Quality Manager

Responsibilities

• Lead implementation, monitoring, and continuous improvement of NABH 6th Edition standards across hospital departments.
• Ensure compliance with NABH, CAHO, and applicable statutory and regulatory requirements.
• Develop, review, and update Quality Manuals, SOPs, policies, protocols, formats, and quality documentation.
• Coordinate internal quality audits, mock audits, tracer activities, departmental audits, and accreditation assessments.
• Identify gaps in compliance and coordinate with respective HODs for Corrective and Preventive Actions (CAPA).
• Monitor and analyze Quality Indicators (QIs), Key Performance Indicators (KPIs), patient safety indicators, and clinical outcomes.
• Coordinate Quality Improvement Projects (QIPs) and support departments in implementing measurable improvement initiatives.
• Facilitate Quality Council / Quality Committee meetings and prepare agendas, minutes, action plans, and follow-up reports.
• Monitor compliance related to patient safety, infection prevention and control, medication management, clinical documentation, biomedical equipment, facility management, and patient rights.
• Conduct staff awareness and training programs on NABH standards, quality systems, patient safety, and hospital policies.
• Maintain accreditation-related records and ensure timely submission of required reports and documents.
• Coordinate with clinical and non-clinical departments to ensure consistent implementation of hospital policies and standards.
• Track audit observations, non-conformities, incident reports, complaints, and improvement actions until closure.
• Promote a culture of continuous quality improvement and patient safety throughout the organization.
• Prepare management reports, dashboards, presentations, and periodic quality performance summaries.

Requirements

• Strong knowledge of NABH 6th Edition standards and accreditation requirements.
• Working knowledge of CAHO standards, quality frameworks, and hospital accreditation processes.
• Good understanding of Quality Management Systems (QMS), CQI, CAPA, RCA, FMEA, and risk management.
• Knowledge of clinical and non-clinical hospital processes.
• Strong skills in audit planning, documentation, data analysis, and quality reporting.
• Good communication, coordination, presentation, and training skills.
• Ability to work effectively with doctors, nurses, technicians, HODs, and management.
• Proficiency in MS Excel, Word, and PowerPoint.
• Preferred NABH Assessor / Internal Assessor training will be an added advantage.
• CAHO training/certification or hands-on experience with CAHO-related quality initiatives will be preferred.
• Experience in a NABH-accredited hospital or in preparing a hospital for NABH accreditation/re-accreditation.
• Experience handling NABH assessments, surveillance assessments, and mock accreditation audits.

Specialisation

• Quality Management | NABH 6th Edition | CAHO | Patient Safety | Accreditation | Internal Auditing | CAPA | RCA | Risk Management | Quality Indicators | Continuous Quality Improvement | Documentation | Training Compliance

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