QUALIFICATION:

- Master’s in Healthcare Administration / Healthcare Management

- Certification in Healthcare Quality / NABH / Quality Management would be an added advantage

EXPERIENCE:

- 12 – 15 years

JOB RESPONSIBILITIES:

- Lead the development, implementation and continuous improvement of the hospital’s Quality Management System (QMS) in alignment with NABH and applicable statutory and regulatory requirements.

- Develop and monitor the hospital’s Quality and Patient Safety strategy, annual quality plan, objectives and key performance indicators.

- Ensure continuous readiness for NABH accreditation, surveillance assessments and other external accreditation/audit requirements.

- Establish and monitor hospital-wide Quality Indicators (QIs) covering clinical, nursing, operational, patient safety and support services.

- Review quality data and dashboards with functional HODs and senior management and identify areas requiring corrective or preventive action.

- Lead Quality Improvement Projects (QIPs) using structured methodologies such as PDCA, RCA, CAPA and other appropriate improvement tools.

- Establish a robust framework for incident reporting, adverse event management, near-miss reporting, root cause analysis and corrective/preventive actions.

- Drive the hospital’s patient safety programme, including identification of risks, implementation of safety practices and monitoring of safety indicators.

- Coordinate and oversee internal audits, clinical audits, departmental audits and compliance assessments.

- Ensure development, review, implementation and periodic evaluation of SOPs, protocols,



clinical pathways and quality-related documentation.

- Work closely with Medical Administration, Nursing, Infection Control, HR, Pharmacy, Laboratory, Radiology, Biomedical Engineering and other departments to improve quality outcomes.

- Lead the Quality Committee and Patient Safety initiatives, including preparation of agendas, reports, dashboards and review of action points.

- Analyse trends related to patient complaints, incidents, medication errors, falls, infections, mortality, readmissions, turnaround times and other relevant quality indicators.

- Ensure timely closure and effectiveness assessment of CAPA arising from audits, incidents, complaints and accreditation observations.

- Promote a culture of quality, accountability, patient-centricity and continuous improvement across the organisation.

- Develop and conduct quality-related training and awareness programmes for doctors, nurses and other hospital employees.

- Benchmark hospital quality indicators and practices against relevant healthcare standards and industry best practices.

- Provide management with periodic Quality MIS, risk reports, compliance reports and strategic recommendations.

- Guide and mentor the Quality team and build organisational capability in quality management and patient safety.

- Support management in evaluating and implementing digital quality systems, dashboards, automation and data-driven quality monitoring

Any other work/responsibility assigned by the HOD/Management in the course of business/work whether within the same unit/dept or any other unit/dept from time to time

📌 Head of Department – Quality (Pune)
🏢 KEM Hospital
📍 Pune