Role & responsibilities

- Lead and oversee the overall Quality Management System (QMS) of the hospital and ensure continuous improvement in healthcare quality and patient safety.
- Develop, implement, review, and monitor quality policies, procedures, SOPs, protocols, and standards across all departments.
- Ensure compliance with applicable NABH, ISO, statutory, regulatory, and hospital quality requirements.
- Plan, coordinate, and monitor NABH accreditation, surveillance, renewal, and assessment activities.
- Conduct regular internal audits, quality audits, clinical audits, and departmental audits and ensure timely closure of observations and non-conformities.
- Establish and monitor Quality Indicators (QIs), Key Performance Indicators (KPIs), and patient safety indicators across departments.
- Analyze quality data, identify trends, and present quality performance reports and dashboards to senior management.
- Lead Root Cause Analysis (RCA), Corrective and Preventive Actions (CAPA) for incidents, complaints, adverse events, and non-conformities.
- Monitor and strengthen patient safety programs, including medication safety, infection prevention, falls prevention, patient identification, surgical safety, and other safety initiatives.
- Coordinate with clinical and non-clinical departments to implement quality improvement projects and process improvements.
- Monitor patient feedback, complaints, grievances,



and satisfaction scores and ensure effective corrective actions.
- Coordinate with the Infection Control team and other committees to ensure implementation of quality and safety practices.
- Organize and coordinate quality committee meetings, departmental reviews, management reviews, and accreditation-related meetings.
- Ensure proper documentation, record maintenance, policy control, and evidence readiness for accreditation and regulatory assessments.
- Conduct training and awareness programs for employees on quality standards, patient safety, SOPs, accreditation requirements, and quality improvement practices.
- Develop a robust quality culture and continuous improvement culture across the organization.
- Benchmark hospital performance against established healthcare quality standards and identify areas for improvement.
- Coordinate with senior management and department heads for strategic quality planning and implementation.
- Monitor compliance with statutory and regulatory requirements and ensure timely corrective action wherever required.
- Ensure effective communication of quality objectives, performance, findings, and improvement plans across the hospital.
- Drive continuous improvement initiatives to enhance patient safety, clinical outcomes, operational efficiency, compliance, and patient experience.

📌 Walk-in || General Manager - Quality (Chennai)
🏢 Dr.Kamakshi Memorial Hospital
📍 Chennai