Role & responsibilities

Key Responsibilities

1. JCI & NABH Coordination
- Coordinate implementation and monitoring of applicable JCI and NABH standards across departments.
- Maintain accreditation-related documentation, records, policies, SOPs and evidence.
- Follow up with departments on pending accreditation requirements and compliance gaps.
- Keep the hospital continuously prepared for accreditation assessments and surveys.

- Quality Monitoring

- Coordinate collection and compilation of Quality Indicators/KPIs from respective departments.
- Maintain quality dashboards, trackers and periodic reports.
- Identify gaps, deviations and recurring issues and bring them to the attention of the Quality Lead.
- Support Quality Improvement Projects and monitor their progress.

- Audits & Tracers

- Assist in planning and conducting internal audits, documentation audits and tracer activities.
- Record observations/non-conformities and maintain audit reports.
- Coordinate follow-up and closure of Corrective and Preventive Actions (CAPA).
- Verify and document evidence of compliance/closure.

- Patient Safety & Incident Reporting

- Coordinate the reporting and documentation of incidents, near misses and patient-safety events.
- Ensure incidents are appropriately routed to the concerned department/authority.
- Maintain incident trackers and follow up on corrective actions.
- Support patient-safety initiatives under the guidance of the Quality Lead.

- Policy & SOP Management

- Maintain the master list of hospital policies, SOPs, forms and other controlled documents.
- Coordinate periodic review, revision, approval and circulation of documents.
- Ensure obsolete documents are appropriately withdrawn and current versions are available at the point of use.

- Training & Awareness

- Coordinate staff training related to JCI/NABH standards, quality, patient safety and hospital policies.
- Maintain training schedules, attendance,



competency records and supporting evidence.
- Assist in conducting accreditation awareness sessions and mock survey preparedness activities.

- Survey & Assessment Readiness

- Assist the Quality Lead in preparing departments for JCI/NABH surveys, surveillance visits and assessments.
- Coordinate availability of required documents, records and evidence.
- Support mock tracers and readiness rounds.
- Maintain a tracker for survey observations and follow-up actions.

- Departmental Coordination

- Act as the day-to-day coordination link between the Quality Department and various hospital departments.
- Follow up with process owners for timely submission of data, records and compliance evidence.
- Escalate delays, repeated non-compliance or critical gaps to the Quality Lead.

- Quality Documentation & Reporting

- Maintain systematic records of audits, indicators, CAPA, incidents, meetings, training and accreditation activities.
- Prepare periodic reports and presentations as required.
- Ensure documents and evidence are readily retrievable during internal and external assessments.

- Continuous Improvement

- Identify opportunities for improving processes, documentation and compliance.
- Support cross-functional quality initiatives aimed at improving patient safety, patient experience and operational efficiency.
- Promote awareness that quality and accreditation are part of everyday hospital operations.

Preferred candidate profile

- Timely collection and reporting of Quality Indicators.
- Completion of scheduled audits and tracer activities.
- Timely follow-up and closure of CAPAs.
- Accuracy and completeness of accreditation documentation/evidence.
- Timely review and updating of policies and SOPs.
- Departmental compliance with JCI/NABH requirements.
- Completion of planned quality and accreditation training.
- Survey readiness and timely closure of survey observations.
- Accuracy and availability of Quality MIS and trackers.

📌 Quality Analyst (Chandigarh)
🏢 M&A Enterprises
📍 Chandigarh