Job Summary:

We are looking for an experienced Quality Manager to establish, implement, monitor, and continuously improve the hospital's quality management and patient safety systems.

The Quality Manager will be responsible for ensuring compliance with hospital policies, clinical and operational SOPs, quality indicators, patient safety requirements, infection-control practices, statutory requirements, and NABH accreditation standards as applicable.

The role will involve close coordination with doctors, nursing, administration, pharmacy, laboratory, radiology, OT, ICU, housekeeping, biomedical, HR, and other hospital departments.

Key Responsibilities:

1. Quality Management System

- Develop, implement, and maintain the hospital's Quality Management System.
- Establish quality policies, procedures, SOPs, protocols, checklists, and departmental standards.
- Ensure departments follow approved SOPs and hospital policies.
- Monitor compliance through regular departmental audits and inspections.
- Identify gaps and coordinate corrective and preventive actions.
- Maintain proper documentation and records related to quality activities.

1. NABH & Accreditation Readiness

- Coordinate the hospital's NABH accreditation and certification activities.
- Interpret applicable NABH standards and communicate requirements to relevant departments.
- Conduct periodic internal assessments against applicable NABH standards.
- Identify non-conformities and prepare action plans.
- Track closure of audit observations and compliance gaps.
- Coordinate documentation and evidence required for accreditation assessments.
- Conduct mock audits and readiness assessments before external inspections.

1. Patient Safety

- Establish and monitor patient-safety practices across the hospital.
- Monitor compliance with patient identification, medication safety, fall prevention, surgical safety, infection prevention, and other patient-safety protocols.
- Monitor and analyze patient safety incidents and near-miss events.
- Coordinate Root Cause Analysis (RCA) for significant incidents.
- Develop and monitor Corrective and Preventive Action (CAPA) plans.
- Track recurring incidents and recommend preventive measures.

1. Quality Indicators & Data Management

- Define and monitor hospital quality indicators.
- Collect and validate quality data from various departments.
- Prepare monthly and periodic quality reports for management review.
- Analyze trends and identify areas requiring improvement.
- Maintain departmental quality dashboards and performance reports.

Typical indicators may include:
- Patient satisfaction
- Medication errors
- Patient falls
- Hospital-acquired infections
- Surgical site infections
- Hand hygiene compliance
- Patient identification compliance
- Average length of stay
- Readmission rates
- Mortality indicators
- OT cancellation rates
- Laboratory turnaround time
- Radiology turnaround time
- Emergency response indicators
- Complaints and grievance resolution




- Documentation compliance

1. Clinical & Departmental Audits

- Prepare an annual internal audit plan.
- Conduct scheduled and surprise quality audits.
- Audit clinical and non-clinical departments for compliance with SOPs.
- Review patient records and clinical documentation for completeness and compliance.
- Coordinate with department heads to close audit findings.
- Maintain audit reports and corrective-action records.

1. Infection Control Coordination

- Work closely with the Infection Control Team.
- Monitor compliance with infection-control policies and procedures.
- Conduct audits for hand hygiene, PPE usage, biomedical waste segregation, sterilization, environmental hygiene, and infection-prevention practices.
- Review infection-control indicators and trends.
- Coordinate corrective actions for identified gaps.

1. SOP & Documentation Management

- Coordinate preparation, review, approval, and revision of hospital SOPs.
- Maintain a master list of hospital policies, SOPs, protocols, forms, and checklists.
- Ensure only current and approved versions of documents are in circulation.
- Establish document-control procedures.
- Ensure departments maintain appropriate records and evidence of compliance.

1. Incident & Complaint Management

- Establish an effective incident-reporting system.
- Review patient complaints, staff complaints, adverse events, near misses, and safety incidents.
- Coordinate investigation of significant incidents.
- Conduct RCA where required.
- Track CAPA implementation until closure.
- Prepare periodic incident and complaint reports for management review.

1. Staff Training & Awareness

- Develop quality and patient-safety training programs.
- Conduct orientation sessions for new employees regarding hospital quality policies.
- Organize training on SOPs, patient safety, infection control, documentation, incident reporting, and NABH requirements.
- Maintain training records and competency documentation.
- Promote a culture of continuous quality improvement across the hospital.

1. Patient Experience

- Monitor patient and attendant satisfaction.
- Develop and monitor patient-feedback mechanisms.
- Analyze complaints and feedback.
- Identify recurring concerns and coordinate corrective actions.
- Work with hospital departments to improve the overall patient experience.

1. Management Review

- Prepare monthly and quarterly quality reports for hospital management.
- Present quality indicators, audit findings, incidents, complaints, and CAPA status during management review meetings.




- Recommend improvement initiatives based on data and audit findings.
- Follow up on decisions and action points from quality meetings.

1. Coordination with Hospital Departments

The Quality Manager will coordinate with:
- Medical Department
- Nursing Department
- ICU & Emergency
- Operation Theatre
- Pharmacy
- Laboratory
- Radiology
- Infection Control
- Housekeeping
- Biomedical Engineering
- Medical Records
- HR & Training
- Purchase & Stores
- Maintenance
- Administration
- Security
- Dietary Services

Key Performance Indicators (KPIs) The Quality Manager will be evaluated based on:
- NABH compliance and accreditation readiness
- Closure rate of audit observations
- Timely implementation of CAPA
- Compliance with hospital SOPs
- Patient-safety incident reduction
- Quality-indicator performance
- Patient satisfaction scores
- Complaint resolution turnaround time
- Infection-control compliance
- Medical-record/documentation compliance
- Completion of departmental audits
- Staff training and competency compliance
- Timely submission of quality reports
- Effectiveness of continuous-improvement initiatives

Qualification
- B.Sc. Nursing / GNM / B.Pharm / MBBS / Allied Health Sciences / Healthcare Management or equivalent qualification.
- Certification in Healthcare Quality Management / NABH / Patient Safety / Hospital Administration will be an advantage.
- Knowledge of NABH standards and hospital accreditation processes is preferred.

Experience
- Minimum 2–5 years of experience in hospital quality management or healthcare operations.
- Experience in NABH-accredited or NABH-preparing hospitals preferred.
- Previous experience as Quality Manager / Quality Executive / NABH Coordinator / Quality & Patient Safety Officer will be an advantage.

Skills & Competencies
- Strong understanding of hospital quality systems.
- Good knowledge of NABH requirements.
- Strong analytical and problem-solving skills.
- Excellent documentation and report-writing ability.
- Strong auditing and inspection skills.
- Good knowledge of RCA and CAPA methodologies.
- Robust communication and interpersonal skills.
- Ability to coordinate effectively with doctors, nurses, and hospital departments.
- Good leadership and training skills.
- Proficiency in MS Office, Excel, PowerPoint, and quality-reporting tools.
- Strong attention to detail.
- Ability to work independently and manage multiple quality initiatives.

Personal Attributes
- Patient-safety focused.
- Ethical and professional.
- Detail-oriented.
- Objective and impartial during audits.
- Proactive in identifying risks and gaps.
- Valuable team player.
- Solid follow-up and coordination ability.
- Able to work effectively in a hospital environment.

Working Conditions

- Work in hospitals and healthcare settings
- Weekend off
- Paid sick leave
- Accommodation and food available
- Yearly hike in salary

Pay: ₹30,000.00 - ₹40,000.00 per month

Benefits

- Paid sick time

Work Location: In person

📌 Quality Manager – Hospital (Sivakasi)
🏢 Little Looms
📍 Sivakasi