Quality Manager (Healthcare)

Position:

Department:

Location:

Reports to:

Role Summary

The Quality Manager is responsible for planning, implementing, monitoring, and improving the hospital’s quality assurance and patient safety programs. This role ensures compliance with NABH standards, drives continuous improvement initiatives, manages audits, risk assessments, and promotes a culture of quality across all departments.

Key Responsibilities

1. NABH Accreditation & Compliance

• Oversee preparation, documentation, and implementation of NABH standards (all chapters).
• Conduct internal audits, gap analysis, and readiness assessments.
• Ensure timely closure of non-conformities and corrective actions.
• Train departments on NABH requirements, quality indicators, and documentation.

2. Quality Assurance & Patient Safety

• Develop and monitor quality indicators for all departments.
• Implement patient safety programs—incident reporting, root cause analysis, medication safety, infection control support.
• Conduct risk assessments and initiate preventive actions.
• Ensure continuous monitoring of clinical and non-clinical quality parameters.

3. Documentation & SOP Management

• Develop, update, and maintain SOPs, policies, manuals, and checklists.
• Ensure proper version control and documentation compliance.
• Coordinate with departments for timely updates and record management as per standards.

4. Internal Audits & Training

• Plan and conduct regular internal quality audits.
• Guide departments in preparing for external audits (NABH, statutory, insurance, fire, safety).
• Organize training programs on quality, patient safety, and compliance.

5. Data Analysis & Reporting

• Collect, analyze, and present monthly quality KPI dashboards.
• Prepare reports for management review meetings (MRM).
• Identify trends and drive quality improvement projects.

6. Coordination & Communication

• Liaise with consultants, HODs, nursing teams, and administrative departments.
• Drive cross-functional quality initiatives and ensure timely action implementation.
• Support committees—HIC, MRM, Safety Committee, Quality & Patient Safety Committee.

Qualifications & Skills

• Education:

  B.Sc/M.Sc Nursing, MHA, MPH, or equivalent healthcare qualification.

• Experience:

  3–7 years of experience in hospital quality. NABH handling experience mandatory.

• Skills Required:

• In-depth knowledge of NABH standards
• Strong audit and documentation skills
• Data analysis & reporting
• Training & leadership skills
• Excellent communication & coordination
• Problem-solving and RCA skills