Quality Head

Job Description – Quality Head

Position: Quality Head / Head of Quality
Department: Quality & Patient Safety
Reports to: Medical Director / CEO
Location: Hospital

Role Summary

The Quality Head is responsible for planning, implementing, and monitoring all quality improvement, patient safety, and accreditation-related activities (NABH/JCI). The role ensures adherence to clinical and administrative standards, drives continuous improvement, and promotes a culture of quality across all departments.

Key Responsibilities1. Quality Management & Compliance

• Develop, implement, and monitor the hospital Quality Management System (QMS).
• Ensure compliance with NABH standards, statutory requirements, and internal policies.
• Lead internal audits, gap analysis, and readiness assessments for accreditation.
• Maintain updated documentation, SOPs, manuals, policies, and reports.

2. Patient Safety & Clinical Excellence

• Implement patient safety programs including incident reporting, RCA, and CAPA.
• Conduct mortality & morbidity (M&M) reviews, clinical indicators monitoring, and safety rounds.
• Ensure adherence to infection control practices in coordination with ICC.

3. Training & Capacity Building

• Plan and execute organisation-wide quality and patient safety training programs.
• Conduct induction training on QMS, safety protocols, and accreditation standards.
• Build capability of department champions, quality coordinators, and auditors.

4. Data Monitoring & Reporting

• Track quality indicators, KPIs, audits, and performance improvement projects.
• Prepare monthly quality dashboards and present results to management.
• Use data analytics for identifying gaps and initiating improvement plans.

5. Accreditation & External Assessments

• Lead hospital-wide efforts for NABH/JCI accreditation and surveillance audits.
• Coordinate with departments for corrective actions and compliance reports.
• Ensure timely submission of statutory and regulatory documentation.

6. Department Coordination & Leadership

• Facilitate Quality Committee, Safety Committee, and other statutory committees.
• Support departments in implementing SOPs and quality improvement actions.
• Promote a culture of transparency, responsibility, and continuous improvement.

Qualification & Experience

• Master’s in Hospital Administration (MHA) or equivalent.
• Certification in NABH Internal Auditor / Lead Auditor preferred.
• 5–10 years of experience in Quality Department, with minimum 2–3 years in a leadership role.
• Strong knowledge of NABH standards, patient safety, audits, and hospital operations.

Key Skills

• Strong analytical and problem-solving skills
• Excellent communication and training capability
• Knowledge of QMS, RCA/CAPA methodology
• Leadership, team management & coordination
• Proficiency in documentation and MS Office tools

Job Type: Full-time

Pay: ₹25,000.00 - ₹40,000.00 per month

Work Location: In person