Responsibilities

- Lead implementation, monitoring, and continuous improvement of NABH 6th Edition standards across hospital departments.
- Ensure compliance with NABH, CAHO, and applicable statutory and regulatory requirements.
- Develop, review, and update Quality Manuals, SOPs, policies, protocols, formats, and quality documentation.
- Coordinate internal quality audits, mock audits, tracer activities, departmental audits, and accreditation assessments.
- Identify gaps in compliance and coordinate with respective HODs for Corrective and Preventive Actions (CAPA).
- Monitor and analyze Quality Indicators (QIs), Key Performance Indicators (KPIs), patient safety indicators, and clinical outcomes.
- Coordinate Quality Improvement Projects (QIPs) and support departments in implementing measurable improvement initiatives.
- Facilitate Quality Council / Quality Committee meetings and prepare agendas, minutes, action plans, and follow-up reports.
- Monitor compliance related to patient safety, infection prevention and control, medication management, clinical documentation, biomedical equipment, facility management, and patient rights.
- Conduct staff awareness and training programs on NABH standards, quality systems, patient safety, and hospital policies.
- Maintain accreditation-related records and ensure timely submission of required reports and documents.
- Coordinate with clinical and non-clinical departments to ensure consistent implementation of hospital policies and standards.
- Track audit observations, non-conformities, incident reports, complaints, and improvement actions until closure.




- Promote a culture of continuous quality improvement and patient safety throughout the organization.
- Prepare management reports, dashboards, presentations, and periodic quality performance summaries.

Requirements

- Solid knowledge of NABH 6th Edition standards and accreditation requirements.
- Working knowledge of CAHO standards, quality frameworks, and hospital accreditation processes.
- Good understanding of Quality Management Systems (QMS), CQI, CAPA, RCA, FMEA, and risk management.
- Knowledge of clinical and non-clinical hospital processes.
- Strong skills in audit planning, documentation, data analysis, and quality reporting.
- Good communication, coordination, presentation, and training skills.
- Ability to work effectively with doctors, nurses, technicians, HODs, and management.
- Proficiency in MS Excel, Word, and PowerPoint.
- Preferred NABH Assessor / Internal Assessor training will be an added advantage.
- CAHO training/certification or hands-on experience with CAHO-related quality initiatives will be preferred.
- Experience in a NABH-accredited hospital or in preparing a hospital for NABH accreditation/re-accreditation.
- Experience handling NABH assessments, surveillance assessments, and mock accreditation audits.

Specialisation

- Quality Management | NABH 6th Edition | CAHO | Patient Safety | Accreditation | Internal Auditing | CAPA | RCA | Risk Management | Quality Indicators | Continuous Quality Improvement | Documentation | Training Compliance

Disclaimer: This job posting has been aggregated from external source. Role details, content, and availability are subject to change. Applicants are advised to confirm the latest information directly on the company website before applying.

📌 Quality Manager (Chennai)
🏢 Dr.Kamakshi Memorial Hospital
📍 Chennai