Experience :
A minimum of
10 years of experience shall be mandatory
in the fields of quality assurance, performance improvement, or risk management within the healthcare industry. The incumbent shall ensure the highest standards of patient care & safety while maintaining compliance with all external regulatory and accreditation requirements. He shall have a good knowledge of project management and team leadership. Further exposure to the following is also strongly preferred.
Proficiency in quality improvement methodologies such as
Lean Six Sigma
(Green Belt or Black Belt) is advantageous.
Knowledge of specific accreditation standards like
NABH, JCI, ISO 9001
or The Joint Commission is essential for the role.
Policy and Procedure Development :
Devising, implementing, and maintaining quality assurance protocols, standard operating procedures (SOPs) & quality manuals across all hospital departments.
Compliance and Accreditation :
Leading the hospital's accreditation and reaccreditation processes (e.g., NABH, JCI) and ensuring continuous compliance with healthcare standards and regulations.
Auditing and Assessment :
Conducting regular internal and external audits, clinical audits and gap analyses to identify areas for improvement and ensure adherence to established standards.
Data Analysis and Reporting :
Collecting, analyzing, and reporting on performance metrics, Key Quality Indicators (KQIs), and patient outcomes to identify trends and drive data-driven improvements.
Quality Improvement Initiatives :
Leading & managing continuous quality improvement (CQI) projects, such as Root Cause Analysis (RCA) & Failure Modes & Effects Analysis (FMEA), to enhance efficiency, patient satisfaction & safety.
Staff Training and Collaboration :
Educating & mentoring staff on quality standards, patient safety protocols, regulatory updates & collaborating with cross-functional teams (medical, nursing, administrative) to foster a culture of quality.
Risk Management :
Developing processes to proactively prevent risk issues, managing incident reporting systems and implementing corrective and preventive actions.
Committee Coordination :
Coordinating hospital committee meetings, including Quality Assurance, Infection Control, Medical Audit and Safety Committees & documenting minutes & action plans.
Education :
A
Master's degree
is typically the minimum requirement in the fields such as Healthcare Administration, Nursing, Public Health, or a related discipline. A Degree in Law shall be considered to be an added qualification.

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