Quality Management Manager

Job Title:

Department:

Job Summary

Assistant Manager is responsible for developing, implementing, and maintaining the hospitals Quality Management System (QMS) in alignment with national and international accreditation standards (e.g., NABH, JCI, ISO). The role ensures continuous improvement in patient safety, clinical outcomes, and service excellence through data-driven quality initiatives and compliance monitoring.

Key Responsibilities

1. Quality Management & Accreditation

• Develop and implement hospital-wide quality policies, procedures, and standard operating protocols (SOPs).
  
• Lead and coordinate accreditation and certification activities (NABH, JCI, ISO, etc.).
  
• Conduct internal audits and facilitate external audits.
  
• Monitor compliance with statutory, regulatory, and accreditation requirements.
  

2. Clinical Governance & Patient Safety

• Establish and oversee patient safety programs and incident reporting mechanisms.
  
• Conduct root cause analyses (RCA) and implement corrective/preventive actions (CAPA).
  
• Lead morbidity & mortality reviews, clinical audits, and quality circles.
  
• Ensure adherence to infection control and biomedical waste management standards.
  

3. Performance Measurement & Improvement

• Develop Key Performance Indicators (KPIs) and Quality Indicators (QIs) for departments.
  
• Monitor quality dashboards and identify trends for performance improvement.
  
• Drive continuous quality improvement (CQI) projects across clinical and non-clinical areas.
  
• Implement Lean Six Sigma and other process optimization initiatives where relevant.
  

4. Training & Capacity Building

• Conduct quality orientation and refresher training for all staff.
  
• Develop internal quality champions and cross-functional quality committees.
  
• Build awareness about patient safety and service excellence culture.
  

5. Data Management & Reporting

• Maintain documentation of quality activities, policies, and compliance reports.
  
• Present periodic quality performance reports to senior management.
  
• Ensure accurate and timely data submission to regulatory and accreditation bodies.
  

Qualifications & Experience

• Education:

  MBBS / BDS / BSc Nursing / MHA / MPH / Postgraduate in Quality Management.

• Certifications:

  NABH Assessor, Lean Six Sigma (Green/Black Belt), or equivalent preferred.

• Experience:

  4–8 years of experience in healthcare quality management,

Skills & Competencies

• Deep understanding of NABH / JCI standards and healthcare regulatory requirements.
  
• Strong analytical, auditing, and problem-solving skills.
  
• Excellent communication and interpersonal abilities.
  
• Proven leadership and team management capabilities.
  
• Data-driven and process-oriented approach to quality improvement.
  

Key Performance Indicators (KPIs)

• Accreditation readiness and compliance score.
  
• Reduction in clinical incidents / sentinel events.
  
• Improvement in patient satisfaction index.
  
• Staff training completion rate on quality topics.