- Lead and coordinate the hospitals NABH accreditation and compliance activities.
- Ensure implementation and monitoring of NABH standards across all applicable departments.
- Develop, review and maintain SOPs, policies, protocols, manuals, forms and quality-related documents.
- Coordinate internal quality audits and department-wise compliance audits.
- Identify gaps/non-conformities and ensure timely Corrective and Preventive Actions (CAPA).
- Monitor and maintain the hospital’s Quality Indicators/KPIs and prepare periodic quality reports.
- Conduct regular Quality Council/Quality Committee meetings and maintain minutes and action-taken reports.
- Coordinate patient safety initiatives, incident reporting and risk management activities.