Job Summary

Key Responsibilities

1. Accreditation & Compliance Management
- Lead the entire NABH/QCI accreditation cycle for hospitals, clinics, or specialized healthcare units (Entry Level, Progressive, or Full Accreditation as applicable).
- Interpret and operationalize all chapters of NABH (Access, Assessment and Continuity of Care, Patient Rights and Education, Infection Control, Facility Management & Safety, etc.) and applicable QCI schemes (e.g., QCI for Ayush, clinical trials, wellness centres).
- Prepare, review, and update Quality Manual, SOPs, policies, and work instructions in alignment with NABH/QCI standards and local regulations.
- Serve as the primary liaison with NABH/QCI empaneled consultants, assessors, and accreditation bodies; coordinate pre-assessment, final assessment, and surveillance visits seamlessly.

2. Quality Improvement & Patient Safety
- Design and drive hospital-wide quality improvement projects using tools like PDCA, FMEA, RCA, and clinical audits.
- Monitor key clinical and non-clinical quality indicators (HCAI rates, medication errors,



patient falls, waiting time, patient satisfaction scores) and present actionable insights to leadership.
- Lead adverse event reporting, sentinel event analysis, and CAPA (Corrective and Preventive Action) implementation.
- Establish and manage infection prevention and control (IPC) programs in close coordination with the infection control team.

3. Internal Audits & Training
- Plan and conduct regular internal quality audits (clinical and non-clinical departments) and mock drills to ensure 24/7 survey readiness at all levels.
- Train and mentor departmental quality champions, nursing staff, paramedics, and support services on NABH/QCI standards, documentation practices, and safety protocols.
- Organize ongoing competency-based training sessions on BLS, ACLS, fire safety, hazardous materials handling, and waste management.

4. Documentation & Data Management
- Maintain a centralized document contro

📌 Quality Manager (Varanasi)
🏢 HospiCare Excellence Solutions
📍 Varanasi