Work Timings : 10:00 AM to 6:00 PM

Job Responsibilities

- NABH Compliance

· Coordinate implementation of NABH standards across all departments.

· Monitor department-wise compliance with NABH requirements.

· Conduct regular NABH self-assessments and internal audits.

· Identify gaps/non-conformities and coordinate corrective and preventive actions.

· Maintain evidence and documentation required for NABH assessments.

· Prepare the hospital for NABH surveillance, assessment and renewal activities.

· Coordinate with department heads during NABH assessor visits.

- Documentation & Record Management

· Maintain and update hospital policies, SOPs, manuals and formats.

· Ensure documents are properly approved, controlled, versioned and implemented.

· Maintain audit reports, meeting minutes and compliance records.

· Collect department-wise records and evidence for compliance requirements.

· Ensure obsolete documents are withdrawn and current versions are available.

- Internal Audit & Monitoring

· Prepare an monthly internal audit schedule.

· Conduct audits of clinical and non-clinical departments.

· Check whether SOPs and policies are actually being followed.

· Prepare audit observations and non-conformity reports.

· Follow up with departments until corrective actions are closed.

· Maintain a compliance tracker/dashboard.

- Quality & Patient Safety

· Monitor quality indicators and Key Performance Indicators (KPIs).

· Track incidents, adverse events,



near misses and sentinel events.

· Coordinate root-cause analysis.

· Monitor patient complaints and closure.

· Support patient-safety initiatives and quality-improvement projects.

· Coordinate quality committee meetings.

- Statutory & Regulatory Compliance

Depending on the hospital's scope, the coordinator may track compliance relating to:

· Clinical Establishment requirements

· Biomedical Waste Management

· Fire & Life Safety

· Pharmacy/drug regulations

· Infection control requirements

· Labour and HR-related statutory requirements

· Medical records and data/privacy requirements

· Licences, registrations and renewals

- Department Coordination

· Coordinate with Nursing, Pharmacy, Laboratory, Medical Records, Infection Control, HR, Engineering, Housekeeping, Security, etc.

· Conduct compliance meetings with department representatives.

· Communicate audit observations to concerned departments.

· Follow up on pending compliance points.

· Escalate critical or overdue issues to the Quality Management team.

- Training & Awareness

· Conduct/coordinate NABH awareness sessions for employees.

· Train staff on SOPs, patient safety, documentation and quality requirements.

· Maintain training attendance and competency records.

· Ensure new employees receive required quality/compliance orientation.

Pay: ₹30,000.00 - ₹40,000.00 per month

Advantages

- Paid sick time

Work Location: In person

📌 NABH Quality Coordinator (Gachibowli)
🏢 Asha Neuromodulation Clinics (A Unit of Vihanga Labs
📍 Gachibowli