / quarterly Quality MIS.
2. Present significant quality observations, audit findings and CAPA status to the Quality Head.
3. Highlight recurring non-compliances and high-risk areas requiring management intervention.
4. Support management in implementing continuous quality improvement initiatives.

5. Key Deliverables / KRAs

- NABH compliance monitoring and evidence readiness.
- Completion of planned internal audits within defined timelines.
- Timely closure of audit observations and CAPA.
- Accurate and timely submission of quality indicators.
- Reduction in recurring non-conformities.
- Improvement in patient safety indicators.
- Timely incident investigation and RCA.

- Maintenance of complete and updated quality documentation.
- Effective coordination of quality committee activities.
- Readiness of departments for NABH assessments and internal inspections.

📌 Quality Assurance Executive (Mumbai)
🏢 Shalby Hospitals
📍 Mumbai