Job
Description
1. NABH Accreditation & Compliance: Ensure the hospital meets NABH accreditation requirements and maintain compliance with its guidelines. Develop, implement, and monitor policies and procedures in line with NABH standards. Conduct internal audits and gap analysis to identify non-conformities and implement corrective actions. Organize and coordinate hospital assessment visits by NABH auditors. 2. Patient Safety & Quality Improvement: Develop and implement hospital-wide Quality Improvement Programs (QIPs) . Monitor Key Performance Indicators (KPIs) such as infection rates, patient feedback, adverse events, and medication errors. Establish protocols for patient safety , including infection control, fall prevention, and medication management. Conduct Root Cause Analysis (RCA) for incidents and suggest preventive measures. 3. Documentation & Reporting: Maintain Quality Manual, SOPs, Policies, and Guidelines as per NABH standards. Ensure proper documentation and record-keeping for audits and accreditation purposes. Prepare monthly and annual quality reports for hospital leadership. 4. Training & Capacity Building: Conduct training programs for hospital staff on NABH standards, patient safety, and quality assurance . Organize workshops on infection control, bio-medical waste management, and clinical audits . Develop a culture of continuous improvement among healthcare teams. 5. Risk Management & Incident Reporting: Establish a system for reporting and investigating sentinel events, near-miss incidents, and complaints . Monitor adherence to hospital policies on emergency preparedness, fire safety, and disaster management . Work closely with the infection control team to prevent hospital-acquired infections. 6. Coordination with Departments: Collaborate with clinical, nursing, administrative, and support teams to ensure compliance with quality standards. Assist in clinical audits, medical records audits, and patient feedback analysis . Support HR in credentialing and privileging of doctors and healthcare professionals. 7. Legal & Ethical Compliance: Ensure adherence to regulatory guidelines such as Biomedical Waste Management Rules, Clinical Establishment Act, PCPNDT Act, Fire Safety Regulations, etc. Maintain compliance with patient rights and responsibilities policies . Qualifications & Skills: Educational Qualification: BAMS/ BDS / MHA / MBA (Hospital Administration) / MPH or relevant degree in healthcare management. Experience: Minimum 4-5 years of experience in hospital quality management. Skills Required: Strong knowledge of NABH accreditation process Analytical and problem-solving skills Excellent communication and leadership abilities Experience in handling audits, documentation, and policy implementation Job Type: Full-time Pay: ₹50,000.00 - ₹70,000.00 per month Benefits: Health insurance Provident Fund Schedule: Day shift Supplemental Pay: Overtime pay Yearly bonus Work Location: In person
