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
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.
Documentation Management
Develop, review, and update:
Policies
SOPs
Manuals
Forms
Registers
Checklists
Ensure document control as per hospital policy.
Maintain department-wise master files.
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.
Quality Indicators
Collect departmental quality indicators.
Analyze trends.
Prepare monthly quality reports.
Present findings to Quality Committee and Management.
Patient Safety
Promote patient safety initiatives.
Monitor:
Incident reporting
Near misses
Sentinel events
Medication errors
Falls
Pressure injuries
Ensure root cause analysis (RCA) and action plans.
Committee Coordination
Coordinate meetings and documentation for:
Quality Committee
Infection Control Committee
Safety Committee
Biomedical Waste Committee
Antibiotic Stewardship Committee
Mortality & Morbidity Committee
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