Job Summary

Key Responsibilities

1. Accreditation & Compliance Management

- Lead the entire NABH/QCI accreditation cycle for hospitals, clinics, or specialized healthcare units (Entry Level, Progressive, or Full Accreditation as applicable).
- Interpret and operationalize all chapters of NABH (Access, Assessment and Continuity of Care, Patient Rights and Education, Infection Control, Facility Management & Safety, etc.) and applicable QCI schemes (e.g., QCI for Ayush, clinical trials, wellness centres).
- Prepare, review, and update Quality Manual, SOPs, policies, and work instructions in alignment with NABH/QCI standards and local regulations.
- Serve as the primary liaison with NABH/QCI empaneled consultants, assessors, and accreditation bodies; coordinate pre-assessment, final assessment, and surveillance visits seamlessly.

2. Quality Improvement & Patient Safety

- Design and drive hospital-wide quality improvement projects using tools like PDCA, FMEA, RCA, and clinical audits.
- Monitor key clinical and non-clinical quality indicators (HCAI rates, medication errors, patient falls, waiting time, patient satisfaction scores) and present actionable insights to leadership.
- Lead adverse event reporting, sentinel event analysis, and CAPA (Corrective and Preventive Action) implementation.
- Establish and manage infection prevention and control (IPC) programs in close coordination with the infection control team.

3. Internal Audits & Training

- Plan and conduct regular internal quality audits (clinical and non-clinical departments) and mock drills to ensure 24/7 survey readiness at all levels.
- Train and mentor departmental quality champions, nursing staff, paramedics, and support services on NABH/QCI standards, documentation practices, and safety protocols.




- Organize ongoing competency-based training sessions on BLS, ACLS, fire safety, hazardous materials handling, and waste management.

4. Documentation & Data Management

- Maintain a centralized document control system; ensure version control, periodic review, and easy retrieval of all quality documents.
- Use quality management software or manual trackers to log non-conformances, audits, and improvement plans, ensuring closure within timelines.
- Prepare monthly quality dashboards and reports for management review meetings (MRM) and statutory submissions.

5. Patient Experience & Regulatory Readiness

- Implement patient feedback mechanisms; analyse feedback and drive service excellence initiatives to enhance the overall patient experience.
- Ensure compliance with Biomedical Waste Management Rules, AERB, fire NOC, and other statutory/legal requirements as applicable to healthcare organisations.
- Collaborate with HR in credentialing and privileging, medical records department for documentation integrity, and engineering for facility safety.

Qualifications & Experience

- Education : Bachelor’s/Master’s degree in Hospital Administration / Healthcare Management / Nursing / Life Sciences.
- Certification (highly preferred) : Certified NABH Internal Auditor / Lead Auditor, Diploma in Quality Management or Healthcare Quality from a recognized institute.




- Experience :Minimum 3+ years** of dedicated experience in a quality role within a NABH/QCI accredited hospital, multi-specialty clinic, or diagnostic centre.
- Proven track record of successfully steering at least one full cycle of NABH/QCI accreditation or re-accreditation across all levels (from gap analysis to final assessment).
- In-depth understanding of the latest NABH standards, QCI framework, clinical governance, and statutory compliance requirements.

Skills & Competencies

- Technical Acumen : Mastery of NABH (5th edition) standards and QCI accreditation processes, medical terminology, hospital operations, and patient safety science.
- Audit & Analytical Skills : Ability to plan and execute internal audits, perform root cause analysis, and derive data-driven decisions using MS Excel/quality dashboards.
- Communication & Training : Excellent command over English and local language(s); capable of drafting clear SOPs and delivering impactful training to multidisciplinary teams.
- Leadership & Collaboration : Robust interpersonal skills to influence across hierarchies—from housekeeping staff to senior consultants—without direct authority.
- Resilience & Detail-Orientation : Ability to work under pressure during survey periods, manage multiple priorities, and maintain an unwavering focus on micro-level compliance.
- Systems Thinking : Skill in building sustainable quality management systems that go beyond accreditation and become part of daily operations.

Work Environment & Benefits

- Full-time, hospital-based role with occasional travel for multisite coordination.
- Opportunity to lead accreditation for emerging specialties (e.g., NABH for Blood Banks, Dental Centres, AYUSH, etc.) and grow into Group Quality Head roles.
- Competi

📌 Quality Manager (Nabh/qci) (Varanasi)
🏢 HospiCare Excellence Solutions
📍 Varanasi