Job Summary: The Executive – Quality is responsible for supporting the planning, implementation, monitoring, and continuous improvement of the hospital’s quality management systems in accordance with NABH standards, statutory regulations, and organizational quality objectives. The role ensures effective coordination of quality initiatives, audits, quality indicators, patient safety activities, and departmental compliance to promote excellence in patient care and operational efficiency.

Key Duties & Responsibilities

1. Quality Management System

· Assist in implementing and maintaining the hospital Quality Management System (QMS) aligned with NABH accreditation standards.

· Coordinate the preparation, review, and control of policies, procedures, protocols, manuals, and quality records.

· Monitor departmental compliance with internal quality standards and statutory requirements.

· Support accreditation activities including NABH audits, surveillance audits, and certification processes.

2. Audit and Compliance

· Plan and coordinate internal audits across departments as per audit schedules.

· Prepare audit reports, identify non-conformities, and follow up for closure of corrective and preventive actions (CAPA).

· Ensure compliance with regulatory, statutory, and accreditation requirements.

· Assist departments in implementing quality improvement initiatives based on audit findings.

3. Quality Indicators Monitoring

· Collect, compile, analyze, and report quality indicators from all clinical and non-clinical departments.

· Track trends in key indicators such as infection control, patient safety, patient satisfaction, and clinical outcomes.

· Prepare dashboards and monthly quality reports for management review.

· Highlight deviations and coordinate action plans for improvement.

4. Patient Safety and Risk Management

· Support implementation of patient safety goals and risk management strategies.

· Facilitate reporting and analysis of incidents, sentinel events, near misses, and adverse events.

· Coordinate root cause analysis (RCA) and monitor closure of action plans.





· Promote a culture of patient safety and quality awareness among staff.

5. Training and Awareness

· Conduct quality induction training for new employees.

· Organize and support periodic training on NABH standards, quality tools, patient safety goals, and documentation practices.

· Create awareness among staff regarding quality policies and compliance expectations.

6. Documentation and Records

· Maintain updated quality documentation including audit reports, quality indicator records, meeting minutes, and compliance reports.

· Ensure proper version control of documents and records as per document management policy.

· Support departmental SOP review and revision processes.

7. Quality Improvement Projects

· Participate in quality improvement projects, including PDSA, Kaizen, RCA, and Lean initiatives.

· Coordinate departmental teams for implementation of corrective and preventive actions.

· Evaluate effectiveness of implemented improvement initiatives.

8. Meetings and Coordination

· Organize and document quality committee meetings, safety committee meetings, and departmental review meetings.

· Coordinate with department heads to ensure timely submission of quality data and compliance reports.

· Present quality performance updates during management review meetings.

9. NABH & Compliance Responsibilities

· Ensure adherence to NABH standards, hospital policies, and quality objectives.

· Support implementation of patient safety goals, infection control standards, and departmental quality indicators.

· Participate in mock drills, audits, and quality reviews.

· Ensure confidentiality and security of quality records and reports.

· Facilitate evidence collection for accreditation assessments.

10. Authority

· Request quality data, audit evidence,



and compliance reports from departments.

· Recommend corrective and preventive actions for quality deviations.

· Escalate unresolved non-compliance issues to the Quality Manager / Management.

11. Required Skills

· Strong knowledge of NABH standards and healthcare quality systems.

· Proficiency in audit management, quality indicator analysis, and documentation.

· Positive analytical and reporting skills.

· Excellent communication, coordination, and presentation abilities.

· Knowledge of patient safety goals, RCA, CAPA, and quality improvement methodologies.

· Proficiency in MS Office applications, especially Excel and PowerPoint.

12. Key Performance Indicators (KPIs)

· Percentage of departments compliant with quality standards.

· Closure rate of audit non-conformities within defined timelines.

· Timely submission and analysis of quality indicators.

· Number of quality improvement initiatives completed.

· Staff training compliance percentage.

· Accreditation readiness score.

13. Working Conditions

· Hospital administrative environment with frequent interdepartmental coordination.

· May require flexible hours during audits, accreditation visits, or quality reviews.

Qualification: Master’s Degree / Bachelor’s Degree in Hospital Administration / Healthcare Management / Quality Management / Nursing / Allied Health Sciences. Certification in NABH/Internal Auditing/Quality Management preferred.

Experience: 1 to 2 years of experience in hospital quality management, accreditation, or healthcare quality assurance. Experience in NABH accreditation processes is mandatory/preferred.

How To Apply: Interested candidates may send their updated CV / resume to [email protected] or WhatsApp their cv to +91-(phone hidden).

Job Types: Full-time, Permanent

Pay: From ₹15,000.00 per month

Benefits:

- Flexible schedule
- Leave encashment
- Paid sick time

Education:

- Master's (Required)

Experience:

- Quality assurance: 1 year (Required)

Location:

- Kollam, Kerala (Required)

Shift availability:

- Day Shift (Preferred)

Work Location: In person

📌 Executive - Quality (Kollam)
🏢 Meditrina Hospital
📍 Kollam