Qualification

- MHA MBA Hospital Management B.Sc Nursing Allied Health Sciences

- Certification in NABH Quality Management preferred

Experience

- Minimum 3-6 years experience in hospital quality department

- Experience in NABH accreditation and audits preferred

- Healthcare hospital experience mandatory

Key Responsibilities

Quality Management

- Implement and monitor quality assurance programs across departments

- Ensure compliance with NABH standards and hospital policies

- Coordinate departmental quality indicators and data collection

- Monitor patient safety goals and quality improvement initiatives

NABH &

- Audit Coordination

- Prepare departments for NABH audits and inspections

- Conduct internal audits and compliance checks

- Maintain audit reports, CAPA and documentation

- Coordinate with departments for closure of non-conformities

Documentation &

- SOP Management

- Prepare and update SOPs, policies and protocols

- Ensure proper documentation practices in all departments

- Maintain quality records, reports and audit documents

- Monitor document control processes

Training &

- Awareness

- Conduct staff training on quality standards and NABH protocols

- Organize orientation programs on patient safety and infection control





- Support departments in implementation of quality initiatives

Patient Safety &

- Infection Control

- Monitor incident reporting and patient safety indicators

- Coordinate with infection control team for compliance activities

- Participate in RCA, risk assessment and quality review meetings

Coordination &

- Reporting

- Coordinate with clinical and non-clinical departments

- Prepare monthly quality reports and presentations

- Analyze quality indicators and suggest corrective actions

- Support management during accreditation processes

Skills Required

- Knowledge of NABH standards and hospital quality systems

- Good communication and presentation skills

- Strong documentation and analytical ability

- Audit and reporting skills

- Team coordination and problem-solving ability

- Computer proficiency (Excel, PowerPoint, HIS)

Key Performance Indicators (KPIs)

- NABH compliance score

- Closure of audit non-conformities

- Timely submission of quality reports

- Staff training completion rate

- Patient safety and incident reduction indicators

Working Conditions

- Full time hospital-based role

- May require extended hours during audits and accreditation visits

- Coordination with all hospital departments

📌 Senior Quality Executive (Chennai)
🏢 Vasantha Subaramanian Hospitals
📍 Chennai