Key Responsibilities

1. Quality Management &
- Compliance

- Support implementation and monitoring of hospital quality policies, procedures, and standards.

- Ensure departmental processes are aligned with applicable healthcare quality standards.

- Monitor compliance with defined SOPs, policies, and quality indicators.

- Identify gaps and coordinate with departments for corrective and preventive actions (CAPA).

- Support continuous quality improvement initiatives across the organization.

1. NABH &
- Accreditation Support

- Assist in maintaining compliance with NABH standards and requirements.

- Prepare and maintain documentation required for NABH assessments and audits.

- Coordinate with departments for implementation of NABH-related policies and processes.

- Support internal and external audits and ensure timely closure of observations/non-conformities.

- Maintain records and evidence related to accreditation requirements.

1. Internal Audit &
- Monitoring

- Conduct/support regular internal quality audits across clinical and non-clinical departments.

- Prepare audit checklists, reports, and observation sheets.

- Identify process deviations and coordinate with concerned departments for corrective action.

- Track audit findings and monitor closure within defined timelines.

- Maintain audit documentation for review and management reporting.

1. Quality Indicators &
- Data Management

- Collect, compile, and monitor departmental quality indicators/KPIs.

- Prepare monthly quality reports and dashboards.

- Analyze quality data to identify trends, gaps, and improvement opportunities.

- Coordinate with departments to ensure timely submission of quality-related data.

- Maintain accurate and updated quality records.

1. Patient Safety &
- Quality Improvement

- Support implementation of patient safety initiatives.





- Monitor compliance with patient safety practices and hospital protocols.

- Assist in monitoring incidents, near misses, complaints, and adverse events.

- Support Root Cause Analysis (RCA) and CAPA processes.

- Participate in quality improvement projects and process improvement initiatives.

1. Documentation &
- SOP Management

- Maintain and update quality-related documents, SOPs, policies, formats, and checklists.

- Ensure proper version control and document availability.

- Coordinate with departments for timely review and revision of documents.

- Maintain records required for internal and accreditation audits.

1. Training &
- Awareness

- Support quality-related training and awareness programs for hospital staff.

- Assist in conducting sessions on SOPs, patient safety, infection control, documentation, and quality standards.

- Maintain training records and attendance documentation.

- Promote a culture of quality and continuous improvement among employees.

1. Coordination &
- Reporting

- Coordinate with clinical, nursing, administrative, and support departments regarding quality requirements.

- Follow up with department heads for pending quality actions and compliance.

- Prepare regular reports for the Quality Manager/Head – Quality.

- Escalate significant quality gaps or non-compliance issues to the reporting authority.

Required Knowledge &

- Skills

- Positive understanding of hospital quality management systems.

- Knowledge of NABH standards and healthcare quality practices.

- Knowledge of internal audits, CAPA, RCA, and quality indicators.

- Good documentation and report-writing skills.

- Strong analytical and problem-solving abilities.

- Good knowledge of MS Excel, Word, and PowerPoint.

- Good communication and coordination skills.

- Strong attention to detail.

- Ability to work with multiple departments and follow up on compliance requirements.

Pay: Up to ₹25,000.00 per month

Work Location: In person

📌 Quality Executive (Nagar)
🏢 Apex Ranthambore Sevika Hospital, Sawai Madhopur
📍 Nagar