ole Overview

We are looking for an experienced Quality Manager – NABH to lead and manage the organisation’s quality management system, NABH accreditation requirements, compliance, documentation and continuous quality improvement initiatives.

The candidate will be responsible for ensuring that clinical and non-clinical processes consistently meet applicable NABH standards, statutory requirements and internal SOPs.

Key Responsibilities

1. NABH Accreditation & Compliance

- Lead preparation, implementation and maintenance of NABH accreditation standards.
- Ensure compliance with applicable NABH requirements across all departments.
- Coordinate internal assessments, audits and accreditation-related activities.
- Track non-conformities and ensure timely corrective and preventive actions (CAPA).
- Maintain readiness for NABH assessments and surveillance audits.

2. Quality Management System

- Develop, implement and regularly review SOPs, policies, protocols and quality manuals.
- Establish and monitor quality indicators across clinical and support departments.
- Identify process gaps and implement improvement initiatives.
- Conduct regular quality review meetings and follow up on action points.

3. Audits & Documentation

- Conduct internal quality audits and departmental audits.
- Maintain proper documentation, registers, checklists and quality records.
- Monitor compliance with approved SOPs and protocols.
- Prepare audit reports and present findings to management.

4. Patient Safety & Experience

- Monitor patient safety incidents, near misses and adverse events.
- Coordinate incident reporting and RCA (Root Cause Analysis).
- Monitor patient complaints and feedback and ensure appropriate corrective action.
- Drive initiatives to improve patient satisfaction and overall patient experience.

5. Infection Control & Clinical Quality





- Coordinate with the Infection Control Team to monitor infection-control practices.
- Monitor hand hygiene, biomedical waste management and related quality parameters.
- Support clinical departments in implementing patient-safety and quality protocols.

6. Training & Staff Awareness

- Conduct NABH and quality-related training programmes for employees.
- Create awareness regarding SOPs, patient safety, documentation and compliance.
- Maintain training records and competency documentation.

Key KPIs
- NABH compliance percentage
- Internal audit compliance
- Closure of NCs/CAPA within timelines
- SOP compliance
- Patient safety indicators
- Patient complaint resolution
- Infection-control compliance
- Staff training completion
- Quality improvement initiatives
- Accreditation readiness

Candidate Profile

Qualification:

- Bachelor's/Master's degree in Hospital Administration, Healthcare Management, Life Sciences, Nursing or a related field.
- Certification in NABH / Healthcare Quality Management will be an advantage.

Experience:

- 3–7 years of experience in hospital/healthcare quality management.
- Strong experience handling NABH accreditation and hospital quality systems preferred.
- Experience in IVF/Fertility or multi-specialty healthcare will be an added advantage.

Skills:

- Strong knowledge of NABH standards
- Quality audit and documentation skills
- SOP development and implementation
- RCA & CAPA
- Excellent communication and coordination
- Robust analytical and reporting skills
- Good knowledge of MS Office
- Ability to work with clinical and non-clinical teams

Ideal Candidate A detail-oriented and proactive quality professional who can independently drive NABH compliance, improve processes, strengthen patient safety and build a strong culture of quality across the organisation. Pay: ₹40,000.00 - ₹70,000.00 per month

Work Location: In person

📌 Quality Manager-NABH (Thiruvananthapuram)
🏢 Lv2 Solution
📍 Thiruvananthapuram