1. Role Purpose

The Manager – Quality & Clinical Operations will drive the implementation, standardisation, monitoring and continuous improvement of clinical service delivery and quality governance across the organisation’s existing hospitals and new facilities. Operating from Head Office, the role will provide central oversight of clinical workflows, patient safety, NABH readiness, clinical documentation, medical administration, nursing practices, resident-doctor deployment and unit-level performance. The incumbent will translate approved operating pillars into practical SOPs, audit plans, dashboards, escalation mechanisms and time-bound corrective actions, validating reported performance through on-ground reviews and direct interaction with unit teams.
1. Key ResponsibilitiesA. Corporate Monitoring, Governance & Unit-Level Intervention

· Monitor clinical operations, quality and medical-administration performance across units through dashboards, audits, reviews and physical rounds, validating findings against actual practices and patient records. · Identify gaps and recurring risks, assign corrective actions with clear accountability and timelines, track closure and escalate critical or unresolved issues.

· Standardize SOPs, workflows and reporting protocols, supporting unit leadership in implementing sustainable operational and clinical improvements.

B. Clinical Service Delivery & Patient Journey

· Standardize and monitor end-to-end patient journeys across OPD, IPD, emergency, diagnostics, OT/Cath Lab, pharmacy, admission, discharge and follow-up.

· Ensure compliance with clinical protocols, documentation, TATs, critical-result communication, consent and emergency/medico-legal processes.

· Identify workflow gaps, drive corrective actions and ensure timely escalation of clinical deviations to improve patient safety and service delivery.

C. Quality Governance, NABH & Patient Safety

· Drive implementation of NABH standards, statutory requirements, clinical protocols and patient-safety practices across all units.

· Coordinate with Quality, Medical, Nursing and Infection Control teams to conduct clinical audits,



monitor compliance and close audit observations.

· Monitor clinical incidents, near misses, medication safety, infection control and CAPA implementation, ensuring root-cause analysis and effective corrective actions.

· Ensure emergency preparedness, high-risk medication controls, emergency drug availability, code response readiness and timely closure of identified gaps.

D. Nursing Operations, Bedside Care & Clinical Coordination

· Monitor nursing deployment, ward coverage, role clarity and compliance with approved clinical protocols across all clinical areas.

· Ensure adherence to nursing documentation, medication administration, vital-sign monitoring, patient counselling and clinical handover protocols.

· Monitor bedside care practices, staff competencies and scope of practice; coordinate training and corrective actions with Nursing leadership.

· Ensure compliance with consent requirements, infection prevention, emergency escalation and patient-safety protocols.

E. Resident Doctors & Medical Administration

· Monitor resident-doctor deployment, duty rosters, attendance, shift coverage, handovers and availability across emergency, wards and critical care.

· Ensure compliance with clinical protocols, inpatient rounds, assessments, treatment documentation, referrals and discharge responsibilities.

· Monitor resident-doctor performance, consultant availability, OPD/IPD productivity, credentialing and competency development in coordination with clinical leadership.

· Identify manpower and performance gaps and recommend appropriate staffing, scheduling, training and workflow improvements.

F. Clinical Analytics, TAT & Performance Improvement

· Monitor clinical performance using HIMS/HMIS/EMR reports, dashboards and audits,



ensuring data accuracy and timely reporting.

· Track key KPIs, including clinical TATs, doctor availability, roster compliance, OPD/IPD productivity, length of stay, patient feedback and quality indicators against approved benchmarks.

· Analyze performance gaps, identify root causes and drive measurable corrective actions, with clear accountability, timelines and management reporting.

G. Clinical Manpower, Training & Competency

· Review staffing levels and deployment against approved plans, patient volumes, workload, acuity and required clinical coverage.

· Coordinate with HR, Nursing leadership and unit management on manpower gaps, roster efficiency, recruitment recommendations, clinical capability induction and training requirements.

· Monitor mandatory training completion, competency assessments, credentialing documentation and implementation of privileging processes.

· Promote deployment according to qualifications, validated competencies and authorised scope of practice.

J. Recent Facility Readiness & Existing Unit Improvement

· Translate operating pillars into implementation plans, SOPs, checklists, KPIs and review mechanisms for new and existing facilities.

· For new facilities, coordinate staffing, clinical workflows, HIMS testing, staff training, mock audits, emergency drills and go-live readiness.

· For existing units, conduct gap assessments, drive corrective actions, monitor sustained compliance and share best practices across the hospital network.

1. Qualifications & Experience

· Qualification: MBBS with MBA in Hospital Administration, with an interest in quality and hospital administration. · Experience: Minimum 10+ years in hospital quality, clinical operations or medical administration, with hands-on NABH implementation, clinical audits, CAPA, nursing operations and resident-doctor management.

· Preferred Skills: Experience in HIMS/HMIS/EMR, clinical analytics, multi-unit monitoring and hospital improvement; relevant professional registration must be verified wherever clinical duties are involved.

Work Location: In person

📌 Manager – Quality & Clinical Operations (Varanasi)
🏢 Heritage Hospital
📍 Varanasi