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.