JOB DESCRIPTION
Position: Quality Manager
Department: Quality / NABH
Location: VIMS Hospital, Salem
Reports To: Medical Superintendent
1. Purpose of the Role
To lead and manage the hospital’s quality assurance, patient safety, and NABH accreditation processes, ensuring compliance with NABH standards, statutory regulations, and continuous quality improvement across all departments.
2. Key Responsibilities
A. NABH Accreditation & Compliance
- Ensure full compliance with NABH standards (latest edition).
- Lead NABH accreditation and re-accreditation processes.
- Coordinate department-wise implementation of NABH requirements.
- Maintain all policies, SOPs, manuals, and documentation.
B. Quality Management System (QMS)
- Develop, implement, and monitor the hospital Quality Management System.
- Establish and track Quality Indicators (KPI dashboards).
- Ensure continuous quality improvement initiatives (CQI projects).
C. Audits & Assessments
- Plan and conduct internal audits across departments.
- Prepare departments for external NABH audits.
- Ensure closure of non-conformities (NCs) within timelines.
- Conduct mock drills and gap analysis.
D. Patient Safety & Risk Management
- Implement patient safety goals.
- Monitor and report:
- Incident reports
- Sentinel events
- Medication errors
- Conduct Root Cause Analysis (RCA) and implement CAPA.
E. Infection Control Coordination
- Work closely with Infection Control Team (ICT).
- Monitor hospital-acquired infection (HAI) indicators.
- Ensure compliance with infection control policies.
F. Documentation & Policy Control
- Ensure standardization of policies and SOPs across departments.
- Maintain document control system.
- Periodic review and updating of policies.
G. Training & Development
- Conduct NABH and quality training programs for staff.
- Ensure induction and periodic training compliance.
- Build awareness on patient safety and quality practices.
H. Regulatory & Statutory Compliance
- Ensure compliance with:
- NABH standards
- Clinical Establishment norms
- Biomedical Waste Management Rules
- Other applicable healthcare regulations
I. Coordination & Leadership
- Liaise with:
- Medical, Nursing, and Administrative departments
- HR and Operations teams
- Lead quality meetings and committee reviews.
3. Key Performance Indicators (KPIs)
- NABH audit score / accreditation status
- Number of non-conformities & closure rate
- Patient safety indicators (incidents, falls, errors)
- Infection rates (HAI indicators)
- Training compliance %
- Patient satisfaction scores
- Turnaround time for CAPA closure
4. Qualifications
- Master’s Degree in Hospital Administration (MHA) / MBA (Hospital Management)
- Certification in Quality / NABH / Healthcare Quality (Preferred)
5. Experience
- 7 to 10 years in hospital quality management
- Experience in NABH accredited hospital (Mandatory)
- Proven experience in handling NABH audits
6. Skills Required
- Strong knowledge of NABH standards & documentation
- Audit and compliance management
- Analytical and problem-solving skills
- Leadership and team coordination
- Training & presentation skills
- Good communication and reporting skills
7. Salary
- ₹70,000 – ₹80,000 per month (Based on experience and performance)
8. Working Conditions
- Full-time role
- May require extended hours during audits
- High coordination across departments
9. Authority
- Can initiate audits and quality checks
- Can recommend corrective and preventive actions
- Can coordinate directly with department heads
10. Accountability
- NABH compliance and accreditation status
- Patient safety and quality outcomes
- Audit readiness and documentation accuracy
Contact:
[email protected]
6383357488
Salem
Pay: ₹60,000.00 - ₹80,000.00 per month
Benefits:
- Paid sick time
- Paid time off
- Provident Fund
Work Location: In person
