Quality Manager - JCI/NABH / Quality Assurance (Hospital)

Contact Number : [phone removed] / Harish

Role & responsibilities

• Lead and maintain NABH (and JCI, if applicable) accreditation and re-accreditation readiness
• Conduct internal audits, mock audits, and gap analysis across all departments
• Monitor, analyse, and report quality indicators and KPIs to management
• Manage incident reporting, RCA, and CAPA for patient safety events
• Prepare and update SOPs, policies, and documentation as per NABH standards
• Coordinate with the Infection Control Committee on HAI surveillance and compliance
• Train clinical and non-clinical staff on quality, safety, and accreditation standards
• Drive patient feedback analysis and service improvement initiatives
• Ensure statutory compliance (biomedical waste, fire safety, licenses, and so on)
• Submit regular MIS and dashboards to the Medical Director and Management

Preferred candidate profile

Must have

• [5-10] years of hospital quality experience with hands-on NABH accreditation work
• Experience in gap analysis, mock audits, and documentation
• Strong knowledge of NABH standards (latest edition)
• Working knowledge of RCA, CAPA, and quality indicators

Good to have

• JCI exposure, NABH Assessor or Internal Auditor certification
• Six Sigma, Lean, or ISO 9001 training
• Clinical background (Nursing, MBBS, BDS, or Ayush)
• Experience with a hospital information system (HIS) and Excel/Power BI dashboards