ACCREDITATION MANAGER

Position: Hospital Quality & Accreditation Manager
Department: Quality / Accreditation
Reporting To: Medical Director / Hospital Administration
Location: Vadodara, Gujarat

Key Responsibilities
- Lead and coordinate the hospital’s NABH 6th Edition accreditation and compliance activities.
- Develop, implement and monitor quality policies, SOPs, protocols, manuals and quality indicators.
- Coordinate with all clinical and non-clinical departments to ensure compliance with NABH standards.
- Conduct regular internal audits, departmental audits, tracer activities and compliance assessments.
- Monitor and analyse Quality Indicators (QI), Patient Safety Indicators and departmental performance data.
- Identify gaps, prepare Corrective and Preventive Action (CAPA) plans and monitor their closure.
- Coordinate incident reporting, adverse events, near-miss reporting and root cause analysis (RCA).
- Maintain and update all NABH accreditation records, documents, registers and evidence required for assessment.




- Conduct training and awareness sessions for employees regarding NABH standards, patient safety, quality and hospital policies.
- Monitor compliance with patient safety goals, infection prevention, medication safety, biomedical waste and other quality requirements.
- Coordinate NABH assessments, surveillance visits and external audits, including preparation of required documentation.
- Prepare and present quality reports, audit findings, QI trends and compliance status to management and relevant committees.
- Ensure effective functioning and documentation of quality-related hospital committees and meetings.
- Promote continuous quality improvement, risk management and patient safety culture throughout the hospital.
- Maintain confidentiality, skilled ethics and compliance with applicable legal, statutory and regulatory requirements.
- Strong knowledge of NABH 6th Edition standards and accreditation requirements.
- Experience in hospital quality

📌 Hospital Quality (Vadodara)
🏢 SWAJAN BANKERS
📍 Vadodara