1. Job Purpose To provide strategic leadership and governance for all medical services across the hospital, ensuring excellence in clinical operations, patient safety, quality outcomes, consultant engagement, accreditation compliance, regulatory adherence, and medical workforce management.

The role acts as a key interface between the medical fraternity and hospital leadership while driving operational efficiency, clinical quality, risk management, and continuous improvement initiatives in alignment with organizational objectives.

2. Key Accountabilities

A. Medical Administration & Clinical Governance

- Lead medical administration functions across all clinical departments.
- Drive implementation and monitoring of clinical governance frameworks.
- Ensure adherence to evidence-based clinical practices and hospital protocols.
- Chair and coordinate clinical governance forums, MRM/MRC meetings, mortality reviews, and multidisciplinary committees.
- Collaborate with clinical leadership to improve patient outcomes and operational performance.

Key Deliverables
- Clinical Governance Dashboard
- Departmental Compliance Reviews
- Medical Committee Effectiveness
- Clinical Outcome Monitoring

B. Consultant Engagement, Credentialing & Medical Staff Governance
- Oversee consultant onboarding, credentialing, privileging, re-privileging, and contract compliance.
- Develop robust medical staff governance processes.
- Lead consultant engagement initiatives and resolution of professional concerns.
- Ensure optimal consultant coverage across specialties and services.
- Manage consultant performance review mechanisms aligned with quality indicators.

Key Deliverables
- 100% Credentialing Compliance
- Consultant Retention & Satisfaction
- Privileging Compliance
- Optimized Clinical Coverage

C. Clinical Operations Leadership
- Direct and monitor operational performance of OPD, IPD, Emergency, Critical Care, OT, and specialized clinical services.
- Ensure coordination between Doctors, Nursing, Operations, Diagnostics, Pharmacy, and Support Services.
- Drive initiatives for clinical throughput, patient flow, and length-of-stay optimization.
- Lead responses to operational escalations impacting patient care.

Key Deliverables
- Improved Patient Flow




- Reduced Clinical Delays
- Enhanced Resource Utilization
- Optimized Bed Management

D. Quality, Accreditation & Clinical Excellence
- Lead NABH, JCI, ISO, and other accreditation initiatives.
- Establish organization-wide clinical quality improvement programs.
- Monitor compliance with standards related to patient care, documentation, infection control, medication safety, and clinical pathways.
- Ensure effective CAPA implementation and closure.

Key Deliverables
- Successful Accreditation Audits
- CAPA Closure Rate >95%
- Improvement in Quality Metrics
- Reduction in Non-Conformities

E. Patient Safety & Clinical Risk Management
- Lead hospital-wide patient safety programs.
- Oversee incident reporting systems and Root Cause Analysis (RCA).
- Monitor sentinel events, near misses, and adverse incidents.
- Drive safety culture initiatives and risk mitigation programs.
- Ensure preparedness for emergencies including Code Blue, Code Red, Mass Casualty, and Disaster Management.

Key Deliverables
- Reduction in Preventable Clinical Incidents
- Timely Incident Closure
- Patient Safety Compliance
- Risk Mitigation Programs

F. Medical Workforce Planning & Development
- Lead workforce planning for RMOs, Registrars, Residents, Clinical Fellows, and Medical Officers.
- Ensure optimum staffing levels and clinical coverage.
- Drive doctor competency development, training, and performance assessments.
- Partner with HR for recruitment and retention of medical professionals.

Key Deliverables
- Workforce Productivity
- Doctor Retention
- Competency Compliance
- Succession Planning

G. Regulatory & Statutory Compliance Ensure compliance with all applicable regulations:
- NABH/JCI standards
- Biomedical Waste Management
- PNDT Act
- AERB Regulations
- Clinical Establishments Act
- Drug & Cosmetics Act
- Fire & Safety Regulations




- Medical Records Regulations
- Bioethics & Consent Requirements

Key Deliverables
- Zero Major Regulatory Non-Compliance
- Successful External Inspections
- Audit Readiness

H. Clinical Analytics & Performance Management
- Establish and monitor hospital-wide clinical KPIs.
- Analyze trends in mortality, morbidity, infection rates, readmissions, clinical incidents, LOS, and quality indicators.
- Present actionable recommendations to leadership.
- Develop dashboards and executive reports for management review.

Key Deliverables
- Executive Clinical Dashboard
- Quality Improvement Insights
- Data-Driven Decision Making

I. Strategic Projects & Service Development
- Support introduction of recent specialties and clinical programs.
- Drive digital transformation initiatives related to HIS, EMR, and clinical automation.
- Participate in capacity planning and service expansion projects.
- Lead cross-functional improvement initiatives.

Key Deliverables
- Successful Clinical Projects
- Service Line Growth
- Technology Adoption
- Process Innovation

3. Competencies

Core Leadership Competencies

- Strategic Thinking
- Leadership & People Development
- Stakeholder Management
- Business Acumen
- Decision Making
- Change Management
- Executive Communication
- Conflict Resolution

Functional Competencies
- Medical Administration
- Clinical Governance
- Hospital Operations
- NABH/JCI Accreditation
- Consultant Management
- Patient Safety & Risk Management
- Regulatory Compliance
- Clinical Documentation
- Healthcare Analytics
- Process Improvement
- HIS/EMR Systems
- Clinical Workforce Management

4. Educational Requirements

Essential

- MBBS / BDS / BAMS / BHMS / BPT

Preferred
- MBA (Hospital Management)
- MHA (Master of Hospital Administration)
- PGDHHM
- Fellowship in Healthcare Quality / NABH / JCI related programs

5. Experience Requirement

- 12 to 18 years of healthcare experience.
- Minimum 5-7 years in Medical Services / Clinical Administration leadership role.
- Experience in large NABH accredited multi-speciality hospitals.
- Experience handling 300+ bed hospitals and complex multi-speciality environments.
- Exposure to JCI accreditation preferred.

📌 Senior Medical Services Manager (Mumbai)
🏢 Sir Hn Reliance Foundation Hospital
📍 Mumbai