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.
Solid knowledge of NABH 6th Edition standards and accreditation requirements.
Experience in hospital quality management and accreditation.
Knowledge of quality indicators, internal audits, RCA, CAPA and risk management.
Valuable documentation, analytical, communication and coordination skills.
Proficiency in MS Office/Excel and quality data analysis.
Ability to coordinate effectively with clinical, nursing, administrative and support departments.

Pay: ₹11,991.38 - ₹48,071.86 per month

Work Location: In person

📌 Hospital Quality & Accreditation Manager – Nabh 6th Edition Vadodara
🏢 SWAJAN BANKERS
📍 Vadodara