Manager Quality

1. NABH Accreditation & Certification

• Lead the NABH accreditation cycle: preparation, application, implementation, and follow-up audits.
• Coordinate with all departments to ensure adherence to NABH 5th Edition (or latest) guidelines.
• Maintain all manuals: Quality Manual, Infection Control Manual, Department SOPs, HR Manual, etc.
• Conduct regular mock audits and tracer activities to ensure readiness.

2. Clinical and Non-Clinical Quality Improvement

• Monitor clinical audits, mortality & morbidity reviews, antibiotic usage audits.
• Implement non-clinical audits: housekeeping, security, biomedical waste, facility maintenance.
• Facilitate interdisciplinary Quality Improvement Committees (QICs) and track action plans.
• Promote clinical governance and evidence-based practices.

3. Key Performance Indicators (KPIs) & Dashboard Management

• Define, monitor, and analyze hospital-wide KPIs / Quality Indicators.
• Prepare and publish monthly dashboards for all departments.
• Conduct trend analysis and drive corrective/preventive actions based on performance data.

4. Internal Audits, Risk & Incident Management

• Develop and execute the Internal Audit Calendar.
• Lead internal audits and assist in closure of non-conformities (NCs).
• Maintain incident reporting system (medication errors, near misses, sentinel events).
• Initiate root cause analysis (RCA) and track CAPAs through completion.

5. Statutory Compliance & Licensing

• Ensure all licenses (Biomedical Waste, Fire NOC, PCPNDT, AERB, etc.) are valid and renewed.
• Maintain records of legal, statutory, and regulatory compliance in accordance with NABH standards.
• Liaise with regulatory authorities for inspections, renewals, and clarifications.

6. Infection Control & Patient Safety

• Collaborate with Infection Control Officer (ICO) and ICN to monitor compliance with infection control practices.
• Actively support the Patient Safety Program, including HAIs, hand hygiene compliance, etc.
• Investigate and report Adverse Drug Events (ADEs), hospital-acquired infections, and sentinel events.

7. Document Control & Policy Management

• Implement a centralized document control system for SOPs, policies, and manuals.
• Review and revise documents periodically or as per changes in NABH standards.
• Conduct version control and ensure proper dissemination of updated protocols.

8. Training, Orientation & CME

• Develop and execute the Annual Training Calendar for quality, safety, and clinical care.
• Conduct induction training for all new staff, covering hospital policies, NABH awareness, etc.
• Organize CMEs, workshops, and continuous training on QMS tools (e.g., RCA, FMEA, 5S, Kaizen).

9. Patient Feedback & Satisfaction Surveys

• Design and administer structured Patient Feedback Forms and exit surveys.
• Compile, analyze, and report on feedback trends.
• Ensure timely resolution of grievances, and conduct Service Recovery.

10. Committees & Meetings

• Act as Member Secretary or Coordinator for:
• Hospital Infection Control Committee (HICC)
• Quality Improvement Committee (QIC)
• Safety Committee
• Mortality & Morbidity Review Committee
• Maintain minutes, track action points, and ensure timely closures.

11. Accreditation Expansion and Sustainability

• Work on additional accreditations such as:
• NABL (Lab Accreditation)
• ISO 9001:2015
• Safe-I Certification
• Implement sustainability and waste reduction initiatives in quality frameworks.

Core Competencies:

• NABH Standards (Latest Edition) – In-depth knowledge and hands-on experience
• Clinical Audit & Quality Tools – 5S, Kaizen, RCA, PDSA, FMEA, etc.
• Data Management & Analytics – Excel, SPSS, BI Tools (preferred)
• Training & Development – Ability to mentor, coach and evaluate teams
• Effective Communication – Written, verbal and inter-departmental coordination

Qualifications & Experience:

• Education: BAMS/BDS/ Master’s in Hospital/Health Administration or Quality Management is preferred.
• Experience: Minimum 4–7 years in a quality role within a healthcare setup, with direct exposure to NABH accreditation processes.
• Certifications: NABH Internal Auditor / NABH Assessor

Job Types: Full-time, Permanent

Pay: ₹40,000.00 - ₹60,000.00 per month

Benefits:

• Health insurance
• Provident Fund

Schedule:

• Day shift
• Morning shift

Supplemental Pay:

• Overtime pay
• Yearly bonus

Work Location: In person