Job Purpose To plan, implement, monitor, and continuously improve the hospital's Quality Management System in accordance with applicable NABH accreditation standards, statutory requirements, patient safety principles, and hospital policies. To coordinate accreditation activities, conduct audits, monitor quality indicators, and ensure compliance across all departments.

Key ResponsibilitiesNABH Accreditation and Compliance

- Implement and maintain the hospital's quality management system in accordance with the applicable NABH standards and edition.
- Coordinate NABH accreditation, assessment, surveillance, and renewal activities.
- Ensure department-wise compliance with applicable NABH standards and objective elements.
- Maintain the NABH compliance matrix and monitor the status of implementation.
- Coordinate with HODs and department in-charges to close identified gaps and non-conformities.
- Maintain updated quality manuals, policies, SOPs, protocols, and other controlled documents.
- Ensure availability of evidence and records required for internal and external assessments.
- Communicate changes in applicable accreditation requirements to concerned departments.

Quality Assurance and Patient Safety
- Develop and monitor the hospital's quality indicators and performance measures.
- Monitor incidents, adverse events, near misses, and patient safety concerns.
- Coordinate root cause analysis (RCA) and corrective and preventive actions (CAPA).
- Monitor compliance with patient identification, medication safety, infection prevention, clinical documentation, and other applicable patient safety practices.
- Coordinate clinical and non-clinical quality improvement initiatives.
- Monitor patient feedback, complaints, and satisfaction indicators in coordination with concerned departments.
- Identify recurring quality issues and recommend preventive measures to management.

Internal Audits and Risk Management
- Prepare the annual internal audit plan and department-wise audit schedules.
- Conduct quality audits and coordinate clinical and non-clinical audits.
- Verify compliance with hospital policies, SOPs, protocols,



and applicable standards.
- Prepare audit reports, document findings, and communicate non-conformities to the concerned HODs.
- Track corrective actions and verify their effectiveness before closure.
- Maintain the risk register and coordinate periodic risk assessments.
- Monitor completion of action plans within approved timelines.

Documentation and Record Management
- Maintain and control quality-related documents, including policies, SOPs, manuals, formats, and registers.
- Ensure documents are approved, reviewed, version-controlled, and communicated to relevant staff.
- Maintain audit reports, quality meeting minutes, CAPA records, incident reports, and indicator data.
- Ensure department-wise quality files and accreditation evidence are updated.
- Coordinate document review and revision with the concerned process owners.

Training and Awareness
- Conduct NABH awareness and quality management training for employees.
- Coordinate induction training on quality policies and patient safety requirements.
- Organize training on SOP implementation, incident reporting, RCA, CAPA, and audit preparedness.
- Maintain training attendance, assessment results, and training effectiveness records.
- Identify department-wise training needs based on audit findings and compliance gaps.

Committee and Management Coordination
- Coordinate quality-related committee meetings as per the hospital's approved structure.
- Prepare meeting agendas, minutes, action plans, and follow-up reports.
- Present quality indicators, audit findings, incident trends, and compliance status to management.
- Coordinate with department HODs, Nursing, Infection Control, Pharmacy, HR, Medical Records, and other relevant departments.




- Ensure action items from management and committee meetings are implemented within the agreed timelines.

Continuous Quality Improvement
- Identify opportunities for improving patient care processes and operational efficiency.
- Monitor the effectiveness of implemented quality improvement projects.
- Use data analysis and trend monitoring to identify recurring issues.
- Recommend process improvements based on audit findings, risk assessments, and patient feedback.
- Prepare monthly quality performance reports for management review.

Daily Responsibilities
- Review pending NABH compliance issues and departmental action plans.
- Follow up on open audit observations and CAPA.
- Coordinate with departments regarding quality documentation and implementation.
- Review reported incidents and escalate significant patient safety concerns.
- Monitor the availability and maintenance of quality records.
- Provide guidance to staff regarding applicable quality standards and procedures.

Monthly Responsibilities
- Prepare and present the monthly quality dashboard.
- Review quality indicators and departmental performance trends.
- Conduct scheduled internal audits and verify corrective actions.
- Review incident reports, patient complaints, and patient safety trends.
- Conduct or coordinate quality committee meetings as scheduled.
- Submit a department-wise NABH compliance and gap-closure report to management.
- Review the status of quality training and documentation updates.

Yearly Responsibilities
- Prepare the annual quality improvement plan and internal audit calendar.
- Review and update the quality manual, policies, and SOPs according to the approved review schedule.
- Coordinate annual risk assessments and quality indicator reviews.
- Evaluate the effectiveness of quality improvement initiatives.
- Coordinate the annual review of department-wise compliance and training requirements.
- Prepare the hospital for scheduled NABH assessments and surveillance activities.

Pay: ₹25,000.00 - ₹40,000.00 per month

Perks

- Paid time off

Work Location: In person

📌 Quality Manager (Tiruppur)
🏢 Sree Saran Medical Center
📍 Tiruppur