Key Responsibilities

- Support implementation and sustenance of NABH 6th Edition standards in accredited and accreditation-seeking hospitals.
- Conduct internal audits, gap assessments, and compliance reviews across hospital departments.
- Assist in developing, reviewing, and implementing hospital policies, SOPs, formats, and quality documentation.
- Monitor compliance with NABH standards, identify gaps, and facilitate corrective and preventive actions (CAPA).
- Coordinate with departmental heads and Quality Teams for implementation of quality improvement initiatives.
- Monitor Quality Indicators (QIs), analyse trends, and facilitate data-driven improvement initiatives.
- Support implementation of patient safety initiatives, including patient identification, medication safety, infection prevention, clinical audits, and incident reporting.
- Facilitate mock assessments, departmental audits, and accreditation preparedness activities.
- Assist in preparation and maintenance of documentation and evidence required for NABH assessments.
- Conduct quality training and awareness sessions for hospital staff.
- Prepare assessment reports, action plans,



and compliance tracking reports.
- Travel extensively to client hospitals across North India as required.

Qualifications & Experience
- Master's in Hospital Administration (MHA) / Healthcare Management or equivalent.
- Minimum 3–5 years of experience in hospital Quality Department.
- Experience in NABH 6th Edition accredited hospitals is essential.
- Solid understanding of NABH standards, measurable elements, and assessment methodology.
- Experience in internal audits, quality indicators, documentation, and CAPA.
- Excellent communication, coordination, and analytical skills.
- Ability to work independently and manage multiple assignments.
- Willingness to travel extensively across North India.

Preferred Skills
- Experience in conducting internal audits and mock assessments.
- Exposure to NABH 6th Edition accreditation assessments or assessor-led assessment processes.
- Knowledge of hospital patient safety practices and quality improvement methodologies.
- Experience in training hospital staff on quality and patient safety.

📌 Hospital Quality Executive (Delhi)
🏢 AccredEdge
📍 Delhi