Job description

- Development and implementation of departmental policies and Procedures, as per JCI/NABH norms.
- To develop quality assurance program for all the departments of the hospital.
- Training of all employees on defined quality assurance program.
- To ensure compliance and continual improvement of Quality indicators by undertaking surprise audits and mock surveys.
- Overall responsibilities for national and international accreditations of the organization i.e. ISO, NABH, JCI etc.
- Responsible for Medical, Clinical & Systems Audits and their follow-up for improvement through corrective & preventive action reports.
- To ensure adherence to statutory and regulatory requirement by updating all the licenses at required interval.
- Co-ordinate external audits, surveillance audits and any external assessment or surprise visit with any external agencies i.e. ISO & NABH
- To review and update the manual on yearly basis and get revisions approved by concerned authorities.
- Supervision and implementation of all aspects described in manual for continuous improvement of the department.
- To attend all the relevant committee meetings and ensure follow up & closure of observations related to his/her concerned department.




- Monitoring quality indicators raw data and analysis in view of suggesting corrective and preventive actions.
- To coordinate in various audits including clinical audits, prescription audit, CPR Audit, Medical Record audit etc.
- To analyse incidents including medication error, adverse drug reaction, near miss and no harm events in view to suggest corrective and preventive actions.
- Take regular rounds of all the departments to ensure compliance to all the policies and protocols.
- Will be responsible for any other duties assigned by the Reporting Authority from time to time. Attributes conscientious and Responsible, Outstanding communication skills, Excellent Organizational and Leadership Skills.
- Proficient in MS Office ensure zero deficiency while working on it.
- In Depth understanding of Quality control procedures and relevant legal standards.
- Monitoring QI, Preparing QI dashboard with RCA/CAPA.
- Conducting Committee meetings and preparing MOM as scheduled.
- To Analyze Incident in View to Suggest CAPA.
- Will be responsible for any other duties assigned by the reporting Authority from time to time.

📌 Quality Executive (Pune)
🏢 Surya Hospital
📍 Pune