Role & responsibilities 1. Monitor implementation of the Hospital Quality Management System. 2. Ensure compliance with applicable NABH standards and hospital policies. 3. Collect, verify and analyse quality indicator data from all departments. 4. Prepare and maintain monthly, quarterly and annual quality reports. 5. Monitor departmental compliance with approved SOPs, policies and protocols. 6. Conduct and coordinate internal quality audits. 7. Conduct clinical audits and identify gaps in patient-care documentation. 8. Monitor incident reporting and ensure timely submission of incident reports. 9. Coordinate RCA and CAPA for reported incidents and non-conformities. 10. Monitor the effectiveness and closure of corrective and preventive actions. 11. Coordinate Quality Improvement Projects (QIPs). 12. Support implementation of PDCA/PDSA, RCA and FMEA activities. 13.
Conduct regular quality and patient-safety rounds. 14. Identify risks, gaps and opportunities for improvement across departments. 15. Monitor compliance with International Patient Safety Goals (IPSG). 16. Coordinate activities related to NABH accreditation, surveillance and assessments. 17. Conduct NABH gap assessments and mock audits. 18. Maintain NABH-related documents, records and supporting evidence. 19. Coordinate Quality Assurance Committee meetings and prepare MoMs. 20. Monitor compliance with decisions and recommendations of quality-related committees. 21. Coordinate with the Infection Prevention & Control Committee for quality indicators and infection-control activities.