Hospital Quality Manager

A Reputed Hospital is looking for Hospital Quality Manager based at Ankleshwar , Gujarat location

Key Responsibilities:

• Implement and monitor compliance with NABH standards.Do periodic Internal Audits for standard Compliance.
• Coordinate periodic gap assessments and ensure timely closure of non-conformities.
• Monitor KPIs and assist departments in achieving targets. Do trend Analysis for KPIs, Patient feedback, Active Audits etc..
• Prepare and maintain documentation as per accreditation norms. Prepare, review, and manage SOPs, manuals, policies, and quality documentation.
• Facilitate incident reporting system hospital-wide. Perform root cause analysis and support CAPA (Corrective and Preventive Action) implementation.
• Maintain incident registers and report trends Conduct regular MRD audits, Analyze documentation gaps and follow up for timely correction.
• Coordinate emergency mock drills (Code Blue, Red, etc.).
• Document findings, perform effectiveness analysis, and report gaps. Ensure training and awareness among staff. Evaluate Committee effectiveness.
• Coordinate with internal committees (Infection Control, PSQI, Safety, etc.), Prepare minutes of meetings (MoMs), follow up on action points, and maintain records.
• Plan and coordinate training programs on quality, patient safety, infection control, and NABH standards.
• Track attendance and maintain training records.
• Plan and support Quality Improvement Projects (QIPs), Document project results and outcomes.
• Assist in digital transformation of EMR. Coordinate with IT and software team for software modules.
• Asses for NABH digital Certification , Plan and conduct clinical and nursing audits as per schedule.
• Analyze findings and coordinate with departments for corrective actions.
• Ensure SOPs, manuals, and policies are current and approved, Coordinate timely review and revision of documents.
• Maintain centralized documentation system.
• Make sure compliance for each documentation.
• Conduct periodic gap assessments across departments.
• Facilitate implementation of CAPA. Document compliance verification and follow-up actions.
• Conduct quality checks and visits to outsourced vendors (e.g., laundry, diet, waste management).
• Ensure compliance with service level agreements Collect, analyze, and report PROM data to measure patient satisfaction and outcomes.
• Coordinate improvement measures based on PROM feedback.