Quality Manager

Department:

Reporting To:

Location:

Purpose of the Role

NABH / NMC / statutory requirements

Key Responsibilities

Quality & Accreditation

• Lead

  NABH accreditation

  (Entry Level / Full Accreditation) and re-assessment processes.
• Develop, implement, and update

  SOPs, policies, manuals, and quality indicators

  for all departments.
• Ensure compliance with

  NABH, NMC, QCI, and state health authority norms

  .
• Coordinate internal audits, gap analysis, and corrective & preventive actions (CAPA).
  

Patient Safety & Clinical Governance

• Implement patient safety goals, risk management, and incident reporting systems.
  
• Monitor sentinel events, near-miss reporting, and root cause analysis (RCA).
  
• Promote infection control practices in coordination with the HICC team.
  

Documentation & Audits

• Maintain quality documentation, records, registers, and audit trails.
  
• Conduct regular

  departmental audits, mock assessments, and tracer audits

  .
• Prepare the hospital for external inspections and regulatory visits.
  

Training & Capacity Building

• Plan and conduct

  quality awareness and NABH training programs

  for doctors, nursing staff, and non-clinical staff.
• Sensitize staff on SOP adherence, patient rights, documentation, and safety protocols.
  

Performance Monitoring

• Track quality indicators, patient satisfaction data, and process outcomes.
  
• Prepare monthly/quarterly quality reports for management review meetings.
  
• Support continuous quality improvement (CQI) and Kaizen initiatives.
  

Coordination & Communication

• Act as a liaison between hospital departments, management, and external assessors.
  
• Support academic quality requirements relevant to a teaching hospital environment.
  

Eligibility Criteria

Educational Qualification

• MBBS / BDS / B.Sc Nursing / MHA / MBA (Hospital Management)
  

• Certified NABH Internal Assessor / Quality Professional

  (preferred)

Experience

• Minimum

  3–5 years

  experience in hospital quality management
• Hands-on experience with

  NABH accreditation

  in a multi-specialty or teaching hospital preferred

Key Skills & Competencies

• Strong understanding of

  NABH standards and hospital operations

• Excellent documentation, analytical, and audit skills
  
• Strong coordination, communication, and training abilities
  
• Proficiency in MS Word, Excel, PowerPoint, and reporting tools
  
• Ability to work independently and under regulatory timelines
  

Working Environment

• Teaching hospital with academic and clinical integration
  
• Opportunity to lead institutional quality systems from establishment to accreditation