The NABH Compliance Officer is responsible for ensuring that the hospital continuously complies with the latest NABH Accreditation Standards, statutory requirements, and internal quality policies. The officer coordinates with all clinical and non-clinical departments to implement quality improvement initiatives, maintain documentation, conduct audits, monitor corrective actions, and support successful NABH accreditation and surveillance assessments. The role focuses on sustaining patient safety, legal compliance, and continuous quality improvement across the hospital. (NABH)
Key Responsibilities
1. NABH Compliance
- Ensure implementation of all NABH Standards throughout the hospital.
- Monitor compliance with patient-centered and organization-centered standards.
- Conduct regular departmental compliance rounds.
- Prepare departments for NABH assessments and surveillance visits.
- Maintain evidence of compliance.
2. Documentation Management
- Develop, review, and update:
- Policies
- SOPs
- Manuals
- Forms
- Registers
- Checklists
- Ensure document control as per hospital policy.
- Maintain department-wise master files.
3. Internal Audits
- Plan and conduct internal NABH audits.
- Prepare audit reports.
- Identify non-conformities.
- Monitor Corrective and Preventive Actions (CAPA).
- Verify closure of audit observations.