Job Purpose To lead and manage the hospital's Quality & NABH compliance framework, ensuring implementation, monitoring and continuous improvement of quality standards, patient safety, documentation and regulatory requirements across the centre.
Key Responsibilities
1. NABH & Accreditation
- Lead implementation and maintenance of NABH standards across all departments.
- Coordinate NABH entry-level/full accreditation and surveillance/reassessment activities.
- Ensure department-wise compliance with applicable NABH requirements.
- Conduct regular NABH readiness assessments and gap analysis.
- Maintain the NABH compliance tracker and action plans.
2. Quality Management
- Develop, implement and monitor Quality Indicators (QI/KPI).
- Conduct internal quality audits and departmental audits.
- Identify non-conformities and coordinate RCA & CAPA.
- Monitor effectiveness of corrective and preventive actions.
- Drive continuous quality improvement initiatives.
3. Documentation & SOP Management
- Develop, review and control SOPs, policies, manuals, formats and checklists.
- Ensure proper document control and version management.
- Verify that departments maintain mandatory registers and records.
- Ensure timely completion of quality-related documentation.
4. Patient Safety
- Monitor patient safety practices and incidents.
- Maintain and analyse incident/near-miss reports.
- Coordinate Patient Safety Committee and Quality Committee activities.
- Monitor infection control, medication safety, emergency preparedness and patient rights.
5. Training
- Conduct NABH awareness and quality training for employees.
- Identify department-wise training requirements.
- Maintain training records, competency assessments and attendance.
- Conduct mock audits and preparedness sessions.
6. Audit & Compliance
- Prepare the annual internal audit calendar.
- Conduct scheduled and surprise audits.
- Prepare audit reports and track closure of observations.
- Coordinate external audits and accreditation assessments.
- Ensure compliance with applicable statutory and regulatory requirements.
7. Management Reporting
- Prepare monthly Quality & NABH MIS reports.
- Present quality indicators, audit findings, incidents and CAPA status to management.
- Identify trends and recommend improvement measures.
- Maintain the centre's NABH readiness dashboard.
Qualification
- Bachelor's degree in Hospital Administration / Healthcare Management / Nursing / Life Sciences or related field.
- PG qualification in Hospital Administration / Healthcare Management preferred.
- NABH Quality/Healthcare Quality certification preferred.
Experience
- 3–7 years of experience in hospital quality management.
- Prior experience in NABH-accredited hospitals is mandatory/preferred.
- Experience handling NABH audits, documentation, QI, RCA, CAPA and internal audits.
- IVF/Fertility hospital experience will be an added advantage.
Required Skills
- Solid knowledge of NABH standards and hospital