Executive

Role & responsibilities

• Accreditation Management: Coordinate all pre-and post-accreditation activities, documentation, and compliance readiness for NABH standards. [1]
• Audits & Rounds: Prepare internal audit schedules, conduct regular departmental quality rounds, and perform mock drills. [1, 2]
• Gap Analysis & CAPA: Identify operational and clinical gaps, track non-conformances, and drive Corrective Action and Preventive Action (CAPA) plans. [1, 2, 3]
• Documentation & SOPs: Assist in drafting, updating, and maintaining Standard Operating Procedures (SOPs), clinical protocols, and quality manuals. [1, 2]
• Incident Reporting: Track patient/staff incidents, monitor adverse events, and facilitate Root Cause Analysis (RCA). [1, 2]
• Committee Meetings: Facilitate hospital quality committee meetings, record minutes, and follow up on assigned action items. [1]
• Training: Conduct quality awareness and compliance training sessions for clinical and non-clinical staff. [1, 2]
• Quality Indicators: Monitor Key Performance Indicators (KPIs) and generate monthly or quarterly quality metrics reports for management. [1, 2]