Primary responsibilities include managing NABH documentation, conducting internal audits, training staff, and overseeing continuous compliance across both clinical (e.g., operating theaters) and administrative departments.
Accreditation & Compliance Management
Spearhead the preparation and implementation of NABH standards and guidelines across all departments.
Manage and maintain accurate, up-to-date documentation of hospital policies, procedures, and clinical manuals.
Act as the primary liaison between the hospital administration and external NABH assessment teams
Auditing & Quality Control
Plan and conduct regular internal audits and inspections to ensure continuous adherence to accreditation requirements.
Monitor key hospital quality indicators (e.g., surgical site infection rates, patient wait times, medication errors).
Identify process gaps and execute Corrective and Preventive Actions (CAPA)
Training & Development
Organize and conduct regular training and awareness programs for clinical and non-clinical staff regarding NABH protocols.
Orient current employees on hospital safety, infection control, and quality policies.
Patient Safety & Feedback
Facilitate patient satisfaction surveys, analyze feedback, and drive continuous improvements to enhance the patient experience.
Coordinate patient safety initiatives, including fire drills, biomedical waste management compliance, and infection control protocols.